Health care utilization and productivity loss associated with pulmonary arterial hypertension: a Swedish nationwide register study

Background

Pulmonary arterial hypertension (PAH) is a rare and serious disease with a significant impact on the quality of life and life expectancy.

Purpose

To estimate the health care resource utilization (HCRU) and productivity loss associated with PAH five years before and five years after diagnosis in a nationwide setting, compared to a matched control group.

Methods

This retrospective observational case-control study included adult patients diagnosed with PAH and registered in the Swedish PAH registry between January 1, 2008, through June 30, 2019. The control group consisted of five individuals per PAH patient matched on sex, birth year and municipality of residence at the time of PAH patients' diagnosis. The study was based on a dataset of individual level data compiled from several interlinked Swedish national registries. Mean (SD) HCRU (inpatient, outpatient, and drug utilization) and productivity loss (sick leave and disability benefits) were summarized for patients versus controls. Patients and controls with up to five years of follow-up data, i.e. alive and uncensored, were analyzed.

Results

In total 749 PAH patients were included in this study of which, 307 were censored and 234 died during the five-year follow-up period post diagnosis. The mean (SD) age of patients and controls were 61.8 (16.2) years and 64% were female. For the PAH group, the mean number of inpatient admissions and outpatient visits followed a similar trend, with an increase starting three years prior to diagnosis that peaked at the time of diagnosis (Figure 1). After diagnosis, mean inpatient admissions and outpatient visits decreased gradually. For the PAH group, drug utilization began to increase three years before diagnosis (Figure 1) and continued to increase after diagnosis. Controls showed much lower healthcare utilization compared to the PAH group.

In a subgroup of the PAH group (work force participants only, n=449, Figure 1), the mean sick leave days per patient per year (PPPY) was three times higher for the PAH group compared to controls five years before diagnosis. On average, over the full ten-year period mean sick leave days was five times higher for PAH patients compared to controls. Mean disability pension days PPPY for the PAH group followed a similar trend as in- and outpatient utilization. This peaked around time of diagnosis and was eight times higher for the PAH group than controls. An estimation of the societal cost burden (Table 1) showed that the top cost drivers for the PAH group were drug use, disability pension and sick leave.

Conclusions

PAH is associated with a heavy economic burden on both the health care system and society, starting several years before time of diagnosis.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Actelion Pharmaceuticals, a Janssen Pharmaceutical Company of Johnson & Johnson, Allschwil, Switzerland.

Presence of anti-citrullinated protein antibodies and costs and disease activity in early rheumatoid arthritis - a 3-year follow-up

Objective: To analyse healthcare utilization, loss of productivity, and disease activity in relation to presence of anti-citrullinated protein antibodies (ACPAs). Method: In total, 447 ACPA-positive and 224 ACPA-negative patients from two early rheumatoid arthritis cohorts, recruited 1996-1998 (cohort 1) and 2006-2009 (cohort 2), were followed during 3 years. Data on disease activity were collected, and patients reported healthcare utilization and days lost from work. Disease activity, healthcare costs, and loss of productivity were compared between ACPA groups. Linear regression was performed, controlling for confounders. Results: Healthcare costs did not differ significantly by ACPA status (EUR 3214 for vs EUR 2174 for ACPA-positive vs ACPA-negative patients in cohort 1, ns; EUR 4150 vs EUR 3820 in cohort 2, ns). Corresponding values for loss of productivity were EUR 9148 vs EUR 7916 (ns) and EUR 5857 vs EUR 5995 (ns). Total prescription of traditional disease-modifying anti-rheumatic drugs was higher in cohort 2 than in cohort 1. Methotrexate prescription was higher in ACPA-positive patients, but biologics did not differ significantly between ACPA groups. Disease activity was significantly more improved in cohort 2, but there was no difference in achieving remission in relation to ACPA status. In cohort 1, 25% of ACPA-positive patients were in remission vs 31% of ACPA-negative (ns) and in cohort 2, 55% vs 60% (ns). Conclusions: With increasing drug treatment for both ACPA-positive and ACPA-negative patients, outcome in ACPA-positive was no more severe than in ACPA-negative patients. Healthcare costs and loss of productivity were similar in the two groups.

Costs and disease activity in early rheumatoid arthritis in 1996-2000 and 2006-2011, improved outcome and shift in distribution of costs: a two-year follow-up

OBJECTIVE

To evaluate changes in healthcare utilization, costs, and disease activity from 1996 to 2011 for patients with early rheumatoid arthritis (RA).

METHOD

Two cohorts of patients with early RA, included in 1996-1998 (T1) and 2006-2009 (T2), were followed regularly. Healthcare utilization, costs, and disease activity were compared between cohorts during 2 years after diagnosis.

RESULTS

Disease activity was significantly improved in T2 vs T1. Drug costs increased in T2 vs T1 (EUR 911 vs EUR 535, respectively; p = 0.017), and costs for RA-related hospitalization decreased. More than 90% in T2 were prescribed disease-modifying anti-rheumatic drugs (DMARDs) at inclusion compared to 50% in T1. At 2 year follow-up, levels were still > 90% in T2, while corresponding values in T1 were just above 70%. Comparing T2 to T1, total direct costs were slightly higher in T2 (EUR 3941 vs EUR 3364, respectively; ns), sick leave decreased (EUR 3511 vs EUR 5672; p = 0.025), while disability pension increased slightly (EUR 4889 vs EUR 4244; ns), but total indirect costs remained unchanged (EUR 8400 vs EUR 9916; ns). Total direct and indirect costs did not differ between the cohorts (EUR 12 342 in T2 vs EUR 13 280 in T1; ns), and loss of productivity still represented the largest component of total costs.

CONCLUSION

T2 patients were prescribed DMARDs earlier and more aggressively than T1 patients. Stable and better improvements in disease activity, function, and quality of life were achieved in T2 compared to T1. There was a shift within the components in direct costs and indirect costs, but total costs remained essentially unchanged.

Association of insomnia severity with well-being, quality of life and health care costs: A cross-sectional study in older adults with chronic pain (PainS65+)

BACKGROUND

Insomnia is one of the most common complaints in chronic pain. This study aimed to evaluate the association of insomnia with well-being, quality of life and health care costs.

METHODS

The sample included 2790 older individuals (median age = 76; interquartile range [IQR] = 70-82) with chronic pain. The participants completed a postal survey assessing basic demographic data, pain intensity and frequency, height, weight, comorbidities, general well-being, quality of life and the insomnia severity index (ISI). Data on health care costs were calculated as costs per year (€ prices) and measured in terms of outpatient and inpatient care, pain drugs, total drugs and total health care costs.

RESULTS

The overall fraction of clinical insomnia was 24.6% (moderate clinical insomnia: 21.9% [95% CI: 18.8-23.3]; severe clinical insomnia: 2.7% [95% CI: 1.6-3.2]). Persons who reported clinical insomnia were more likely to experience pain more frequently with higher pain intensity compared to those reported no clinically significant insomnia. Mean total health care costs were € 8469 (95% CI: €4029-€14,271) for persons with severe insomnia compared with € 4345 (95% CI: €4033-€4694) for persons with no clinically significant insomnia. An association between severe insomnia, well-being, quality of life, outpatient care, total drugs costs and total health care costs remained after controlling for age, sex, pain intensity, frequency, body mass index and comorbidities using linear regression models.

CONCLUSIONS

Our results determine an independent association of insomnia with low health-related quality of life and increased health care costs in older adults with chronic pain.

SIGNIFICANCE

The concurrence and the severity of insomnia among older adults with chronic pain were associated with decreased well-being and quality of life, and increased health care costs to society.

Future complications of chronic hepatitis C in a low-risk area: projections from the hepatitis c study in Northern Norway

BACKGROUND

Hepatitis C (HCV) infection causes an asymptomatic chronic hepatitis in most affected individuals, which often remains undetected until cirrhosis and cirrhosis-related complications occur. Screening of high-risk subjects in Northern Norway has revealed a relatively low prevalence in the general population (0.24%). Despite this, late complications of HCV infection are increasing. Our object was to estimate the future prevalence and complications of chronic HCV infection in the period 2013-2050 in a low-risk area.

METHODS

We have entered available data into a prognostic Markov model to project future complications to HCV infection.

RESULTS

The model extrapolates the prevalence in the present cohort of HCV-infected individuals, and assumes a stable low incidence in the projection period. We predict an almost three-fold increase in the incidence of cirrhosis (68 per 100,000), of decompensated cirrhosis (21 per 100,000) and of hepatocellular carcinoma (4 per 100,000) by 2050, as well as a six-fold increase in the cumulated number of deaths from HCV-related liver disease (170 per 100,000 inhabitants). All estimates are made assuming an unchanged treatment coverage of approximately 15%. The estimated numbers can be reduced by approximately 50% for cirrhosis, and by approximately one third for the other endpoints if treatment coverage is raised to 50%.

CONCLUSION

These projections from a low-prevalence area indicate a substantial rise in HCV-related morbidity and mortality in the coming years. The global HCV epidemic is of great concern and increased treatment coverage is necessary to reduce the burden of the disease.

Prevalence of different pain categories based on pain spreading on the bodies of older adults in Sweden: a descriptive-level and multilevel association with demographics, comorbidities, medications, and certain lifestyle factors (PainS65+)

Background and objective

There is limited knowledge about the prevalence of pain and its relation to comorbidities, medication, and certain lifestyle factors in older adults. To address this limitation, this cross-sectional study examined the spreading of pain on the body in a sample of 6611 subjects ≥65 years old (mean age = 75.0 years; standard deviation [SD] = 7.7) living in southeastern Sweden.

Methods

Sex, age, comorbidities, medication, nicotine, alcohol intake, and physical activity were analyzed in relation to the following pain categories: local pain (LP) (24.1%), regional pain medium (RP-Medium) (20.3%), regional pain heavy (RP-Heavy) (5.2%), and widespread pain (WSP) (1.7%).

Results

RP-Medium, RP-Heavy, and WSP were associated more strongly with women than with men (all p<0.01). RP-Heavy was less likely in the 80–84 and >85 age groups compared to the 65–69 age group (both p<0.01). Traumatic injuries, rheumatoid arthritis/osteoarthritis, and analgesics were associated with all pain categories (all p<0.001). An association with gastrointestinal disorders was found in LP, RP-Medium, and RP-Heavy (all p<0.01). Depressive disorders were associated with all pain categories, except for LP (all p<0.05). Disorders of the central nervous system were associated with both RP-Heavy and WSP (all p<0.05). Medication for peripheral vascular disorders was associated with RP-Medium (p<0.05), and hypnotics were associated with RP-Heavy (p<0.01).

Conclusion

More than 50% of older adults suffered from different pain spread categories. Women were more likely to experience greater spreading of pain than men. A noteworthy number of common comorbidities and medications were associated with increased likelihood of pain spread from LP to RP-Medium, RP-Heavy, and WSP. Effective management plans should consider these observed associations to improve functional deficiency and decrease spreading of pain-related disability in older adults.

Prevalence of Different Pain Categories Based on Pain Spreading in Older Adults in Sweden: A Multilevel Association With Socio-Demographic Characteristics, Comorbidities and Drug Consumption (Pain S65+)

Introduction

Understanding of factors related to chronic pain in elderly is limited.

Objectives and aims

To estimate the prevalence of pain categories based on spreading of pain on the body and to investigate how such spreading is related to demographic variables, pain intensity, comorbidities and medication in an elderly general population in southeastern Sweden.

Methods

A total of 6611 adults aged ≥ 65 years participated (mean age = 76.2; SD = 7.4). Pain categories were assessed by a self-reported postal questionnaire covering 45 anatomical predefined pain regions along with demographics, pain intensity during previous seven days, comorbidities and medication. Poisson regression models with robust error variance were used for data analyzing.

Results

The prevalence of pain spreading categories was: chronic local pain (CLP) 16%; chronic regional pain medium (CRP-Medium) 17%; chronic regional pain heavy (CRP-Heavy) 5% and chronic widespread pain (CWSP) 2%. Overall, increased prevalence for CRP-Heavy and CWSP in subjects 75–79 years old compared to those 65–69, 70–74, 80–84 and ≥ 85 years were revealed. In men, 75–79 years old, CRP-Heavy was more common than in the other pain categories. In women, 75–79 years old CWSP, was more common than in the other pain categories. Pain intensity was strongly associated with all pain categories (P < 0.001). CLP was associated with trauma, rheumatoid arthritis, cancer, prescribed and non-prescribed analgesics. CRP-Medium was associated with rheumatoid arthritis, CRP-Heavy with rheumatoid arthritis and lung diseases and CWSP with rheumatoid arthritis and prescribed analgesics (P < 0.001).

Conclusions

Our findings elucidate heterogeneity of pain in elderly which has to be further investigated.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Changes in sociodemographic characteristics at baseline in two Swedish cohorts of patients with early rheumatoid arthritis diagnosed 1996-98 and 2006-09

OBJECTIVES

To compare baseline sociodemographic characteristics in two rheumatoid arthritis (RA) cohorts enrolled 10 years apart, and to examine differences with respect to the general population.

METHOD

Clinical and sociodemographic data were collected in 320 early RA patients during 1996-98 (TIRA-1) and 467 patients in 2006-09 (TIRA-2). Multivariate logistic regression tests were performed and intercohort comparisons were related to general population data, obtained from official databases.

RESULTS

TIRA-2 patients were older than TIRA-1 (58 vs. 56 years). Women (both cohorts, 67%) were younger than men in TIRA-1 (55 vs. 59 years) and in TIRA-2 (57 vs. 61 years). Disease activity was similar but TIRA-2 women scored worse pain and worse on the HAQ. Approximately 73% were cohabiting, in both cohorts and in the general population. Education was higher in TIRA-2 than in TIRA-2 but still lower than in the general population. Women had consistently higher education than men. Education was associated with age, younger patients having higher education. In both cohorts, lower education was associated with increased disability pension and increased sick leave. Sick leave was lower in TIRA-2 than in TIRA-1 (37% vs. 50%) but disability pension was higher (16% vs. 10%). In TIRA-1, 9% of women had disability pension compared with 17% in TIRA-2. A similar decrease in sick leave and an increase in disability pension were also seen in the general population. Older age and a higher HAQ score were associated with increased sick leave and being in the TIRA-2 cohort was associated with decreased sick leave.

CONCLUSIONS

TIRA-2 patients were slightly older, better educated, had lower sick leave and higher disability pension than those in TIRA-1. Similar changes were seen simultaneously in the general population. Belonging to the TIRA-2 cohort was associated with decreased sick leave, indicating that societal changes are of importance.