Transcript Indirect costs - University of Leicester

RHEUMATOID ARTHRITIS:
THE COSTS OF CARE
Dr Nicola J Cooper
Department of Epidemiology & Public Health,
University of Leicester
Funded by an Arthritis Research Campaign (ARC) PhD Studentship
ACKNOWLEDGEMENTS
Professor Miranda Mugford
School of Medicine, Health
Policy and Practice, University
of East Anglia
Professor Deborah Symmons, ARC Epidemiology Unit,
Dr Nicola Wiles
University of Manchester
Bett Barrett,
Norfolk Arthritis Register, St
NOAR Metrologists
Michaels Hospital, Aylsham
Professor David GI Scott,
Norfolk and Norwich
Rheumatology staff
Hospitals
GPs
Norwich Area Health
Authority
All individuals with RA who participated in the research
OUTLINE
• Cost of illness (COI) studies;
• State of knowledge of economic impact
of RA; and
• Study One: Retrospective study of the
secondary health care and second line drug
costs of early RA.
• Study Two: Prospective study of costs of
early RA to patient, health service and other
agents
COST OF ILLNESS STUDIES
• Definition:
“Descriptive studies which provide
informative data to emphasise the scale and
nature of a disease as a health problem and
raise the profile of people with that disease
as a patient group.”
VALUE OF COI STUDIES
• Provides policy-makers with information
on total costs of a disease;
• Identifies where major burden of cost
might lie in treatment and care of these
people;
• Helps to prioritise research agendas; &
• Provides an indication of potential gains
from preventing the condition.
TYPES OF COSTS
• Direct costs: Borne by the health care
system, community & family in directly
addressing the problem.
• Indirect costs: Mainly productivity losses
caused by illness, borne by the individual,
family, society or employer.
• Psycho-social costs: Usually costs of
pain, grief, suffering & loss of leisure time.
PERCENT DISTRIBUTION OF ECONOMIC
COSTS OF ILLNESS, BY DIAGNOSIS &
TYPE OF COST: 1980 (Adapted from Rice et al,1985)
All other diseases
Genitourinary system
Musculoskeletal system
Nervous system & sense organs
Mental disorders
Respiratory system
Digestive system
Neoplasms
Injury & poisoning
Circulatory system
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100
%
Direct
Morbidity
Mortality
COHORT CHARACTERISTICS BY STUDY
COUNTRY
CLINICAL-BASED
Meenan et al 1978
USA
Liang et al 1984
USA
Lubeck et al 1986
USA
Wolfe et al 1986
USA
Jacobs et al 1988
USA
Yelin 1996
USA
Lanes et al 1997
USA
Clarke et al 1997
Canada
van Jaarsveld et al 1998 The Netherlands
COMMUNITY-BASED
Stone 1984
USA
Spitz 1984
USA
Jonsson et al 1992
Sweden
USA
Gabriel et al 1997b
USA
Gabriel et al 1997a
%
FEMALE
MEAN
AGE
MEAN
MEAN
DURATION OF HAQ
DISEASE (YRS) SCORE
76
80
76
76
77
75
69
48
61
55
56
62
60 (median)
9.8
13.5
14.5
15.4
20.8
=< 6
1.2
1.21
1.38
1.25
70
83
73
68
54
63
61
15
19
-
0.96
KEY FINDINGS
• Mean costs per person per annum
– Direct = UK£3,575 (US$5,720 )
[Range: UK£1,189 to UK£7,189]
– Indirect = UK£3,060 (US$4,900 )
[Range: UK£ 676 to UK£11,514]
• Ratio Direct : Indirect
Ranged from 0.40 to 3.00
KEY FINDINGS (cont.)
• Annual direct costs
RA
= UK£4,546 (US$7,274)
non-RA= UK£1,198 (US$1,917)
• Annual indirect costs
RA
= UK£1,171 (US$1,874)
non-RA= UK£ 531 (US$ 849)
CONCLUSION
• Few previous studies of the cost of RA in
the UK
• Previous studies took a ‘top down’
rather than a ‘bottom up’ approach
• Few previous studies considered the cost
to the individual patient and their family
RECOMMENDATIONS FOR
FUTURE COI STUDIES
1.Report direct & indirect costs separately as
well as in aggregate;
2.Identify different components of costs to
identify budgets on which major economic
burden falls;
3.State data sources & unit costs to allow
estimates to be reworked for different locations;
4.Test sensitivity of results by varying
assumptions underlying key parameters.
STUDY ONE
Objective:
“A retrospective study to
estimate the secondary health
nd
service care & 2 line drug
costs over first 5 years of
inflammatory polyarthritis”
STUDY POPULATION
• 433 people with inflammatory polyarthritis
(IP), who registered with the Norfolk Arthritis
Register (NOAR) project in 1990/91.
• Selection criteria:
1) Aged over 16 years;
2) Swelling of two or more joints;
3) Disease duration  4 weeks; &
4) Disease onset after January 1989.
• Of which, 208 people (48%) diagnosed as
RA (defined by the ACR 1987 revised criteria).
NORFOLK ARTHRITIS
REGISTER (NOAR)
• Primary care based inception cohort of patients with
inflammatory polyarthritis (IP)
• NOAR Methdology
– Patients seen by a metrologist
within 2 weeks of notification
– Followed annually for at
least five years
– Annual assessment includes
Health Assessment
Questionnaire (HAQ)
DATA SOURCES
• RESOURCE USE DATA:
– NOAR Database (e.g. No. of outpatient visits
& inpatient stays, medications, patient
characteristics)
– Hospital Medical Records & H.I.S. (e.g.
Length of hospital stay & department Rheumatology or Orthopaedic)
– GP Guidance Notes (e.g. Typical treatment
regimes and routine laboratory tests)
DATA SOURCES (cont.)
• UNIT COSTS:
– British National Formulary (e.g. Medication)
– Hospital Laboratories (e.g. Laboratory tests)
– Hospital Finance Department (e.g. Inpatient
day & outpatient visit)
COSTING EQUATION
n
m
TOTAL COST =   (frequency)ij* (unit cost)i
i=1 j=1
where
i = ith individual (i = 1,......n)
j = jth service received (j = 1,......m)
COHORT CHARACTERISTICS
OTHER IP
N = 225
HAQ score
< 1.0
73%
27%
 1.0
Mean: 52 (se 1.19)
Age (years)
63%
% female
29%
% smoking now
44%
% smoked past
% Rfactor1
17%
Social Class2
3%
I (%)
25%
II (%)
18%
IIIM (%)
26%
IIIN (%)
23%
IV (%)
6%
V (%)
1
2
13.6% missing data; 14.6% missing data.
RA
N = 208
41%
59%
Mean: 56 (se 1.08)
67%
29%
40%
55%
1%
26%
21%
25%
24%
4%
MEAN OUTPATIENT, INPATIENT & 2ND
LINE DRUG COSTS PER PERSON PER
YEAR (RA)
Cost £
600
500
400
300
200
100
0
1st year
Outpatient
2nd year
3rd year
Inpatient
4th year
2nd line drugs
5th year
Total
KEY RESULTS
[Cost estimates expressed in 1997/8 UK£’s]
• Total 5-year cost:
RA = £487,230
Other IP = £193,590
• Mean annual cost per person
RA = £410 (CI £315 to £505)
Other IP= £150 (CI £111 to £189
• Cost breakdown (RA-cohort):
55% Inpatient stays; 9% Outpatient visits &
36% 2nd line drugs
KEY RESULTS (cont.)
• RA-Cohort
– 11% incurred ‘no costs’.
– 23% (who all incurred inpatient costs)
responsible for approx. 75% of total 5-yr
costs.
• High costs over first 5yrs related to:
- HAQ score  1.0;
- Presence of Rheumatoid factor.
COSTS OF EARLY RA
IN THE UK
• Based on 15,000 new cases of RA per
year (Symmons et al 1994):
• Total 5-year secondary care and 2nd line
drug costs (including monitoring) for new
cases approx. £30.9 million [1997/8£].
- £17.0m = Inpatient care;
- £ 2.8m = Outpatient care; &
- £11.1m = 2nd line drugs.
STUDY TWO
Objective:
“A prospective longitudinal
study to estimate the costs to
the patient, their families and
the health service, over first 5
years of inflammatory
polyarthritis”
OBJECTIVES
• PART A: To develop a resource-use
and expenditure questionnaire for
self-completion by early IP individuals over
a 6-month period
• PART B: To estimate the costs associated
with early IP (Health service (e.g. health
professionals’ time, hospital costs, prescribed medication)
and Non-health service (e.g. travel time, informal care,
lost time from work, aids & modifications, over-the-counter
medication, alternative therapies)
PART A: METHODS
• Study methods:
– 2 Focus Groups
– 3-Month Data Collection (Pilot &
validation)
• Study population:
– Focus groups: RASCAL & NOAR
patients
– Pilot & validation study: 12 NOAR
& 12 Cheshire patients with early IP
FOCUS GROUPS ‘QUESTIONS ROUTE’
OPENING QUESTIONS:
1. How would you spend your time differently if you did not have
arthritis?
2. What would you say was the most significant consequence of your
arthritis?
3. How has your lifestyle changed to accommodate your arthritis?
MORE SPECIFIC QUESTIONS:
4. Tell me about the aids you have and modifications you have had
done to help you around the home.
..What about outside the home?
5. Have you become more reliant on other people (e.g. friends,
neighbours, relatives, social services) since the onset of your
arthritis?
….If so, who?
….How do they help i) you, ii) your children, iii) other dependants?
FOCUS GROUPS ‘QUESTIONS ROUTE’ (cont.)
6. How do you cope with everyday chores such as shopping and
housework?
7. Has your arthritis had an impact (both positive and negative) on
important events in your life?
….Changing pattern of work / job?
….Family relationships?
….Accommodation?
8. Can you describe how your arthritis has affected you emotionally?
9. Have your family, relatives and/or friends incurred any additional
costs as a results of your arthritis?
CLOSING QUESTION:
Following a summary of the issues and topics discussed…..
10. In keeping with the discussion that has just occurred, are there
any other forms of costs that you think should be considered?
RESULTS
• Forgone leisure time / activities
– “..planning in advance is a must…not actually just go and do
it - we’d have to plan is it feasible? ”
– “My husband did do a lot of orienteering so it’s spoilt it for
him - so it’s not just yourself”
• Reliance on other people
– “[My husband] had to do everything - I couldn’t get to the
bathroom, I couldn’t get out of bed, I couldn’t sit up…”
– “I need help with packing [my shopping]”
• Life events
– “I loved my job…..I’ve worked for the whole of my life and
that was my life basically…”
RESULTS (cont.)
• Emotions
– “Emotionally [having arthritis] an awful thing to adjust
to…..you’re sitting there now waiting for other people to
do things for you all day long”
• Aids & modifications to home, garden & car
– “I had to have the bathroom altered to make it easier. I
had to bear that expense myself!”
– “I would so welcome powered steering but I can’t afford
to change [my car]….if I could have adaptations I would
feel able to travel further [on my own]”
QUESTIONNAIRES
INITIAL:
FOLLOW-UP:
• Participant
characteristics
• Employment
• Assistance & Care
• Travel to the GP surgery,
hospital, other health
professionals
• Aids and Modifications
• Miscellaneous
• General Health
• Employment
• GP surgery, hospital,
other health professional
visits
• Inpatient stays
• Prescription
Medications
• Other Medications
• Assistance & Care
• Aids & Modifications
• Miscellaneous
• General Health
Health Service
Individuals
Miscellaneous
Informal care
time
Companion's
time
Lost work
Lost leisure
time
Travel time
Waiting + 'inappointment'
time
Formal care
Alternative
care
Prescription
charges
Over-thecounter
medication
Aids &
Modifications
Travel
30,000
Medication
Secondary
Care
Primary Care
Costs (£)
RESULTS OF PILOT STUDY
35,000
Norwich
Cheshire
25,000
20,000
15,000
10,000
5,000
0
Friends, relatives,
employer
PART B: METHODS
• Study methods:
– Prospective longitudinal study conducted
over 6 month period
• Study population:
– Random sample of 133 individuals with IP
recruited from NOAR database (<5years
disease duration)
• Data collection:
– Self-completion postal questionnaire,
‘Memory aid’ diary
COSTING METHODS
COSTS
METHOD
Forgone Paid Work
Average wage rate
Forgone Unpaid (House) Work
Housekeeper replacement
Forgone Leisure Time/Activities
30% of average wage rate
Informal Care
Replacement of care
Health service
Generic costs for UK
RESULTS
• 115 out of 133 (86%) individuals completed
6-months follow-up
Characteristics of study participants at baseline:
% Female
Mean age (SD)
71%
57 years (13.9)
Mean disease duration (SD)
47 months (81.6)
Median EuroQol score (IQR)
0.62 (0.59 to 0.73)
Median HAQ score (IQR)
0.63 (0.13 to 1.28)
MEAN 6-MONTH COSTS
(UK£1999)
COSTS TO…..
MEAN
MEDIAN
COST (SD)
COST (IQR)
£385 (1060)
£154 (32-343)
14%
£1,297 (2557)
£265 (65-1134)
46%
Relatives and friends
£983 (1747)
£44 (0-1192)
35%
Employer
£126 (221)
£0 (0-60)
5%
TOTAL
£2,791 (4236)
£869 (273-3451)
100%
Health service
Individual
%
A HISTOGRAM OF 6MONTH COST
50
40
Number of individuals
30
20
10
0
0
3000
6-month cost
6000
9000
12000 15000 18000
COSTS BY DISEASE DURATION
£20,000
£15,000
Total 6-month cos
£10,000
£5,000
N=
21
53
38
0-2
2-4
4+
Categories of disease duration in years
HEALTH SERVICE COSTS
22%
30%
15%
33%
GP visits
O/P visits
I/P stays
Medication
NON-HEALTH SERVICE COSTS
2%
25%
35%
19%
13%
4% 2%
Household help
Forgone paid work
Miscellaneous
Health prof visits
Forgone unpaid work
OTC Medication
Forgone leisure
COSTS TO THE INDIVIDUAL
2% 1%
15%
1%
3%
41%
37%
Paid help
Aids & modifications
Forgone leisure
Special diet
Forgone paid work
Health professional visits
Forgone unpaid work
MEAN 6-MONTH COSTS SPLIT BY
CHARACTERISTICS (UK£)
Female
Male
HAQ score <0.36
0.36-1.00
>1.00
Age at onset 16-39 years
40-59 years
>=60 years
Social Class I-IIIN
IIIM-V
Rfactor
positive
negative
RA classified YES
NO
EuroQol
<0.5870
0.5870-0.6910
>0.6910
N
78
34
36
38
35
10
52
50
52
59
33
74
57
55
38
43
31
Mean Cost (SD)
3132 (4470)
2127 (3716)
1164 (2518)
2950 (4471)
4573 (4964)
2997 (2548)
3139 (4790)
2468 (3984)
2227 (2948)
3384 (5145)
4472 (5359)
2197 (3610)
2416 (4777)
2216 (3601)
5262 (5591)
2377 (3248)
468 (628)
Median Cost (IQR)
1237 (340-3794)
444 (106-1701)
294 (88-838)
1130 (379-3313)
3007 (482-6675)
2920 (508-5056)
978 (283-3984)
508 (215-3066)
933 (326-3184)
752 (221-5260)
2251 (721-6288)
518 (187-2817)
1000 (412-5329)
482 (158-2969)
3382 (842-8159)
872 (273-2969)
221 (87-658)
CONCLUSIONS
•85% of Total costs = Non-health care costs
•Vast variability in costs between individuals
- 6% of individuals who incurred an
inpatient stay accounted for 42% of the total
6-month costs
•Health service and Non-health service costs
highly correlated
•Main predictors of cost: HAQ score and
Rheumatoid factor – positive association
COMPARISON (1999 UK£)
Study
%
female
Mean
Age
Mean
HAQ
score
Mean
duration
Direct costs
(%)
Indirect costs
(%)
Community-based (Annual costs, UK£)
Spitz (USA)
83%
54yrs
-
15yrs
£4,777
-
Jonsson et al (Sweden)
-
-
-
19yrs
£1,985 (62%)
£1,202 (38%)
McIntosh (UK)
78%
-
-
-
£4,906 (48%)
£5,282 (52%)
Gabriel et al (USA)
68%
61yrs
0.96
-
-
£1,366
Gabriel et al (USA)
73%
63yrs
-
-
£5,304
-
Newhall-Perry et al (USA) 80%
51yrs
1.24
0.5yrs
£1,820 (42%)
£2,557 (58%)
NOAR (UK)
56yrs
0.79
4yrs
£1,568 (28%) £4,086 (72%)
71%
OVERALL CONCLUSIONS
•Similarities to Asthma and Multiple Sclerosis
- High inpatient stay costs
- High informal care costs
•Costs likely to be higher in established IP (i.e.
in terms of surgery & care costs)
• Useful information for budget planning
both health & social services
RELATED PUBLICATIONS
•Cooper NJ. Economic burden of rheumatoid arthritis: A
systematic review. Rheum. 2000; 39: 28-33.
•Cooper NJ, Mugford M, Scott DGI, Barrett E. Secondary
health service care and second line drug costs of early
inflammatory arthritis in Norfolk. J. Rheum. 2000; 27: 21152122.
•Cooper NJ, Mugford M, Symmons DPM, Barrett EM, Scott
DGI. Total costs and predictors of costs in individuals with
early inflammatory polyarthritis: A community prospective
study. Rheum. 2002;41: 767-774.
•Cooper NJ, Mugford M, Whynes DK, Symmons DPM,
Barrett EM, Scott DGI. Development of resource-use and
expenditure questionnaires for use in rheumatology
research. (Submitted to J. Rheum.)