CLINICAL
plifying the patient’s voice, and can be clinically impor tant to aid healthcare professionals in tailoring the use of oral and biologic DMARDs. RA instruments that assess patient-reported outcomes include the Health Assessment Questionnaire (HAQ), the modified HAQ, and the multidimensional HAQ, with questions ranging from 8 to 20 items and assessing various aspects of patient functionality and overall mental health status.19 In these instruments, patients are asked about various aspects of their functionality (eg, dressing themselves, getting out of bed without difficulty, bending), and the degree to which it is difficult to perform these functions on a regular basis. Therefore, patient self-reports of their functional limitations are a widely accepted method of assessing RA severity.17,18 The cost of untreated RA represents a significant financial burden on the US healthcare system and the economy, predominantly because of lost productivity.20,21 Patients, employers, family members or caregivers, payers, and society as a whole share this significant economic burden. A US claims-based analysis of excess payer- and beneficiary-paid costs per patient with RA (compared with matched controls) reported annual excess healthcare costs of $8.4 billion, indirect costs of $10.9 billion, and total annual societal costs of $19.3 billion (including direct, indirect, and intangible costs, such as QOL deterioration).22 According to this analysis, patients incurred an estimated 28% of that burden, employers incurred 33% of that burden, the government spent 20% of the cost, and caregivers incurred an estimated 19% of the total cost. Adding intangible costs of QOL deterioration ($10.3 billion) and premature mortality ($9.6 billion), the total annual societal costs of RA (direct, indirect, and intangible) increased to $39.2 billion.22 Benefits in terms of enhanced productivity and quality-adjusted life-years conferred by the use of TNF-alpha blockers have been demonstrated in several cost-effectiveness analyses.23-25 These evaluations have been based on the concept that, if treated, patients with RA will not progress to a greater disease severity—or will not progress as quickly—and thereby will avoid or defer the high costs and low utilization associated with more severe and progressed disease.26 Previous studies have looked at patterns of TNF-alpha blocker treatment but have not linked these patterns to productivity-based, financial expenditures–based, and utilization-based outcomes.6-8,10 In addition, population- based studies of patients with RA using nationally representative data sources have not been successful in identifying differences in severity for patients with RA, because the information required to determine RA severity is often not available in these data sources. The Medical Expenditure Panel Survey (MEPS) database,
128
l
American Health & Drug Benefits
l
cosponsored by the Agency for Healthcare Research and Quality and the National Center for Health Statistics, is a nationally representative survey of the US civilian noninstitutionalized population. The uniqueness of the MEPS database lies in its abundance of information, which includes patient self-reported outcomes of functioning and mental health, along with information on sociodemographics, medical utilization, cost of healthcare services, employment, missed workdays, and Short Form (SF)-12 scores. The ability to link these many domains within the MEPS data source allowed the authors of this study to develop different severity categories for RA based on a unique algorithm created by the authors for this study. This RA severity–ranking algorithm was based on 5 health-related outcomes (ie, SF-12 physical and mental summary scores, patient’s perceived physical and mental health status, and the number of comorbid conditions), which were used to group TNF-alpha blocker nonusers into the 3 mutually exclusive RA severity cohorts— mild, moderate, and severe RA. Patients with RA using TNF-alpha blockers were not grouped using this algorithm and were not ranked. In addition, the MEPS data provide self-reports of work loss because of illness. The objective of the present study was to use data from the MEPS for the following outcomes—healthcare expenditures, utilization, and self-reported productivity— and to compare these outcomes between patients with RA who are TNF-alpha blocker users and TNF-alpha blocker nonusers with mild, moderate, or severe RA.
Methods We used 1998-2007 MEPS data that are available for public use. The MEPS is used to collect detailed information on (1) sociodemographic characteristics, such as age, sex, race, ethnicity, and education; (2) economic characteristics, such as employment status, annual wage(s), and missed workdays because of illness and injury; and (3) health characteristics, such as perceived physical and mental health status, SF-12 physical and mental summary scores, health conditions, comorbidities, smoking status, and physical function variables. Outcome Measures The main outcomes of interest in the current analysis were healthcare expenditures, medical service utilization, and work-related productivity of patients with RA. Total annual healthcare expenditures were defined as the sum of all-cause medical and pharmacy expenditures; in addition, medical and pharmacy expenditures were described separately, and were inflation adjusted to 2010 costs. Medical service utilization and pharmacy components
www.AHDBonline.com
March/April 2013
l
Vol 6, No 2