Rheumatoid Arthritis: Mau W

Mau W, Beyer W, Ehlebracht-König I, Engel M, Genth E, Greitemann B, Jäckel WH, Zink A. · Institut für Rehabilitationsmedizin, Medizinische Fakultät der Martin-Luther-Universität Halle-Wittenberg, 06097, Halle (Saale), Deutschland. · Z Rheumatol. · Pubmed #18299856 No free full text.

Abstract: A synopsis of different socio-medical consequences of inflammatory rheumatic diseases is not yet available for Germany. Therefore, the data reported during the past decade for rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, systemic sclerosis, systemic lupus erythematodes, and Wegener's granulomatosis are summarized in this article. Apart from clinical studies, relevant data sources were the national data base of the German collaborative arthritis centres, statistical figures from the compulsory health insurance and the national pension insurance scheme.Data were mainly available for sick leave and work disability showing limitations, which frequently occurred during the early course of diseases and increased with disease duration. Furthermore, different risk factors were identified. Measures to maintain continued participation in the labour force, such as part-time employment, partial work disability instead of full work disability, were not being adequately utilized. Only few data regarding the need of help and care were available. The proportion of patients in need of help and care increased with the duration of rheumatoid arthritis to more than 50% after more than 2 decades.This review presents detailed information concerning aspects of the burden of rheumatic diseases, which are frequently not adequately taken into account. They may be useful for the advice and care of individual patients as well as for decision processes concerning the health care system.

Merkesdal S, Ruof J, Mittendorf T, Mau W, Zeidler H. · Abteilung für Rheumatologie Medizinische Hochschule Hannover Carl-Neuberg Str. 1 30625 Hannover, Germany. · Z Rheumatol. · Pubmed #11974488 No free full text.

Abstract: Costs of illness are of major economic relevance in rheumatoid arthritis (RA) as in other chronic diseases. Overall costs of 15,000 Euro/year: 10,000 Euro indirect costs, and 5000 Euro direct costs are estimated, respectively. A further detailed analysis of direct costs underlines that inpatient care (50%) is the most prominent cost driver. Medication costs are also evaluated in detail since they are expected to gain importance with the introduction of the more expensive biologicals. While annual costs for regular disease modifying drugs (DMARDs) vary from 160 to 5000 Euro per patient, costs for the new biologicals amount up to 20,000 Euro (100-125% of the current estimated overall costs). For a comparison of different therapeutic strategies, costs are related to effectiveness in cost-effectiveness analyses. Based on present clinical trials, the ratios of medication costs and response according to the ACR 20-criteria of various DMARDs and biologicals are compared. The most cost-effective medication is sulfasalzine, followed by methotrexate, and leflunomide. Combining etanercept and methotrexate is preferable to methotrexate monotherapy and the combination of infliximab and methotrexate. This review shows that important economic issues in RA have already been addressed by applying cost-of-illness analyses and cost-effectiveness analyses. However, the knowledge about cost-effective therapeutic options is still scarce. Thus, primary data will have to be obtained using standardized approaches. These economic findings can be taken into account in the development of disease-management recommendations for RA-therapy.

Ruof J, Merkesdal S, Huelsemann JL, Schoeffski O, Maetzel A, Mau W, Zeidler H. · Division of Rheumatology, Hannover Medical School, Forschungsstelle Gesundheitsökonomie, Universität Hannover, Germany. · J Rheumatol. · Pubmed #11296978 No free full text.

Abstract: We compared the major characteristics of internationally applied cost assessment instruments (CAI) in rheumatic conditions. Fifteen utilization questionnaires were identified and assessed using a structured approach. The forms differed considerably with respect to applied characteristics: length (3-113 items), recall period (between 1 week and 1 year), format (2 interview, 13 self-administered), response categories, cost units (physical vs monetary), and cost domains covered. While all included a gross assessment of outpatient and inpatient costs, the level of disaggregation differed. Only a few CAI included an assessment of other direct disease related costs (e.g., home remodeling or home health care services) and out-of-pocket expenditure. Productivity costs were included in all but 2 CAI. Efforts to further standardize the applied CAI should (1) be based on sound psychometric data, (2) define a required core set of cost domains covered, (3) discriminate between generic and relevant disease related cost components, and (4) examine the feasibility of developing international standards for cost data.

Merkesdal S, Ruof J, Huelsemann JL, Schoeffski O, Maetzel A, Mau W, Zeidler H. · Division of Rheumatology, Hannover Medical School, Center for Health Economics, University of Hannover, Germany. · J Rheumatol. · Pubmed #11296977 No free full text.

Abstract: The aim of our study was to comprehensively review and critically appraise the cost domains used in economic evaluations of the rheumatic diseases and to use this information to propose standardization of cost domains. The literature search identified 210 abstracts, 32 of which included original cost data. The listed cost categories were grouped into 3 major areas: (direct) health care costs, other (direct) disease related costs, and productivity costs (indirect costs). The number of individual cost categories was reduced by considering the following criteria: (1) inclusion of all relevant cost domains; (2) avoidance of double counting; (3) summarizing of related categories under one representative heading; (4) feasibility of level of aggregation. After adjustment for synonymous labeling, 38 cost categories remained. The subsequent development of a classification scheme of cost categories led to a set of 19 separate cost domains including 7 outpatient, 3 inpatient, 6 other disease related, and 3 productivity cost domains. This literature review indicates that cost assessment in economic evaluations in rheumatoid arthritis lacks standardization. A preliminary scheme to categorize cost assessment in rheumatic conditions is presented. The adoption of standards for economic evaluation would greatly facilitate national and international comparisons.

Zink A, Mau W, Schneider M. · Deutsches Rheuma-Forschungszentrum Berlin, Forschungsbereich Epidemiologie, Schumannstrasse 21-22, 10117 Berlin. · Internist (Berl). · Pubmed #11244876 No free full text.

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Mau W, Zeidler H. · Abteilung Rheumatologie, Medizinischen Hochschule Hannover. · Versicherungsmedizin. · Pubmed #10516834 No free full text.

Abstract: The spectrum of rheumatoid arthritis (RA) ranges from benign remitting manifestations to rapidly progressive forms with increased mortality. About 10% of the patients show an intractable rapidly progressive course associated with severe extraarticular manifestations. Within the first three years, 70% of the patients develop radiological erosions of the joints and 31% deformities of the hands. Life expectancy is shortened by 3-18 years. Particularly, infections are more frequent causes of death in RA compared with controls. Work disability occurs in about a quarter of the patients within the first three years of RA and in 43-85% after eight to ten years. The ratio of direct to indirect costs is 1:3 in RA. Preliminary data show that regular rheumatological treatment leads to a marked reduction in indirect costs caused by production loss. The most important early indicators of an unfavourable disease course are the large number of swollen joints, early severe functional impairment, highly elevated laboratory markers of inflammation and rheumatoid factor. Knowledge of the current data regarding the course and prognosis of RA are helpful for assessment of the disease for insurance purposes.

Mau W, Zeidler H. · Abteilung Rheumatologie, Medizinischen Hochschule Hannover. · Versicherungsmedizin. · Pubmed #10420834 No free full text.

Abstract: Rheumatoid arthritis is an inflammatory systemic disease mainly affecting the joints. Frequent extra-articular manifestations are often recognized too late. Particularly the skin, the cardiovascular system, the kidneys, the eyes, the gastrointestinal tract, the liver, the nervous system and the blood may be involved. Examples of important complications affecting different organs are bacterial infections, AA-amyloidosis and hyperviscosity syndrome. Current data on the different disease manifestations and complications provide the basis for the assessment of the morbidity and mortality relevant for insurance purposes.

Merkesdal S, Ruof J, Huelsemann JL, Mittendorf T, Handelmann S, Mau W, Zeidler H. · Division of Rheumatology, Hannover Medical School, Hannover, Germany. · Arthritis Rheum. · Pubmed #15818718 links to  free full text

Abstract: OBJECTIVE: To render information on the accuracy of patient-reported indirect cost data compared with payer-derived data of the real indirect costs on a patient-by-patient basis concerning disease-related productivity losses in rheumatoid arthritis (RA). METHODS: The assessment of indirect cost data was part of a clinical, multicenter, randomized RA trial. A total of 234 patients of working age with a diagnosis of RA (according to 1987 American College of Rheumatology criteria) were recruited. Demographics of the cohort were mean age 53 years, mean disease duration 8 years, 76% were women, and all had membership in the regional statutory health insurance plan. Every 3 months corresponding indirect cost data were derived for the cohort from a health economic questionnaire for cost assessment in patients with RA and the payer's database over a period of 18 months. Comparative statistical analyses were performed between patient-reported and insurance claims data. RESULTS: The mean annual productivity losses due to sick leave amounted to 14 and 17 days per patient (questionnaire versus payer data), and productivity losses due to work disability amounted to 3 days (both); monetary valuation renders overall costs of 1,240 and 1,590, respectively. The difference of 17% in overall productivity losses is not significant. Comparison of productivity losses reveals a strong correlation of r = 0.83 in those due to sick leave and of kappa = 0.84 in those due to work disability between questionnaire and payer data. CONCLUSION: The comparison of questionnaire and payer data shows that RA patients report their productivity losses adequately. Indirect cost assessment should therefore be included in further RA trials and observational studies.

Bräuer W, Merkesdal S, Mau W. · Arbeitsgruppe Rheumaepidemiologie und Rehabilitation, Abteilung Rheumatologie, Medizinische Hochschule Hannover. · Psychother Psychosom Med Psychol. · Pubmed #11536074 No free full text.

Abstract: This study examines the applicability of the questionnaire "Fragebogen zur Erhebung von Kontrollüberzeugungen zu Krankheit und Gesundheit - KKG" to patients with early course of rheumatoid arthritis (RA) or undifferentiated Arthritis (uA), and the relationship between the severity of the disease and locus of control by controlling for socio-demographic variables and personality characteristics. 326 patients with early RA or uA with a disease duration of less than 12 months (mean disease duration 6 months +/- 3.5, mean age 53 +/- 14) were assessed. Full clinical investigations were performed and patients questionnaires were administered at the outset of the study (T1), after 12 months (T2) and after 24 months (T3). The factor-solution of the KKG-questionnaire in patients with early course of RA/uA is not different from healthy controls. A marked influence on coping types can be demonstrated for the covariates sex, age, cognitive components of anxiety and the severity of RA. These results should be considered in education programs for RA applying special techniques of behaviour therapy. Such interventions in the early phase of RA might lead to a reduction of cognitive anxiety and thus to more active coping in patients with RA.

Ehlebracht-König I, Mau W. · Rehazentrum Bad Eilsen, Brunnenpromenade 2, 31707, Bad Eilsen. · Z Rheumatol. · Pubmed #18946676 No free full text.

Abstract: Today, medical rehabilitation of patients with rheumatic diseases is based on the International Classification of Functioning, Disability and Health (ICF). In addition to the biomedical view, rehabilitation includes the individuals' activities and participation in society; the ICF integrates personal and environmental factors. Disability due to rheumatic disease results from the health condition itself and its structural and functional limitations as well as individual personal and environmental contextual factors. Two case reports--a patient with early rheumatoid arthritis and a patient with advanced ankylosing spondylitis--illustrate interdisciplinary treatment in medical rehabilitation that is based on the ICF.

Mau W, Müller A. · Institut für Rehabilitationsmedizin, Martin-Luther-Universität Halle-Wittenberg, 06097, Halle/Saale. · Z Rheumatol. · Pubmed #18825393 No free full text.

Abstract: Rehabilitation and outpatient physiotherapy were investigated from the perspectives of patients suffering from rheumatoid arthritis (RA) or ankylosing spondylitis (AS) and of rheumatologists. In 2007, 204 outpatients with RA and 47 with AS at the Arthritis Center in Halle, Germany, and 117 rheumatologists from all over the country participated in two questionnaire surveys. Patients and rheumatologists gave predominantly positive judgements of physiotherapy, psychological interventions, and patient education programs. However, outpatient care including these interventions was judged to be mainly limited by fixed budgets and other formal restrictions. Even though these therapeutic options are part of (primarily inpatient) rehabilitation programs, the estimate of the need for multidisciplinary rehabilitation programs varied widely among the rheumatologists. Significant objections against rehabilitation include reluctance of the patients, administrative burden for the physicians, payers' rejections, and limited choice of rehabilitation clinic. Despite major functional limitations, a substantial portion of the patients received no multidisciplinary medical rehabilitation, outpatient physiotherapy, psychological interventions, or patient education. Recommendations for the improvement of care are derived from these data.

Mau W, Listing J, Huscher D, Zeidler H, Zink A. · Institute for Rehabilitation Medicine, Martin-Luther University Halle-Wittenberg, Halle, Germany. · J Rheumatol. · Pubmed #15801031 No free full text.

Abstract: OBJECTIVE: To compare labor force participation across chronic inflammatory rheumatic diseases in order to assess the influence of the disease, disease duration, sex, education, and labor market conditions on employment. METHODS: Data from the German rheumatological database on outpatients of working age (20-59 yrs) between 1993 and 2001 were analyzed. The patients had rheumatoid arthritis (RA; n = 26,071), ankylosing spondylitis (AS; n = 5564), psoriatic arthritis (PsA; n = 6041), systemic lupus erythematosus (SLE; n = 4603), systemic sclerosis (SSc; n = 802), or Wegener's granulomatosis (WG; n = 385). Using population data, standardized employment ratios (SER) and part-time employment ratios of observed versus expected cases with 95% CI were calculated by means of indirect standardization for age and year of documentation. RESULTS: Across all diseases the overall employment rates were significantly lower than in the general population. Significant differences in SER were found between the diseases. The lowest SER of 0.76 to 0.81 (1.0 = population) were found in patients with RA, SLE, SSc, and WG. Higher SER were seen in AS (0.94) and PsA (0.92). In patients with a disease duration > 10 years the relative risk of being employed compared to RA, was 1.42 for AS, 1.26 for PsA, and 1.15, 1.03, 0.62 for PsA, SLE, SSc and WG, respectively. Comparing areas with low and high unemployment rates, a highly significant influence of labor market conditions on the SER was observed. The SER were significantly lower in patients with < 10 years of school education. CONCLUSION: Differences between employment rates in the population and the rates for the diseases under study are smaller than assumed by most clinical studies, especially in AS and PsA. However, these differences increase with longer disease duration. Specific measures to prevent patients from losing their job are needed, especially in areas with overall high unemployment.

Bräuer W, Merkesdal S, Mau W. · Abt. Rheumatologie Medizinische Hochschule Hannover Carl-Neuberg-Str. 1 30623 Hannover, Germany. · Z Rheumatol. · Pubmed #12426848 No free full text.

Abstract: OBJECTIVES: Work disability (WD) in early rheumatoid arthritis (RA) has not been extensively evaluated in Germany. Therefore, the occurrence of WD pension within the first seven years of RA and prognostic indicators of the first year including the duration of sick leave (SL) were analyzed. PATIENTS AND METHODS: Within the first year of RA according to the ACR 1987 criteria, 141 gainfully employed patients were entered into a prospective multicenter study (61% females, mean age 47 +/- 9 years, mean disease duration 6 +/- 3.5 months). One hundred and ten patients (78%) participated in a reevaluation (postal questionnaire) after a mean follow-up of 6.1 +/- 0.4 years. Predictors of WD pension were identified in univariate analyses and in backward multivariate Cox regression analyses (p < 0.05) with Hazard-ratios [H-R] as measures of WD risk. RESULTS: Of 110 patients 53 (48%) were still employed at reexamination. WD due to RA occurred in 5% after one year disease duration, in 15% after 2 years, in 20% after 3 years, and in 28% after 6.5 years. Other reasons for leaving the labor force were found in 24%. High pain intensity, radiographic erosions, comorbidity and the pain behavior of avoidance were associated with WD only in univariate analyses. Age > 45 years [H-R 6.3] and the following job-related prognostic indicators were identified in the multivariate analyses: working under pressure of time [H-R 9.0], limited joint motion interferring with job tasks [H-R 5.9], feeling overworked [H-R 3.8] and work status (unskilled blue-collar workers vs white-collar professionals and self-employed persons) [H-R 3.4]. In an alternative final Cox-regression model the variables feeling overworked and work status were replaced by SL duration > 8 weeks within the first year of RA [H-R 7.1]. CONCLUSIONS: Since WD frequently occurs already within the first 3 years (20%) adequate interventions resulting from the prognostic indicators have to begin early in the course of RA. Apart from the rheumatological treatment and rehabilitation focusing on the reduction of pain, improved coping with pain, reduced joint destruction and improved mobility particularly working under pressure of time should be avoided and the work place has to be adjusted in case of limited joint motion interferring with job tasks. SL of several weeks duration already within the first year of RA is a red flag for impending WD.

Jäckel WH, Beyer WF, Droste U, Engel JM, Genth E, Kohlmann T, Kriegel W, Mau W, Pott HG, Rehberg W, Sangha O, Schmidt K, Wassenberg S, Zink A. · Hochrhein-Institut für Rehabilitationsforschung Bergseestr. 61 79713 Bad Säckingen, Germany. · Z Rheumatol. · Pubmed #11759234 No free full text.

Abstract: By application of a standardized core set of outcome measurement instruments, comparison between studies as well as meta-analyses in rehabilitation research can be facilitated. The German Society for Rheumatology has commissioned its working group on rehabilitation with the development of a proposal for such a core set of outcome measurement instruments. In a first step, dimensions for outcome measurement in rehabilitation were defined by a group of experts which represented rehabilitation hospitals, acute care hospitals, and research groups specialized in outcome measurement. The Delphi method was used in a multiple step consensus process. In a second step, instruments and procedures to operationalize the relevant dimensions were chosen. Reliability, validity, sensitivity to change, and practicability were used as criteria for selecting measurement instruments. The main intention of the proposed core set of outcome measurement instruments is to facilitate the processes of planning and carrying out rehabilitation research studies. Furthermore, the proposed instruments can be used for clinical documentation systems as well as for internal or external quality assurance programs.

Merkesdal S, Ruof J, Schöffski O, Bernitt K, Zeidler H, Mau W. · Hannover Medical School, Germany. · Arthritis Rheum. · Pubmed #11263766 links to  free full text

Abstract: OBJECTIVE: To investigate 1) the magnitude of indirect costs, 2) changes in cost components, and 3) correlations between changes in cost and social, clinical, and occupational variables within the first 3 years of rheumatoid arthritis (RA). METHODS: We evaluated the indirect costs per person-year in 133 consecutive gainfully employed out-patients with early RA, in a prospective multicenter followup study. Costs due to RA-related sick leave, work disability, and other work loss were assessed using the human capital approach. Variables associated with reduction in lost productivity were tested by multivariate logistic regression analysis. RESULTS: Mean +/- SEM annual indirect costs were $11,750 +/- 1,120 per person. During the 3-year period of observation, a marked reduction in the costs associated with sick leave was seen, which exceeded the increase in costs due to work disability and other work loss. This phenomenon resulted in an overall reduction in indirect costs of 21%. The final logistic regression model of reduced loss of productivity included 3 variables: no problems with standing (odds ratio [OR] 7.1), no problems with working speed (OR 4.1), and no problems with outdoor work (OR 3.1). CONCLUSION: High indirect costs in early RA were demonstrated. An overall decrease of costs can be seen in the first 3 years, due to the reduction in sick leave. Since the absence of problems due to strenuous working conditions was found to be associated with a reduction in indirect costs, it is assumed that early intensified vocational rehabilitation, apart from controlling disease activity by adequate treatment, might help to reduce indirect costs.