Despite advances in pharmacological treatment, work disability among individuals with chronic arthritis is substantial [
In Norway, multidisciplinary rehabilitation care for patients with inflammatory or noninflammatory arthritis is available in rheumatology departments at national, and regional hospitals and in specialised rehabilitation centres. Rheumatology hospital departments offer multidisciplinary rehabilitation care through in- and outpatient programmes, and the teams usually consist of several types of health professionals, for example, rheumatologist, nurse, physical therapist, occupational therapist, social worker, and psychologist. The teams in the rehabilitation centres are often limited to rheumatologist, nurse, and physical therapist, and hence, there is a less costly health service. There exists no unanimous practice for referring arthritis patients in need of rehabilitation care to a hospital or a rehabilitation centre. However, since patients referred to a rehabilitation centre must be able to take care of basic self care activities, it is expected that these patients have a lower level of disease severity, for example, as measured by physical function outcomes. Similarly, it is expected that patients, who can attend outpatient rehabilitation programmes at hospitals, have less activity limitations than patients in need of inpatient multidisciplinary rehabilitation care.
A few previous studies have shown that multidisciplinary rehabilitation care, provided in outpatient rehabilitation programmes, has significantly lower costs than inpatient programmes [
The purpose of this study was to describe healthcare consumption and related costs over a period 3 months prior to, during, and 6 months after receiving multidisciplinary rehabilitation care for various clinical subgroups of patients with inflammatory or noninflammatory arthritis. A second aim was to investigate the effect of diagnosis, clinical setting, age, gender, severity of disease, comorbidity, and work status on total healthcare costs. We expected that patients with arthritis had a reduced need for healthcare in the first months following multidisciplinary rehabilitation care of at least one week duration. Further, we expected that the healthcare costs were higher by higher age, higher severity of disease (as measured by diagnosis, physical function outcomes, co-morbid conditions), for patients who were on sick leave, and higher among patients referred to a rehabilitation stay in a hospital as compared to a rehabilitation centre.
This was a multicenter, longitudinal observational study in which all institutions/hospital units, which provided multidisciplinary rehabilitation care, in South-East Norway were invited to participate. There were 15 rehabilitation centres and 4 rheumatology units in hospital eligible, of which 9 specialised rehabilitation centres and the 4 rheumatology hospital departments agreed to participate in the study. Eligible patients at the participating centres were consecutively recruited over a three-month period from September to December in 2006 and followed in 6 months after discharge.
All patients aged 18 to 75 years with an inflammatory joint disease or osteoarthritis of any location and scheduled for a rehabilitation stay of at least one week were invited to participate in the study. Patients diagnosis was confirmed by a rheumatologist at each of the clinical sites. Exclusion criteria were serious psychiatric comorbidity or inability to communicate in written Norwegian. The patients were recruited by research assistants at the institutions/departments, who provided information about the study to the patients, including informed agreement and written consent. The study was approved by the regional committee for medical research ethics.
At admission physicians examined the patients and provided diagnostic information. The patients filled in a comprehensive questionnaire at admission and discharge and a postal questionnaire at six-month follow-up. The baseline questionnaire included sociodemographic and health status variables. Sociodemographic variables concerned age, gender, level of education, work status, co-morbidity (number of diseases from a list of 12 possible diagnostic groups), use of medication (pain, inflammatory, relaxation), and use of assistive tools. Health outcomes were the Modified Health Assessment Questionnaire (MHAQ) [
Use of health care services during the 3-month period before the rehabilitation stay was collected in the baseline questionnaire before the patients started their rehabilitation. Use of health care services in the 6-month follow-up was recorded by a monthly cost diary, including registrations of number of visits to a general practitioner, physical or manual therapist, medical specialist, social worker, and alternative therapist, number of days of hospitalization and/or rehabilitation, use of medication (both on prescription and over the counter medication), and number of days of sick leave from work. Different types of healthcare costs are presented in four cost groups: cost group 1 considers costs for primary healthcare services, cost group 2 for secondary healthcare services, cost group 3 covers use of medication, and cost group 4 provides costs for production loss for employed patients. The four cost groups are presented in Table
Cost categories, units, valuation, and unit price, all numbers in EURO (
Cost categories | Unit | Valuation | Unit price |
---|---|---|---|
General practitioner | Visits | NAV | 38 |
Specialist (several types) | Visits | NAV | 171 |
Physiotherapy² | Per treatment | Charge | 38 |
Manual therapy² | Per treatment | Charge | 41 |
Chiropractor² | Per treatment | Charge | 63 |
Occupational therapy² | Per treatment | Charge | 41 |
Others (psychologist, social worker, nurse, practical assistant other types)² | Per treatment | Charge | 38 |
Alternative treatment3 | Visits | Out of pocket | From 29 to 1,625 |
Rehabilitation centre | Days | Direct communication | 188 |
Hospital inpatient unit | Days | DRG 462 B | 711 |
Hospital outpatient unit | Days | NAV | 195 |
Hip/knee prosthesis surgery | Per patient | DRG 211 | 17,783 |
Inpatient hospital stay before/after rehab stay | Days | DRG-average | 1,193 |
Abatacept (Orencia) | 3 set à 250 mg | Price per month | 511 |
Etnaercept (Enbrel) | 4 sett (50 mg) | Price per month | 665 |
Adalmimumab, ikke adalmimumab (Humira) | 40 mg * 2 | Price per month | 1,312 |
Infliximab (Remicade) | 3 mg per kilo (300 mg) * 0.5 | Price per month | 2,201 |
Tocilizumab (Ro-Actemra) | 8 mg per kilo (400 mg) * 2 | Price per month | 1,246 |
Anakinra (Kineret) | 100 mg per day * 30 | Price per month | 1,016 |
Leflunomide (Arava) | 20 mg 30 tablets | Price per month | 83 |
Other medication | Price per month | 25 | |
Hours | Wage rate per day | 244 |
²Treatment time varies from 30 to 45 minutes.
3Treatment modalities such as acupuncture, homeopathy, Thai massage, and Turkey bath/spa rehab stay
NAV: Norwegian Labor and Welfare Administration.
DRG: diagnosis-related groups.
Information on cost per unit was collected from different sources (Table
The rehabilitation length was calculated as number of days between admission and discharge, including the weekends (7 days per week). Costs incurred at the hospital were based on diagnosis-related groups (DRGs) 2006. DRG is an international coding system, used for administrating both clinical and financial activity, in the specialist health care. In Norway there are about 500 DRG groups. All DRG groups are given a specific weight to reflect the treatment intensity relative to the average patient. The cost for a DRG group is estimated by multiplying the cost weight for that specific DRG group with the cost of one DRG. In 2006 the cost of one DRG was
Unit cost for the different types of treatment (physiotherapy, manual therapy, etc.) was based on charges. For the group “others” we used the lowest charge of the other treatments as an estimate. Medication costs were based on the price list from the Norwegian Medicines Agency. The costs of acupuncture, homeopathy, and other types of treatments were based on out of pocket cost reported by the patients. The cost of sick leaves (for those who were employed) is estimated to be equal to average income inclusive social costs [
In Norway, the social security system covers almost all costs related to hospital stay, including the costs for medication and other treatments during the stay, and the costs related to production loss. Furthermore, the social security system covers the main costs for rehabilitation stay and use of primary care health services for people with a rheumatic disease diagnoses, whereas there is a minor out-of-pocket payment for these services. The out-of-pocket payment for a stay at the rehabilitation institutions is in average
Continuous variables are presented by means with standard deviations and categorical variables are presented by frequencies and percentages for the total sample and for each of the diagnostic subgroups. As the cost data were highly skewed, we present the total costs with both median (with min-max) and mean with standard deviation. Cost estimates within the subgroups are presented with mean and confidence intervals, which were estimated with the bootstrap method. For differences in trends within the cost groups and between clinical subgroups, we used rank sum based on “Kruskal-Wallis equality-of-populations rank test” according to the clinical subgroups and time periods, respectively.
When assessing associations between the total costs and potential predictors, we used the total healthcare costs in groups 1, 2, and 3 for the rehabilitation stay and the 6-months follow-up as main outcome. The effects of clinical subgroup, age, gender, comorbidity, working status, baseline scores of the MHAQ, SF36 physical and mental function, and use of assistive tool were tested separately in the inflammatory and non-inflammatory subgroups by means of Ordinary Least Square regressions. Statistical analysis was performed with SPSS 14.0 and STATA 10.5% level of significance was used.
Of 581 eligible patients a total of 460 (72.2%) accepted to participate in the study. There was incomplete diagnostic data for 3 patients, 23 patients withdrew before they started the rehabilitation, and 70 patients dropped out in the period between discharge from the rehabilitation stay and 6 months of follow-up. Of the 367 responders to 6-month follow-up 61 patients had lacking or incomplete data for the use of healthcare, leaving a total of 306 patients for current analyses. There were no significant differences between the initial included study sample and the final set of 306 responders with regard to diagnostic group, clinical setting, gender, work status, co-morbidity, and baseline physical function (MHAQ and SF36 Physical function sum score). The non responders, however, were slightly younger, were more frequently single, and had lower level of education and poorer mental health scores according to the SF36 Mental health.
The mean age was 61 years (SD 9.6), 75% were female, and the majority had an old age- or disability-related pension (68%) (Table
Sociodemographic and health variables at baseline for the total sample
ALL | Inflamm. disease hospital | Inflamm. disease outpatient hospital | Inflamm. disease rehab centre | OA conventional rehab centre | OA postsurgery rehab | |
---|---|---|---|---|---|---|
Age (y), mean (SD) | 60.7 (9.6) | 54.4 (11.2) | 51.6 (11.2) | 58.2 (9.5) | 60.7 (8.1) | 64.9 (7.1) |
Female, | 229 (74.8) | 26 (54.2) | 10 (71.4) | 48 (96.0) | 61 (96.8) | 84 (64.1) |
Married/cohabitant, | 213 (69.6) | 35 (74.5) | 11 (78.5) | 32 (66.7) | 38 (60.3) | 97 (75.8) |
Education, | ||||||
≤9 years | 77 (25.2) | 15 (31.9) | 5 (35.7) | 13 (26.5) | 15 (24.2) | 29 (22.8) |
≤12 years | 70 (22.9) | 11 (23.4) | 3 (21.4) | 11 (22.4) | 18 (29.0) | 27 (21.3) |
>12 years | 152 (49.7) | 21 (44.7) | 6 (42.9) | 25 (51.0) | 29 (46.8) | 71 (55.9) |
Missing | 7 | 1 | — | 1 | 1 | 4 |
Work situation, | ||||||
Employed | 40 (13.2) | 10 (21.3) | 7 (50.0) | 6 (12.2) | 8 (12.7) | 9 (7.0) |
Employed, but on sick leave | 50 (16.3) | 4 (8.5) | 4 (28.6) | 4 (8.2) | 10 (15.9) | 28 (21.7) |
Disability pension | 111 (36.3) | 23 (48.9) | 2 (14.3) | 29 (59.2) | 29 (46.0) | 25 (19.4) |
Age pension | 99 (32.4) | 7 (14.9) | 1 (7.1) | 9 (18.4) | 16 (25.4) | 65 (50.4) |
Homeworker | 4 (1.3) | 2 (4.2) | 0 | 0 | 0 | 2 (1.6) |
Unemployed | 2 (0.7) | 1 (2.1) | 0 | 1 (2.0) | 0 | 0 |
Missing | 4 | 1 | — | 1 | — | 2 |
Co-morbidity, | ||||||
None | 52 (17.0) | 14 (29.2) | 5 (35.7) | 4 (8.0) | 5 (7.9) | 24 (18.3) |
One | 106 (34.6) | 17 (35.4) | 4 (28.6) | 19 (38.0) | 11 (17.5) | 55 (42.0) |
Two or more | 148 (48.4) | 17 (35.4) | 5 (35.7) | 27 (54.0) | 47 (74.6) | 52 (39.7) |
Daily use pain medication, | 152 (49.7) | 23 (53.5) | 15 (35.7) | 23 (53.5) | 3 (30.0) | 20 (31.7) |
Daily use anti-inflammatory medication, | 93 (30.4) | 24 (58.5) | 6 (54.5) | 17 (44.7) | 36 (45.0) | 93 (43.3) |
Daily use relaxing/sleeping med, | 51 (16.7) | 5 (13.5) | 2 (22.2) | 12 (30.8) | 12 (21.8) | 20 (23.0) |
Assistive tools, mean (SD) | 0.9 (1.8) | 1.2 (2.0) | 1.9 (2.8) | 0.8 (1.7) | 0.5 (1.4) | 1.0 (1.7) |
Days of rehab stay mean (SD) | 21.3 (6.2) | 16.7 (5.8) | 11.9 (2.0) | 26.7 (5.9) | 25.5 (4.8) | 19.8 (3.8) |
MHAQ1, mean (SD) | .77 (.48) | .71 (.46) | .49 (.43) | .63 (.46) | .65 (.45) | .94 (.46) |
SF36 physical sum score2, mean (SD) | 30.5 (8.9) | 34.1 (10.8) | 38.3 (8.5) | 31.4 (8.1) | 30.5 (9.0) | 27.8 (7.5) |
SF36 mental sum scores2, mean (SD) | 49.1 (12.7) | 47.7 (13.1) | 42.6 (13.2) | 46.1 (12.3) | 48.3 (12.8) | 52.0 (12.2) |
OA: osteoarthritis; rehab: rehabilitation.
1MHAQ score 0–3,
2SF-36 sum scores, score 0–100,
3
The mean duration of the rehabilitation stay was significantly shorter at the hospital units (mean days 15.7, SD 5.6) than at the rehabilitation institutions (mean days 22.7, SD 5.5) (
Mean costs related to health consumption in the primary healthcare services (cost group 1), secondary healthcare services (cost group 2), use of medication (cost group 3), and production loss (cost group 4) for each of the five subgroups prior to, during, and after the rehabilitation stay are presented in Table
Mean costs in Euro (
Cost group | Pre rehab stay | Rehabilitation stay | 0–3 months post rehab stay | 4–6 months post rehab stay | ||
---|---|---|---|---|---|---|
Inflamm. disease hospital | 1 | 378 (88–422) | — | 545 (87–595) | 586 (110–649) | .16 |
2 | 2,010 (−1,258–2,776) | 11,884 (10,940–13,443) | 3,808 (961–7,334) | 1,073 (−1,475–1521) | .61 | |
3 | 640 (−172–850) | 544 (261–587) | 1,136 (190–1492) | 1,136 (190–1492) | .45* | |
41 | 8,191 (3,209–9,039) | 3,158 (2,559–3,296) | 8,480 (3,721–9,335) | 8,480 (3,721–9,335) | .59* | |
Inflamm. disease outpatient hospital | 1 | 518 (248–645) | — | 652 (164–731) | 600 (69–715) | .54 |
2 | 1,448 (−1,991–2,385) | 2,309 (1,628–2,374) | 851 (−1,347–2,172) | 85 (−2,035–104) | .40 | |
3 | 636 (−786–1,458) | 371 (62–440) | 637 (−813–1498) | 637 (−813–1498) | 1.000* | |
41 | 6,059 (−532–8,516) | 2,437 (1,891–2,522) | 7,583 (1,410–9,849) | 7,583 (1,410–9,849) | .20* | |
Inflamm. disease rehab centre | 1 | 483 (362–606) | — | 830 (626–1,035) | 802 (595–1,009) | .01 |
2 | 1,411 (160–2,663) | 5,010 (4,703–5,316) | 522 (83–961) | 814 (−236–1,865) | .74 | |
3 | 232 (−69–534) | 665 (545–786) | 231 (−64–526) | 231 (−64–526) | .76* | |
41 | 9,637 (7,571–11,704) | 4,773 (4,451–5,004) | 10,215 (8,263–12,167) | 10,215 (8,263–12,167) | .77* | |
OA conventional rehab centre | 1 | 479 (181–533) | — | 897 (302–1,074) | 990 (201–1,367) | .005 |
2 | 2,629 (−691–3,447) | 4,780 (4,098–4,855) | 165 (−767–238) | 1,070 (−1,410–714) | .01 | |
3 | 73 (−530–72) | 587 (336–600) | 72 (−518–71) | 72 (−518–71) | .65* | |
41 | 7,997 (3,058–8,703) | 4,608 (4,074–4,679) | 9,191 (4,589–9,888) | 9,191 (4,589–9,888) | .24* | |
OA postsurgery rehab | 1 | 415 (138–448) | — | 1,009 (498–1,112) | 659 (225–678) | <.001 |
2 | 17,268 (17,142–19,899) | 3,704 (3,065–3,733) | 1,207 (−67–1,603) | 579 (−1,656–714) | <.001 | |
3 | 99 (−542–108) | 430 (187–433) | 89 (−505–91) | 89 (−505–91) | .002* | |
41 | 4,863 (438–5,176) | 3,636 (3,161–3,648) | 6,153 (1,854–6,549) | 6,153 (1,854–6,549) | .21* |
Cost groups 1–4 refer to costs related to health consumption in the primary healthcare services (cost group 1), secondary healthcare services (cost group 2), use of medication (cost group 3), and costs related to production loss in terms of sick leave (cost group 4). All costs are presented in Euros: 1
OA: osteoarthritis; rehab: rehabilitation
B = Bootstrap 95% confidence interval.
1Production loss includes only sick leave for employed patients. Age and disability pension are not included.
2
Healthcare consumption and costs during the 3-month period prior to and 6-month period after multidisciplinary rehabilitation care were similar with no significant changes within the two groups with inflammatory arthritis treated at a hospital. For the three clinical subgroups receiving rehabilitation at a rehabilitation centre, there was a significant increase in mean costs due to healthcare consumption in the primary care, whereas there was a significant decrease in mean costs of secondary healthcare services for the two osteoarthritis subgroups. There was also a significant decrease in use of medication in the postsurgery osteoarthritis subgroup across the time periods. Furthermore, the mean costs due to medication use were higher among patients with an inflammatory diagnosis as compared to patients with osteoarthritis within all the time periods.
The costs related to production loss were the highest across all the clinical subgroups and were 2-3 times higher than total healthcare costs (Table
Mean (SD) and median (min-max) health care costs (summary of 1, 2, and 3) and health care- and social costs (summary of 1, 2, 3, and 4) for the whole observation period. Costs are in Euro (
Inflamm. disease hospital | Inflamm. disease outpatient hospital | Inflamm. disease rehab centre | OA conventional rehab centre | OA postsurgery rehab | |
---|---|---|---|---|---|
Cost group 1, 2 and 3 including rehab stay | |||||
Mean (SD) | 23,605 (17,399) | 8,749 (7,971) | 11,038 (7,998) | 11,817 (8,978) | 25,136 (7,298) |
Median (min-max) | 15,145 (7,779–91,336) | 5,208 (3,033–27,687) | 8,575 (3,900–38,793) | 8,019 (5,006–46,703) | 24,239 (4,539–48,468) |
Cost group 1, 2, 3 and 4 including rehab stay | |||||
Mean (SD) | 51,492 (29,894) | 32,410 (24,498) | 45,880 (24,109) | 42,804 (24,288) | 45,952 (20,889) |
Median (min-max) | 59,986 (32,410–24,498) | 24,993 (5,714–73,993) | 57,801 (8,040–92,906) | 52,065 (9,196–89,801) | 40,993 (7,951–90,491) |
Cost groups 1–4 refer to costs related to health consumption in the primary healthcare services (cost group 1), secondary healthcare services (cost group 2), use of medication (cost group 3), and costs related to production loss in terms of sick leave (cost group 4). All costs are presented in Euros: 1
OA: osteoarthritis; rehab: rehabilitation.
The arthritis-related healthcare costs (sum of cost groups 1, 2, and 3) ranged from
The average total healthcare cost (sum of Cost groups 1, 2, and 3) from inclusion in the multidisciplinary team rehab stay until 6-month follow-up was mean
The influence of clinical subgroup, age, gender, comorbidity, and work status on total health care costs (sum of cost groups 1 to 3 for rehabilitation period and 6 months after) for patients with inflammatory disease. The results are presented as Unstandardised Coefficients (
Variable | Model 1 | Model 2 | Model 3 | Model 4 |
---|---|---|---|---|
Clinical subgroup | ||||
Ref. | Ref. | Ref. | Ref. | |
Inflammatory disease inpatient hospital unit | 13,412 (8,744 to 18,080)** | 12,952 (8,299 to 17,605)** | 12,935 (8,173 to 17697)** | 13,721 (8,806 to 18,635)** |
Inflammatory disease outpatient hospital unit | −2,595 (−9,388 to 4,196) | −2,406 (−5,875 to 3,727) | −2,560 (−9,514 to 4,395) | −73 (−7,089 to 6,940) |
Gender | −2,968 (−8,055 to 2,118) | −3,272 (−8,371 to 1,826) | −3,555 (−8,744 to 1,633)* | −4,025 (−9,402 to 1,352) |
Age | 1,682 (−4,712 to 8,077) | 1,843 (−4,583 to 8,271) | 4,430 (−1,762 to 10,624) | 4,045 (−2,379 to 10,469) |
Comorbidity | ||||
One | 3,170 (−2,373 to 8,714) | 3,291 (−2,282 to 8,864) | 3,795 (−1,849 to 9,439) | 4,851 (−1,002 to 10,632) |
Two or more | 2,939 (−2,830 to 8,708) | 2,274 (−3,457 to 8,005) | 2,885 (−3,003 to 8,775) | 3,346 (−2,759 to 9,452) |
Working status | 1,732 (−3,288 to 6,753) | 1,716 (−3,333 to 6,765) | 448 (−4,589 to 5,485) | 402 (−4,827 to 5,632) |
MHAQ | −5,179 (−12,174 to 1,815) | — | 1,151 (−4,092 to 6,396) | 4,122 (−921 to 9,166)* |
SF Physical function | −172 (−301 to −42)** | −106 (−202 to −11)* | — | — |
SF Mental function | −1 (−21to 19) | 41 (−21 to 19) | — | — |
Assistive tools | 1,447 (414 to 2,540)** | 1,315 (268 to 2,361)* | 1,619 (542 to 2,695)** | — |
Constant | 16,367 (4,568 to 28,168)** | 10,292 (10763 to 18,819)** | 3,367 (−3,134 to 9,869) | 2,178 (−4,522 to 8,878) |
Adj R-squared | 0.3593 | 0.3518 | 0.3276 | 0.2750 |
Cost values (in Euro) are estimated means by OLS. All costs are presented in Euros: 1
*
The difference between the three models is only the inclusion of different severity measures in addition to clinical setting, diagnosis, age, gender, and working status.
Model 1: all severity measures are included: MHAQ, SF36 Physical function, SF36 Mental function, and assistive tools.
Model 2: we include only SF36 Physical function, SF36 Mental function and assistive tools.
Model 3: we include only MHAQ and assistive tools.
Model 4: we include only MHAQ.
The influence of clinical subgroup, age, gender, comorbidity, and work status on total health care costs (sum of cost groups 1 to 3 for rehabilitation period and 6 months after) for patients with osteoarthritis (OA). The results are presented as Unstandardised Coefficients (
Variable | Model 1 | Model 2 | Model 3 | Model 4 |
---|---|---|---|---|
Clinical subgroup | ||||
Ref. | Ref. | Ref. | Ref. | |
OA postsurgery rehabilitation | −675 (−2,664 to 1,313) | −220 (−2,135 to 1,694) | −683 (−2,658 to 1,290) | −57 (−2,723 to1,207) |
Gender | −2,086 (−4,166 to −6)* | −2,037 (−4,125 to −50) | −2,103 (−4,142 to −65)* | 1,915 (−3,903 to 72) |
Age | 651 (−1,282 to 2585) | 386 (−1,527 to 2,300) | 693 (−1,217 to 2,605) | 578 (−1,312 to 2,468) |
Comorbidity | ||||
One | 1,054 (−1,445 to 3,554) | 1,080 (−1,429 to 3,590) | 1,178 (−1,265 to 3,622) | 1,148 (−1,292 to 3,589) |
Two or more | 1,341 (−1,160 to 3,842) | 1,470 (−1,036 to 3,977) | 1,514 (−891 to 3,920) | 1,507 (−335 to 3,163) |
Working status | 192 (−1,805 to 2,190) | −34 (−2,020 to 1,951) | 263 (−1,707 to 2,234) | 128 (−1,814 to 2,072) |
MHAQ | 1,512 (−365 to 3,390) | — | 1,614 (−199 to 3,428) | 1,414 (−335 to 3,163) |
SF Physical function | −2 (−13 to 9) | −4 (−15 to 6) | — | — |
SF Mental function | −1 (−9 to 6) | −2 (−9 to 6) | — | — |
Assistive tools | −216 (−738 to 305) | −106 (−612 to 399) | −220 (−739 to 299) | — |
Constant | 6,592 (3,301 to 9,882)** | 7,650 (4,621 to 10,679)** | 6,158 (3,303 to 9,013)** | 6,244 (3,399 to 9,090)** |
Adj R-squared | 0.0101 | 0.0128 | 0.0193 | 0.0209 |
Cost values (in Euro) are estimated means by OLS. All costs are presented in Euros: 1
*
The difference between the three models is only the inclusion of different severity measures in addition to clinical setting, diagnosis, age, gender and working status.
Model 1: all severity measures are included: MHAQ, SF36 Physical function, SF36 Mental function, and assistive tools.
Model 2: we include only SF36 Physical function, SF36 Mental function, and assistive tools.
Model 3: we include only MHAQ and assistive tools.
Model 4: we include only MHAQ.
For patients with inflammatory disease all the models showed that the total costs in a hospital unit were significant more costly than rehabilitation in a hospital outpatient and at a rehabilitation centre (Table
For the patients with osteoarthritis there was no significant difference in total costs across the other three clinical subgroups at the rehabilitation centres (Table
This study provides a descriptive analysis of direct and indirect costs incurred by various subgroups of patients with inflammatory or non-inflammatory arthritis receiving multidisciplinary rehabilitation care. Three main findings were observed: first, the total healthcare costs ranged from
In general, vast cost discrepancies have been reported across studies [
Overall, in-patient hospital costs accounted for the largest proportion of direct healthcare costs, whereas the costs related to primary healthcare and medication accounted for lower costs. Even though the rehabilitation stay at hospitals was significantly shorter than in rehabilitation institutions (16 versus 23 days), the costs for rehabilitation were significantly higher at the hospitals. The main reason for this difference is the large difference in the price per day/night per person in hospitals as compared to rehabilitation centres. This finding is in line with our a priori expectations and also with several previous studies [
We expected that the healthcare costs prior to a rehabilitation stay were higher as compared to the period after rehabilitation, in particular in the first 3-month period after the rehabilitation stay. An underlying assumption was that patients with arthritis had a reduced need for healthcare in the first months following multidisciplinary rehabilitation care of at least one-week duration. Opposite to our expectations, the healthcare costs were surprisingly high during the whole observation period, in particular for the three clinical subgroups receiving rehabilitation at a rehabilitation centre. Some of the increased costs right after the rehabilitation stay might have been a consequence of interventions that were initiated during the rehabilitation stay followed up in the primary care after discharge. It can also be argued that six months of follow-up was too short time to show that the healthcare costs might have reached the level prior to the rehabilitation stay. On the other hand, similar to the findings in our study a recently published observational study from Germany [
The mean direct cost of outpatient rehabilitation in our study was about doubled compared to the German study [
The costs due to production loss associated with arthritis exceeded by far the direct costs of healthcare. Although this finding is similar to previous reviews of cost-of-illness studies for patients with arthritis [
Another limitation is the lower number of patients in the outpatient group, which must be considered when interpreting the results within this group. As mentioned above, one might argue that 6-month follow-up was short and a longer follow-up period could have helped to explore whether costs due to healthcare consumption in the primary care decreased back to the level prior to a rehabilitation stay. Furthermore, the fact that the response rate at 6 months of 66% and nonresponders were slightly younger and more frequently single, with lower level of education and poorer mental health, might indicate a potential for selection bias. High rates of nonrespondents among younger people have also been reported in other studies using mailed surveys [
The main strengths of this study were a large sample size, further data for all study institutions were concurrently collected, and investigation of the use of healthcare as well as production loss after the rehabilitation stay was performed in a detailed way. We also consider that this study has implications for further research. The observed large differences in costs across clinical settings in which rehabilitation is provided should be tested out in a randomised, controlled trial in order to assess whether the increased costs can be justified with increased effectiveness. Moreover, it is important to investigate whether a good follow-up procedure in the primary care can prevent or reduce the need for costly inpatient multidisciplinary rehabilitation. Finally, the study results can be used in a discussion regarding what is optimal level of healthcare consumption and/or rehabilitation in various subgroups of patients with arthritis. The patients in this study had a lower level of healthcare consumption prior to the rehabilitation period than afterwards. That might seem contradictory as one would assume that their condition was more severely affected before than after. It is crucial to understand the relationship between need and/or use of healthcare consumption and severity of chronic diseases, in order to develop longer-term optimal disease management plans.
To conclude, our data demonstrated substantial costs related to multidisciplinary rehabilitation care and use of healthcare consumption among patients with arthritis, before, during, and after the rehabilitation stay. The time period following a scheduled rehabilitation stay was characterized by surprisingly high healthcare consumption and costs in patients with arthritis. Both the clinical setting in which rehabilitation was provided and disease severity itself had a large impact on healthcare consumption and costs. In patients still working, indirect costs in terms of sick leave were considerable. As a clinical implication, methods to reduce the length of rehabilitation stay should be developed, in particular at hospitals, and regarding production loss with a focus on cost saving, given that health outcomes are constant. Clinical studies on different rehabilitation strategies should include health-economic analyses contributing to the best management of rheumatic diseases.
The authors want to thank the SPOR collaboration group, who collaborated in collecting the data for the present study. The SPOR collaboration group consisted of the following institutions in Norway: Bakke Senter, Borger bad, Grande rehabiliteringssenter, Jeløy kurbad, Martina Hansens hospital, Diakonhjemmet sykehus, Revmatismesykehuset, Ringen rehabiliteringssenter, Skogli helse-og rehabiliteringssenter, Sykehuset Østfold, Tonsåsen rehabilitering, Valnesfjord helsesportsenter, and Vikersund kurbad. The study was partly financed by EXTRA funds from the Norwegian foundation for Health and Rehabilitation. This study was partly financed by EXTRA funds from the Norwegian Foundation for Health and Rehabilitation and partly by Diakonhjemmet Hospital, Norway. The funding source had no implication on the study design, conduct, or reporting.