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Background: Chronic diseases are at epidemic proportions and continuing to increase in both incidence and prevalence globally. Therefore, there is a growing need to assess and improve on the value currently provided within chronic care pathways. Examining the costs associated with care pathways is a critical part of assessing this value in order to better understand and introduce potential cost-saving interventions. Objectives: Examining one such chronic disease, Rheumatoid Arthritis (RA), this study aimed to assess the cost associated with RA in primary care within the Health Service Executive (HSE) in Ireland. Methods: Following mapping of the care pathway, patient vignettes based on exemplar RA patient types were used to conduct semi-structed interviews with every member (N = 21) of the primary care RA pathway. Time-Driven Activity-Based Costing (TDABC) was then used to calculate the overall cost of each patient (vignette) type. Results: RA is an expensive condition regardless of disease stage. However, newly diagnosed patients as well as those with advanced disease in need of surgical interventions demonstrated the highest costs in terms of primary care personnel use. Additionally, patients prescribed Biological Disease-Modifying Anti-Rheumatic Drugs (bDMARDs) cost significantly more than those on Conventional Synthetic Disease-Modifying Anti-Rheumatic Drugs (csDMARDs) regardless of disease stage or personnel resource use. Conclusion: RA and a subset of RA patients that exert the highest healthcare costs are growing in prevalence. Therefore, this study contributes by assessing the costs associated with RA in HSE primary care that can facilitate better understanding the current value being provided and improve upon the current care pathway to cut future costs.
RESUMO
BACKGROUND: Chronic kidney disease (CKD) is associated with increased risk of fragility fracture but whether this is independent of osteoporosis is unclear. METHODS: We conducted a retrospective cross-sectional study of 1,702 female patients referred for dual-energy X-ray absorptiometry (DXA) scanning (Lunar IDXA) between September 2006 and April 2007. Estimated glomerular filtration rate (eGFR; ml/min/1.73 m(2)) by Modification of Diet in Renal Disease was calculated within 1 year (median interval 4 weeks) of the DXA scan. The independent association of self-reported fracture occurrence with eGFR category was assessed using multivariate logistic regression. RESULTS: Mean age (SD) was 61.7 (10.8) years; mean eGFR (SD) was 68.8 (12.2). The percentages of subjects with an eGFR of 75-89, 60-74, 30-59 and <30 was 34, 45, 20 and 0.8%, respectively. Forty-seven percent had osteoporosis. Mean T scores for the above eGFR categories were -2.2, -2.3, -2.5 and -3.0, respectively (p trend <0.001). Osteoporosis was significantly associated with eGFR on univariate analysis but not following adjustment for age. The percentage of patients with a fracture (29%) and with multiple prior fractures (3.5%) was higher at lower eGFR (p < 0.001, χ(2) test). The adjusted odds ratios (95% confidence interval) of any prior fracture for eGFR 75-89, 60-74 and 30-59 were 1.0 (reference), 1.2 (0.9-1.6) and 1.4 (1.0-1.9), respectively, adjusting simultaneously for age, T score, risk factors and treatment for osteoporosis. CONCLUSION: Moderate CKD is a significant independent predictor of fracture occurrence.
