MEDVERSATION^®

Rheumatoid Arthritis-Related Disability and Other Concerns

Rheumatoid arthritis (RA) is a chronic and debilitating disease for the vast majority of RA patients. Inflammation and joint deformity is responsible for the structural damage caused by RA, which can result in significant loss of physical function and disability that contribute to major economic losses, and can have a profound impact on the quality of life of both patients and their families. It remains a challenge for patients to overcome the effects RA has on both the social and economic aspects of life.

Risk Factors for Disability Associated with Rheumatoid Arthritis

One of the greatest challenges both the patients and society face, as a result of RA, is the degree to which it affects the patient’s ability to work. The incidence and prevalence of RA-attributed work disability was measured in the U.S. by Allaire, et al., in adults ≤64 years of age in three periods from 2003-2005. Analysis showed that the incidence of RA-attributed work disability in each period cohort was 42, 61, and 42 (n=908, n=828, n=866), respectively.¹¹⁹⁸⁰  Prevalence of work cessation attributable to RA increased as duration of disease increased (from 13.6% for ~2 years’ duration through 42.2% for ≥25 years’ duration).¹¹⁹⁸⁰ 

Unfortunately, ability is influenced by many different factors; for example, studies suggested that patients who are disabled, or who stopped working due to RA, are generally older, less educated, work <30 hours per week, and have a lower income, relative to those patients with RA who continued to work.¹⁰⁶²⁴  , ¹¹⁹⁸¹  In terms of clinical variables, work-disabled patients tend to have longer disease durations and a number of variables that reflect more active or aggressive disease, including higher erythrocyte sedimentation rate, numbers of swollen and tender joints, more radiographic damage, and worse scores on objective measures of disease severity and functionality (such as the disease activity score and health assessment questionnaire), relative to patients who continue to work, thus requiring more intensive therapy with disease-modifying antirheumatic drugs (DMARDs) or glucocorticoids than those who work with RA.^{10624,  11981}  Studies are divided on the importance sex may have on RA-related disability in patients, primarily because of the social, physical, and psychological differences of the disease between males and females.¹¹⁹⁸¹  ,¹¹⁹⁸²  ,¹¹⁹⁸³ 

It is critical for clinicians, employers, and payers, as well as patients, to identify those baseline factors that are associated with the development of work disability so that individuals who would benefit from earlier therapeutic intervention can be identified and can continue to work. Morales-Romero, et al., evaluated the incidence of permanent work disability (PWD) in 300 salaried Mexican workers with RA and concluded that a low education level, positive rheumatoid factor, and a delay in the use of DMARDs were risk factors for PWD.¹⁰⁴⁷⁶  Verstappen, et al., conducted a literature review to identify published RA-related work disability reports from 1980 to May 2002, identifying the proportion of patients with work disability and what social and demographic characteristics, clinical variables, or work-related factors might be associated with, or predict, work disability. The results were divided into cross-sectional and longitudinal reports (See See Table :Prevalence of Rheumatoid Arthritis).¹⁰⁶²⁴ 

Author Year	Disease Duration/ Age	Education Level/ Marital Status	Sex/ ESR	RF+/ Functional Disability	Joint Count / X-ray Damage	Pain Score/ Well Being	Disease Severity/ Blue Collar Job
Doeglas 1995	+ / –	+ / NA	– / +	NA / +	NA	NA	NA
Eberhardt 1993	NA / –b	–b / –b	–b / –b	NA / +b	–b / NA	–b / NA	–b /NA
Borg 1991	NA / +b	–b / –b	–b / –b	NA / +b	–b / NA	–b / –b	NA / +b
Young 2002	NA / +b	NA	+b / +b	– / +b	–b / +b	NA	NA / +b
Reisine 1989	– / +	– / –	NA	NA / +	NA	NA	+ / –
Mau 1996	+b / +b	NA	NA / –b	+b / +b	+b / +b	NA	NA / –b
Fex 1998	NA / +b	+b / –b	–b / NA	NA / +b	–b / –b	–b / NA	NA
Callahan 1992	– / +	– / –	– / NA	– / +	– / –	NA	NA / +
Reisine 1995	–b / +b	–b / –b	–b / NA	NA	+b / NA	–b / NA	NA
De Roos 1999	+ / +	+ / –	+ / NA	NA / +	NA	+ / NA	NA / –
Yelin 1987	–b / +b	–b / –b	–b / –b	–b / +	+ / –b	NA	–b / NA
Wolfe 1998	–m / –m	+m / NA	+m / +m	NA / +m	–m / NA	+m / NA	–m / +
Jantti 1999	NA	NA	NA	NA / +	NA / –	NA	NA
Sokka 1999	NA / +b	–b / –b	–b / NA	–b / NA	+b / NA	NA	NA / –b
Barrett 2000	NA / –b	NA	–b / NA	–b / +b	–b / NA	NA	NA
ESR = erythrocyte sedimentation rate; NA=not applicable; RF = rheumatoid factor; + = significant predictor of work disability corrected for all other variables; – = included in analysis; however, not a significant predictor; b = baseline values; m = mean values from baseline until last visits. 10624  Centocor Ortho Biotech Inc. Adapted. Table 4, Page 493, Arthritis Rheum. 2004;51(3):488-497. Copyright © reprinted with permission of Wiley Liss, Inc., a subsidiary of John Wiley & Sons, Inc.

Costs Due to Rheumatoid Arthritis

The importance of preventing loss of function as a primary goal in the treatment of RA is underscored by studies that have demonstrated a correlation between reduced function and a decrease in earnings, an increase in related costs, or both.^{4818,  10427,  11984} 

Functional disability (demonstrated by a worsened health assessment questionnaire [HAQ] score) is strongly associated with work disability.¹¹⁹⁸⁵  Given the association between reduced function and disability, it is not surprising that there has been a correlation found between RA patients and loss of income, decreased household productivity, and increased indirect cost.^{4818,  10427,  11984}  Wolfe, et al., demonstrated an annual earnings loss of between $2,319 and $3,407 in patients with RA, with a 0.25-point difference in the HAQ score representing a $1,095 reduction in annual earnings.⁴⁸¹⁸  Ozminkowski, et al., used data from 9 US employers in 2003 and found that an employee with RA costs an average of $4,088 per year more in direct medical costs than an employee without RA ( Fig.3233). ¹¹⁹⁸⁴  A survey conducted by the Kaiser Family Foundation in 2003 reported the average annual cost of a single-coverage healthcare plan to be $3,383.¹¹⁹⁸⁷ 

Functional disability has been shown to be directly correlated with the overall medical care costs associated with RA (direct cost). Fries, et al, demonstrated that current disability, as assessed by HAQ score, is strongly predictive of total medical care (direct) costs over the subsequent 5 years ( Fig.1048).¹⁰¹⁸⁹ 

Although there have been many investigations attempting to define the economic burden of RA, it has been difficult to clearly quantify the total direct (prevention, detection, and treatment or care) cost. Despite the amount of research dedicated to this subject, studies often report differing data because of the lack of uniformity in both sample populations and underevaluated advances in biologic drugs that would, undoubtedly, drive up treatment costs since the late 1990s.¹¹⁹⁸⁸  For these reasons, it becomes difficult to pinpoint trends in RA direct costs in the United States and therefore, difficult to predict future expenditures.^{11988,  11989} 

Numerous studies have commonly demonstrated, however, that there is a correlation between increased direct costs and more severe functional disability (increased HAQ), which consequently drives up indirect costs associated with work disability.^{4645,  4678,  4710,  4713,  4726,  4807,  4824,  11984,  11990}  In terms of clinical and disease variables, HAQ scores appear to be one of the most important predictors of direct medical and indirect employment costs, leading researchers to believe that a lesser magnitude of improvement in HAQ with therapeutic intervention predicts higher, future overall costs.^{4726,  11990}  Yelin, et al., found a potential opportunity for significant cost savings by maintaining or improving a patient’s functional status to an HAQ score of ≤1.25. Data suggest that preserving or improving functional status (as assessed by HAQ) may lead to better patient outcome and potential cost savings with regard to RA.^{4824,  11990} 

Quality of Life in Rheumatoid Arthritis Patients

Rheumatoid arthritis is a chronic, progressive inflammatory condition that results in characteristic joint problems that can become debilitating, making it difficult to perform activities of daily life and work. This, in conjunction with the increased need for medical care, can decrease quality of life (QoL) for both the patient and society as a whole.

One of the more common tools to measure health-related quality of life (HR-QoL) in patients with RA is the Short Form-36 (SF-36); a patient self-administered questionnaire with 36 questions, grouped into 8 multi-item subscales, measuring various assets of physical and mental health.⁴⁷⁰⁸  The concepts measured by the SF-36 are not specific to any age, disease, or treatment group, thereby allowing comparison of relative burden of different diseases and the relative benefit of different treatments.²⁷²⁷  What makes the SF-36 useful in determining HR-QoL in RA patients is that it has a dedicated section for physical ability that focuses on dexterity, and it performs similarly to disease-specific measures of HR-QoL in RA patients.¹¹⁹⁹¹  Studies indicate that, in general, and relative to a healthy population, the mental component summary score of the RA population’s SF-36 is normal, and the physical component summary score is reduced.^{4816,  10198,  10738}  A study by West and Jonsson reported RA symptoms having an effect on patient’s SF-36 scores as early as 12 months after discovery.⁴⁸¹⁶  Singh, et al., demonstrated that relative to non-RA controls, patients with RA in the lowest tertile of the physical and mental component summary scores had significantly higher odds of hospitalization and death (odds ratio [OR] 1.49; 95% confidence interval [CI], 1.25-1.76 and OR 1.69; 95% CI, 1.18-2.42, respectively).¹⁰⁸⁶⁴ 

Another common tool used in the measurement of HR-QoL in RA patients is the health assessment questionnaire (HAQ), a nonspecific instrument that indexes HR-QoL by gauging the patient’s ability to perform 20 daily living tasks. Patients respond to each questions with a score from 0 to 3 (0 = without difficulty, 3 = unable to do), then 2 or 3 questions are assigned to 8 categories, the highest scoring question being assigned as the category score. The average of each category’s score is the overall HAQ score, from 0-3.¹¹⁹⁹¹  The HAQ is a common tool for use in measuring functional disability, costs, and disease activity; all of which are influential factors on a patient’s QoL.

Disease Activity, Structural Damage, and Disability

A number of studies have been conducted to investigate the strength of the relationship between disease activity, joint damage, and disability. Reviewing published literature, Scott, et al., summarized available data of cross-sectional studies, evaluating the relationship between radiological joint damage and functional disability, as assessed by health assessment questionnaire in established rheumatoid arthritis (RA).⁶⁶¹⁵  This review summarized available results for several longitudinal studies conducted in patients with RA of both early and late duration ( Fig.3232). Also, as noted in Fig.3231, results gathered from 4 studies generally support an annual increase in disability experienced by patients. These studies also generally support a correlation between the radiographic damage and functionality, although there is evidence that the association is weaker earlier in the disease and becomes stronger as time increases.⁴⁶⁰⁵ 

Drossaers-Bakker, et al, investigated the relative contribution of disease activity and joint destruction to the loss of functional capacity as part of a 12-year prospective study in 112 patients.⁴⁶⁰⁵  Parameters assessed during the study included measures of disease activity (swollen and tender joints (using the Ritchie articular index), morning stiffness, erythrocyte sedimentation rate, visual analogue scale for disease activity and fatigue, and disease activity score (DAS), as well as radiographic evaluations of the hands and feet (obtained at baseline and Years 3, 6, and 12), which were scored using the Van der Heijde modification of the Sharp score. Additionally, several instruments were utilized to describe function, including the HAQ, which indicated a strong correlation between HAQ score and DAS (r=0.68) at baseline and a weaker one with the Sharp score (r=0.22). Over time, the correlation between HAQ score and DAS remained almost stable and the correlation between HAQ and Sharp score increased from 0.22 to 0.57 at 12 years. Of the single disease activity measures, the Ritchie articular index had the strongest correlation to HAQ over the course of the study, ranging from 0.51 to 0.70.

Later studies by Welsing, et al., and Maillefert, et al., on the relationship between radiologic damage, disease activity, and functional disability in RA patients provided additional evidence that HAQ scores were correlated with DAS primarily in the earlier stages of disease progression, while measures of radiologic damage (Sharp score) were correlated with HAQ as damage accumulated in long-standing cases of RA.^{10473,  10718} 

Mortality and Rheumatoid Arthritis

Much of the focus of the treatment of RA continues to be on the clinical inflammatory manifestations involving the joints and the day-to-day management of the resulting clinical sequelae, which constitute much of the morbidity associated with the disease; however, it is also well established that RA is associated with an increased mortality. ^{4627,  4630,  4674,  4748,  4749,  4762,  4778,  4812,  4823,  11007,  11992}  Rheumatoid arthritis can result in a lifespan shortened by up to 15 years.⁴⁸²³  This increase in mortality was first described in the modern era in the work of Pincus, et al, who followed a cohort of 75 patients with RA over a 15-year period starting in 1973.⁴⁷⁴⁵  Compared with rates for the US population matched for age and gender, the standardized mortality rates at 5, 10, and 15 years were 1.86, 1.92, and 1.62, respectively.⁴⁷⁴⁵  Analysis of variables associated with increased mortality demonstrated a correlation with indicators of more severe disease including higher swollen joint counts and more morning stiffness, as well as greater disability. Indeed, decreased functional ability has been associated with an increased mortality in clinical investigations involving other cohorts of RA patients.^{4630,  4748,  4784,  11007}  Interestingly, 10-year survival among patients with higher joint counts and worse disability in this cohort was similar to that of patients with triple-vessel coronary artery disease and Stage III/IV Hodgkin’s disease at the time.⁴⁷⁴⁹ 

As new therapies have become available over the last 3 decades, and therapeutic paradigms for the management of RA have been modified, it is interesting to note that most published studies continue to report an increased mortality rate associated with RA. Some more recent studies have reported decreased mortality rates in RA patients, compared with some older investigations; however, this may be due to study design, in that many of these more recent studies involved inception cohorts. ⁴⁸¹²  A more recent study by Björnådal, et al., reported on a population-based cohort of Swedish RA patients followed from first hospital discharge. They noted a decreased mortality rate in patients ages 40 to 59 for the period 1985 to 1994 (standard mortality rate 1.63) compared with the period 1964 to 1974 (standard mortality rate 2.68).⁴⁶²⁷ 

Although RA is associated with an increased mortality; it is infrequently reported as the primary cause of death. Common causes of death in patients with RA seem to mirror those of the general population, albeit they occur earlier than would be expected, and include infection (particularly respiratory), cardiovascular/cerebrovascular disease, and malignancy.^{4627,  4630,  4745,  4778,  11007,  11993,  11994}  Additionally, some studies have demonstrated an increased risk of mortality with these outcomes in RA patients over the general population. ^{4627,  4630,  4778,  11007,  11993,  11994} 

This concludes the discussion of the topic Natural History of Rheumatoid Arthritis. We encourage you to read other topics on the MEDVERSATION^® website.

Content on this page was last changed on October 06, 2009.

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2727

Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care . 1992 Jun;30(6):473-483.

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4605

Drossaers-Bakker KW, de Buck M, van Zeben D, Zwinderman AH, Breedveld FC, Hazes JM. Long-term course and outcome of functional capacity in rheumatoid arthritis: the effect of disease activity and radiologic damage over time. Arthritis Rheum . 1999;42(9):1854-1860.

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4627

Björnådal L, Baecklund E, Yin L, Granath F, Klareskog L, Ekbom A. Decreasing mortality in patients with rheumatoid arthritis: results from a large population based cohort in Sweden, 1964-95. J Rheumatol . 2002;29(5):906-912.

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4630

Book C, Saxne T, Jacobsson LT. Prediction of mortality in rheumatoid arthritis based on disease activity markers. J Rheumatol . 2005;32(3):430-434.

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4645

Clarke AE, Zowall H, Levinton C, et al. Direct and indirect medical costs incurred by Canadian patients with rheumatoid arthritis: a 12 year study. J Rheumatol . 1997;24(6):1051-1060.

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4674

Gordon P, West J, Jones H, Gibson T. A 10 year prospective followup of patients with rheumatoid arthritis 1986-96. J Rheumatol . 2001;28(11):2409-2415.

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4678

Guillemin F, Durieux S, Daurès JP, et al. Costs of rheumatoid arthritis in France: a multicenter study of 1109 patients managed by hospital-based rheumatologists. J Rheumatol . 2004;31(7):1297-1304.

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4708

Kvien TK, Uhlig T. Quality of life in rheumatoid arthritis. Scand J Rheumatol . 2005;34(5):333-341.

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4710

Lajas C, Abasolo L, Bellajdel B, et al. Costs and predictors of costs in rheumatoid arthritis: a prevalence-based study. Arthritis Rheum . 2003;49(1):64-70.

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4713

Leardini G, Salaffi F, Montanelli R, Gerzeli S, Canesi B. A multicenter cost-of-illness study on rheumatoid arthritis in Italy. Clin Exp Rheumatol . 2002;20(4):505-515.

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4726

Michaud K, Messer J, Choi HK, Wolfe F. Direct medical costs and their predictors in patients with rheumatoid arthritis: a three-year study of 7,527 patients. Arthritis Rheum . 2003;48(10):2750-2762.

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4745

Pincus T, Brooks RH, Callahan LF. Prediction of long-term mortality in patients with rheumatoid arthritis according to simple questionnaire and joint count measures. Ann Intern Med . 1994;120(1):26-34.

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4748

Pincus T, Keysor J, Sokka T, Krishnan E, Callahan LF. Patient questionnaires and formal education level as prospective predictors of mortality over 10 years in 97% of 1416 patients with rheumatoid arthritis from 15 United States private practices. J Rheumatol . 2004;31(2):229-234.

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4749

Pincus T, O’Dell JR, Kremer JM. Combination therapy with multiple disease-modifying antirheumatic drugs in rheumatoid arthritis: a preventive strategy. Ann Intern Med . 1999;131(10):768-774.

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4762

Riise T, Jacobsen BK, Gran JT, Haga HJ, Arnesen E. Total mortality is increased in rheumatoid arthritis. A 17-year prospective study. Clin Rheumatol . 2001;20(2):123-127.

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Aviña-Zubieta JA, Choi HK, Sadatsafavi M, Etminan M, Esdaile JM, Lacaille D. Risk of cardiovascular mortality in patients with rheumatoid arthritis: a meta-analysis of observational studies Arthritis Rheum. 2008;59(12):1690-1697.

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