RA: How High Is the Toll?

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Recently, I met a 60-year-old man with seropositive rheumatoid arthritis (RA) who described himself as “an old country boy.” He was diagnosed with RA 10 years ago. Triple therapy (i.e., methotrexate, sulfasalazine and hydroxychloroquine in combination) and adalimumab failed to help him, but in 2018, he found etanercept. This drug was a game changer for him, improving his symptoms by 90–95%. His insurance “covered” the drug, but the out-of-pocket cost remained enormous. He managed to bring the cost down to $7,500 per year with help from a drug manufacturer co-pay card and paid this for years. But two months ago, he was told he’d reached the maximum use on the co-pay card and it couldn’t be used for the rest of the year. He was forced to stop his medication because he could no longer afford it.

“Which joints are painful and swollen today?” I asked.

“It’d probably be quicker to tell you which ones don’t hurt,” he responded.

Nearly every joint in his body was painful and swollen. He was an industrial mechanic and had just finished a month-long push of machine maintenance at the factory where he worked. To make matters worse, his wife was hospitalized. Between long hours at work, trips to and from the hospital, and the stress of his wife’s illness, things were not going well.

How many of you have heard similar stories? Or perhaps a better question: How many of these stories do you hear in your clinics per day? The simple answer? Too many. The statistically correct answer? Look no further than recent data published by Huang et al. in summer 2024.¹

Background

RA is the most common form of autoimmune arthritis, affecting about 1.36 million adults in the U.S.² The cost of RA medications—in particular, biologics—imparts a significant economic burden to patients and society, contributing to large increases in health expenditures.^3,4 What’s more, RA comes with a hefty humanistic toll on patients’ quality of life, ability to perform activities of daily living and even life expectancy.^5–7

Huang et al. aimed to provide an updated understanding of the economic and humanistic burden of RA among adults in the U.S. Most studies to date have been limited to payers’ perspectives, performed outside the U.S., or focused on patients with difficult-to-treat RA.8-10 Few data exist on the overall health expenditure impact on patients with RA in the U.S. across all payer types. What’s more, few U.S. data exist on the assessment of health-related quality-of-life (HRQoL) in patients with RA. As the largest study evaluating the healthcare expenditure and quality of life of patients with RA compared with all other populations, the study by Huang et al. bridges this gap.

Summary of Research

This retrospective, observational study with a cross-sectional design analyzed results from the Medical Expenditure Panel Survey (MEPS) from 2018 to 2020. MEPS is an annual, nationally representative survey involving families and individuals in the U.S. It includes data on their sociodemographic characteristics, medical conditions, health service use and expenditure.¹¹

The study included patients aged 18 years or older with self-reported RA or an International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) code diagnosis of RA. The non-RA comparator group included all remaining individuals aged 18 or above. Annually, 4.27 million adults with RA were identified.

To assess the economic burden of RA, Huang et al. examined the aggregate expenditure associated with any healthcare services. This included the costs of “inpatient, outpatient, emergency department, prescription medication, dental, home health and other services (such as ambulance, equipment and glasses).”¹ Expenditure estimates included the actual amount paid by patients or payers as opposed to the cost of services received by providers, and adjustments were made to account for inflation.

The mean annual unadjusted healthcare expenditure for RA was $24,068 [95% confidence interval (CI) $20,627.49–27,508.25]—far higher than that of the non-RA group ($8,642.27 [95% CI $8,120.12–8,642.27]). Most of the healthcare expenditures for patients with RA were for prescription medications, the inpatient setting and office-based visits.

After adjusting for all covariates (e.g., sociodemographics and comorbidities), the total healthcare expenditure for RA was $3,382.97 [95% CI $1,816.50–4,949.44; P<0.0001] higher than that for non-RA patients. And in adjusted analyses, the average expenditures for prescription medication in RA were $2,319.15 (95% CI $1,408.39–3,229.90; P<0.001) higher than that for the non-RA group. No significant differences for other types of expenditures were identified in this study.

The humanistic burden of RA was measured via quality-of-life questionnaires, which included a physical component summary (PCS) and mental component summary (MCS). The health status variables activities of daily living (ADL) and instrumental ADL (IADL) were also considered as measures for autonomy and self-dependence.

The RA group was associated with lower PCS scores (mean 4.78 [95% CI 3.47–6.09]) and similarly lower MCS scores (mean -0.84 [95% CI -2.18–0.50]). Patients with RA also had increased odds of requesting ADL and IADL assistance (adjusted odds ratio 2.02 [95% CI 1.59–2.56] and 2.11 [95% CI 1.59–2.56] respectively).

Simply put, patients with RA were more likely to have a suboptimal quality of life than patients without RA.

Implications for Clinical Practice

Yinan Huang, MS, PhD, assistant professor of pharmacy administration, School of Pharmacy, and research assistant professor, Research Institute of Pharmaceutical Sciences, University of Mississippi, was kind enough to share her take on the clinical implications of this fascinating research.

The Rheumatologist (TR): What should practicing rheumatologists take away from your findings?  

Dr. Huang

Dr. Yuang (YH): Patients with RA not only suffer from functional limitations but also face increased healthcare costs, primarily due to prescription drug use.

TR: What can’t this study tell us?

YH: Some data variables are not available in the MEPS data, such as the type of RA, duration of RA and disease severity. The lack of this RA-related clinical information [may] introduce unmeasured variable bias, which further limits the explanation of these findings.

TR: Why is this kind of research important?

YH: Our study’s findings outline the overall burden facing the RA population. In particular, it helps raise awareness of the humanistic and economic burden facing the group with RA. Our findings have implications for health policy and clinical practice, particularly regarding the prioritization of healthcare resources for RA management. In clinical practice, it may be beneficial to assess humanistic outcomes, such as HRQoL and functional limitations, to inform treatment strategies for RA.

Overall, findings from this study highlight the need to prioritize functional outcome improvement, such as physical independence, the ability to perform daily tasks and mobility in patients with RA.

TR: Are there any other major takeaways that you want to stress to readers?

YH: Our findings suggest that RA is a chronic progressive disease with substantial economic and humanistic burden as compared to the general population. These national-level data found that most RA-related health expenditures were due to prescription medication administration and hospital inpatient services. In addition, patients with RA have suboptimal HRQoL compared to controls without RA.

Overall, prescribers should evaluate the HRQoL impact when prescribing treatment to adults with RA, and managed care professionals and payers should be aware of the high expenditures of RA due to high-cost prescription medications.

Conclusion

RA continues to take a major toll on our patients, both physically and economically. Studies like these provide the proof needed to effect change on healthcare policy down the pipeline.

Dr. Shapiro

Samantha C. Shapiro, MD, is a clinician educator who is passionate about the care and education of rheumatology patients. She writes for both medical and lay audiences and practices telerheumatology.

References

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10. Tatangelo M, Tomlinson G, Paterson JM, et al. Health care costs of rheumatoid arthritis: A longitudinal population study. PLoS One. 2021 May 6;16(5):e0251334.
11. Cohen JW, Cohen SB, Banthin JS. The medical expenditure panel survey: A national information resource to support healthcare cost research and inform policy and practice. Med Care. 2009 Jul;47(7 Suppl 1):S44–S50.