Arthritis and related conditions make up a
large group of disorders affecting the joints, ligaments, tendons,
bones and other components of the musculoskeletal system. Arthritis
is a leading cause of pain, physical disability and health care
utilization in Canada. To date, however, arthritis surveillance
activities have been minimal.
Arthritis in Canada is the first
report to paint a comprehensive picture of the impact of arthritis
in Canada. It brings together data from national population health
surveys, provincial physician billing and drug databases, data on
hospital admissions and day surgery procedures, as well as
mortality data. This is also the first national report to aggregate
data from provincial health service databases for surveillance
purposes.
The key findings of the report are summarized
below and are followed by their implications for manpower and
training, access to care, and improvements in data for
surveillance.
Key Findings
The Impact of Arthritis on
Canadians
- According to the 2000 Canadian Community Health Survey (CCHS),
arthritis and other rheumatic conditions affected nearly 4 million
Canadians aged 15 years and older - approximately 1 in 6 people.
Two-thirds of those with arthritis were women, and nearly 3 of
every 5 people with arthritis were younger than 65 years of
age.
- By the year 2026, it is estimated that over 6 million Canadians
15 years of age and older will have arthritis.
- Compared with people with other chronic conditions, those with
arthritis experienced more pain, activity restrictions and
long-term disability, were more likely to need help with daily
activities, reported worse self-rated health and more disrupted
sleep and depression, and more frequently reported contact with
health care professionals in the previous year.
- Overall, 19% of Aboriginal people reported having arthritis -
equivalent to 27% if the Aboriginal population had the same age
composition as the overall Canadian population.
The Burden of Arthritis in Canada:
Mortality, Life Expectancy and Health-Adjusted Life Expectancy
(HALE), Economic Burden
- In 1998, arthritis or related conditions were reported as the
underlying cause in 2.4 deaths per 100,000 in Canada, making
arthritis a more common underlying cause of death than melanoma,
asthma or HIV/AIDS, especially among women.
- The mortality burden of arthritis and related conditions has
been underestimated, because contributing causes of death (such as
complications of arthritis treatment) are not available. People
with arthritis are the most frequent users of non-steroidal
anti-inflammatory drugs (NSAIDs), which can cause gastrointestinal
(GI) bleeding. In 1998, GI bleeding resulted in 1, 322 deaths.
- Eliminating arthritis would achieve an overall gain in the
health-adjusted life expectancy (HALE) of 1.5 years for each female
and nearly 1 year for each male in the Canadian population, with an
overall increase in life expectancy of 0.16 years for males and
0.35 years for females.
- In 1998, estimates placed the economic burden of arthritis to
Canadian society at $4.4 billion. This figure likely underestimates
the total costs, however, because data for some expenditures (such
as costs related to health professionals other than physicians and
to over-the-counter medications) are unavailable. In addition, the
estimate uses only a subset of the arthritis conditions used
elsewhere in this report.
- Long-term disability accounted for almost 80% of the economic
costs of arthritis in 1998, at nearly $3.4 billion; the 35-64 year
age group incurred 70% of these costs.
- The economic burden of musculoskeletal conditions in Canada
accounted for 10.3% of the total economic burden of all illnesses
but only 1.3% of health science research.
Ambulatory Care
Services
- Approximately 160 in every 1,000 people over the age of 15
years made a visit to a physician in 1998/1999 for arthritis and
related conditions - an estimated total of 8.8 million visits in
Canada. More women than men made arthritis-related visits; the rate
of consultation was highest among older people of both
sexes.
- Eighty-two percent of patients who made visits for arthritis
and related conditions made at least one of these to a primary care
physician. Overall, 18.5% of people with arthritis-related visits
saw a surgical specialist at least once, and 13.7% saw a medical
specialist at least once.
- Visit rates varied by province, ranging from 146 to 207 per
1,000 people aged 15+ years. Differences in the provincial
physician billing databases may account for some of this variation.
Differences in the availability of physicians, especially
specialists, may also be a contributing factor.
- There appears to be a trade-off provincially between seeing a
rheumatologist and seeing an internist for arthritis and related
conditions, particularly rheumatoid arthritis.
Arthritis-related Prescription
Medications
- The percentage of people with prescriptions for
disease-modifying anti-rheumatic drugs (DMARDs), which are
effective in treating rheumatoid arthritis, has increased steadily
over time. Nevertheless, the overall rate of provision of these
drugs falls short of the estimated prevalence of the
disease.
- The prescription of conventional NSAIDs has shown a notable
decline since 1998 for individuals over the age of 65. The release
of COX-2 inhibitors onto the Canadian market in 1999 has likely
contributed to this trend.
- Some of the increases/decreases in prescriptions may be a
result of changes in the provincial drug plan formularies over
time.
- Prescribing patterns of arthritis-related drugs varied among
the provinces. This variation may be related in part to the
availability of drugs on provincial formularies.
Hospital
Services
- The number of arthritis-related orthopedic procedures per
capita has remained remarkably static since 1994.
- Medical admissions per capita for arthritis and related
conditions declined somewhat from 1994 to 2000, although this
decline was somewhat less than that for all other
admissions.
- The only procedures whose rates increased significantly were
hip and knee replacements.
- The number of outpatient procedures has increased, likely as a
result of the increased use of arthroscopic (keyhole)
surgery.
- The higher prevalence of arthritis among women is only
partially reflected in the rates of orthopedic procedures; the
slightly higher rate of hip and knee replacement procedures among
women does not wholly reflect their greater need.
- The rate of orthopedic procedures reached a plateau in older
age groups, but the rate of medical admissions continued to
climb.
- Considerable provincial variation in both orthopedic procedures
and medical admissions was apparent, even after adjustment for
differences in the age and sex composition of the provincial
populations.
Implications
- Approximately 1 in 6 Canadians aged 15 years and over reported
having arthritis as a long-term health condition. Within a decade,
1 million more Canadians are expected to have arthritis or related
conditions. The need to understand the tremendous burden of
arthritis on both individuals and society as a whole is, therefore,
urgent.
- Surveillance for arthritis can be developed and maintained by
integrating national and provincial data from population surveys,
provincial physician billing databases, hospital separation and
surgical data, data on medications and drugs, and mortality
databases.
- Future surveillance efforts could include initiatives to
collect data about arthritis in children and about rehabilitation
and community support services for people with arthritis and
related conditions of all ages.
Manpower and
Training
- Manpower issues, such as shortages of both rheumatologists and
orthopedic surgeons, are a concern that could be addressed through
more recruitment and training of specialists in these
fields.
- Primary care physicians play a central role in the management
of arthritis, yet gaps in musculoskeletal education have been
documented in undergraduate medical education and postgraduate
training. When setting curricula, medical educators may wish to
draw on information regarding the amount of illness, disability and
health care utilization that these conditions cause in the
population.
- Since a considerable amount of arthritis care is provided by
internists (for rheumatoid arthritis) and orthopedic surgeons
(non-surgical care of osteoarthritis) these specialty groups might
wish to consider further training and continuing education with
respect to arthritis.
Access to
Care
- Barriers that limit access to specialty services (such as
rheumatology), including lack of locally available services and low
rates of referral by primary care physicians, need
investigation.
- Access to arthritis medications that have proven to be
effective in preventing joint damage is a key issue. This includes
access to DMARDs as well as the newly developed biologic
drugs.
- Provincial variations in the provision of arthritis-related
drugs have been identified.
- In spite of the increasing prevalence of arthritis in Canada,
the static trend in rates of orthopedic procedures suggests that
the system may be operating at capacity, and there may be potential
problems with the capacity of the system to respond to the
projected increases in the number of people with arthritis.
- The causes of provincial variations in rates of surgery for
arthritis and related conditions and in their impact, both at the
individual and population levels, need to be determined.
- The decline in rates of surgery at older ages and sex
differences in surgery rates raise issues of inequities in access
to care that need to be investigated.
- Although increasing, the rate of hip and knee replacements is
insufficient to meet current and future needs. This is reflected in
long waiting times for these procedures.
- Currently, the published data on arthroscopic knee surgery for
osteoarthritis are unclear on the procedure's effectiveness.
More research is required in this area to properly define the
appropriate indications for these procedures.
Improvements in Data for
Surveillance
- Future national surveys should include more detailed diagnostic
questions about arthritis. Physical measures for arthritis (such as
assessment of physical function) could also be considered for
inclusion in future surveys.
- The 2000 CCHS asked respondents about arthritis and rheumatism
“diagnosed by a health professional.” This question
fails to capture many people with arthritis/chronic joint symptoms
who do not see a doctor for their symptoms and whose condition
consequently remains undiagnosed. Including a question on
“chronic joint symptoms” would help provide a more
complete picture of the burden of arthritis in Canada.
- In order to accurately describe the impact of arthritis,
surveys could collect health status and health care utilization
data that are directly attributable to arthritis.
- In order to accurately describe the full impact of arthritis on
mortality for surveillance purposes, contributing causes of death
should be made available.
- The continued development of national and provincial registries
related to hip and knee replacement would help ensure complete
coverage. If appropriate in scope, such registries could allow
tracking of waiting times, patient-based indicators of need,
complications after surgery and failure rates of
prostheses.
- Strong surveillance efforts depend on both standardized
definitions of common terms and their consistent use in different
settings. A consensus on definitions would allow coordinated and
constant surveillance across Canada. If provinces wish to pursue
this matter, they could consider the following options:
- Using the same diagnostic codes for billing purposes would be a
major step toward standardizing provincial physician billing data.
Allowing physicians to enter three diagnostic codes for each claim,
as currently practised in Alberta and Nova Scotia, would also
provide a more accurate representation of the reasons for each
visit.
- Physicians' specialties could be determined in the same
manner in each
provincial health insurance database and this information actively
updated to reflect changes in specialty and subspecialty
training.
- Diagnostic codes in physician claims data need to be validated.
Algorithms using specified numbers of visits in a time period for a
specific diagnosis need further exploration and validation,
building on earlier work for rheumatoid arthritis and
diabetes.
- Future surveillance of arthritis and related conditions could
include the following:
- Monitoring changes in health status (including mortality and
HALE) and health care utilization that may be related to drug
therapy and other new treatments.
- Monitoring direct costs of arthritis in relation to indirect
costs (such as
increased drug costs leading to decreased long-term disability
costs).
- Linking prescription data to patient diagnoses to enable better
examination of prescribing patterns for arthritis and related
conditions.
- Linking hospitalization data to provincial physician billing
data to facilitate better understanding of the processes of
arthritis care and the outcomes of surgery.
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