Chapter 1
Introduction

Elizabeth Badley, Marie DesMeules 

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 one of Canada's most common chronic conditions and is a leading cause of pain, physical disability and use of health care services.^1-7 Such adverse health outcomes not only have significant impact on individuals with the disease but inevitably affect their families and have major consequences at the population level as well. Among many aspects of life, arthritis disability has an impact on leisure, and social and labour force participation at all ages.^4,8 Arthritis is also one of the most costly illnesses from an economic standpoint.⁹ However, since it is not usually life-threatening, physicians - and even those who have the condition - often dismiss it as “just aches and pains” and an inevitable part of aging.¹⁰ As a result of this viewpoint, individuals with arthritis fail to receive the appropriate and adequate help that they require, and services aimed at helping them are not generally regarded as a priority. The scarcity of available information on the impact of arthritis on Canadians has added to this difficulty. 

This lack of vital Canadian information has inspired Arthritis in Canada. This is the first comprehensive report to document the impact of the condition in Canada. Its purpose is to provide an overview of the current situation in Canada for health care professionals, policymakers and members of the interested public, particularly individuals with arthritis. 

Specifically, the goals of Arthritis in Canada are to 

• provide an overview of the magnitude of the impact of arthritis on the Canadian
  population, including health and social outcomes and the use of health care services; 
• identify strategies that might reduce the adverse consequences of arthritis and enhance access to care and services; and 
• explore approaches to arthritis surveillance in Canada. 

Acquiring national information in order to document the impact of arthritis in Canada presents a number of challenges. First, the term “arthritis” covers a range of different conditions, the best known of which are described in Table 1-1. While every effort has been made to maintain a consistent definition through the chapters in this report, the use of a variety of data sources has necessitated some variation in the range of arthritis conditions included. Where considered relevant, these variations are noted. Second, arthritis is not always recorded as the underlying diagnosis in administrative databases such as those related to hospital admissions or death, creating a challenge for surveillance. Arthritis in Canada is the first national report to create a picture of the impact of a specific type of disease by bringing together data from provincial physician billing databases and drug plans. It also brings together information about the impact of arthritis on individuals from national population surveys and evaluates the economic costs associated with this condition. 

Table 1-1    Major types of arthritis
	Osteoarthritis (OA)	Rheumatoid Arthritis (RA)	Systemic Lupus Erythematosus (SLE)	Ankylosing Spondylitis (AS)	Gout
Background	OA results from the deterioration of the cartilage in one or more joints. Leads to joint damage, pain, and stiffness. Typically affects the hands, feet, knees, spine and hips.	RA is caused by the body's immune system attacking the body's joints (primarily hands and feet). This leads to pain, inflammation and joint damage. RA may also involve other organ systems such as eyes, heart, and lungs.	SLE is a connective tissue disorder causing skin rashes and joint and muscle swelling and pain. There may also be organ involvement. This disease, as with RA, fluctuates over time, with flare-ups and periods of remission.	AS is inflammatory arthritis of the spine. Causes pain and stiffness in the back and bent posture. In most cases the disease is characterized by acute painful episodes and remissions. Disease severity varies widely among individuals.	Gout is a type of arthritis caused by too much uric acid in the body that is normally flushed out by the kidneys. Most often affects the big toe but can also affect the ankle, knee, foot, hand, wrist or elbow.
Prevalence	The most common type of arthritis, affecting an estimated 10% of Canadian adults.	RA affects approximately 1% of Canadian adults, and at least twice as many women as men.	SLE affects 0.05% of Canadian adults. Women develop lupus up to 10 times more often than men.	AS affects as many as 1% of Canadian adults. Men develop AS 3 times more often than women.	Gout affects up to 3% of Canadian adults. Men are 4 times more likely than women to develop gout.
Possible Risk Factors	Old age, heredity, obesity, previous joint injury	Sex hormones, heredity, race (high disease prevalence is seen among Aboriginal Peoples)	Heredity, hormones and a variety of environmental factors	Heredity and, possibly, gastrointestinal or genitourinary infections	Heredity, certain medications (e.g. diuretics), alcohol and certain foods
Disease Management	There is no cure for OA. Treatments exist to decrease pain and improve joint mobility, and include medication (e.g. analgesics, anti-inflammatory drugs), exercise, physiotherapy and weight loss. In severe cases, the entire joint - particularly the hip or knee - may be replaced through surgery.	There is no cure for RA. Early, aggressive treatment by a rheumatologist can prevent joint damage. Drugs used for treatment include non-steroidal anti- inflammatory drugs (NSAIDs), corticosteroids, disease-modifying anti- rheumatic drugs (DMARDs), and biologic response modifiers.	There is no cure for SLE. The aim of treatment is to control symptoms, reduce the number of flare-ups and prevent damage. Commonly used medications include analgesics, anti-inflammatory drugs, cortisone and disease-modifying anti- rheumatic drugs (DMARDs). Diet and exercise are also important in the management of lupus.	There is no cure for AS. Medications similar to those used for other types of arthritis are often prescribed to treat AS. Exercise is the cornerstone of AS manage- ment. If damage is severe, surgery may be considered.	There is no cure for gout. Non- steroidal anti-inflammatory drugs (NSAIDs) are often used to help reduce the pain and swelling of joints and decrease stiffness. Cortisone may also be used for this purpose. Drugs such as allopurinol can be used on a long-term basis to reduce uric acid levels and prevent future attacks. Other methods for controlling gout include dietary changes, weight loss and exercise.
Data source: www.arthritis.ca

All forms of arthritis share such symptoms as pain, swelling or stiffness in or around the joints. If left untreated, they can affect the structure and functioning of the joints, leading to increased pain, disability and difficulty in performing everyday activities.^11,12 Although there is no known cure for arthritis at the present time, appropriate treatment has been shown to prevent disability, maintain function and reduce pain.^11,13 While the exact nature of medical treatment will vary according to the type of arthritis, general management and rehabilitation strategies are similar for all types. Typically, once started, arthritis lasts for the rest of one's life and has a course that fluctuates between exacerbations and remissions. Care must be available, therefore, over the full course of the disease. Figure 1-1 outlines the components of a comprehensive care approach for managing arthritis. 

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Figure 1-1 Components of a Comprehensive Care Approach for the Management of Arthritis and Related Conditions

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A comprehensive care approach for managing the impact of arthritis and related conditions incorporates several components, including primary care services, medication, hospital and specialist care, rehabilitation and community support services, and education and health promotion. The ultimate goal of care is to improve the quality of life for individuals with arthritis and their families. 

The components of a comprehensive care approach may be viewed as sub-components of the already existing health care system. Even with most services in place, however, issues of adequacy, availability and accessibility for people with arthritis and related conditions may lead to less than optimal results. Coordination of the components within the health care system also has a great impact on overall success in achieving integrated care. Coordination of care includes the manner of triaging and referring patients, the comprehensiveness and continuity of services, and the appropriateness of care to the stage of disease. 

Chapter 2, Arthritis in Canada, begins by documenting the impact of arthritis on Canadians as reported by Canadians themselves, then compares this impact to that of other chronic conditions. Chapter 2 uses data from national health surveys - the Canadian Community Health Survey (CCHS) and the National Population Health Survey (NPHS) - to examine various health outcomes such as pain, disability, self-rated health, labour force participation, and the use of medications and health care services. Projections of the number of people who will have arthritis in Canada within the next two decades are also presented. 

Chapter 3 documents arthritis-associated mortality in Canada and considers the impact of arthritis on both average life expectancy and average health-adjusted life expectancy (HALE). HALE sheds more meaning on longer life by determining whether an increase in the average lifespan is accompanied by better quality of life. Finally, the chapter presents the economic burden of arthritis in Canada, in terms of both its total costs and its direct and indirect components. Direct costs include hospital, physician and medication costs; indirect costs include short- and long-term disability. 

Arthritis and related conditions are among the most frequent reasons for visits to primary care physicians.¹⁴ These physicians provide the majority of prescriptions for arthritis drugs and act as gatekeepers to other services, such as consultations with specialists and rehabilitation professionals. Visits to primary care physicians and specialists, particularly rheumatologists, internists and orthopedic surgeons, are examined in Chapter 4 using provincial physician billing data. Rates of visits with these physicians are presented for different types of arthritis, focusing on the grouping of all arthritis and related conditions in general, and specifically on osteoarthritis and rheumatoid arthritis. 

The most frequent type of treatment for arthritis and related conditions is the use of medications. Chapter 5 examines the use of medications commonly prescribed for these conditions, including both conventional non-steroidal anti-inflammatory drugs (NSAIDs) and the newly developed COX-2 inhibitors, as well as corticosteroids and disease-modifying anti-rheumatic drugs (DMARDs). The data in Chapter 5 were compiled from provincial drug claims. Data on the newly developed biologic response modifiers, a new category of medications for treating inflammatory conditions such as rheumatoid arthritis, were not yet available for inclusion in this chapter. 

Although most people with arthritis are treated on an outpatient basis, some require admission to a hospital and/or surgical intervention. Medical admissions may be required to manage the complex consequences of arthritis, arthritis-related pain and disability, or the side effects of drugs used to treat arthritis. Orthopedic surgery presents a viable alternative for individuals for whom attempts at non-surgical management have failed to adequately prevent joint pain or damage. Chapter 6 examines hospital services for arthritis and related conditions, including rates of medical admissions and surgical procedures. 

Although this report provides a comprehensive examination of arthritis in Canada, some relevant areas could not be included because of the current lack of data in those areas. While arthritis is more common in older age groups, children are also affected. However, data on arthritis in children are generally lacking. The new Participation and Activity Limitations Survey (2001) will include arthritis in its section on health conditions causing disability in children. This survey, soon to be released, should provide essential information on children living with arthritis and its impact on their lives. 

Rehabilitation, including physical and occupational therapy, serves to prevent the loss of physical function and to restore function after surgery or severe episodes of inflammatory arthritis.^15,16 Systematic information about rehabilitation for people with arthritis and related conditions is not currently available. In addition, there are no routine sources of information about other community support services for people with arthritis: these range from social work services to community exercise and pool programs. 

Education and health promotion are important and essential components of a comprehensive approach to the management of arthritis and related conditions. Many types of arthritis and related conditions are minor and self-limiting and, therefore, do not require medical intervention. Education for managing and preventing the complications of these disorders should provide information not only on the use of over-the-counter medication and the appropriate use of simple physical remedies (such as ice, heat or mechanical support) but also on when medical care should be sought. Research shows patient educational interventions to be 20% to 30% as effective as pharmaceutical treatments in reducing pain and 40% as effective in improving disability, thereby leading to fewer physician consultations.¹⁷ Exercise programs for people with arthritis have been shown to yield significant improvements in pain and disability as well as a decrease in the need for medication.^18-20 Surveillance data in these areas are currently unavailable. 

Arthritis and related conditions create a large burden of morbidity and disability in the population and, consequently, high costs to society. The Canadian health care system is oriented to acute care and short-term needs and, as a result, it may not be in the best position to deal with long-term and evolving diseases such as arthritis and related conditions. With the aging of the population, this burden can only be expected to increase. This report takes the first steps towards a national surveillance system for arthritis in Canada and provides a foundation for the development of ways to reduce the impact of arthritis on the Canadian population.  

References 

1.    Badley EM. The effect of osteoarthritis on disability and health care use in Canada. J Rheumatol 1995;22(suppl 43):19-22. 

2.    Badley EM, Wang PP. Arthritis and the aging population: projections of arthritis prevalence in Canada 1991 to 2031. J Rheumatol 1998;25:138-44. 

3.    Badley EM, Rothman LM, Wang PP. Modeling physical dependence in arthritis: the relative contribution of specific disabilities and environmental factors. Arthritis Care and Research 1998;11:335-45. 

4.    Badley EM, Wang PP. The contribution of arthritis and arthritis disability to nonparticipation in the labor force: a Canadian example. J Rheumatol 2001;28(5):1077-82. 

5.    Raina P, Dukeshire S, Lindsay J, Chambers LW. Chronic conditions and disabilities among seniors: an analysis of population-based health and activity limitation surveys. Ann Epidemiol 1998;8(6):402-09. 

6.    Coyte P, Wang PP, Hawker G, Wright JG. The relationship between variations in knee replacement utilization rates and the reported prevalence of arthritis in Ontario, Canada. J Rheumatol 1997;24:2403-12. 

7.    Clarke AE, Zowall H, Levinton C, Assimakopoulos H, Sibley JT, Haga M, et al. Direct and indirect medical costs incurred by Canadian patients with rheumatoid arthritis: a 12 year study. J Rheumatol 1997;24:1051-60. 

8.    Badley EM. The impact of disabling arthritis. Arthritis Care and Research 1995;8:221-8. 

9.    Health Canada. Economic Burden of Illness in Canada, 1998. Ottawa: Public Works and Government Services Canada; 2002 (Catalogue # H21-136/1998E). 

10.    Verbrugge LM. Women, men and osteoarthritis. Arthritis Care and Research 1995;8(4):212-20. 

11.    Russel A, Haraoui B, Keystone E, Klinkhoff A. Current and emerging therapies for rheumatoid arthritis, with a focus on infliximab: clinical impact on joint damage and cost of care in Canada. Clin Ther 2001;23:1824-38. 

12.    Lisse J, Espinoza L, Zhao SZ, Dedhiya SD, Osterhaus JT. Functional status and health-related quality of life of elderly osteoarthritis patients treated with Celecoxib. J Gerontol A Biol Sci Med Sci 2001 Mar; 56(3):M167-M0175. 

13.    Schiff M. Emerging treatments for rheumatoid arthritis. Am J Med 1997;102(suppl 1A):11S-15S. 

14.    Badley EM, Rasooly I, Webster GK. Relative importance of musculoskeletal disorders as a cause of chronic health problems, disability, and health care utilization: findings from the 1990 Ontario Health Survey. J Rheumatol 1994;21:505-14. 

15.    Guccione AA. Physical therapy for musculoskeletal conditions. Rheum Dis Clin North Am 1996;22:551-62. 

16.    Helewa A. Physical therapy management of patients with rheumatoid arthritis and other inflammatory conditions. In: Walker JM, Helewa A, editors. Physical therapy in arthritis. Philadelphia: Saunders; 1996. p. 245-63. 

17.    Superio-Cabuslay E, Ward MM, Lorig K. Patient education interventions in osteoarthritis and rheumatoid arthritis: a meta-analytic comparison with nonsteroidal anti-inflammatory drug treatment. Arthritis Care and Research 1996;9:292-301. 

18.    Minor MA, Hewett JE, Webel RR, Anderson SK, Kay DR. Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis. Arthritis Care and Research 1989;32:1396-1405. 

19.    McKeag DB. The relationship of osteoarthritis and exercise. Clinical Sports Medicine 1991;11:471-87. 

20.    US Department of Health and Human Services. Physical activity and health. A report of the Surgeon General. Atlanta, Georgia: The Department, Centers for Disease Control and Prevention, and National Center for Chronic Disease Prevention and Health Promotion; 1996. 

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