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The burden of rheumatic disease
Introduction
The burden of rheumatic disease
There are over 200 types of musculoskeletal disease, which together are a major burden to the individual, society and health services. Musculoskeletal conditions include all types of arthritis and conditions affecting the muscles, bones, soft tissue, joints and spine. The burden of these conditions is evaluated by assessing their prevalence and incidence. Accurate morbidity estimates of these conditions are useful in healthcare planning, although these estimates will differ depending on which level of care is assessed. At the community level, there will be more cases of non-specific musculoskeletal pain compared to cases ascertained from general practice or a hospital environment. Furthermore, differences in the wording and case-definition may result in differences in prevalence estimates.
Alexandra M Clarke Deborah P M Symmons
Abstract Musculoskeletal conditions are a major burden to the individual, society and the health service. Most new musculoskeletal GP consultations are for self-limiting conditions such as soft tissue rheumatism, chronic widespread pain and arthralgia. Incident cases of osteoarthritis are ten times more common compared to rheumatoid arthritis. The prevalence of musculoskeletal conditions is more common in women and tends to rise with age. Approximately one tenth of GP consultations are for diseases of the musculoskeletal system. It is likely that prevalence rates will continue to rise as life expectancy increases. This will in turn lead to an increase in health professional workloads and a further burden on healthcare services. Costs for musculoskeletal conditions include those to healthcare services, to society and indirect costs. A fifth of all incapacity claims in Great Britain are for diseases of the musculoskeletal system. Combined costs for rheumatoid arthritis patients amount to £7000 per person affected per year, while each hip and knee replacement costs on average £5000. Risk factors for musculoskeletal conditions include age and gender. The prevalence of certain musculoskeletal conditions can vary depending on ethnicity, lifestyle factors and genetic predisposition. The main consequences of having a musculoskeletal disease are chronic pain and disability. The burden of musculoskeletal conditions is high. The impact of these conditions on the health service and society will continue to rise alongside increasing life expectancy.
Incidence Based on attendance in general practice, the number of new onsets of musculoskeletal disease in 2001 was 947 per 10,000 persons; 832 for males, 1057 for females.1 Most new musculoskeletal consultations in the UK were for self-limiting conditions (soft tissue rheumatism, chronic widespread pain, arthralgia). In persistent conditions, new onsets of osteoarthritis were ten times more common than those for rheumatoid arthritis (RA) (Figure 1). Prevalence The prevalence of musculoskeletal conditions generally increases with age (Figure 2). The ratio of men to women amongst those who consult their GPs for a musculoskeletal condition is 1:1.4. In 2004, 16% of the UK population were 65 years and older.3 This is expected to increase to 25% by 2020;4 and in turn, the proportion of people of working age will decrease. With increasing life expectancy, the prevalence of musculoskeletal conditions can be expected to increase, leading to a rise in consultation rates and GP workloads, and an increase in demand for services, especially from elderly patients. Four percent of children (under the age of 15 years; equivalent to 410,000 children in the UK) attended their GPs in 2004 for a musculoskeletal condition.2,3 The prevalence of musculoskeletal disorders in adults are detailed in Table 1.
Keywords epidemiology; musculoskeletal; rheumatic; morbidity; prev alence; incidence; mortality; disability; cost; risk factors
Mortality In England and Wales, there were 4393 (1255 male, 3138 female) deaths attributable to diseases of the musculoskeletal system
Percentage of new musculoskeletal consultations in the UK in 20011
Alexandra M Clarke BSc (Hons) MSc is a research assistant and PhD student, working for the Arthritis Research Campaign Epidemiology Unit at the University of Manchester. She has a BSc in mathematics and a MSc in statistics. Her research interests include the burden of musculoskeletal disease and evidence for inequalities within the UK. Conflicts of interest: none declared.
Soft tissue rheumatism and chronic widespread pain (30%) Arthralgia (25%) Back pain (22%)
Deborah P M Symmons MD MFPH FRCP is Professor of Rheumatology and Musculoskeletal Epidemiology at the University of Manchester, UK, and Honorary Consultant Rheumatologist for the East Cheshire NHS Trust. She qualified from Birmingham University and trained in rheumatology at the Hammersmith Hospital, Guy’s Hospital and Birmingham. Her research interests include the burden of musculoskeletal conditions and risk factors for the occurrence and progression of rheumatoid arthritis. Conflicts of interest: none declared.
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Osteoarthritis (10%) Rheumatoid arthritis (1%) Osteoporosis (1%) Other (11%)
Figure 1
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© 2006 Published by Elsevier Ltd.
Introduction
Predictors of musculoskeletal disease
Annual prevalence of musculoskeletal conditions presenting to UK primary care in 20042
Certain risk factors are known to affect the occurrence of musculoskeletal conditions. For example, musculoskeletal conditions are more common in women and increase with age. The prevalence of certain musculoskeletal conditions varies with ethnicity. RA prevalence is lower in people of Pakistani and African-Caribbean origin compared to Caucasians;13 osteoarthritis of the hip has a lower prevalence in Indians and African-Caribbeans compared to Caucasians;13 systemic lupus erythematosus is more common in Asian and African-Caribbean women compared to Caucasian women.14 Obesity is a major risk factor for some musculoskeletal conditions. The rise in obesity is contributing to the increase in prevalence of osteoarthritis.13 Those in deprived areas are more likely to report back pain compared to more affluent areas (determined by postcode of residence). Some conditions such as RA and gout tend to run in families, which could be a result of genetic predisposition or shared environmental factors.
Prevalence (per 10,000 persons)
4500 4000
Female Male
3500 3000 2500 2000 1500 1000 500 0 1
1–4
5–14
15–24
25–44
45–64
65–74
75+
Age (years) Figure 2
and connective tissue in 2004. 40% of these were attributed to arthropathies.6
Cost Disability associated with musculoskeletal disease
The costs to the healthcare service for musculoskeletal conditions include drugs, physiotherapy, GP attendance, hospital referrals/ admissions, and surgery. Costs to society include disability pensions and incapacity benefits. Musculoskeletal conditions are the second most common cause of loss of time from work in Great Britain after mental disorders.7 Over 20% of all incapacity claims in 2004 were for diseases of the musculoskeletal system.8 Average hospital, medication and indirect costs for RA patients are considerable,9 amounting to £7000 per person affected per year; it is estimated that RA costs the UK health service £4 billion per year.10 In 2004, over 33 million prescriptions (single items on a prescription form) were dispensed in England for musculoskeletal and joint diseases and drugs affecting bone metabolism.11 In 2003, over 100,000 hip and knee replacements were performed, costing over £500 million. There were over 1 million outpatient attendances for rheumatology conditions and nearly 6 million for trauma and orthopaedics.12
The main consequences of having a musculoskeletal disease are chronic pain and disability. The Health Survey for England in 2001 reported 18% of adults having a moderate or serious disability; 40% of these disabilities were attributed to musculoskeletal conditions. This suggests that there are 3.4 million adults in the UK who are disabled by a musculoskeletal condition.3,15
Conclusion The burden of musculoskeletal conditions is high. The impact of these conditions on the health service and society will continue to rise alongside increasing life expectancy. ◆
References 1 Medicines and Healthcare products Regulatory Agency. The general practice research database. www.gprd.com 2 Birmingham Research Unit. Weekly returns service annual report 2004. Available at: www.rcgp.org.uk/bru/annual_report/ finalAnnualReport2004.pdf 3 Office for National Statistics. Health statistics quarterly. Winter 2005, No.28. London: HMSO, 2006. 4 Government Actuary’s Department. Population projections. Available at: www.gad.gov.uk/Population/index.asp 5 Office for National Statistics. Table 7.12: Chronic sickness: rate per 1000 reporting longstanding condition groups, by sex; General Household Survey 2003. www.statistics.gov.uk/statbase/Expodata/ Spreadsheets/D8791.xls 6 Office for National Statistics. Mortality statistics: cause. Review of the Registrar General on deaths by cause, sex and age, in England and Wales, 2004. London: HMSO, 2005. 7 Health and Safety Commission. Health and safety statistics 2004/05. Suffolk: Health and Safety Executive, 2005. 8 Department for Work and Pensions. Incapacity benefit and severe disablement allowance quarterly summary of statistics. www.dwp. gov.uk/asd/ib_sda.asp
Prevalence in adults • 29% of responders to a community health survey (2001) reported having had arthritis in the previous year; this reduced to 19% when asked if they had seen a doctor about it. (source: Unpublished data from the Wigan and Bolton Health Survey, 2001) • Results from the General Household Survey suggest that 6.9 million UK adults (14.5%) reported having a long-standing condition relating to the musculoskeletal system in 2003; 3 million men, 3.9 million women.3,5 • 11.4% of GP consultations in 2004 in England and Wales related to diseases of the musculoskeletal system and connective tissue.2 Table 1
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© 2006 Published by Elsevier Ltd.
Introduction
9 McIntosh E. The cost of rheumatoid arthritis. Br J Rheumatol 1996; 35: 781–90. 10 Palferman T G. Principles of rheumatoid arthritis control. J Rheumatol 2003; 30: 10–3. 11 Department of Health. Prescription cost analysis: England, 2004. Available at: www.dh.gov.uk/PublicationsAndStatistics/Publications/ PublicationsStatistics/PublicationsStatisticsArticle/fs/en?CONTENT_ ID= 4107504&chk=nsvFE0 12 Department of Health. NHS reference costs 2004. Available at: www.dh.gov.uk/PublicationsAndStatistics/Publications/ PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/ fs/en?CONTENT_ID=4105545&chk=znAfqu 13 Silman A J, Hochberg M C. Epidemiology of the rheumatic diseases. 2nd ed. Oxford: Oxford University Press, 2001.
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14 Johnson A E, Gordon C, Palmer R G et al. The prevalence and incidence of systemic lupus erythematosus in Birmingham, England. Relationship to ethnicity and country of birth. Arthritis Rheum 1995; 38: 551–8. 15 Bajekal M, Prescott A. Health survey for England 2001: disability. London: The Stationery Office, 2003.
Further reading Arthritis Research Campaign. Arthritis: the big picture. Chesterfield: ARC, 2002. Hochberg M C, Silman A J, Smolen J S et al. Practical rheumatology. 3rd ed. London: Mosby, 2004. Silman A J, Hochberg M C. Epidemiology of the rheumatic diseases. 2nd ed. Oxford: Oxford University Press, 2001.
335
© 2006 Published by Elsevier Ltd.
The burden of rheumatic disease
There are over 200 types of musculoskeletal disease, which together are a major burden to the individual, society and health services. Musculoskeletal conditions include all types of arthritis and conditions affecting the muscles, bones, soft tissue, joints and spine. The burden of these conditions is evaluated by assessing their prevalence and incidence. Accurate morbidity estimates of these conditions are useful in healthcare planning, although these estimates will differ depending on which level of care is assessed. At the community level, there will be more cases of non-specific musculoskeletal pain compared to cases ascertained from general practice or a hospital environment. Furthermore, differences in the wording and case-definition may result in differences in prevalence estimates.
Alexandra M Clarke Deborah P M Symmons
Abstract Musculoskeletal conditions are a major burden to the individual, society and the health service. Most new musculoskeletal GP consultations are for self-limiting conditions such as soft tissue rheumatism, chronic widespread pain and arthralgia. Incident cases of osteoarthritis are ten times more common compared to rheumatoid arthritis. The prevalence of musculoskeletal conditions is more common in women and tends to rise with age. Approximately one tenth of GP consultations are for diseases of the musculoskeletal system. It is likely that prevalence rates will continue to rise as life expectancy increases. This will in turn lead to an increase in health professional workloads and a further burden on healthcare services. Costs for musculoskeletal conditions include those to healthcare services, to society and indirect costs. A fifth of all incapacity claims in Great Britain are for diseases of the musculoskeletal system. Combined costs for rheumatoid arthritis patients amount to £7000 per person affected per year, while each hip and knee replacement costs on average £5000. Risk factors for musculoskeletal conditions include age and gender. The prevalence of certain musculoskeletal conditions can vary depending on ethnicity, lifestyle factors and genetic predisposition. The main consequences of having a musculoskeletal disease are chronic pain and disability. The burden of musculoskeletal conditions is high. The impact of these conditions on the health service and society will continue to rise alongside increasing life expectancy.
Incidence Based on attendance in general practice, the number of new onsets of musculoskeletal disease in 2001 was 947 per 10,000 persons; 832 for males, 1057 for females.1 Most new musculoskeletal consultations in the UK were for self-limiting conditions (soft tissue rheumatism, chronic widespread pain, arthralgia). In persistent conditions, new onsets of osteoarthritis were ten times more common than those for rheumatoid arthritis (RA) (Figure 1). Prevalence The prevalence of musculoskeletal conditions generally increases with age (Figure 2). The ratio of men to women amongst those who consult their GPs for a musculoskeletal condition is 1:1.4. In 2004, 16% of the UK population were 65 years and older.3 This is expected to increase to 25% by 2020;4 and in turn, the proportion of people of working age will decrease. With increasing life expectancy, the prevalence of musculoskeletal conditions can be expected to increase, leading to a rise in consultation rates and GP workloads, and an increase in demand for services, especially from elderly patients. Four percent of children (under the age of 15 years; equivalent to 410,000 children in the UK) attended their GPs in 2004 for a musculoskeletal condition.2,3 The prevalence of musculoskeletal disorders in adults are detailed in Table 1.
Keywords epidemiology; musculoskeletal; rheumatic; morbidity; prev alence; incidence; mortality; disability; cost; risk factors
Mortality In England and Wales, there were 4393 (1255 male, 3138 female) deaths attributable to diseases of the musculoskeletal system
Percentage of new musculoskeletal consultations in the UK in 20011
Alexandra M Clarke BSc (Hons) MSc is a research assistant and PhD student, working for the Arthritis Research Campaign Epidemiology Unit at the University of Manchester. She has a BSc in mathematics and a MSc in statistics. Her research interests include the burden of musculoskeletal disease and evidence for inequalities within the UK. Conflicts of interest: none declared.
Soft tissue rheumatism and chronic widespread pain (30%) Arthralgia (25%) Back pain (22%)
Deborah P M Symmons MD MFPH FRCP is Professor of Rheumatology and Musculoskeletal Epidemiology at the University of Manchester, UK, and Honorary Consultant Rheumatologist for the East Cheshire NHS Trust. She qualified from Birmingham University and trained in rheumatology at the Hammersmith Hospital, Guy’s Hospital and Birmingham. Her research interests include the burden of musculoskeletal conditions and risk factors for the occurrence and progression of rheumatoid arthritis. Conflicts of interest: none declared.
MEDICINE 34:9
Osteoarthritis (10%) Rheumatoid arthritis (1%) Osteoporosis (1%) Other (11%)
Figure 1
333
© 2006 Published by Elsevier Ltd.
Introduction
Predictors of musculoskeletal disease
Annual prevalence of musculoskeletal conditions presenting to UK primary care in 20042
Certain risk factors are known to affect the occurrence of musculoskeletal conditions. For example, musculoskeletal conditions are more common in women and increase with age. The prevalence of certain musculoskeletal conditions varies with ethnicity. RA prevalence is lower in people of Pakistani and African-Caribbean origin compared to Caucasians;13 osteoarthritis of the hip has a lower prevalence in Indians and African-Caribbeans compared to Caucasians;13 systemic lupus erythematosus is more common in Asian and African-Caribbean women compared to Caucasian women.14 Obesity is a major risk factor for some musculoskeletal conditions. The rise in obesity is contributing to the increase in prevalence of osteoarthritis.13 Those in deprived areas are more likely to report back pain compared to more affluent areas (determined by postcode of residence). Some conditions such as RA and gout tend to run in families, which could be a result of genetic predisposition or shared environmental factors.
Prevalence (per 10,000 persons)
4500 4000
Female Male
3500 3000 2500 2000 1500 1000 500 0 1
1–4
5–14
15–24
25–44
45–64
65–74
75+
Age (years) Figure 2
and connective tissue in 2004. 40% of these were attributed to arthropathies.6
Cost Disability associated with musculoskeletal disease
The costs to the healthcare service for musculoskeletal conditions include drugs, physiotherapy, GP attendance, hospital referrals/ admissions, and surgery. Costs to society include disability pensions and incapacity benefits. Musculoskeletal conditions are the second most common cause of loss of time from work in Great Britain after mental disorders.7 Over 20% of all incapacity claims in 2004 were for diseases of the musculoskeletal system.8 Average hospital, medication and indirect costs for RA patients are considerable,9 amounting to £7000 per person affected per year; it is estimated that RA costs the UK health service £4 billion per year.10 In 2004, over 33 million prescriptions (single items on a prescription form) were dispensed in England for musculoskeletal and joint diseases and drugs affecting bone metabolism.11 In 2003, over 100,000 hip and knee replacements were performed, costing over £500 million. There were over 1 million outpatient attendances for rheumatology conditions and nearly 6 million for trauma and orthopaedics.12
The main consequences of having a musculoskeletal disease are chronic pain and disability. The Health Survey for England in 2001 reported 18% of adults having a moderate or serious disability; 40% of these disabilities were attributed to musculoskeletal conditions. This suggests that there are 3.4 million adults in the UK who are disabled by a musculoskeletal condition.3,15
Conclusion The burden of musculoskeletal conditions is high. The impact of these conditions on the health service and society will continue to rise alongside increasing life expectancy. ◆
References 1 Medicines and Healthcare products Regulatory Agency. The general practice research database. www.gprd.com 2 Birmingham Research Unit. Weekly returns service annual report 2004. Available at: www.rcgp.org.uk/bru/annual_report/ finalAnnualReport2004.pdf 3 Office for National Statistics. Health statistics quarterly. Winter 2005, No.28. London: HMSO, 2006. 4 Government Actuary’s Department. Population projections. Available at: www.gad.gov.uk/Population/index.asp 5 Office for National Statistics. Table 7.12: Chronic sickness: rate per 1000 reporting longstanding condition groups, by sex; General Household Survey 2003. www.statistics.gov.uk/statbase/Expodata/ Spreadsheets/D8791.xls 6 Office for National Statistics. Mortality statistics: cause. Review of the Registrar General on deaths by cause, sex and age, in England and Wales, 2004. London: HMSO, 2005. 7 Health and Safety Commission. Health and safety statistics 2004/05. Suffolk: Health and Safety Executive, 2005. 8 Department for Work and Pensions. Incapacity benefit and severe disablement allowance quarterly summary of statistics. www.dwp. gov.uk/asd/ib_sda.asp
Prevalence in adults • 29% of responders to a community health survey (2001) reported having had arthritis in the previous year; this reduced to 19% when asked if they had seen a doctor about it. (source: Unpublished data from the Wigan and Bolton Health Survey, 2001) • Results from the General Household Survey suggest that 6.9 million UK adults (14.5%) reported having a long-standing condition relating to the musculoskeletal system in 2003; 3 million men, 3.9 million women.3,5 • 11.4% of GP consultations in 2004 in England and Wales related to diseases of the musculoskeletal system and connective tissue.2 Table 1
MEDICINE 34:9
334
© 2006 Published by Elsevier Ltd.
Introduction
9 McIntosh E. The cost of rheumatoid arthritis. Br J Rheumatol 1996; 35: 781–90. 10 Palferman T G. Principles of rheumatoid arthritis control. J Rheumatol 2003; 30: 10–3. 11 Department of Health. Prescription cost analysis: England, 2004. Available at: www.dh.gov.uk/PublicationsAndStatistics/Publications/ PublicationsStatistics/PublicationsStatisticsArticle/fs/en?CONTENT_ ID= 4107504&chk=nsvFE0 12 Department of Health. NHS reference costs 2004. Available at: www.dh.gov.uk/PublicationsAndStatistics/Publications/ PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/ fs/en?CONTENT_ID=4105545&chk=znAfqu 13 Silman A J, Hochberg M C. Epidemiology of the rheumatic diseases. 2nd ed. Oxford: Oxford University Press, 2001.
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14 Johnson A E, Gordon C, Palmer R G et al. The prevalence and incidence of systemic lupus erythematosus in Birmingham, England. Relationship to ethnicity and country of birth. Arthritis Rheum 1995; 38: 551–8. 15 Bajekal M, Prescott A. Health survey for England 2001: disability. London: The Stationery Office, 2003.
Further reading Arthritis Research Campaign. Arthritis: the big picture. Chesterfield: ARC, 2002. Hochberg M C, Silman A J, Smolen J S et al. Practical rheumatology. 3rd ed. London: Mosby, 2004. Silman A J, Hochberg M C. Epidemiology of the rheumatic diseases. 2nd ed. Oxford: Oxford University Press, 2001.
335
© 2006 Published by Elsevier Ltd.