LEDDEGIGT – - Sundhedsstyrelsen

The therapeutic efficacy of the TNF-alpha antagonists relative to
the existing pharmacother-apy with slowly-acting anti-rheumatic drugs.
The situation for rheumatoid arthritis patients as regards
physical, emotional and social effects.
The organizational consequences of early referral and diagnosis
and of treatment with TNF-alpha antagonists.
The probable economic consequences of early referral and
diagnosis and the use of TNF-alpha antagonists.
These assessments were supplemented with a review of the evidence for the
clinical effect of non-pharmacological treatment methods in order to assess:
The efficacy of surgical treatment methods and when during
the course of the disease they should be offered.
The available documentation for the effect of physiotherapy,
occupational therapy, emotional support and patient education.
These issues were elucidated on the basis of systematic literature searches and
analyses coupled with knowledge and experience among experts and generalists
in the project group and in the project’s seven topic-specific subgroups. During
the period June-December 2000 several literature searches were thus conducted
– a general search about rheumatoid arthritis and specific searches to answer the
questions pertaining to the HTA and status parts of the study. Supplementary
searches were made up to September 2001 to answer a few specific questions,
since when a small number of relevant articles have been regularly identified.
Rheumatoid arthritis – a major health problem
No accurate figures are available for the number of rheumatoid arthritis patients
in Denmark, or for the treatment they receive. The number of new cases of
rheumatoid arthritis diagnosed each year is estimated to be approximately
1,700, corresponding to 0.4 per thousand of the adult population. According
to a spot survey based on patient information, the total number of patients is
estimated to be approx. 35,000. The number of patients attended by rheumatologists
is estimated to be 18,000.
The majority of patients live with chronic pain and progressive loss of function
despite pharmacotherapy and the disease thus comprises a widespread
health problem among the Danish population. Rheumatoid arthritis has proven
to entail excess mortality, the mean lifetime being 8-10 years less than for
the population as a whole. The mortality has decreased in step with intensification
of treatment over the past decades, however.
The extent of the physical handicaps varies from patient to patient. Some are
more affected by the disease than others, and the possibilities for predicting
the course of the disease in individual patients are limited. The disease gener-
ally entails painful swelling of the joints and progressive joint damage, with
resultant deformation of joints and postural abnormalities. The disease also
causes general feelings of illness in the form of fatigue, possibly fever and loss
of weight, poor condition and an enhanced risk of depression.
Referral and diagnosis
Damage to the joints starts early in the course of the disease, often within the
first year. In the early phase it can be difficult to make a certain diagnosis of
rheumatoid arthritis. A reliable joint examination and clinical assessment necessitates
knowledge and experience at the specialist level.
Initiation of treatment with slowly-acting anti-rheumatic drugs in the
early phase of the disease delays or prevents joint damage to a greater
extent, increases overall treatment efficacy and apparently improves the
long-term prognosis. It is therefore important that the diagnosis is
made as early as possible. Specialists and hospital outpatient clinics
should strive to reduce waiting times for patients suspected of rheumatoid
arthritis such that the patients can be examined no later than three
months after onset of the disease, irrespective of where they live.
The time of diagnosis can be brought forward considerably (approximately
2 months) and in most cases the diagnosis can be made no later
than three months after the onset of joint problems provided early referral
and diagnosis are introduced whereby all patients with joint swelling
of over six-weeks duration are immediately referred to a specialist. It is
estimated that such early referral and diagnosis would reduce the number
of patients with irreversible joint damage at the time of diagnosis,
and hence at the time of initiation of treatment, from 25% to 20%. In
addition, initiation of treatment is brought forward for all rheumatoid
arthritis patients by approximately two months, thus resulting in improved
treatment efficacy.
With increased awareness among general practitioners and earlier referral to
specialists it is expected that the annual costs will increase in that the annual
number of patients referred to specialists for diagnosis of rheumatoid arthritis
will increase by approximately 2,000, the duration of treatment of newly-diagnosed
will increase by two months and the number of patients diagnosed
with rheumatoid arthritis will increase by 5% corresponding to approximately
90 diagnosed patients annually. In the case of patients with rheumatoid
arthritis, initiation of pharmacotherapy will be brought forward by approximately
two months. From the organizational point of view the additional referrals
are expected to necessitate a total of 10 additional full-time positions
annually, hereunder 4 physicians and 1 nurse, as well as an additional 3 fulltime
positions during the first year, hereunder 1.4 physicians and 0.3 nurses
due to the earlier initiation of treatment.
26 LEDDEGIGT – medicinsk teknologivurdering af diagnostik og behandling
LEDDEGIGT – medicinsk teknologivurdering af diagnostik og behandling 27