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Management of Rheumatoid Arthritis in Germany – Findings of a
Claims Database Analysis
Hagenmeyer EG1, Gothe H1, Höer A1, Runge C2, Häussler B1
1 IGES – Institute for Healthcare and Social Research GmbH, Berlin, Germany; 2Wyeth Pharma, Ltd., Muenster, Germany
Figure 3: Sick leaves and hospitalisations in patients prior to TNF-α
inhibitors therapy and all enrolees with RA
Rheumatoid Arthritis (RA) imposes a significant burden of disease to
Prevalence of Rheumatoid Arthritis
both affected patients and the society as a whole. We performed the first
Out of the 728,111 beneficiaries continuously enrolled between 2000 and 2004
Enrolees with RA prior to initiation of TNF- α
German claims database analysis among members of a German health
n = 5,850 (mean age: 43 ± 14 years) fulfilled the inclusion criteria for RA.
insurance fund to estimate RA treatment prevalence, to describe
All enrolees with RA
prescription patterns and assess overall disease burden.
The total number of women in the study population was n = 2,847 (mean age:
50 ± 14 years), the number of men was n = 3,003 (mean age: 48 ± 12 years).
RA treatment prevalence for the year 2004, standardized by age and sex to the
general German population was 0.68 % for men and 1.25 % for women or
er 100 en
We based our analysis on billing data from the years 2000 to 2004 of a
German sickness fund covering 1.5 million beneficiaries. RA patients
Treatment with traditional DMARDs or TNF-α inhibitors
were identified by either inpatient or sick leave records due to ICD-10
In total 42.6 % of the patients with RA received a disease modifying therapy,
codes (seropositive rheumatoid arthritis, other rheumatoid arthritis) or at
38.2 % of the male and 47.3% of the female patients respectively. 42.6% of
least two prescriptions of a disease-modifying drug (Figure 1). In the
patients had a therapy with traditional DMARDs and 3.0% with TNF-α inhibitors.
disease modifying agents used for therapy of RA we distinguished
Figure 2 shows the distribution of disease modifying drugs in RA patients, MTX
traditional disease-modifying antirheumatic drugs (traditional DMARDs,
and SSZ being the most frequently used agents (Figure 2).
i.e. Anakinra, antimalaria drugs as Chloroquine and Hydroxychloroquine,Penicillamine, Gold, Leflunomide, Methotrexate (MTX), Sulfasalazine
The RA treatment prevalence described in this study corresponds
(SSZ)) and TNF-α inhibitors (Adalimumab, Etanercept, Infliximab).
with European cross-sectional population studies that found
combined prevalence rates for RA of 0.5 % to 1.1 % and a female to
When identifying RA patients from prescriptions of disease-modifying
male excess of around 2 times (Silman and Hochberg 2001).
drugs, we excluded cases with a variety of diagnoses that are also
indications for traditional DMARD or TNF-α inhibitors therapy, e.g.
Compared to the prevalence of treatment with TNF-α inhibitors in the
psoriasis, ankylosing spondylitits, Crohn´s disease, scleroderma,
patients of the national database of the German Collaborative
systemic lupus erythematosus and malignant disease.
Arthritis Centers, a register of patients in rheumatology specialist
care (8.6 %, Zink et al. 2006), the prevalence in the patients from
We specified treatment prevalence and patterns of RA disease
our statutory sickness fund population is considerably lower (3.0 %).
management with traditional DMARDs and TNF-α inhibitors in the
This difference can be explained with a selection bias, which is
stronger in specialist care data than in our statutory sickness fund
We specified subpopulations with a newly started therapy of either
traditional DMARDs or TNF-α inhibitors. The condition for the initiation of
As less than half of RA-patients had a prescription of a disease
a therapy was defined by the identification of an index prescription of the
modifying therapy, this may indicate that therapeutic standards are
particular agent without any precedent prescription of the same agent
during 365 days before the index date.
Internal medicine specialists prevail as the prescribing specialty as
Figure 1: Rheumatism patients’ selection workflow
well for traditional DMARDs as for TNF-α inhibitors. An important
percentage of all traditional DMARD therapies (25 %) and all TNF-α
Total population of the sickness fund
TNF-α inhibitors Other DMARDs
inhibitors (10 %) is initiated by general practitioners.
Included population of beneficiaries
The high number of sick leaves and hospitalizations in RA patients
age >= 18 years, continuously enrol ed 2001 to 2004
Specialty Prescribing Disease Modifying Therapy
prior to initiation of TNF-α inhibitor therapy indicates that thesebiologicals are mainly prescribed in a high burden RA
In 58% of RA patients traditional DMARD therapy was initiated by an internal
medicine specialist, in 25% by a general practitioner, in 6% by rheumatology
clinics and in 10% by other disciplines.
TNF-α inhibitor therapy was initiated in 69% of RA patients by an internal
medicine specialist, in 10% by a general practitioner, in 19% by rheumatology
Silman AJ, Hochberg MC (eds). Epidemiology of the Rheumatic Diseases Second
Edition. Oxford: Oxford University Press, 2001.
clinics and in 2% by other disciplines.
Zink A, Huscher D. The National Database of the German Arthritis Centres – 12
Sick Leaves and Hospitalizations in Patients with Rheumatoid Arthritis
ear balance. Z Rheumatol 2006, 65:144-151.
RA patients with
RA patients with
RA patients with
diagnosis of RA from
Compared to the RA population as a whole RA patients receiving TNF-α
sick leave or
inhibitors were characterized by a 2.6 fold number of sick leaves (25.8 per 100
IGES-Institute for Healthcare and Social Research GmbH
enrolees compared to 9.8) and a 6.4 fold number of hospitalizations (45.3 per
Total population of patients with RA
100 enrolees compared to 7.1) in the year prior to therapy initiation (Figure 3).
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