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The aim of the study was to analyze the efficacy and satisfaction of multidisciplinary dermatology–rheumatology management for patients with moderate-to-severe psoriasis and psoriatic arthritis (PsA). We conducted a systematic literature search in MEDLINE, EMBASE, and Cochrane Library up to September 2015. Selection criteria include (1) adult patients with moderate-to-severe psoriasis and PsA, (2) assessed in a multidisciplinary consultation, (3) comparison with routine separate consultations, and (4) outcome measures to evaluate efficacy and/or satisfaction. Meta-analyses, systematic reviews, clinical trials, cohort studies, and case series were included. The quality of the studies included was graded according to the Oxford Level of Evidence scale. Of 195 articles, three studies complied with the inclusion criteria: two case series and one descriptive study in which 506 patients were evaluated. Patients were referred to the multidisciplinary consultation from dermatology and rheumatology consultations in all but one study, in which primary care was also involved. The reason for the referral was to confirm the diagnosis and/or treatment. Patients were evaluated on a weekly and monthly basis in two and one study, respectively. The evidence obtained is scarce but suggests the efficacy of multidisciplinary consultations in terms of improved skin and joint symptoms after changing treatment (82–56 %), showing higher scores for this type of consultation compared to the usual [4.91 vs. 2.85 (0–5)] and a high level of satisfaction among patients (94 % “very satisfied”). However, waiting times were higher. With the limited evidence found, multidisciplinary management seems to be more effective and more satisfactory for patients with moderate-to-severe psoriasis and PsA than conventional consultations, though this could not be conclusively demonstrated. The results of this review support the benefit of implementing this type of consultation.

Gout flares have been challenging to identify in retrospective databases due to gout flares not being well documented by diagnosis codes, making it difficult to conduct accurate database studies. Previous studies have used different algorithms, and in this study, we used a computer-based method to identify gout flares. The objectives of this study were to identify gout flares in gout patients newly initiated on urate-lowering therapy and evaluate factors associated with a patient experiencing gout flares after starting drug treatment. This was a retrospective cohort study identifying gout patients newly initiated on a urate-lowering therapy (ULT) during the study time period of January 1, 2007–December 31, 2010. The index date was the first dispensed ULT prescription during the study time period. Patients had to be ≥18 years of age on index date, have no history of prior ULT prescription during 12 months before index date, and were required to have 12 months of continuous membership with drug benefit during pre-/post-index. Electronic chart notes were reviewed to identify gout flares; these reviews helped create a validated computer-based method to further identify patients with gout flares and were categorized into 0 gout flares, 1–2 gout flares, and ≥3 gout flares during the 12 months post-index period. Multivariable logistic regression was used to examine patient and clinical factors associated with gout flares during the 12-month follow-up period. There were 8905 patients identified as the final cohort and 68 % of these patients had one or more gout flares during the 12-month follow-up: 2797 patients (31 %) had 0 gout flares, 4836 (54 %) had 1–2 gout flares, and 1272 patients (14 %) had ≥3 gout flares. Using a multivariate regression analyses, factors independently associated with 1–2 gout flares and ≥3 gout flares versus no gout flares were similar, however, with slight differences, such as younger patients were more likely to have 1–2 gout flares and patients ≥65 years of age had ≥3 gout flares. Factors such as male gender, not attaining sUA goal, having ≥3 comorbidities, diuretics use, no changes in initial ULT dose, and not adhering to ULT all were associated with gout flares versus no gout flares. Using a new method to identify gout flares, we had the opportunity to compare our findings with the previous studies. Our study findings echo other previous studies where older patients, male, diuretics, having a greater number of comorbidities, and non-adherence are more likely to have more gout flares during the first year of newly initiating ULT. There is an unmet need for patients with gout to be educated and managed more closely, especially during the first year.

We aimed to estimate the annual direct medical costs of South Korean systemic lupus erythematosus (SLE) patients, and their predictors. The 2010 annual direct medical costs of SLE patients in the Hanyang BAE Lupus cohort in South Korea were assessed. The information was taken directly from the hospital database and medical records, and included clinical characteristics, disease activity, organ damage, and healthcare utilization. Cost predictors were estimated with a multivariate linear regression model. A total of 749 SLE patients (92.7 % female, mean age 35.7 ± 11.3 years, mean disease duration 9.6 ± 4.9 years) were studied. Their mean annual direct medical costs amounted to USD 3305. The largest component of these costs was the cost of medication (USD 1269, 38.4 %), followed by those of diagnostic procedures and tests (USD 1177, 35.6 %). Regression analysis showed that adjusted mean SLE disease activity index score ( p  < 0.0001), systemic damage index ( p  < 0.0001), and renal ( p  = 0.0039) and hematologic ( p  = 0.0353) involvement were associated with increased direct medical costs, whereas longer disease duration was associated with lower direct medical costs. Greater disease activity and greater organ damage predict higher costs for South Korean SLE patients. Major organ involvement such as renal disorder and hematologic involvement also predicts higher costs, whereas longer duration of disease predicts lower costs.

To our knowledge, no prior report focused on the risk factors for proximal humerus fractures in patients with rheumatoid arthritis. The purpose of this study was to evaluate the association between potential risk factors and the occurrence of proximal humerus fractures in patients with rheumatoid arthritis. A total of 11,907 patients with rheumatoid arthritis were enrolled in our observational cohort rheumatoid arthritis study between 2000 and 2012. Self-reported proximal humerus fractures were verified using the patients’ medical records. Cox proportional hazard models were used to analyze the independent contribution of risk factors to the occurrence of proximal humerus fractures. During follow-up (mean 5.6 years), 92 proximal humerus fractures were verified in 91 patients. Multivariate Cox regression analyses estimated that the hazard ratios of sustaining a proximal humerus fracture were 1.37 for every 10-year increase in age [95 % confidence interval (CI) 1.10–1.70; P  < 0.01], 1.95 for increases in serum C-reactive protein levels (mg/100 mL; 95 % CI 1.15–3.34; P  < 0.05), 2.13 for a history of fractures (95 % CI 1.34–3.40; P  < 0.01), 1.07 for the daily prednisolone dose (per mg; 95 % CI 1.01–1.13; P  < 0.05), and 1.97 for oral bisphosphonate use (95 % CI 1.20–3.23; P  < 0.01). Better control of rheumatoid arthritis with a smaller daily prednisolone dose in elderly patients with a history of fractures may be important for preventing proximal humerus fractures.

The objective of this study was to describe the variability in the prescription of csDMARDs for the treatment of RA between centers in Spain and to explore how this variability relates to demographic, disease, physician, and institutional characteristics. A cross-sectional nationwide study was carried out to examine data from 1352 patients. Multilevel logistic regression with two levels was performed to assess the relationships between individual and disease-related factors, as well as physician and hospital characteristics, vis-à-vis csDMARD prescription. Having three or more comorbidities (OR 0.353 [0.173–0.721]), disease duration (OR 0.321 [0.174–0.595]), and the existence of an early-arthritis unit (OR 0.552 [0.335–0.910]) were negatively associated with the prescription of one csDMARD versus nonprescription; contrary, the presence of rheumatoid factor (OR 1.909, 95 % CI [1.181–3.086]) was positively associated. On the other hand, while corticoid intake (OR 1.561 [1.088–2.240]), the maximum number of painful joints, and the presence of nursing consultation (OR 1.626 [1.078–2.452]) were positively associated with the prescription of multiple csDMARDs versus one csDMARD, patient’s age (OR 0.984 [0.974–0.995]) and disease duration (OR 0.669 [0.462–0.968]) were negatively associated. Despite all these, variability in the prescription of csDMARDs between hospitals remained statistically significant after adjusting for these individual and hospital characteristics. Within the emAR II study, there was a marked variation in the number of csDMARDs prescribed between hospitals. The reasons for these variations remain unclear and cannot be solely related to disease or center characteristics.

Biological drugs have proven efficacy and effectiveness in treatment of rheumatoid arthritis (RA), although none has been shown to be superior. Few studies have evaluated the cost-effectiveness of biological drugs in real-life clinical conditions. The objective of this study was to compare the cost-effectiveness of infliximab, etanercept and adalimumab in achieving clinical remission (DAS28 < 2.6) when used as initial biological therapy. Patients were diagnosed with RA who began treatment with infliximab, etanercept or adalimumab in the Reina Sofia Hospital (Cordoba, Spain) between January 1, 2007, and December 31, 2012. Effectiveness was measured as the percentage of patients who achieved clinical remission after 2 years. The cost analysis considered the use of direct health resources (perspective of the healthcare system). Cost-effectiveness was calculated by dividing the total mean cost of each treatment by the percentage of patients who achieved remission. One hundred and thirty patients were included: 55 with infliximab, 44 with adalimumab and 31 with etanercept. After 2 years, 45.2 % of patients with adalimumab achieved clinical remission, versus 29.1 % with infliximab ( p  = 0.133) and 22.7 % with etanercept ( p  = 0.040), with no differences between etanercept and infliximab ( p  = 0.475). The average total cost at 2 years was €29,858, €25,329 and €23,309 for adalimumab, infliximab and etanercept, respectively, while the mean cost (95 %CI) to achieve remission was €66,057 (48,038–84,076), €87,040 (78,496–95,584) and €102,683 (94,559–110,807), respectively. Adalimumab was more efficient than etanercept ( p  < 0.001) and infliximab ( p  = 0.026), with no differences between etanercept and infliximab ( p  = 0.086). Adalimumab was the most cost-effective treatment in achieving clinical remission in real-life clinical conditions in RA patients during the study period.

The aim of this study was to compare anti-tumor necrosis factor-α (TNFα) treatment status in rheumatoid arthritis (RA) patients with the Korean National Health Insurance (KNHI) reimbursement eligibility criteria and with American College of Rheumatology (ACR) recommendations, Japan College of Rheumatology (JCR) guidelines and British Society for Rheumatology (BSR) guidelines. Between December 2011 and August 2012, outpatients from 17 South Korean general hospitals diagnosed with RA according to the 1987 ACR criteria were enrolled into a noninterventional, cross-sectional, observational study. Of 1700 patients (1414 female (83.2 %), mean age of 56.6 ± 12.0, mean disease duration 97.9 ± 91.8 months), 306 (18.0 %) had used anti-TNFα agents, and 224 (13.2 %) were currently using an anti-TNFα agent. Of 1394 anti-TNFα-naive patients, 32 (2.3 %) met KNHI reimbursement guidelines, 148 (10.6 %) met ACR recommendations, and 127 (9.1 %) and 126 (9.0 %) were considered eligible for anti-TNFα agents according to JCR and BSR guidelines, respectively. The main discrepancy was the higher active joint count required by the KNHI eligibility criteria. In the opinion of treating rheumatologists, the KNHI reimbursement criteria ineligibility accounted for 15.3 % ( n  = 213) of the reasons for not initiating anti-TNFα agents in anti-TNFα-naive group. The anti-TNFα user group showed significantly higher disease activity than the anti-TNFα-naive group based on DAS28 score. In comparison with the ACR recommendations and JCR and BSR guidelines, fewer patients met KNHI reimbursement eligibility criteria for anti-TNFα agents. The current amendment of the KNHI criteria based on DAS28 score will improve an access to biologic agents including anti-TNFα treatment for South Korean patients with active RA.

To evaluate the efficacy of a program for subacute physical disability due to musculoskeletal disorders (MSD) in the elderly. We carried out a randomized controlled evaluator-blinded intervention study in a health district (October 2005 to April 2008). Subjects older than 64, starting a subacute MSD episode of physical disability—defined as moderate disability or higher in the Rosser classification—and identified by general practitioners, were randomized into standard care or an early specific program. The program was carried out by rheumatologists following detailed proceedings. Efficacy was defined as the difference between groups in the duration of episodes—time from onset until an improvement larger than a point in the Rosser classification). Hazard ratios (HR) to recovery of the program over standard care were obtained from Cox regression analyses. One hundred and twenty-three patients were included, generating 244 episodes of subacute MSD. Mean duration of episodes was 5 months; 14.5 % of them were chronically disabled throughout follow-up. The program was associated with shorter duration of episodes compared with CG analyzing just the ended ones ( p  = 0.004). The HR to recovery between groups did not achieve statistical differences. Nevertheless, recovery rate at 12 months and HR from those with moderate physical disability at the inclusion period (Rosser disability level 4, n  = 84) were superior in the IG (HR 1.9, p  = 0.03; HR 1.93; p  = 0.03 respectively). An early intervention program for subacute MSD-related disability in elderly has partial efficacy; the program benefited patients with moderate physical disability and after a year of follow-up.

Traumatic events are common globally; however, comprehensive population-based cross-national data on the epidemiology of posttraumatic stress disorder (PTSD), the paradigmatic trauma-related mental disorder, are lacking. Data were analyzed from 26 population surveys in the World Health Organization World Mental Health Surveys. A total of 71 083 respondents ages 18+ participated. The Composite International Diagnostic Interview assessed exposure to traumatic events as well as 30-day, 12-month, and lifetime PTSD. Respondents were also assessed for treatment in the 12 months preceding the survey. Age of onset distributions were examined by country income level. Associations of PTSD were examined with country income, world region, and respondent demographics. The cross-national lifetime prevalence of PTSD was 3.9% in the total sample and 5.6% among the trauma exposed. Half of respondents with PTSD reported persistent symptoms. Treatment seeking in high-income countries (53.5%) was roughly double that in low-lower middle income (22.8%) and upper-middle income (28.7%) countries. Social disadvantage, including younger age, female sex, being unmarried, being less educated, having lower household income, and being unemployed, was associated with increased risk of lifetime PTSD among the trauma exposed. PTSD is prevalent cross-nationally, with half of all global cases being persistent. Only half of those with severe PTSD report receiving any treatment and only a minority receive specialty mental health care. Striking disparities in PTSD treatment exist by country income level. Increasing access to effective treatment, especially in low- and middle-income countries, remains critical for reducing the population burden of PTSD.

Objective Our objective was to examine perspective and costing approaches used in cost-effectiveness analyses (CEAs) and the distribution of reported incremental cost-effectiveness ratios (ICERs). Methods We analyzed the Tufts Medical Center’s CEA and Global Health CEA registries, containing 6907 cost-per-quality-adjusted-life-year (QALY) and 698 cost-per-disability-adjusted-life-year (DALY) studies published through 2018. We examined how often published CEAs included non-health consequences and their impact on ICERs. We also reviewed 45 country-specific guidelines to examine recommended analytic perspectives. Results Study authors often mis-specified or did not clearly state the perspective used. After re-classification by registry reviewers, a healthcare sector or payer perspective was most prevalent (74%). CEAs rarely included unrelated medical costs and impacts on non-healthcare sectors. The most common non-health consequence included was productivity loss in the cost-per-QALY studies (12%) and patient transportation in the cost-per-DALY studies (21%). Of 19,946 cost-per-QALY ratios, the median ICER was $US26,000/QALY (interquartile range [IQR] 2900–110,000), and 18% were cost saving and QALY increasing. Of 5572 cost-per-DALY ratios, the median ICER was $US430/DALY (IQR 67–3400), and 8% were cost saving and DALY averting. Based on 16 cost-per-QALY studies (2017–2018) reporting 68 ICERs from both the healthcare sector and societal perspectives, the median ICER from a societal perspective ($US22,710/QALY [IQR 11,991–49,603]) was more favorable than from a healthcare sector perspective ($US30,402/QALY [IQR 10,486–77,179]). Most governmental guidelines (67%) recommended either a healthcare sector or a payer perspective. Conclusion Researchers should justify and be transparent about their choice of perspective and costing approaches. The use of the impact inventory and reporting of disaggregate outcomes can reduce inconsistencies and confusion.