Musculoskeletal Health in Europe Health services utilisation

What impact do musculoskeletal conditions have on health care resource utilisation across Member States?

Indicators of health services utilisation A number of indicators for health services utilisation are included in the eumusc.net core and additional indicator sets. These indicators are grouped under the following categories: Hospital services utilisation Health services utilisation Human resources Drugs The following slides present each of these indicators briefly describing the rationale for including the indicator and giving definitions, data sources, relevant data and comments.

Hospital Services Utilisation

Hospital services utilisation core indicator Number in-patient days related to specific musculoskeletal diagnoses Rationale: Measure of efficiency of use of health care resources. Indicator often used for health planning. Definition: Average Length Of Stay (ALOS) total number of occupied hospital bed-days divided by the total number of admissions or discharges. LOS of one patient is date of discharge – date of admission. Data source: WHO European Hospital Morbidity database Diseases of the musculoskeletal system and connective tissue. ISHMT: 1300 (ICD-10 M00-99, ICD , 1361, 2794, 446, ). Comments: All else being equal a short ALOS will reduce the cost per discharge and shift care to less expensive post acute services. But shorter stays could lead to adverse health outcomes. National differences in the type of reimbursement system or health insurance plan may affect the patient length of stay in hospitals.

Average length of stay in days for MSC, 2007 or latest available

Hospital service utilisation core indicator Number of hospital in-patient discharges for musculoskeletal diagnoses Rationale: Measure of efficiency in use of health care resources. Indicator often used for health planning purposes. Definition: Number of hospital in-patient discharges from all hospitals during the given calendar year expressed per 1,000 population for diseases of the musculoskeletal system and connective tissue. Data source: WHO European Hospital Morbidity database Diseases of the musculoskeletal system and connective tissue. ISHMT: 1300 (ICD-10 M00-99, ICD , 1361, 2794, 446, ). Comments: International comparisons of hospital discharge statistics are complicated by differences in national health information systems. Most musculoskeletal problems and conditions are managed predominantly in primary care or as outpatients.

Hospital discharges by diagnosis per 100,000 population as percentage of all discharges 2007

Hospital services utilisation indicator Age-standardised admission rates Rationale: Measure of the utilisation of hospital services for MSC and the burden of MSC on health services. Definition: Age-standardised admission rates per 1,000 population for musculoskeletal and connective tissue diseases (M00-99). Data sources: WHO European Hospital Morbidity database Diseases of the musculoskeletal system and connective tissue. ISHMT 1300 (ICD-10 M00-99; ICD ,1361, 2794, 446, )

Age-standardised admission rate for MSC per 1,000 population, 2007 or latest available

In-patients and day cases for MSC per 1,000 population, 2007 or latest available

Variation in utilisation of hospital services for MSC Source: EUROSTAT 2011

Hospital services utilisation core indicator Number of surgeries hip arthroplasty Rationale: Volume of surgeries is product of prevalence and severity of condition and availability of appropriate medical resources. Definition: Number of hip replacements performed in hospital as in-patient surgery per 100,000 population. Data sources: OECD Health Database 2009 and national arthroplasty registers. Comments: Arthroplasty registers: Austria, Italy, Denmark, Finland, Romania, Slovakia, Sweden, Hungary, France, England, Scotland Czech Republic, Portugal.

Hip replacement The number of hip replacement procedures differ significantly across EU Member States. The volume of surgeries is a product of: prevalence of the condition availability of appropriate medical resources Differences in clinical treatment guidelines and practices International mobility across EU borders Low rates may point to under-treatment or may be due to good control of the underlying systemic disease.

Hip replacement procedures Source: Surgical procedures by ICD-9-CM, Hip replacement, Procedures per population (in- patient). OECD Health Data Version: November 09

Number of Primary Total Hip Replacements per Diagnosis and Age Swedish Hip Register Diagnosis< 50 years50-59 years60-75 years> 75 yearsTotal Share Primary osteoarthritis53.5%79.5%81.6%68.1%75.7% Fracture3.5%4.3%8.2%21.4%11.7% Inflammatory arthritis17.3%6.6%4.2%2.2%4.5% Idiopathic femoral head necrosis 6.3%2.7%2.0%3.8%2.9% Childhood disease13.7%4.0%0.8%0.3%1.7% Secondary osteoarthritis1.5%0.6%0.7%1.4%0.9% Tumor1.1%0.8%0.4%0.3%0.5% Secondary arthritis after trauma0.8%0.3%0.2%0.3% (missing)2.3%1.3%1.9%2.2%1.9% Total100%

Hospital services utilisation core indicator Number of surgeries knee arthroplasty Rationale: Volume of surgeries is product of prevalence and severity of condition and availability of appropriate medical resources. Definition: Number of knee replacements performed in hospital as in-patient surgery per 100,000 population. Data sources: OECD Health Database 2009 and national arthroplasty registers. Comments: Arthroplasty registers: Austria, Italy, Denmark, Finland, Romania, Slovakia, Sweden, Hungary, France, England, Scotland Czech Republic, Portugal

Knee replacement procedures

Health Services Utilisation

MSC in Primary & Community Care People with musculoskeletal complaints are frequent visitors to primary health care centres, hospitals, and paramedical institutions (e.g. physiotherapy and chiropractic). Comparison of GP utilisation between countries is limited because in some countries the GP has much more of a gatekeeping function than in others. In Spain, Portugal, Italy, Finland, Denmark, Norway, United Kingdom, Ireland and the Netherlands the GP has an explicit gatekeeping role. (Kroneman et al., 2006) In Luxemburg, Belgium, Germany, Austria, France, Sweden and Greece direct access to most other services is possible (Kroneman et al., 2006).

Health services utilisation core indicator Primary care visits related to diagnostic code Rationale: Provides information on the burden of MSC on health services. Necessary for planning of prevention and health care policy. Definition: % of annual primary care visits (all causes) that are due to MSC (as defined by ICD10 or ISHMT). Data sources: National routinely collected data on primary care visits by ICD10 or ISHMT. Comments: Availability of national health statistics on primary care patient visits by diagnosis very variable between countries. Comparability problematic because of differences in nature and use of primary care services between countries.

Primary care visits for musculoskeletal conditions In one UK study one in seven of all recorded consultations during 2006 was for a musculoskeletal problem. One in four of the registered population consulted for a musculoskeletal problem in that year, rising to more than one in three of older adults. The back was the most common reason for consultation, followed by the knee, chest and neck (Jordan et al 2010). Data from the second Dutch national survey of general practice indicate neck and upper extremity symptoms are common in Dutch general practice with GPs consulted approximately seven times per week for a complaint relating to the neck or upper extremity (Bot et al 2005). In Italy the frequency of visits to GPs for musculoskeletal conditions ranges between 10% and 18% of total consultations (Cimmino 2007).

The burden of MSC on primary care in the UK – consultation rates 2003

The burden of MSC on primary care in the UK – consultation rates for non-infectious disease 2003 Non-infectious GP consultations per 100,000 population

Netherlands: the number of persons diagnosed by the GP as having a musculoskeletal disease or complaint per 1,000 registered patients Total musculoskeletal disorders 133 Sprain 15 Low back pain with radiation 15 Arthrosis 15 Shoulder syndrome / PHS 14 Osteoporosis 7 Rheumatoid arthritis 4 Other disorders 77

Percentage of adults visiting GP for MSC, UK 2006 The table below presents the percentage and estimated number in the adult UK population who visit their general practitioner at least once during a year with any musculoskeletal complaint. These rates have been consistent over the past 6 years.

GP consultations for MSC by age and gender, UK 2006

Other providers of MSC care Occupational therapists, physiotherapists and chiropractors provide care for those with MSC. It is very difficult to obtain comparable data across the EU on consultations for MSC with these professionals. One source of data is the European Health Interview Survey (EHIS) which asks a general questions about visits to physiotherapists, occupational therapists and chiropractors.

Percent respondents visited health provider in past 12 months

Health services utilisation indicator Outpatient / ambulatory consultations with physician or surgeon related to diagnostic code Rationale: Provides information on the burden of MSC on health services. Necessary for planning of prevention and health care policy. Provides information on how far recommended standards of care in MSC health services are being met. Definition: Number of outpatient visits per 100,000 population per year for MSC. Data sources: National routinely collected data on out-patient visits, RA, OA, Back Pain, SPA. Comments: Availability of national health statistics on out patient visits by diagnosis is variable between countries. Variability between countries on what is treated on an outpatient basis therefore needs to be considered together with national in- patient data.

Out-patient visits for MSC (ICD10 codes M00-99) It is difficult to obtain comparative data on out- patients visits for MSC. The number of out-patient visits can differ significantly between countries. For example in Romania in 2010 the number of outpatient visits per 1,000 population per year for musculoskeletal conditions was 22.4 while in Spain for 2009 the comparable number was 2.8:

Health services utilisation indicator Day cases related to diagnostic code Rationale: Provides information on the burden of MSC on health services. Necessary for planning of prevention and health care policy. Definition: Number of hospital day cases from all hospitals during the given calendar year expressed per 1,000 population for diseases of the musculoskeletal system and connective tissue. Data sources: WHO European Hospital Morbidity database Diseases of the musculoskeletal system and connective tissue. ISHMT 1300 (ICD-10 M00- 99; ICD ,1361, 2794, 446, ) Comments: Variability may exist between countries on what is treated as a day case.

Human Resources A range of practitioners, manage musculoskeletal problems. These include specialists, general practitioner, community pharmacists, physical therapists (chiropractors, osteopaths and physiotherapists), behavioural therapists (counsellors, psychologists and psychotherapists) and complementary medicine practitioners (for example, acupuncturists and aromatherapists). Measuring human resources is problematic because concepts used for medical specialities differ across the EU Member States. In particular there are differences in the roles carried out by associated health professionals such as Occupational Therapists which makes direct comparison of human resources between countries problematic. Whilst on a national level there may be good access to health professionals there may be large regional variations. This regional variation in availability may affect the equity of access.

Human resources core indicator Number of rheumatologists Rationale: Assessment of availability (not necessarily accessibility) of health care services. Definition: Number Rheumatology specialists per 100,000 inhabitants Data sources: Eurostat indicator; Data obtained from national administrative sources. Comments: Practising physicians provide services directly to patients, tasks include: conducting medical examination and making diagnosis, prescribing medication and giving treatment for diagnosed illnesses, disorders or injuries, giving organized medical or surgical procedures. It describes availability of staff for the whole country; may differ by region.

Rheumatology physicians per 100,000 inhabitants 2006 EUROSTAT

Human resources core indicator Number of orthopaedic surgeons Rationale: Assessment of availability (not necessarily accessibility) of health care services. Definition: Number orthopaedic surgeons per 100,000 inhabitants Data sources: National statistics and professional organisations Comments: Some problems in obtaining comparable data between countries, some collect practising, others licensed etc. Availability of staff may differ by region.

Orthopaedic specialists per 100,000 inhabitants 2010

Number of practising Occupational Therapists per 100,000 inhabitants 2011 COTEC

Physiotherapists

Number of diagnostic DXA scanners in EU

Drug use In recent years, for the majority of MSC, there has been considerable progress in medical and surgical management techniques leading to a reduction in the pain and disability arising from these conditions. In particular there have been significant advances in the effectiveness of treatments for RA and there is evidence to suggest that the improvement in the health status of those with RA can be attributed to the more aggressive use of and increased accessibility to, these treatments (Heiberg et al 2005;Krishnan et al 2003; Uhlig et al 2008). Treatment of RA focuses on the suppression of inflammation. It is treated with non-steroid anti-inflammatory drugs (NSAIDs) usually in combination with disease modifying antirrheumatic drugs (DMARDs). In the late 1990s so called ‘biologics’ such as TNF inhibitors were introduced. They have a strong effect on inflammation and can prevent or slow the progression of joint erosion. These drugs are expensive. A 2007 study estimated the costs at between 9, ,000 Euros per patient per year ( Engel-Nitz 2007).

Variations in drug use Across the EU in recent decades there has been an upward trend in expenditure on pharmaceuticals. There is a wide variation between different countries Factors in variation include: Differences in the demography and health status of the population e.g. proportion of elderly in the population. Differences in organization and financing of pharmaceuticals supplies e.g. reimbursement policies. Cultural differences in the use of medication. Differences in clinical practice e.g. differences in prescribing practice. Differences in service organisation and delivery e.g. access to specialists.

Drug use indicator Self-reported medication use for MSC Rationale: Health resources utilization - relates to accessibility, quality of care and costs Definitions: Percent of population who report having used medication prescribed by a physician during the past 2 weeks for pain in joints, neck or back Percent of population who report having used medication NOT prescribed by a physician during the past 2 weeks for pain in joints, neck or back Data sources: EHIS and National Health Interview Surveys

Reasons for long-term medical treatment

Longterm treatment because of longstanding troubles with muscles, bones and joints (arthritis, rheumatism)

Percentage of all respondents taking medication for MSC in past 2 weeks

Drug use indicator Pharmaceuticals consumption for MSC Rationale: Health resources utilization - relates to accessibility, quality of care and costs Definitions: Amount of medicine use (based on sales statistics) per day per 1,000 population for treatment of MSC (ATC codes M) expressed in Defined Daily Doses (DDDs) per day. Amount of medicine use (based on sales statistics) per day per 1,000 population for Antiinflammatory and antirheumatic products (ATC codes M01) expressed in Defined Daily Doses (DDDs) per day. Data sources: OECD Health database - data obtained from national medicine sales register Comments: There are a number of possible sources of under-reporting of drug sales in different countries. Most drugs in this area can be used for different non MSC conditions therefore difficult to interpret.

Pharmaceutical consumption, Musculoskeletal System, Defined daily dosage per 1000 inhabitants per day

Pharmaceutical consumption, M01A- Antiinflammatory,antirheumatic prod. non-steroids, Defined daily dosage per 1000 inhabitants per day

Drug use indicator Pharmaceuticals sales for MSC Rationale: Health resources utilization - relates to accessibility, quality of care and costs Definitions: Sales of pharmaceutical products for MSC (ATC codes M) or sales of pharmaceutical products for Antiinflammatory and antirheumatic non- steroid products (ATC codes M01) on the domestic market based on retail prices (the final price paid by the customer). Expressed as: i. % Total sales ii. US$ Purchasing Power Parity (PPP) per annum. Data sources: OECD Health database - data obtained from national medicine sales register Comments: There are a number of possible sources of under-reporting of drug sales in different countries. Most drugs in this area can be used for different non MSC conditions therefore difficult to interpret.

Pharmaceutical sales, Musculoskeletal system per capita US$ PPP

Pharmaceutical sales, M01A Antiinflam, antirheumatic prod. Non-steroids per capita US$ PPP

Pharmaceutical sales musculoskeletal system, % total sales

Pharmaceutical sales M01A Antiinflam, antirheumatic prod. non-steroids % total sales

International variation in use of TNF inhibitors & DMARD Jonsson et al (2008) examined international variation in the use of TNF inhibitors and of conventional DMARDS for the treatment of rheumatoid arthritis for the period High uptake was observed for Sweden, the Netherlands and Finland, France Spain and the UK were around the EU 13 average. Germany Italy and countries of central and eastern Europe were below this average. Possible reasons for differences proposed by the authors were: Differences in GDP (although there were large differences between countries with similar GDP) Differences in relative price levels Differences in national preferences and priorities Variations in access to rheumatologists Variations in clinical guidelines have also been suggested as a reason for variation in usage of biological treatments (Kobelt & Kasteng 2009).

eumusc.net is an information and surveillance network promoting a comprehensive European strategy to optimise musculoskeletal health. It addresses the prevention and management of MSC’s which is neither equitable nor a priority within most EU member states. It is focused on raising the awareness of musculoskeletal health and harmonising the care of rheumatic and musculoskeletal conditions. It is a 3 year project that began in February It is supported by the European Community (EC Community Action in the Field of Health ), the project is a network of institutions, researchers and individuals in 22 organisations across 17 countries, working with and through EULAR. eumusc.net: creating a web-based information resource to drive musculoskeletal health in Europe Disclaimer The Executive Agency for Health and Consumers is not responsible for any use that is made of the information contained within this publication