Fit for Work Europe: What can early intervention in MSDs deliver for patients and health systems?

8/8/2019 Fit for Work Europe: What can early intervention in MSDs deliver for patients and health systems?

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Early interventionin the treatment of MSDs:

What can it deliver for patients and healthsystems?

Professor Paul Emery , Professor of Rheumatology of Molecular

Medicine, University of Leeds, President of EULAR



Total annual costs1,860,000,000 € (2001)

Total annual costs12,332,000,000 £ (1998)

Dagenais S et al. The Spine Journal 2008: 8;8-20

Costs of MSDsFor Low Back Pain, indirect costs contribute to the majority of total costs in Europe

Sweden UK

Direct costs16%

Indirect costs84%

Direct costs13%

Indirect costs87%



Early intervention means better outcomes and staying in work:Physical function in MSDs (RA example) and work productivity

Inflammation (early) and joint damage(subsequently) lead to;• Significant decline in physical function• Limitations in performing work related tasks• Eventual disability

Outcome: inability to work same hours, inability tocontinue on same job, and eventually, loss of earning potential• Job loss may occur within as early as 12 weeks

from onsetSignificant economic impact:• Cost of managing disease and co-morbidities

• Lost production• Lost income• Draw on social benefit funds

Work Disability

InflammatoryProcess

JointDamage

Functional Disability



Background:Types of work productivity outcomes

Absenteeism

Presenteeism

Employment/employability

Days or hours of work missed owing to MSDs.

Reduced performance at work owing to MSDs.

Actual or assessed (in)ability to continue working owing toMSDs-related disability – even if a job is available.

Work instabilityConsequences of a mismatch between functional abilityand work tasks owing to MSDs.



Background:The work productivity continuum

AbsenteeismPresenteeism

Employment/EmployabilityWork Instability

Compromised workperformance

Actual work days missed

Severe continuedphysical inability to meet

job expectations

Loss of employment

SOFT/ SURROGATEOUTCOMES

HARD OUTCOMES



Back to work:Right treatment means better outcomes

Augustsson et al . Ann Rheum Dis. 2009; 0nline.108035v1

0

Time on treatment (years) Time on treatment (years)1 2 3 4 5 0 1 2 3 4 5

0

10

20

30

40

0

10

20

30

40

H o u r s w o r k e d

/ w e e

k

H A Q

Women Men Total



Impact of Early Intervention

Early referral to specialised early arthritisclinicsTargeted optimal therapy at presentationDramatically improved outcomes



anti-TNF at presentation produces long-lasting benefit (one year after stopping therapy)

Quinn et al A&R 2005

years-100

-80

-60

-40

-20

00 14 30 46 54 78 104

% c

h a n g e HAQ MTX + placebo

HAQ MTX + Infliximab

RAQoL MTX + placebo

RAQoL MTX + Infliximab

Anti-TNF treatment 21

MTX Treatment



Backed by research findings:Timing of Imaging (IR) and Clinical Remisssion (CR)induced by TNF in early RARJ Wakefield et al Arthritis and Rheum 2007

Time course of patients response in early disease

Clinical remission with biologic/DMARD combinationachieved around 14 weeks (90% in DAS28 remission)

beforeImaging remission , occurs around 22 weeks

... Which can lead to reducing expenditure withinboth health AND social budgets



8 year follow-up of remission-inductionregime in early RA: Results

Bejarano et al 2010

DAS28 was significantly lower 2.7 vs. 4.3, p=0.02

44% patients in the INF-MTX group were inremission (10% drug-free). vs. 0% in the placebo-MTX group• RAQoL 3 vs. 8, p=0.18;• median HAQ 1.0 vs. 1.5, p=0.12

10



Early intervention can dramatically improve outcomes:Leeds Remission Study: Flow chart

Early treatmentgroupN=27

Delayedtreatment groupN=20

TNF blocker therapy stopped

FlareN=11Time toflare:median 14m

SustainedRemissionN=16

59%

FlareN=17Time toflare:median4weeks

SustainedRemission

N=3 15%

TNF blockerrestarted

85%

RemissionRegainedN=15

Remissionregainedwith DMARDescalationN=8

RemissionrequiredrestartingTNF blocker

N=3 11%



Importance of workVicious circle

Stopworking

Feel bad

Feelill



Importance of workVirtuous circle

Keepworking

Feelwell

Feel good



Washout period Double-blind,placebo-controlled period

160Week

56 weeksUp to 4 weeks

Placebo + MTX

Adalimumab40 mg eow+MTX

S t a t i s t i c al

an

al y

si

s

148 patients

n = 73

n = 75

One of the first studies to SPECIFICALLY look at impact of RA on staying in work

Abbott. Data on File. PROWD Study Demographics and Trial Data. LN0015344

The evidencePROWD

56



†P = 0.005 for MTX vs Adalimumab + MTX*Missing data are counted as no all cause/imminent job loss. Emery P et al. ACR 2006.

Result:

More people were able to stay in work when placed on a-TNF than thosewho were on methotrexate alone


PROWD: Primary AnalysisAll Cause/Imminent Job Loss at Week 56

MTX + PlaceboN = 73

Adalimumab + MTXN = 75

YES (N [%]) 29 (39.7) 14 (18.7)†

No (N [%]) 44 (60.3) 61 (81.3)



# p=0.055 MTX vs Ada + MTX


Time to (imminent) job loss



Conclusion

With investment in education, infrastructure,and therapies we already have means todramatically reduce disability and subsequent

workloss

Fit for Work Europe: What can early intervention in MSDs deliver for patients and health systems?

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