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The burden of musculoskeletal diseases in the United States
Author’s Accepted Manuscript The burden of musculoskeletal diseases in the U.S Edward Yelin, Stuart Weinstein, Toby King
www.elsevier.com/locate/semarthrit
PII: DOI: Reference:
S0049-0172(16)30144-5 http://dx.doi.org/10.1016/j.semarthrit.2016.07.013 YSARH51082
To appear in: Seminars in Arthritis and Rheumatism Revised date: 15 July 2016 Accepted date: 21 Cite this article as: Edward Yelin, Stuart Weinstein and Toby King, The burden of musculoskeletal diseases in the U.S, Seminars in Arthritis and Rheumatism, http://dx.doi.org/10.1016/j.semarthrit.2016.07.013 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
The Burden of Musculoskeletal Diseases in the U.S. Edward Yelin, PhD1 Stuart Weinstein, MD2 Toby King, CAE3 1
Rosalind Russell/Ephraim Engleman Rheumatology Research Center and Philip R Lee Institute for Health Policy Studies, University of California, San Francisco 2 Departments of Orthopedic Surgery and Pediatrics, University of Iowa 3 United States Bone and Joint Initiative, Rosemont, Illinois
Acknowledgments: NIAMS Grant P60 AR-053308 (Dr. Yelin)
It has long been a truism that conditions perceived as increasing mortality, such as heart conditions and cancer, garner more attention, and thus NIH funding, than conditions perceived to affect the quality of life, but not its quantity, including musculoskeletal and neurological impairments 1,2. This dichotomy may be too simple because now we know that several musculoskeletal conditions are often associated with higher mortality, with the most evidence for rheumatoid arthritis 3-6. Nevertheless, it remains true that conditions perceived to affect quality of life receive less attention. To try and achieve equal treatment for persons with musculoskeletal conditions the research, advocacy, provider, and policy communities need a set of metrics to level the playing field across conditions that have a similar effect on the number of years lost to healthy living 7. In response to the need to increase the visibility of various forms of musculoskeletal conditions, a coalition of the communities with an interest in musculoskeletal conditions joined together to provide periodic updates on their prevalence and impact. Several volumes of The Burden of the Musculoskeletal Diseases in the United States: Prevalence, Societal, and Economic Cost were
produced as a result, initially published by the American Academy of Orthopedic Surgeons on behalf of several professional and advocacy organizations and industry partners (editions in 1984, 1992, and 1999) and by the Bone and Joint Decade and its successor, the U.S. Bone and Joint Initiative (editions in 2008 and 2010) 8. Starting with the 2nd edition, published in 2010, the entire content of The Burden was made available on-line as an exact replica of the print edition. In recognition of the importance of the conditions, continuing need to emphasize their impact, and inherent efficiencies of web-based production, an on-line version of the Burden, starting with the current volume, will be updated each year 9. The volume can be accessed with this URL: http://www.boneandjointburden.org/ The current volume also permits users to customize data retrieval to their specific purposes via a query function. Thus, timely and useful data are and will continue to be available to the communities with an interest in improving the lives of persons with musculoskeletal conditions. In addition to the traditional chapters on spinal conditions, arthritis and related disorders, osteoporosis, and injuries, the current volume includes chapters on the impact on children and adolescents who have one or more of the conditions, rare conditions such as tumors affecting bone, and the impacts of musculoskeletal conditions across the lifespan and among women who have the highest rates of most of these conditions. In this editorial, we can’t possibly summarize all of the information within the Burden. Instead, our goal is to inform the communities with an interest in the welfare of persons with musculoskeletal conditions about the availability of this important tool. However, in doing so, we would be remiss in not highlighting some of the key findings about the growing prevalence
and economic impact of these conditions. The Burden’s summary chapter on prevalence and impact uses the U.S. Government’s Medical Expenditures Panel Survey (MEPS) from 1996 through 2011 10. MEPS data are often influential in policy circles because they provide a common metric across conditions for evaluating their relative importance, something that savvy policymakers in Washington now ask of those trying to make the case for individual diseases.
Key Findings
The proportion of the population reporting musculoskeletal conditions increased from 28.0% in 1996-1998 to 33.2% in 2009-2011, an increase of about 19%. The number with the condition increased from 76.0 million in the earlier period to 102.5 million in the later one.
A disproportionate amount of this increase has occurred among those 45-64 years of age, the baby-boom generation. Although the prevalence rate remained greater among those 65 years of age or older, there were more people 45-64 with musculoskeletal conditions (just under 40 million) than among those 65 or greater (about 25 million).
Musculoskeletal conditions are associated with 574 million physician visits, 379 million visits to non-physician health providers, 390 million home health care visits, and about 21 million hospital admissions. The fastest growing forms of health care utilization are visits to non-physician providers and home health care visits.
Use of prescription medications for musculoskeletal conditions are increasing at a rapid rate. In 1996-1998, persons with musculoskeletal conditions averaged 13.1
prescriptions filled for these conditions; by 2009-2011, this had increased to 20.8 per person. Overall, the number of prescriptions for musculoskeletal conditions rose from about 996 million in the earlier period to about 2.1 billion in the later one.
The aggregate economic impact of musculoskeletal conditions is increasing rapidly. This reflects both the increase in prevalence and increase in per person costs described above. In constant dollars, persons with musculoskeletal conditions accounted for an aggregate economic impact of $367.1 billion in 1996-1998 and $796.3 billion in 20092011, an increase of 117 percent in real terms. Using the more conservative estimates of the incremental impact of musculoskeletal conditions beyond what one would expect of persons with the same demographic characteristics as those with musculoskeletal conditions, such conditions still accounted for an increment of $212.7 billion in 20092011, an increase of 119 percent compared to the $97.3 billion figure for 1996-1998.
Overall, U.S. society is experiencing a pandemic of musculoskeletal conditions due to the aging of the baby boomers and, owing to the increase in per person medical care costs, it is experiencing a rapid increase in medical care expenditures associated with these conditions, even when measured by the most conservative estimation techniques. The Burden documents these profound impacts and now will continue to do so with annual updates. In the zero sum game that affects allocations for groups of conditions in the contemporary policy climate, the data may alter, however slightly, the inherent bias against conditions thought to affect quality of life, not its quantity. Because the Burden is intended to be both a compendium of hard facts and an organizing tool for advocacy in policy debates, we
welcome feedback on what can be done to make it more effective in both functions as it segues from a periodic volume to a continuously updated one.
References 1 Verbrugge L, Patrick D. Seven chronic conditions: their impact on US adults' activity levels and use of medical services. Am J Public Health 1995; 85:173-182 2 Perruccio AV, Power JD, Badley EM. The relative impact of 13 chronic conditions across three different outcomes. J Epidemiol Community Health 2007; 61:1056-1061 3 Avina-Zubieta JA, Choi HK, Sadatsafavi M, Etminan M, Esdaile J, Lacaille D. Risk of cardiovascular mortality in patients with rheumatoid arthritis: a meta-analysis of observational studies. Arthritis Rheum 2008; 59:1690-1697 4 Boyer JF, Gourraud PA, Cantagrel A, Davignon J, Constantin A. Traditional cardiovascular risk factors in rheumatoid arthritis: a meta-analysis. Joint Bone Spine 2011; 78:179-183 5 Meune C, Touze E, Trinquart L, Allanore Y. Trends in cardiovascular mortality in patients with rheumatoid arthritis over 50 years: a systematic review and meta-analysis of cohort studies. Rheumatology (Oxford) 2009; 48:1309-1313 6 Yurkovich M, Vostretsova K, Chen W, Avina-Zubieta J. Overall and cause-specific mortality in patients with systemic lupus erythematosus: a meta-analysis of observational studies. Arthritis Care Res (Hoboken) 2014; 66:608-616 7 Global Burden of Disease Disability Life Years Collaboration. Murray C Barber R, Foreman K, Abbasoglu Ozgoren A, Abd-Allah F, Abera S. et al. Global, regional, and national disabilityadjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for
188 countries, 1990-2013: quantifying the epidemiological transition. Lancet 2015; 386:21452191 8 US Bone and Joint Decade. The Burden of Musculoskeletal Diseases in the United States, 2nd edition. Rosemont, Illinois: American Academy of Orthopedic Surgeons, 2010; 9 US Bone and Joint Initiative. The Burden of Musculoskeletal Diseases in the United States, 3rd Edition. Rosemont, Illinois: U.S Bone and Joint Initiative, 2016; 10 Cohen J, Monheit A, Beauregard K, Cohen S, Lefkowitz D, Potter D, et al. The Medical Expenditures Panel Survey: A National Information Resource. Inquiry 1996/97; 33:373-389
www.elsevier.com/locate/semarthrit
PII: DOI: Reference:
S0049-0172(16)30144-5 http://dx.doi.org/10.1016/j.semarthrit.2016.07.013 YSARH51082
To appear in: Seminars in Arthritis and Rheumatism Revised date: 15 July 2016 Accepted date: 21 Cite this article as: Edward Yelin, Stuart Weinstein and Toby King, The burden of musculoskeletal diseases in the U.S, Seminars in Arthritis and Rheumatism, http://dx.doi.org/10.1016/j.semarthrit.2016.07.013 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
The Burden of Musculoskeletal Diseases in the U.S. Edward Yelin, PhD1 Stuart Weinstein, MD2 Toby King, CAE3 1
Rosalind Russell/Ephraim Engleman Rheumatology Research Center and Philip R Lee Institute for Health Policy Studies, University of California, San Francisco 2 Departments of Orthopedic Surgery and Pediatrics, University of Iowa 3 United States Bone and Joint Initiative, Rosemont, Illinois
Acknowledgments: NIAMS Grant P60 AR-053308 (Dr. Yelin)
It has long been a truism that conditions perceived as increasing mortality, such as heart conditions and cancer, garner more attention, and thus NIH funding, than conditions perceived to affect the quality of life, but not its quantity, including musculoskeletal and neurological impairments 1,2. This dichotomy may be too simple because now we know that several musculoskeletal conditions are often associated with higher mortality, with the most evidence for rheumatoid arthritis 3-6. Nevertheless, it remains true that conditions perceived to affect quality of life receive less attention. To try and achieve equal treatment for persons with musculoskeletal conditions the research, advocacy, provider, and policy communities need a set of metrics to level the playing field across conditions that have a similar effect on the number of years lost to healthy living 7. In response to the need to increase the visibility of various forms of musculoskeletal conditions, a coalition of the communities with an interest in musculoskeletal conditions joined together to provide periodic updates on their prevalence and impact. Several volumes of The Burden of the Musculoskeletal Diseases in the United States: Prevalence, Societal, and Economic Cost were
produced as a result, initially published by the American Academy of Orthopedic Surgeons on behalf of several professional and advocacy organizations and industry partners (editions in 1984, 1992, and 1999) and by the Bone and Joint Decade and its successor, the U.S. Bone and Joint Initiative (editions in 2008 and 2010) 8. Starting with the 2nd edition, published in 2010, the entire content of The Burden was made available on-line as an exact replica of the print edition. In recognition of the importance of the conditions, continuing need to emphasize their impact, and inherent efficiencies of web-based production, an on-line version of the Burden, starting with the current volume, will be updated each year 9. The volume can be accessed with this URL: http://www.boneandjointburden.org/ The current volume also permits users to customize data retrieval to their specific purposes via a query function. Thus, timely and useful data are and will continue to be available to the communities with an interest in improving the lives of persons with musculoskeletal conditions. In addition to the traditional chapters on spinal conditions, arthritis and related disorders, osteoporosis, and injuries, the current volume includes chapters on the impact on children and adolescents who have one or more of the conditions, rare conditions such as tumors affecting bone, and the impacts of musculoskeletal conditions across the lifespan and among women who have the highest rates of most of these conditions. In this editorial, we can’t possibly summarize all of the information within the Burden. Instead, our goal is to inform the communities with an interest in the welfare of persons with musculoskeletal conditions about the availability of this important tool. However, in doing so, we would be remiss in not highlighting some of the key findings about the growing prevalence
and economic impact of these conditions. The Burden’s summary chapter on prevalence and impact uses the U.S. Government’s Medical Expenditures Panel Survey (MEPS) from 1996 through 2011 10. MEPS data are often influential in policy circles because they provide a common metric across conditions for evaluating their relative importance, something that savvy policymakers in Washington now ask of those trying to make the case for individual diseases.
Key Findings
The proportion of the population reporting musculoskeletal conditions increased from 28.0% in 1996-1998 to 33.2% in 2009-2011, an increase of about 19%. The number with the condition increased from 76.0 million in the earlier period to 102.5 million in the later one.
A disproportionate amount of this increase has occurred among those 45-64 years of age, the baby-boom generation. Although the prevalence rate remained greater among those 65 years of age or older, there were more people 45-64 with musculoskeletal conditions (just under 40 million) than among those 65 or greater (about 25 million).
Musculoskeletal conditions are associated with 574 million physician visits, 379 million visits to non-physician health providers, 390 million home health care visits, and about 21 million hospital admissions. The fastest growing forms of health care utilization are visits to non-physician providers and home health care visits.
Use of prescription medications for musculoskeletal conditions are increasing at a rapid rate. In 1996-1998, persons with musculoskeletal conditions averaged 13.1
prescriptions filled for these conditions; by 2009-2011, this had increased to 20.8 per person. Overall, the number of prescriptions for musculoskeletal conditions rose from about 996 million in the earlier period to about 2.1 billion in the later one.
The aggregate economic impact of musculoskeletal conditions is increasing rapidly. This reflects both the increase in prevalence and increase in per person costs described above. In constant dollars, persons with musculoskeletal conditions accounted for an aggregate economic impact of $367.1 billion in 1996-1998 and $796.3 billion in 20092011, an increase of 117 percent in real terms. Using the more conservative estimates of the incremental impact of musculoskeletal conditions beyond what one would expect of persons with the same demographic characteristics as those with musculoskeletal conditions, such conditions still accounted for an increment of $212.7 billion in 20092011, an increase of 119 percent compared to the $97.3 billion figure for 1996-1998.
Overall, U.S. society is experiencing a pandemic of musculoskeletal conditions due to the aging of the baby boomers and, owing to the increase in per person medical care costs, it is experiencing a rapid increase in medical care expenditures associated with these conditions, even when measured by the most conservative estimation techniques. The Burden documents these profound impacts and now will continue to do so with annual updates. In the zero sum game that affects allocations for groups of conditions in the contemporary policy climate, the data may alter, however slightly, the inherent bias against conditions thought to affect quality of life, not its quantity. Because the Burden is intended to be both a compendium of hard facts and an organizing tool for advocacy in policy debates, we
welcome feedback on what can be done to make it more effective in both functions as it segues from a periodic volume to a continuously updated one.
References 1 Verbrugge L, Patrick D. Seven chronic conditions: their impact on US adults' activity levels and use of medical services. Am J Public Health 1995; 85:173-182 2 Perruccio AV, Power JD, Badley EM. The relative impact of 13 chronic conditions across three different outcomes. J Epidemiol Community Health 2007; 61:1056-1061 3 Avina-Zubieta JA, Choi HK, Sadatsafavi M, Etminan M, Esdaile J, Lacaille D. Risk of cardiovascular mortality in patients with rheumatoid arthritis: a meta-analysis of observational studies. Arthritis Rheum 2008; 59:1690-1697 4 Boyer JF, Gourraud PA, Cantagrel A, Davignon J, Constantin A. Traditional cardiovascular risk factors in rheumatoid arthritis: a meta-analysis. Joint Bone Spine 2011; 78:179-183 5 Meune C, Touze E, Trinquart L, Allanore Y. Trends in cardiovascular mortality in patients with rheumatoid arthritis over 50 years: a systematic review and meta-analysis of cohort studies. Rheumatology (Oxford) 2009; 48:1309-1313 6 Yurkovich M, Vostretsova K, Chen W, Avina-Zubieta J. Overall and cause-specific mortality in patients with systemic lupus erythematosus: a meta-analysis of observational studies. Arthritis Care Res (Hoboken) 2014; 66:608-616 7 Global Burden of Disease Disability Life Years Collaboration. Murray C Barber R, Foreman K, Abbasoglu Ozgoren A, Abd-Allah F, Abera S. et al. Global, regional, and national disabilityadjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for
188 countries, 1990-2013: quantifying the epidemiological transition. Lancet 2015; 386:21452191 8 US Bone and Joint Decade. The Burden of Musculoskeletal Diseases in the United States, 2nd edition. Rosemont, Illinois: American Academy of Orthopedic Surgeons, 2010; 9 US Bone and Joint Initiative. The Burden of Musculoskeletal Diseases in the United States, 3rd Edition. Rosemont, Illinois: U.S Bone and Joint Initiative, 2016; 10 Cohen J, Monheit A, Beauregard K, Cohen S, Lefkowitz D, Potter D, et al. The Medical Expenditures Panel Survey: A National Information Resource. Inquiry 1996/97; 33:373-389