WP4 - Musculoskeletal health status in Europe

1
Musculoskeletal Health in Europe Health
services utilisation
2
What impact do musculoskeletal conditions have on
health care resource utilisation across Member
States?
3
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.

4
Hospital Services Utilisation

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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-9 0993, 1361,
2794, 446, 710-739). 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.
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Average length of stay in days for MSC, 2007 or
latest available
7
Hospital service utilisation core
indicatorNumber 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-9 0993, 1361,
2794, 446, 710-739). 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.
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Hospital discharges by diagnosis per 100,000
population as percentage of all discharges 2007
9
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-9 0993,1361, 2794, 446, 710-739)
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Age-standardised admission rate for MSC per 1,000
population, 2007 or latest available
11
In-patients and day cases for MSC per 1,000
population, 2007 or latest available
12
Variation in utilisation of hospital servicesfor
MSC
Source EUROSTAT 2011
13
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.
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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.

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Hip replacement procedures
Source Surgical procedures by ICD-9-CM, Hip
replacement, Procedures per 100 000 population
(in-patient). OECD Health Data 2009 - Version
November 09
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Number of Primary Total Hip Replacements per
Diagnosis and AgeSwedish Hip Register 1992-2005
Diagnosis lt 50 years 50-59 years 60-75 years gt 75 years Total Share
Primary osteoarthritis 53.5 79.5 81.6 68.1 75.7
Fracture 3.5 4.3 8.2 21.4 11.7
Inflammatory arthritis 17.3 6.6 4.2 2.2 4.5
Idiopathic femoral head necrosis 6.3 2.7 2.0 3.8 2.9
Childhood disease 13.7 4.0 0.8 0.3 1.7
Secondary osteoarthritis 1.5 0.6 0.7 1.4 0.9
Tumor 1.1 0.8 0.4 0.3 0.5
Secondary arthritis
after trauma 0.8 0.3 0.2 0.3 0.3
(missing) 2.3 1.3 1.9 2.2 1.9
Total 100 100 100 100 100
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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
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Knee replacement procedures
19
Health Services Utilisation
20
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).

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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.
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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).

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The burden of MSC on primary care in the UK
consultation rates 2003
24
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
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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
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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.

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GP consultations for MSC by age and gender, UK
2006
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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.

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Percent respondents visited health provider in
past 12 months
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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.
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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

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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-9 0993,1361, 2794,
446, 710-739) Comments Variability may exist
between countries on what is treated as a day
case.
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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.

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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.
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Rheumatology physicians per 100,000 inhabitants
2006EUROSTAT
36
Human resources core indicatorNumber 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.
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Orthopaedic specialists per 100,000 inhabitants
2010
38
Number of practising Occupational Therapists per
100,000 inhabitants 2011COTEC
39
Physiotherapists
40
Number of diagnostic DXA scanners in EU
41
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 2005Krishnan 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- 18,000 Euros per patient per year
  ( Engel-Nitz 2007).

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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.

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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
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Reasons for long-term medical treatment
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Longterm treatment because of longstanding
troubles with muscles, bones and joints
(arthritis, rheumatism)
46
Percentage of all respondents taking medication
for MSC in past 2 weeks
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Drug use indicatorPharmaceuticals 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.
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Pharmaceutical consumption, Musculoskeletal
System, Defined daily dosage per 1000 inhabitants
per day
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Pharmaceutical consumption, M01A-Antiinflammatory
,antirheumatic prod. non-steroids, Defined daily
dosage per 1000 inhabitants per day
50
Drug use indicatorPharmaceuticals 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.
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Pharmaceutical sales, Musculoskeletal system per
capita US PPP
52
Pharmaceutical sales, M01A Antiinflam,
antirheumatic prod. Non-steroids per capita US
PPP
53
Pharmaceutical sales musculoskeletal system,
total sales
54
Pharmaceutical sales M01A Antiinflam,
antirheumatic prod. non-steroids total sales
55
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 2000-2006.
• 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).

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eumusc.net is an information and surveillance
network promoting a comprehensive European
strategy to optimise musculoskeletal health. It
addresses the prevention and management of MSCs
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 2010. It is
supported by the European Community (EC Community
Action in the Field of Health 2008-2013), 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 www.eumusc.net  
Disclaimer The Executive Agency for Health and
Consumers is not responsible for any use that is
made of the information contained within this
publication