hello and welcome to this edition of joint action [Music] this podcast is dedicated to all those out there who have osteoarthritis on the show we unpack the truth and demystify the myths about the disease and its management if you have joint pain and want to know more about how to manage it from the world's best experts you've come to the right place without further ado it is time to welcome your host david hunter hello and welcome to this edition of joint action this week we have the privilege of discussing osteoarthritis economics 101 now the economic burden due to osteoarthritis is massive and is the result of direct cost to the health care system indirect cost to individuals living with the disease and the intangible costs of living with a chronic disabling condition compared to age and sex match peers osteoarthritis patients incur higher out-of-pocket health-related expenditures people with osteoarthritis also incur substantial costs due to lost productivity including both absenteeism which is days off work and presenteeism which has reduced self-reported productivity at work now as the burden of osteoarthritis rises globally so too will the economic burden and as a society we spend a considerable portion of our health budget on osteoarthritis and the economic consequences in terms of underemployment lost taxation and poverty are immense and the purpose of this episode of joint action is to examine the economics of osteoarthritis from both an individual and a societal perspective and to look at the cost effectiveness of various treatments particularly in our current economic climate where the limitations of health care resources are pressured it's really important to understand the burden of disease from the illness to the individual to society and also better understand rational treatment choices from their cost effectiveness and particularly as it relates to disinvestment in low value care to discuss and help us to understand this complex topic we're joined by none other than elena lesina and professor elena lesina is the robert w lovett professor of orthopedic surgery and biostatistics at harvard medical school and she's an internationally recognized investigator in the epidemiology and outcomes of musculoskeletal disorders she is a director of the policy and innovation evaluation in orthopedic treatments center and co-director of the orthopedic and arthritis center for outcomes research and is a principal investigator of the methodology core of the robert brigham multi-springer clinical research center at brigham and women's hospital in boston dr lesina has published over 460 peer-reviewed articles she leads an nih-funded multi-site project to conduct health policy evaluations related to surgical and non-surgical management of knee osteoarthritis and she is recognized internationally for expertise in melding rigorous clinical research methodologies across multiple clinical disciplines from orthopedics and osteoarthritis to global health elena welcome to the show it's wonderful to have a chance to chat with you and i really really appreciate your time in doing this well my pleasure thanks so much for inviting me now it's a really interesting time you're in the lead up to the first presidential debate over there and so from both an economic and a health perspective there's lots and lots happening around the world now you're a really deep thinker and i've had the privilege of interacting with you in many different ways over a number of years but i still think there's a lot i can learn about you and the first part of the show is i usually try and dig in and work out a little bit more about you both for myself and for the listeners but i'm wondering if you had to describe yourself in five words what would they be okay so data driven storyteller mother orange and fun storyteller well i hope i hope we get a good story out of this today but from a professional perspective can you tell me a little bit more about what you might do on a day-to-day basis so i think you know the activities quite vary they depend on what stage of the projects we're doing we're conducting a few clinical studies we are designing economic evaluations and we spend a lot of time talking to clinicians because ultimately we would like to promote value-driven care and how do we know what are the most pressing clinical issues that's what we talk to clinicians we talk to patients and that's how we identify the critical questions that we are focused on addressing and you you do it really well and i think you engage with a broad segment of clinicians and other people to to gain that perspective and i think you really meaningfully involve them as as someone who's been involved in a number of those conversations over over a long period of time now it may be storytelling it may be something else but when you're not doing your day job what is it that you like to do oh that is quite rich uh my recent hobby i learned and totally enjoyed baking artisan breads and french pastries that takes a lot of time but we need to do it with love i love tandem biking with my husband i like to read and i totally enjoy entertaining my family and friends which is getting a little more complicated it requires quite a lot of kind of creativity to keep at it these days yeah i mean i think with some of the social distancing some of those social interactions have become a a lot more complex and obviously hence zoom and other interactions have taken off but the bread and pastry making is that something you did before covert or something that you just picked up drink of it i think i actually started to artistic to bake bread about a year ago when one of our research assistants left and gifted me a beautiful book about bread making and i said okay i'm gonna give it a try and that's turned into a wonderful hobby and my entire family enjoys it and it's not that difficult that's that's the key a little flour a little salt a little yeast and a lot of love and some water and you have bread i'm sure you do it incredibly well but it's uh it sounds like there's a number of people who picked up hobbies like that during lockdown and other things now this is obviously an incredibly complex area and it's one that you've been engaged in such a pivotal way for such a long period of time but i guess what i want to do in the first instance is just get a better handle on what it is that we're talking about and how big that magnitude of this is so when we're talking about average direct healthcare costs for someone with osteoarthritis what are those costs typically made up of and you ask a very very good question and it's important to recognize that the interpretation of the meaning of the question is very important what i would like to maybe start is to say is when we say cost or when we use the term cost different people have very different meanings and even different researchers use very different matrix to estimate those costs so the costs are sometimes being estimated or substituted by charges payments reimbursements it's important who pays whether it's a private insurer whether it's a patient using his out-of-pocket dollars or whether it's a government payer and i think often when we uh see the numbers whether they are highlighted by media whether we read it in scientific press i think it's important to recognize and understand what those numbers mean for example i would like to touch on the very subtle but very useful distinctions so when we talk about the cost incurred by patients with asteroid traitors we need to distinguish two type of direct medical costs ones are directly related to the osteoarthritis pain and another one are not directly to their away pain and this is something people with away often have cardiovascular disease they have some problems with their digestive systems we know that people who have osteoarthritis often tend to be a little heavier so they may have a higher chance of having diabetes so people wasted with osteoarthritis incur a variety of direct medical costs and only a portion of them relates directly to osteoarthritis that really um relate directly to osteoarthritis include cost of x-ray for example a cost of undergoing physical therapy or cost of undergoing total knee replacement surgery but people with osteoarthritis also come to visit their cardiologists and they have some cardiovascular procedures and they may have some stomach pain and so when we talk about the cost in persons with osteoarthritis what often happens is that we capture all costs related to health care of people who have osteoarthritis and often researchers trying to capture or trying to distinguish between those two types of costs directly related to oa and overall costs but that doesn't happen very often and that's why it's really important to understand you know what numbers are being quoted because of this such variety of methods um that are being used and definitions and the data that are being used then we're seeing the direct medical cost not related to a can vary from about 1 000 us dollars to eight thousand dollars for those people who don't have any core morbid conditions and this is the kind of the lower level and they can go as high as about to 14 to 20 thousand dollars per year in people who have two to three cormorant conditions because of this complexity in capturing or mixing together cost directly related to osteoarthritis care and overall health in persons with osteoarthritis we see a wide spread of estimates which are capturing cost in persons with oa and they vary from about a thousand dollars per year to 21 000 per year so that's why if we really would like to focus on costs directly related to oe compared to overall cost in people with away who receive medical care the ratio is about one to ten it's a loaded question and i think the answer is it depends because the question is is it the cost of osteoarthritis in kind of today's days is it the cost for one year is it the cost of the lifetime so the cost of the lifetime of a person who is in the osteoarthritis is about 15 000 so it's about 14 millions of people with neostar arthritis in united states and if we multiply that so we get about kind of 20 billion dollars so that's the that's the approximation of cost yeah so that was a really helpful preamble and explanation for a very complex area and you mentioned that when we're thinking about costs healthcare costs some of those costs come directly out of a person's pocket approximately what proportion of the expenditure relates to out of pocket expenditure again very good question and i feel that when people ask me what's what's your favorite almost used answer that you give to people unfortunately it depends and so it depends on what people are willing to do because it depends what people have what kind of health insurance and where they live but most of the time again the pain relieving medications with proven short-term effectiveness are relatively inexpensive and they can be purchased in pharmacies for relatively low cost the challenge is that because they're not very very effective over the long term people are seeking hungrily seeking some other means of relieving their pain and in order to do this they unfortunately using some unproven treatments that are being widely and happily advertised to them they are different modes of um advertisement and communication and those treatments usually offered with cash payments and those payments can range from thousand dollars to ten thousand dollars so and i think of course it depends what whether patients are willing whether they have the means and whether they are believers understood all right so it sounds sounds like it's it depends a little bit on there on there exactly now with regards obviously the other aspect of the substantial costs related here that are separate from the direct healthcare costs there are these things called indirect costs what are they and on average what do they amount to per person and to an economy such as the us and again i think given what you were saying before i guess let's just try and focus on the osteoarthritis elements of it as distinct from other health conditions a very important question because it's critical to understand the entirety of cost involved in managing chronic conditions such as osteoarthritis and before we get to indirect cost i would like just to list all the costs that sometimes we do think and sometimes would not necessarily think about related to the presence of the disease or the burden of the disease so we talked already about direct medical costs this is the costs that directly relate to treatment so this is seeing a doctor paying for a visit to a doctor receiving x-ray receiving a surgery it's important to recognize there is another sort of sort because that's that are called direct non-medical costs so these costs are also maybe non-trivial travel to the hospital somebody who lives in rural areas and is interested to undergo to real knee replacement for example they made to undertake a trip to a regional center they may bring somebody with them and they will incur much bigger costs so they direct non-medical cost also a component of cost and then there are indirect or time costs these are the costs related to reduced productivity and they can be stratified in two groups one is i think david you mentioned this it's presentees when people with osteoarthritis come to work but cannot work as productively as they otherwise would be if they would not experience some joint pain and absenteeism what they need to miss the work because of their osteoarthritis both of them are non-trivial and one of the key reasons for that is because it has been shown there is a large evidence that occupational exposure is one of the risk factors for osteoarthritis so people who are involved in manual labors may have a higher risk of getting osteoarthritis and because they their work is so related to use of their joints that this indirect cause have a particular high toll in person with osteoarthritis because they even need to move to another occupation or to try to do different activity and it has impact on their earnings and it has impact on their well-being in terms of what's the variability of cost we also need to recognize that osteoarthritis it used to hit people often when they already retired in the mid 60s 70s and older and now it's being diagnosed at younger ages and so more and more people are diagnosed with osteoarthritis while still being in a workforce and so estimated annual time cost to indirect costs for persons with osteoarthritis after we account for the fact that only 60 of them are in the workforce it's about 1400 per year in u. s dollars and this number is increasing greatly if we take into consideration the year when persons with osteoarthritis decide to undergo joint replacement in that year these indirect costs increase about fivefold and again similar to what you did with the direct healthcare costs if we talk about the number of people that are affected presumably we can then compute the total cost to the us and would that number still be about 40 million people so again i think you know right now in united states for example there is about 700 000 total knee replacements are being done on an annual basis so if you multiply it by about seven thousand dollars so that will give an estimate of the indirect cost at the year of the and related to the receiving total replacement and if we take this overall people with new osteoarthritis and getting multiplied by a thousand dollars we are getting to again billions very very quickly numbers add up and being multiplied because of the very high prevalence it's very frequently occurring now one element that you've done for many years and have worldwide recognition is that of cost effectiveness analysis and it's an area where it's particularly employed to i guess the limited healthcare resources and budgets that we are constrained by and so in that context economic evaluations are critical to understand the merits of different management strategies and one particular approach as mentioned is a cost effectiveness evaluation now can you briefly explain what these are and particularly focus on some of the terminology that you might use and some of the subsequent questions i might ask yes this is thank you this is very important because we have so many misperceptions related to cost-effectiveness analysis and unfortunately because of misperceptions um and you know this methodology is not used as frequently and as often in health policy decisions as we hope it would be again in some settings in some countries it's being used more frequently and in others unfortunately not as often so what is cost effectiveness analysis as you david just stated we would like you to not we do live in the era of limited resources and because resources are limited we need to figure out how to use them and so cost effectiveness analysis combines two outcomes once related to health benefits and another one related to cost and so health benefits in cost-effectiveness analysis often expressed in quality adjusted life years why is it so important to do quality adjustment there are some diseases such as cancer lead to premature mortality and so treating cancer extends life some other diseases such as osteoarthritis do not directly affect the length of life although more recent evidence suggests that it might through limiting mobility but most of the time it limits and affects the quality of life the joy that people have by you know waking up every day and doing activities that they like and so that's why it's important in order to understand for the society for the peers how to distribute those resources that are dedicated for health care it's important to recognize those two components the duration of life and quality of life so cost effectiveness analysis does exactly that the key feature or the key matrix of such analysis is determined by incremental cost effectiveness ratio which is the ratio that compares the differential cost between two strategies two treatment strategies and the differential impact on quality justice life expectancy the beauty of this analysis is that it can be compared this matrix can be compared across different diseases different areas and so if we need to prioritize high value care versus low value care versus no okay no value care i think we can do it across different conditions let me spend perhaps one more minute to define this high value care low value care and no value care and how we look here is the then when we're spending not a lot of money for getting a lot of benefits and that kind of know a lot of money is defined by so-called willingness to pay threshold low-value care is when we spend a lot of money and receive very little benefits and that is important to identify that type of care because we can address it in two ways we either can think whether we can reduce the cost and turn the low value care into high value care we can discuss and decide whether it's worth paying for such care and no value care is the care where we're spending a lot of money but unfortunately do not get any benefits and that care should not be implemented but the only way to even divide care or different interventions that we now use is to perform the formal cost effectiveness analysis it will help that will help such stratification that's brilliant thanks elena and that will really be a helpful context for some of the the questions that come after that now you've been leading and i've had the privilege of working with you on a project to conduct health policy evaluations for both surgical and non-surgical management of knee osteoarthritis and have done a number of evaluations looking at the cost effectiveness of a range of those strategies this is a really unfair question because it's packaging years and years of work into one question but of those which are cost effective and which are not so i think the strategies that incorporate physical activity and weight loss in people with osteoarthritis particularly with osteoarthritis are very cost effective total joint replacement is very cost effective opioids are not at all cost affected in fact they're not even low weight you care are using opioids for australia try to scare from the policy decisions this is nowhere to care brilliant that's a very very great summary of years years and years of work that you've been doing there but how is that influencing policy and how are you disseminating the results that you've got from those great range of studies to increase the impact of what you do this is a very important question and we're spending quite a bit of time thinking of the ways of how to do it better as scientists we have one traditional way of disseminating our research we conduct our investigations we publish them into scientific journals and we hope that that's the way to uh providing the evidence the work that we do on cost effectiveness often is being picked uh up by the treatment guidelines in osteoarthritis specifically so that helps to establish the guidelines that you know treatment hopefully defines standard of care another way to disseminate work is to present work in scientific and non-scientific meetings and you know i'm trying to use every opportunity and the more recently it's the social media i think you know we are exploring and having fun with twitter and that's how the research is being propagated and hopefully that's how people will know about it and that's how makers will take a note and hopefully make the determination what is highway leo and what is nowhere you care yeah it's uh so important because i think as you say historically a lot of researchers really have limited themselves to the submission of a manuscript in publication in a journal rather than necessarily thinking about getting that message out there now in some really pivotal work that you've done with hacksby abbott in new zealand you've looked at a number of factors that i think are really illuminating when thinking about the burden of this disease one is about the average mean health loss over a person's lifetime and then another parameter which you've done some work on there is the proportion of quality adjusted life years lost out of a total quality adjusted life expectancy in a person that's got neos to authority so just wonder if you want to just briefly explain those very complex concepts um and then just give us some estimates as to what that was for at least in new zealand so quality adjusted life here is a matrix that defines a year spent in perfect health whatever the definition of perfect each of us has the challenge is that people with chronic conditions such as osteoarthritis obviously cannot say that the health is perfect and so they are discount or they they use some factor that would say you know the year is spent with osteoarthritis obviously is not as good as the year spent in perfect health under this the question is how much worse it is a few years ago i found a very um surprising to me data is suggesting that people with severe osteoarthritis their quality of life is similar for the two people with stage four breast cancer and it's taking both emotional component and physical component and so people who live with severe osteoarthritis their quality of life is equivalent to about 0. 65 of the year of life in perfect health and so when you multiply this or take into consideration that osteoarthritis is a chronic conditions that and people live with it for over two decades so that's basically uh accounts for the fact that there is a lot of losses in quality adjusted live years so we did analysis in united states trying to estimate how much australis contributes to quality adjusted life losses and we're estimated that people with osteoarthritis and or obesity lose between 10 and 25 of the remaining quality adjusted life expectancy and when we conducted similar analysis in new zealand we came up with similar magnitude of about 23 yeah that's a really jarring statistic and i think potentially brings home the importance of appropriate management i mean getting getting well treated and also i guess underpins the importance of developing new and effective therapies now like many other non-communicable diseases like diabetes and heart disease social determinants play a really important role in the etiology of osteoarthritis and inequities and disparities in particular are prevalent both in determining the development of disease and the care that's received how can economic analyses assist in more appropriate apportioning of care particularly when one takes into account the costs of delaying or foregoing treatment in people who are less well-off or from a disparate group and also the impacts that would have on their labor market productivity this is a good question again the cost effectiveness and economic evaluation is a policy of most of the time it's addresses policy-based questions but we would like to use the methodology that we're using for cost-effectiveness analysis and things about the ways to inform and educate people who perhaps do not understand or appreciate the value of certain procedures certain treatment modalities one example is total knee replacement there is a substantial body of evidence suggesting that in united states hispanics and african american people you know usually do not undergo thrombi replacement with the same rates as caucasian patients with new osteoarthritis and a lot of it may be cultural a lot of it may be understanding a lot of it may be access to care and so the challenge is how do you help to not only respect the preferences because we would like to respect the preferences but also help people to understand the detriments in their health that they're taking and one way of doing this is to present information in a way that is being perceived as useful and meaningful to a person who are affected by the condition so that's why the quality adjusted years that may be lost if somebody would prefer not to have knee replacement compared to taking knee replacement i think is one of the matrix that helps to bring the value of certain treatment closer to patients i think that's how the some of the matrix and cost effectiveness analysis could be used to reduce disparities and inform the preferences yeah it's really really helpful and i think it's obviously depends a lot on context and the nature of the healthcare system and whether a person has insurance or whether there's universal coverage and obviously also speaks a lot to the disparities that are pervasive in many communities that influence health and health care now some interesting analyses have been done relatively recently looking specifically at the impact of arthritis in general that at least it has on average weekly income and the likelihood of a person being in poverty and just wondering whether you'd want to comment on that at all yes this is important question and again very multifaceted because people are suffering from osteoarthritis often in their second part of life and some of them already out of workforce the challenging part in trying to estimate the impact of osteoarthritis on the wages and the income loss is again so complex that i would not be willing to come up with a single number and again the challenge is related to what is the occupation of people who are suffering by osteoarthritis and because it's more likely to affect people in manual labor and in construction worker that may um depending on where they work you know they may or may not be the highest paid employees so it may be perceived that if you multiply the number of people who needed to take earlier retirement or would lose the income due to osteoarthritis because of the average pay per hour it may not be as high as if you would do it for for uh physicians or computer scientists but i think it's important to recognize it's not just the total number with the global economic burden each person is an individual who has a family who has some aspirations and some ways to live and i think you know if having osteoarthritis bring them closer to poverty this is an issue that needs to be taken into consideration very very clearly and we need to understand if somebody is getting away as a part of the occupational exposure maybe we need to consider some of the social problems that would help them to alleviate the economic impact on their health and on their family yeah that's really helpful and i think really i guess just to emphasize that the frequency of the disease and the number of people who are disabled and out of work as a consequence of the disease have has massive financial implications for economies around the world both in terms of reductions in weekly income the likelihood of a person being in poverty and reductions in both retirement income and savings as well as taxation revenue so it has a massive economic impact now you alluded to this a little bit before and it obviously varies by country but for a lot of countries they do take into account cost effectiveness as part of the regulatory approval process and historically a lot of guidelines you know when i reflect on this for osteoarthritis in general a lot of guidelines pay no attention to the cost effectiveness of drugs and really just focus on efficacy and safety i'm just wondering what do you think cost effectiveness should be considered as part of guidelines i think absolutely but again i'm a biased person because i kind of do this kind of research and i think the reason why is it important because that's the way that we can distinguish high and low wealthy care and i think as a society our overall health will be improved if we will focus and promote high volume care and try to really lower the use of the low winning when you care unfortunately over many many many years physicians were staying shy of considering cause because i think you know the goal of physician is to improve lives at whatever cost and i think what is the important to recognize that if we're going to spend a lot of resources in low-wage care we just won't have money to spend on new evolving treatment that you know would be highly efficacious but likely to be costly and so in order to incorporate that opportunity cost we need to really work through the therapies that and treatments modalities that are really not worth using and cost effectiveness analysis helps to helps to delineate that that's wonderful and really helpful explanation and i think a helpful prelude to the next thing that i wanted to ask you about which is just this concept of disinvestment in low value care options and potentially reapportioning that to more appropriate care are there any particular targets that you would highlight where we should be disinvesting in low value care you mentioned opioids before but there may be others like arthroscopy opioids i would say that would be the the most important component because i think opioids while is being perceived by some patients and some physicians who tried many different options and that's the only way to alleviate pain i think it's important to again educate and provide information and then i think physicians and patients should choose but choose it based on the proper evidence with respect to arthroscopy i think this is a big discussion and probably would require a special issue because there is a lot of interesting data that are coming i think nobody is saying that arthroscopy should be used for treatment of osteoarthritis and i think there is a lot of the evidence that is evolving and i think we see the decrease of use of the procedure as the result of that evidence but again i wouldn't go as far as to say that atroscopy should not be used because there is specific groups of patients where it can provide some temporal relief that could be perceived as important all right what we might do is get you back for that arthroscopy conversation for on another day because as you suggest it's probably a little bit more complicated than just one throwaway line from me in the interests of um me having not managed this time particularly well are there any patient friendly resources or links that might shed further light on this topic or anything that i should have asked that i forgot to i think this cdc website in united states provides quite a bit of very good information arthritis foundation and i showed that those was arthritis foundation analogous in australia and in other countries i think this is usually patient-driven very good information that helps to highlight important interventions but i think what we all recognize and learn more and more that there is no single magic pill which that will alleviate pain from osteoarthritis it requires work it requires work on the patient and it requires the shared decision making and what is very important is that physical activity weight loss those the interventions that have been over and over proven very effective and cost effective that's really helpful now in the interest of getting you home so you can uh watch trump v biden in the first presidential debate i'm just going to ask you a couple more questions but why do you do what you do what motivates you that's a very good question so i think because i feel that this is the ways to make a difference in people's lives because by promoting highway care we can help to re-adjust the spending of resources and educate people and provide them with matrix hopefully that they're meaningful to them that they will start helping themselves as i said there is no magic pill we need to uh identify a combination of medical treatments behavioral treatments surgical treatments and doing this as a multi-disciplinary groups with physicians with methodologists like i am and with behavioral scientists i think that's the way the goal is to make people feel better and do not perceive that osteoarthritis is inevitable part of aging i think people can live through this i think they can enjoy life and i think our job is to help them to do so wonderful i hope you maintain the motivation and enthusiasm because you make a huge difference for the field and i know for people who are out there provide a lot of information that's incredibly valuable now just in closing is there one piece of advice knowledge or wisdom that you'd like to give to people with osteoarthritis i think that this is a very all but very relevant advice physical activity saves lives improves smart lives and alleviates pain so we shall all do whatever we can and more to be more physically active elena thank you so much it's wonderful to have a chance to spend some time with you and really appreciate the time that you've dedicated to have a chat to me about this greatly appreciate it you're very welcome it has been a pleasure thank you david that is all for this episode of joint action if you like what you hear and want to support us please rate us on your favorite podcast platform alternatively visit the website www.
jointaction. info to post a question donate to our research or send us some feedback between now and next time please do take care of yourself stay strong and stay active thank you so much for listening thanks for listening to joint action with david hunter if you like our show and want to know more check out www. jointaction.
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