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8/8/2019 Fit for Work Europe: What can early intervention in MSDs deliver for patients and health systems?
http://slidepdf.com/reader/full/fit-for-work-europe-what-can-early-intervention-in-msds-deliver-for-patients 1/17
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
8/8/2019 Fit for Work Europe: What can early intervention in MSDs deliver for patients and health systems?
http://slidepdf.com/reader/full/fit-for-work-europe-what-can-early-intervention-in-msds-deliver-for-patients 2/17
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%
8/8/2019 Fit for Work Europe: What can early intervention in MSDs deliver for patients and health systems?
http://slidepdf.com/reader/full/fit-for-work-europe-what-can-early-intervention-in-msds-deliver-for-patients 3/17
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
8/8/2019 Fit for Work Europe: What can early intervention in MSDs deliver for patients and health systems?
http://slidepdf.com/reader/full/fit-for-work-europe-what-can-early-intervention-in-msds-deliver-for-patients 4/17
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.
8/8/2019 Fit for Work Europe: What can early intervention in MSDs deliver for patients and health systems?
http://slidepdf.com/reader/full/fit-for-work-europe-what-can-early-intervention-in-msds-deliver-for-patients 5/17
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
8/8/2019 Fit for Work Europe: What can early intervention in MSDs deliver for patients and health systems?
http://slidepdf.com/reader/full/fit-for-work-europe-what-can-early-intervention-in-msds-deliver-for-patients 6/17
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
8/8/2019 Fit for Work Europe: What can early intervention in MSDs deliver for patients and health systems?
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Impact of Early Intervention
Early referral to specialised early arthritisclinicsTargeted optimal therapy at presentationDramatically improved outcomes
8/8/2019 Fit for Work Europe: What can early intervention in MSDs deliver for patients and health systems?
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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
8/8/2019 Fit for Work Europe: What can early intervention in MSDs deliver for patients and health systems?
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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
8/8/2019 Fit for Work Europe: What can early intervention in MSDs deliver for patients and health systems?
http://slidepdf.com/reader/full/fit-for-work-europe-what-can-early-intervention-in-msds-deliver-for-patients 10/17
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
8/8/2019 Fit for Work Europe: What can early intervention in MSDs deliver for patients and health systems?
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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%
8/8/2019 Fit for Work Europe: What can early intervention in MSDs deliver for patients and health systems?
http://slidepdf.com/reader/full/fit-for-work-europe-what-can-early-intervention-in-msds-deliver-for-patients 12/17
Importance of workVicious circle
Stopworking
Feel bad
Feelill
8/8/2019 Fit for Work Europe: What can early intervention in MSDs deliver for patients and health systems?
http://slidepdf.com/reader/full/fit-for-work-europe-what-can-early-intervention-in-msds-deliver-for-patients 13/17
Importance of workVirtuous circle
Keepworking
Feelwell
Feel good
8/8/2019 Fit for Work Europe: What can early intervention in MSDs deliver for patients and health systems?
http://slidepdf.com/reader/full/fit-for-work-europe-what-can-early-intervention-in-msds-deliver-for-patients 14/17
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
8/8/2019 Fit for Work Europe: What can early intervention in MSDs deliver for patients and health systems?
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†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
Abbott. Data on File. PROWD Study Demographics and Trial Data. LN0015344
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)
8/8/2019 Fit for Work Europe: What can early intervention in MSDs deliver for patients and health systems?
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# p=0.055 MTX vs Ada + MTX
Abbott. Data on File. PROWD Study Demographics and Trial Data. LN0015344
Time to (imminent) job loss
8/8/2019 Fit for Work Europe: What can early intervention in MSDs deliver for patients and health systems?
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Conclusion
With investment in education, infrastructure,and therapies we already have means todramatically reduce disability and subsequent
workloss