Executive Summary

Arthritis and related conditions make up a large group of disorders affecting the joints, ligaments, tendons, bones and other components of the musculoskeletal system. Arthritis is a leading cause of pain, physical disability and health care utilization in Canada. To date, however, arthritis surveillance activities have been minimal. 

Arthritis in Canada is the first report to paint a comprehensive picture of the impact of arthritis in Canada. It brings together data from national population health surveys, provincial physician billing and drug databases, data on hospital admissions and day surgery procedures, as well as mortality data. This is also the first national report to aggregate data from provincial health service databases for surveillance purposes. 

The key findings of the report are summarized below and are followed by their implications for manpower and training, access to care, and improvements in data for surveillance. 

Key Findings 

The Impact of Arthritis on Canadians 

• According to the 2000 Canadian Community Health Survey (CCHS), arthritis and other rheumatic conditions affected nearly 4 million Canadians aged 15 years and older - approximately 1 in 6 people. Two-thirds of those with arthritis were women, and nearly 3 of every 5 people with arthritis were younger than 65 years of age. 
• By the year 2026, it is estimated that over 6 million Canadians 15 years of age and older will have arthritis. 
• Compared with people with other chronic conditions, those with arthritis experienced more pain, activity restrictions and long-term disability, were more likely to need help with daily activities, reported worse self-rated health and more disrupted sleep and depression, and more frequently reported contact with health care professionals in the previous year. 
• Overall, 19% of Aboriginal people reported having arthritis - equivalent to 27% if the Aboriginal population had the same age composition as the overall Canadian population. 

The Burden of Arthritis in Canada: Mortality, Life Expectancy and Health-Adjusted Life Expectancy (HALE), Economic Burden 

• In 1998, arthritis or related conditions were reported as the underlying cause in 2.4 deaths per 100,000 in Canada, making arthritis a more common underlying cause of death than melanoma, asthma or HIV/AIDS, especially among women. 
• The mortality burden of arthritis and related conditions has been underestimated, because contributing causes of death (such as complications of arthritis treatment) are not available. People with arthritis are the most frequent users of non-steroidal anti-inflammatory drugs (NSAIDs), which can cause gastrointestinal (GI) bleeding. In 1998, GI bleeding resulted in 1, 322 deaths.
• Eliminating arthritis would achieve an overall gain in the health-adjusted life expectancy (HALE) of 1.5 years for each female and nearly 1 year for each male in the Canadian population, with an overall increase in life expectancy of 0.16 years for males and 0.35 years for females. 
• In 1998, estimates placed the economic burden of arthritis to Canadian society at $4.4 billion. This figure likely underestimates the total costs, however, because data for some expenditures (such as costs related to health professionals other than physicians and to over-the-counter medications) are unavailable. In addition, the estimate uses only a subset of the arthritis conditions used elsewhere in this report. 
• Long-term disability accounted for almost 80% of the economic costs of arthritis in 1998, at nearly $3.4 billion; the 35-64 year age group incurred 70% of these costs. 
• The economic burden of musculoskeletal conditions in Canada accounted for 10.3% of the total economic burden of all illnesses but only 1.3% of health science research. 

Ambulatory Care Services 

• Approximately 160 in every 1,000 people over the age of 15 years made a visit to a physician in 1998/1999 for arthritis and related conditions - an estimated total of 8.8 million visits in Canada. More women than men made arthritis-related visits; the rate of consultation was highest among older people of both sexes. 
• Eighty-two percent of patients who made visits for arthritis and related conditions made at least one of these to a primary care physician. Overall, 18.5% of people with arthritis-related visits saw a surgical specialist at least once, and 13.7% saw a medical specialist at least once. 
• Visit rates varied by province, ranging from 146 to 207 per 1,000 people aged 15+ years. Differences in the provincial physician billing databases may account for some of this variation. Differences in the availability of physicians, especially specialists, may also be a contributing factor. 
• There appears to be a trade-off provincially between seeing a rheumatologist and seeing an internist for arthritis and related conditions, particularly rheumatoid arthritis. 

Arthritis-related Prescription Medications 

• The percentage of people with prescriptions for disease-modifying anti-rheumatic drugs (DMARDs), which are effective in treating rheumatoid arthritis, has increased steadily over time. Nevertheless, the overall rate of provision of these drugs falls short of the estimated prevalence of the disease. 
• The prescription of conventional NSAIDs has shown a notable decline since 1998 for individuals over the age of 65. The release of COX-2 inhibitors onto the Canadian market in 1999 has likely contributed to this trend. 
• Some of the increases/decreases in prescriptions may be a result of changes in the provincial drug plan formularies over time. 
• Prescribing patterns of arthritis-related drugs varied among the provinces. This variation may be related in part to the availability of drugs on provincial formularies. 

Hospital Services 

• The number of arthritis-related orthopedic procedures per capita has remained remarkably static since 1994. 
• Medical admissions per capita for arthritis and related conditions declined somewhat from 1994 to 2000, although this decline was somewhat less than that for all other admissions. 
• The only procedures whose rates increased significantly were hip and knee replacements. 
• The number of outpatient procedures has increased, likely as a result of the increased use of arthroscopic (keyhole) surgery. 
• The higher prevalence of arthritis among women is only partially reflected in the rates of orthopedic procedures; the slightly higher rate of hip and knee replacement procedures among women does not wholly reflect their greater need. 
• The rate of orthopedic procedures reached a plateau in older age groups, but the rate of medical admissions continued to climb. 
• Considerable provincial variation in both orthopedic procedures and medical admissions was apparent, even after adjustment for differences in the age and sex composition of the provincial populations. 

Implications 

• Approximately 1 in 6 Canadians aged 15 years and over reported having arthritis as a long-term health condition. Within a decade, 1 million more Canadians are expected to have arthritis or related conditions. The need to understand the tremendous burden of arthritis on both individuals and society as a whole is, therefore, urgent. 
• Surveillance for arthritis can be developed and maintained by integrating national and provincial data from population surveys, provincial physician billing databases, hospital separation and surgical data, data on medications and drugs, and mortality databases. 
• Future surveillance efforts could include initiatives to collect data about arthritis in children and about rehabilitation and community support services for people with arthritis and related conditions of all ages. 

Manpower and Training 

• Manpower issues, such as shortages of both rheumatologists and orthopedic surgeons, are a concern that could be addressed through more recruitment and training of specialists in these fields. 
• Primary care physicians play a central role in the management of arthritis, yet gaps in musculoskeletal education have been documented in undergraduate medical education and postgraduate training. When setting curricula, medical educators may wish to draw on information regarding the amount of illness, disability and health care utilization that these conditions cause in the population. 
• Since a considerable amount of arthritis care is provided by internists (for rheumatoid arthritis) and orthopedic surgeons (non-surgical care of osteoarthritis) these specialty groups might wish to consider further training and continuing education with respect to arthritis. 

Access to Care 

• Barriers that limit access to specialty services (such as rheumatology), including lack of locally available services and low rates of referral by primary care physicians, need investigation. 
• Access to arthritis medications that have proven to be effective in preventing joint damage is a key issue. This includes access to DMARDs as well as the newly developed biologic drugs. 
• Provincial variations in the provision of arthritis-related drugs have been identified.
• In spite of the increasing prevalence of arthritis in Canada, the static trend in rates of orthopedic procedures suggests that the system may be operating at capacity, and there may be potential problems with the capacity of the system to respond to the projected increases in the number of people with arthritis.
• The causes of provincial variations in rates of surgery for arthritis and related conditions and in their impact, both at the individual and population levels, need to be determined. 
• The decline in rates of surgery at older ages and sex differences in surgery rates raise issues of inequities in access to care that need to be investigated.
• Although increasing, the rate of hip and knee replacements is insufficient to meet current and future needs. This is reflected in long waiting times for these procedures.
• Currently, the published data on arthroscopic knee surgery for osteoarthritis are unclear on the procedure's effectiveness. More research is required in this area to properly define the appropriate indications for these procedures. 

Improvements in Data for Surveillance 

• Future national surveys should include more detailed diagnostic questions about arthritis. Physical measures for arthritis (such as assessment of physical function) could also be considered for inclusion in future surveys. 
• The 2000 CCHS asked respondents about arthritis and rheumatism “diagnosed by a health professional.” This question fails to capture many people with arthritis/chronic joint symptoms who do not see a doctor for their symptoms and whose condition consequently remains undiagnosed. Including a question on “chronic joint symptoms” would help provide a more complete picture of the burden of arthritis in Canada. 
• In order to accurately describe the impact of arthritis, surveys could collect health status and health care utilization data that are directly attributable to arthritis. 
• In order to accurately describe the full impact of arthritis on mortality for surveillance purposes, contributing causes of death should be made available. 
• The continued development of national and provincial registries related to hip and knee replacement would help ensure complete coverage. If appropriate in scope, such registries could allow tracking of waiting times, patient-based indicators of need, complications after surgery and failure rates of prostheses. 
• Strong surveillance efforts depend on both standardized definitions of common terms and their consistent use in different settings. A consensus on definitions would allow coordinated and constant surveillance across Canada. If provinces wish to pursue this matter, they could consider the following options: 
  • Using the same diagnostic codes for billing purposes would be a major step toward standardizing provincial physician billing data. Allowing physicians to enter three diagnostic codes for each claim, as currently practised in Alberta and Nova Scotia, would also provide a more accurate representation of the reasons for each visit. 
  • Physicians' specialties could be determined in the same manner in each
    provincial health insurance database and this information actively updated to reflect changes in specialty and subspecialty training. 
  • Diagnostic codes in physician claims data need to be validated. Algorithms using specified numbers of visits in a time period for a specific diagnosis need further exploration and validation, building on earlier work for rheumatoid arthritis and diabetes. 
• Future surveillance of arthritis and related conditions could include the following: 
  • Monitoring changes in health status (including mortality and HALE) and health care utilization that may be related to drug therapy and other new treatments. 
  • Monitoring direct costs of arthritis in relation to indirect costs (such as
    increased drug costs leading to decreased long-term disability costs). 
  • Linking prescription data to patient diagnoses to enable better examination of prescribing patterns for arthritis and related conditions. 
  • Linking hospitalization data to provincial physician billing data to facilitate better understanding of the processes of arthritis care and the outcomes of surgery. 

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