Patients with Axial Spondyloarthritis are Great Consumers of Healthcare Resources, Especially Young and Women: Results from the Spanish Atlas

The present study has demonstrated that younger age, female gender, greater disease activity, higher functional limitation and longer diagnostic delay were associated with higher healthcare utilization by patients with axSpA. Furthermore, three quarters (77.9%) of patients with axSpA used at least one healthcare resource per year, with an average of 42.3 healthcare resource uses per year (including healthcare visits, medical tests, hospital admissions or emergency visits) and the median was 25. Therefore, half of the patients used 25 or more healthcare contact.

Healthcare Utilization

Our study shows that the proportion of patients who had at least one healthcare resource use per year was higher than that shown in a previous study of 612 British patients with axSpA (77.9% vs 59.0%) [5]. A possible explanation for this difference in healthcare utilization proportions may be a higher disease activity (5.7) of patients with axSpA in Spain in the Atlas study compared to the lower disease activity of patients with axSpA in the UK (4.6). In our study, one in three patients visited the physiotherapist (with an average of 20 visits per year). This makes sense as physiotherapeutic interventions for axSpA have been shown to be an integral part of disease management, being effective in inducing short-term improvement in spinal mobility [12].

Socio-demographic Factors and Healthcare Utilization

The fact that younger patients were associated with a higher healthcare utilization could be due to the early onset of functional limitations in daily activities among these patients [13]. In this sense, a Dutch study reported that younger patients with Ankylosing Spondylitis (AS) more often withdrew from work than older patients [14]. Perhaps the disease is more uncontrollable and less well managed in younger patients with more acute symptoms than in older patients, with fewer acute symptoms and better managed. However, the possibility that younger people take more care of their personal health owing to increased health education cannot be ignored. In addition, our results show that women are associated with higher healthcare utilization, which may be because, compared to men, women with axSpA have higher disease activity and pain [15,16,17], severe extra-musculoskeletal manifestations [18], poor quality of life [17] and less adherence to treatment [19, 20].

Patient-reported Outcomes and Healthcare Utilization

In the present study, patients with axSpA with a higher utilization of healthcare resources were associated with higher disease activity, greater limitation and a longer diagnostic delay. These results are in line with previous studies which demonstrated that patients with more visits to the general practitioner, the physiotherapist, and more hospital admissions or outpatient visits had higher disease activity [3, 5, 6]. Another factor associated with higher healthcare utilization was diagnostic delay; indeed, previous studies have shown that diagnostic delay resulted in increased healthcare costs and utilization [21, 22]. A similar study among European patients, including patients from the present Spanish Atlas study, showed that longer diagnostic delay was associated with younger age at symptom onset, female gender and higher number of healthcare professionals (HCPs) seen before diagnosis [23]. Furthermore, in our study, patients with higher healthcare utilization were associated with a higher functional limitation, which might make sense as Rafia et al.’s study showed a relationship between higher number of visits to the general practitioner and greater loss of function [5].

As we have shown, half of patients with axSpA used 25 or more healthcare resources during a year, representing a high level of utilization. In addition, the present study show that young people and women are the two groups that use healthcare resources the most. In relation to patient-related outcomes, patients with active disease, with functional limitations in daily activities and with a longer diagnostic delay are the most frequent users. These results suggest that there are specific profiles of patients with axSpA who may need more specific follow-up to reduce their number of visits, such as women, young people and those with uncontrolled disease and functional limitations. From a socio-demographic point of view, these young patients who are making their debut in the disease typically do not have coping tools, which has a negative impact on their health status and the need for more healthcare; this also applies to women whose disease outcomes are poorer. Likewise, both young people and women represent groups for whom there is still the erroneous perception that they have a lower prevalence of axSpA, compared to men and the elderly [24, 25].

Strength and Limitations

The study is not free of limitations. Firstly, the cross-sectional design of the survey does not allow one to establish causality between healthcare utilization and socio-demographic and patient-reported outcomes factors. However, we might expect that those patients who use more healthcare resources have worse disease outcomes such as disease activity, functional limitation and diagnostic delay. Secondly, the survey relied on self-reported data, and did not attempt to confirm participant diagnosis nor to support participant responses with clinician-reported assessments. Therefore, healthcare utilization may also suffer from response bias because patients may not accurately recall their use of healthcare [26]. Another limitation of the study is the missing values in the regression analyses, since these analyses work only with subjects with complete data. During the preliminary phase of survey development, patients expressed concerns about aspects of their disease that were not being adequately measured. Therefore, it was decided to develop the functional limitation index and the spinal stiffness index. Although an adequate Cronbach alpha value was obtained for both scales, the fact that these scales are not validated should be considered a limitation of the study.

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