Original Articles 187
Physical, psychosocial and economic impact of
rheumatoid arthritis: A pilot study of patients seen at
a tertiary care referral centre
AMITA AGGARWAL, SHELLY CHANDRAN, RAMNATH MISRA
arthritis is associated with marked physical disability.
In addition, it has an impact on patients’ psyche
and social well-being, and entails a major financial burden.
The impact of the disease in different cultural and social
backgrounds is varied. Limited data are available from
India on this aspect.
Methods. Patients with rheumatoid arthritis satisfying
the 1987 modified American College of Rheumatology criteria
were included. Besides demographic data, functional impact
was assessed using the Health Assessment Questionnaire
(HAQ). The psychosocial impact was measured using the medical
outcomes study short form 36 (SF-36) with minor modifications.
Data on direct and indirect health costs were collected
by direct interview.
mean age of 101 patients (90 women) was 43.2 years and
mean duration of disease was 8 years. Their mean
(SD) HAQ score was 0.97 (0.69) with 8 patients having scores >2.
On the SF-36 scale (0–100) the mean (SD) score for
various domains were: physical functioning 49.90 (28.55),
social functioning 55.51 (20.59), role limitation due to
physical problems 32.67 (41.34), role limitation due to
emotional problems 47.54 (40.08), mental health 47.36 (7.99),
general health perception 52.38 (8.30), energy and vitality
58.56 (6.09), and bodily pain 49.26 (18.87). The summary
score for the physical component was 37.95 (9.03) and for
the mental component it was 47.71 (4.81). While the physical
component summary score had excellent negative correlation
with the HAQ score (r=–0.84), correlation with the
mental component summary score was poor (r=0.32). The annual
average total cost burden per patient was Rs 16 758, of
which Rs 11 617 (67%) was spent on health services and
the rest on non-health services (travel, home help and
loss of wages).
Conclusion. Rheumatoid arthritis causes significant physical
and social disability besides being an economic burden.
Indian patients had good scores for mental and social health
suggesting good family support systems or reluctance to
express their feelings despite physical disability.
Natl Med J India 2006;19:187–91
Rheumatoid arthritis (RA) is a chronic autoimmune arthritis
that causes significant morbidity and mortality and affects
almost 1% of the global population. Patients with RA have
a higher all-cause mortality as compared with age-matched
controls, which has remained unaltered over the past 4–5
has been calculated that RA reduces the life span by 5–10
years depending on the age of onset.2 Patients
with RA have a 7-fold higher risk of disability as compared
with age- and gender-matched controls.3 They
gradually lose their functional capacity and at the end
of 15 years nearly 30%–50% of the patients are in
functional class III/IV and need help for vocational/self-care
with functional disability, RA has an impact on the emotional
and psychological functioning of
It has been suggested that one disease-specific and one
generic instrument be used to assess the impact of the
instruments measure broad aspects of the quality of life
(QOL) and provide a general sense of
the effects of an illness. The major limitation of generic
QOL instruments is that they do not assess potential condition-specific
domains of QOL. Because of this, they may not be sensitive
enough to detect subtle treatment effects. In contrast,
disease-specific instruments are more sensitive in detecting
minor treatment effects.
The Stanford Health Assessment Questionnaire Disability
Index (HAQ-DI)6 is
the most widely used disease-specific tool in RA. It is
a valid tool for the assessment of physical
function in patients with RA. The Stanford HAQ is a scale
of 20 activities of daily living (ADL) in 8 categories
to assess functional disability, with four patient response
0 Without any difficulty
1 With some difficulty
2 With much difficulty
3 Unable to do
The 8 categories of two or three ADLs
address dressing, arising, eating, walking, bathing, reaching,
performing errands. The score for each category is the
highest score among the two or three ADLs within the category;
if the patient uses aids ordevices for that category, it
is scored as 2. The total score is the mean score that
is derived from 8 scores, one for each category.6 The
total score for the HAQ-DI varies from 0 (no disability)
The medical outcomes study short form 36 (SF-36)7 is
an abridged version of 149 health status questions. SF-36
is a valid, disease-independent tool to assess the QOL.
It measures health-related QOL along 8 different domains:
physical functioning, role limitations due to physical
problems, bodily pain, general health perception, vitality,
social functioning, role limitations due to emotional problems
and mental health. In SF-36 the scores are calculated for
8 subscales from 0 to 100 (0: worst; 100: best). Composite
mental and physical component summary scores are also computed
from a weighted linear combination of 8 individual subscales.
Studies in patients with RA have revealed lower physical
and mental scores as compared to the general population.8,9
The impact on social and psychological domains is dependent
on the functional status and support system in the society
and ethnicity.10 In
India, there is a strong family support system but poor
social support system. Thus, it is likely
that the impact of RA will be different in India. Further,
RA also leads to considerable cost to family and society.
In a recent review the annual cost of RA averages US$ 1503–16
504 (based on US$ costs in 2000) depending on the patient
population and the country.11 Total
medical costs were in the range of US$ 5720–5822
(based on costs in 1996) with the maximum amount being
spent on inpatient
costs also have a major contribution to the economic burden
of RA.13 In India, it is difficult
to make an accurate assessment of economic burden as most
patients with RA are homemakers and calculating their contribution
in economic terms is difficult. We assessed the direct
costs incurred on the disease such as cost of drugs, laboratory
tests and travel for consultations. Indirect costs included
loss of wages, need for home help, etc.
One hundred and one patients with RA (1987 American College
of Rheumatology [ACR] criteria14)
attending the RA clinic of a tertiary care hospital during
a 3-month period were
included in the study. Verbal informed consent was taken
from all the participants.
Besides demographic data, duration and state of disease
were recorded. Remission was defined as per the ACR criteria15 and
all patients not fulfilling the remission criteria were
classified as having active disease. Patients were
also asked whether or not
they were using disease-modifying antirheumatoid
All patients who consented were administered the HAQ-DI
and SF-36 questionnaires by a medical graduate (SC). Minor
modifications were made in the questionnaires. In HAQ-DI,
the type of chores for the category ‘performing errands’ was
substituted by questions to suit Indian conditions, e.g.
car was substituted by rickshaw/bus and vacuuming by sweeping.
In SF-36 minor modifications included
- Question number 23 was modified
from ‘Did you
feel full of pep?’ to ‘Did you feel full
- Question number 25 was modified
from ‘Have you
felt so down in the dumps that nothing can cheer you up?’ to ‘Have
you felt so sad that nothing can cheer you up?’
- Question number 28 was modified
from ‘Have you
felt downhearted and blue?’ to ‘Have
you felt depressed?’
the economic impact, expenditure incurred during the
past 1 year on medicines, laboratory
tests and travel to hospital was calculated and indirect costs of home help,
loss of wages, etc. were asked for.
The data were analysed using SPSS software version 11 and
Spearman rank correlation coefficient
was calculated to assess any association between different variables.
There were 90 women among the 101 patients studied.
Their mean age (SD) was 43.2 (11.69)
years and the mean (SD)
duration of disease was 8.1 (5.6) years.
Ninety-six patients were on disease-modifying
disease was present
in 95 patients and 6 were in remission.
The distribution of the HAQ-DI scores show that
the mean (SD)
HAQ-DI score was 0.97 (0.69) with 6 patients
On the SF-36 scale (0–100)
the mean (SD) score for various domains was:
social functioning 55.51 (20.59), role
limitation due to physical problems 32.67
(41.34), role limitation due to emotional problems
47.54 (40.08), mental health 47.36 (7.99), general
health perception 52.38
and vitality 58.56
(6.09) and bodily pain 49.26 (18.87).
The summary score for the physical component was 37.95
(9.03) and that for the mental component 47.71 (4.81)
There was a good inverse correlation between
physical disability as assessed by HAQ-DI
and various domains
of SF-36. The
correlation with various physical domains
was as follows:
physical functioning –0.778 (p<0.001), role
limitation due to physical function –0.711 (p<0.001),
physical component summary score –0.836 (p<0.001,
Fig. 2). HAQ correlated well with the bodily pain (–0.755;
p<0.001), emotional (–0.561; p<0.002) and
social functioning domains (–0.610; p<0.001).
However, there was no significant correlation with
the global health domain, vitality domain and summary
score for mental health (Fig. 2).
The mean (SD) annual income of the
families was Rs 138 533 (74 397). The distribution
revealed that 8%
earned less than Rs 50 000, 30% earned Rs 50 000–100
000, 26% earned
Rs 100 000–150 000, 18% earned Rs 150 000–200
000 and 18% earned more than Rs 200 000. The annual
average total cost burden per patient was Rs 16 758,
of which Rs 11 617 (67%) was spent on health services
and the rest on non-health services (travel, home help
and loss of wages). Among the direct costs, expenditure
included those on medicines (Rs 9179), investigations
(Rs 1974), hospital registration (Rs 100) and hospitalization
Table II). Among the indirect costs (Rs 5141 [17 233])
was a major expenditure (Rs 2453 ). Only 10 patients
received complete reimbursement for their medical expenses
from their employers while 15 received partial reimbursement.
None of the patients had any medical insurance. The
cost of treatment had no significant correlation with
duration of disease or HAQ-DI due to a ceiling effect
(Fig. 3) but it had a weak correlation with income
Ours is possibly the first study in India to show that
RA has a major economic impact and the cost does not
increase proportional to disability due to limited
income. Our data also show that RA has a considerable
impact on the physical, emotional and mental health
of patients. Further, the mental and social scores
are better than the physical scores. There was a good
correlation between HAQ-DI and the physical scores
Our patients had a mean HAQ-DI score of 0.97 at a mean
disease duration of nearly 8 years. Cross-sectional
studies from other countries have also found an average
HAQ-DI score of 1.00
FIG 3. Scatter plot showing the correlation between
HAQ and total cost of rheumatoid arthritis
at 7 years, 1.25 at 12 years and 1.5 at 18 years of
our patients have comparable physical disability.
However, when individual patients
are followed up over time there is considerable variation
seen in an individual’s HAQ score17 as HAQ-DI
is a composite measurement of disability resulting
from damage and activity of the disease. Thus, longitudinal
studies provide a better measure of outcome.
In SF-36 scores, physical domains
were more affected compared with mental health domains.
SF-36 has been
previously used in India on 40 patients with RA to
measure QOL and mental health scores were found to
be much higher than physical function scores; however,
that study included a very select group of patients
with RA enrolled for an anti-tumour necrosis factor
agent trial.19 Another study from India involving
patients with RA but using the WHO QOL-Bref scale
made a similar
observation, i.e. better scores on psychological,
emotional and environmental domains as compared with
The physical domains of SF-36 had excellent correlation
with the HAQ-DI score, suggesting that both scales
measure similar physical disability. The good correlation
of social and emotional functioning with HAQ-DI score
suggests that these components of health are influenced
by physical disability. However, the summary score
for the domains of mental health, energy and vitality
were significantly higher than physical domain scores
and did not show any correlation with HAQ-DI in contrast
to a study from the UK.8 Similar observations have
been made in Parkinson disease using a disease-specific
QOL scale21 and in systemic lupus erythematosus using
the WHO-QOL scale.22 This may suggest that the patients
were well adjusted and received good support to cope
with physical disability and illness. In India, the
family support system is excellent and thus the immediate
environment of the patient is supportive. This may
partly explain the good mental scores. Another reason
could be a reluctance to express their feelings, which
can also explain the narrow dispersion in mental health,
vitality and general health scores.
Spending nearly Rs 17 000 annually
on RA means that almost 15% of the household income
is spent on expenses
related to the disease. Direct costs constituted
two-thirds of the total costs. In the West, indirect
costs are more than the direct costs due to loss
of wages, home help, etc.23 In
India, as most patients are either homemakers or
men working in a joint family
business or government jobs, loss of wages is not
a major contributor to the cost of RA. In the only
in Parkinson disease, the annual expenditure was
reported to be Rs 7372. This difference could be
due to a difference in treatment
for the two diseases as well as the lower average
annual income of those patients compared with our
group (Table II).
most studies from the West, the cost of RA increases
with the duration of the disease due to
accumulation of damage.23 In contrast, we did not find
any association with duration of the disease, as most patients
could not afford joint replacement, special devices, biological
agents, etc. A correlation has also been found between
healthcare costs and SF-36/HAQ-DI scores.23 This is due
to an increase in visits to the physician, hospitalization
and drug costs with increasing disability. However, due
to a ceiling effect on spending related to low income of
the family we did not find a good correlation between HAQ
and cost of treatment.
Our study has a few limitations. First, it is a cross-sectional
study and HAQ and SF-36 can change over a period of time
with control of disease activity. Second, SF-36 has not
been validated in our population as an instrument for QOL.
Third, the direct and indirect cost calculations are at
best a rough estimate. Furthermore, our patient population
consists of middle class people, so these data may not
be applicable to the general population.
Thus, RA causes significant disability
in all domains of health. Indian patients have better scores
on mental health,
probably due to a better family support system. Due to
a low income, most patients cannot afford the current state-of-the-art
treatment. Early effective treatment may not only postpone
and retard disease progression, thereby improving the QOL,
but also decrease costsby preserving productivity and reducing
the need for surgery and admission to hospital. Data are
beginning to accumulate on the excess costs associated
with biological therapies and other new second-line drugs.
There is a need to analyse the economic impact of RA in
India in a larger sample size, so that policy-makers can
provide ways to optimize the treatment of patients with
We acknowledge the technical help of Ms Catherine T. Schentag,
Research Associate, Centre for Prognosis Studies in Rheumatic
Diseases, Toronto Western Hospital, 399 Bathurst Street,
Ontario, Canada M5T 2S8 in calculating SF-36 scores.
- Gabriel SE,
Crowson CS, Kremers HM, Doran MF, Turesson C, O’Fallon
WM, et al. Survival in rheumatoid arthritis: A population-based analysis of trends
over 40 years. Arthritis Rheum 2003;48:54–8.
- Wolfe F, Mitchell DM, Sibley JT, Fries JF, Bloch
DA, Williams CA, et al. The mortality of rheumatoid
arthritis. Arthritis Rheum 1994;37:481–94.
- Sokka T, Krishnan E, Hakkinen A, Hannonen P. Functional
disability in rheumatoid arthritis patients compared
with a community population
in Finland. Arthritis
- Scott DL, Symmons DP, Coulton BL, Popert AJ. Long-term
outcome of treating rheumatoid arthritis: Results
after 20 years. Lancet 1987;1:1108–11.
- Scott DL, Garrood T. Quality of life measures: Use
and abuse. Baillieres Best Pract Res Clin Rheumatol 2000;14:663–87.
- Pincus T, Summey JA, Soraci SA Jr, Wallston KA, Hummon
NP. Assessment of patient satisfaction in activities
of daily living
using a modified
Questionnaire. Arthritis Rheum 1983;26:1346–53.
- Ware JE, Kosinski M, Keller SD. SF-36
physical and mental health summary scales: A user’s
manual. Boston, MA:The Health Institute, New England
Medical Center; 1994.
- Ruta DA, Hurst NP, Kind P, Hunter M, Stubbings A.
Measuring health status in British patients with
responsiveness of the short form 36-item health survey
(SF-36). Br J Rheumatol 1998;37:425–36.
- Escalante A, del Rincon I. How much disability in
rheumatoid arthritis is explained by rheumatoid arthritis?
- Thumboo J, Fong KY, Machin D, Chan SP, Soh CH, Leong
KH, et al. Quality of life in an urban Asian population:
impact of ethnicity
status. Soc Sci Med 2003;56:1761–72.
- Rosery H, Bergemann R, Maxion-Bergemann S. International
variation in resource utilisation and treatment costs
for rheumatoid arthritis:
review. Pharmacoeconomics 2005;23:243–57.
- Cooper NJ. Economic burden of rheumatoid arthritis:
A systematic review. Rheumatology (Oxford) 2000;39:28–33.
- Ethgen O, Kahler KH, Kong SX, Reginster
JY, Wolfe F. The effect of health related quality
of life on
of health care
resources in patients
with osteoarthritis and rheumatoid arthritis:
A longitudinal analysis. J Rheumatol 2002;29:1147–55.
- Arnett FC, Edworthy SM, Bloch DA, McShane
DJ, Fries JF, Cooper NS, et al. The American
of rheumatoid arthritis. Arthritis Rheum 1988;31:315–24.
- Pinals RS, Masi AT, Larsen RA. Preliminary
criteria for clinical remission in rheumatoid
Arthritis Rheum 1981;24:1308–15.
- Lassere M, Wells G, Tugwell P, Edmonds
J. Percentile curve reference charts of
physical function: Rheumatoid
- Wolfe F. A reappraisal of HAQ disability
in rheumatoid arthritis. Arthritis
- Wolfe F, Hawley DJ, Cathey MA. Clinical
and health status measures over time:
rheumatoid arthritis. J Rheumatol 1991;18:1290–7.
- Misra R, Amin S, Joshi VR, Rao URK,
Aggarwal A, Fatima F, et al. Open-label
of the efficacy
J Indian Rheumatol Assoc 2005;13:131–4.
- Bedi GS, Gupta N, Handa R, Pal
H, Pandey RM. Quality of life in
- Ray J, Das
SK, Gangopadhya PK, Roy T. Quality of life in
disease—Indian scenario. J Assoc Physicians
- Khanna S, Pal H, Pandey RM,
Handa R. The relationship between
quality of life
in systemic lupus erythematosus.
- Rat AC, Boissier MC. Rheumatoid
arthritis: Direct and indirect
costs. Joint Bone