An Ontario, Canada, study has estimated that standardized mortality rates are 41% to 51% higher in people with rheumatoid arthritis (RA) than in the general population, although the rates have been declining since 1997.1 In 1996-1997 the standardized mortality rate (SMR) among Ontario residents aged 15 years and older who had RA was 1.51, compared with those without RA. The rates were 1.50 in 2000-2001, 1.43 in 2004-2005, and 1.41 in 2008-2009; the decrease over time is not statistically significant.
“The excess mortality rate in people with RA, compared to the general population, did not significantly fall over time—survival has improved in both RA patients and the general population,” investigator Jessica Widdifield, PhD, a postdoctoral fellow at the Institute for Clinical Evaluative Sciences, Toronto, and McGill University, Montreal, said in an email to Value-Based Care in Rheumatology when queried about the mortality decline.
In an accompanying editorial, Theodore Pincus, MD, of Rush University School of Medicine, Chicago, Illinois, and 2 other experts praised the study and said that mortality is usually overlooked in rheumatology.2 They hypothesized that payers may be more willing to reimburse providers for use of expensive rheumatology medications if the medications are shown not only to reduce patients’ symptoms and improve quality of life, but also to reduce mortality.
When asked by Value-Based Care in Rheumatology whether this means that he believes biologics should be used earlier and more aggressively in people with severe RA, Pincus responded with a qualified “yes.”
“Of course biologics should be used earlier and more aggressively in patients with severe RA. But many patients who are treated with biologics donʼt need them,” noted Pincus in an emailed response. “The big problem is matching need and implementation through appropriate measurement—most rheumatologists practice by intuition rather than measurement—that’s not awful, but leaves many interventions poorly managed.”
The increased rate of mortality among people with RA has been studied for many years, but there is a paucity of proof as to whether this mortality gap is closing or widening. That is why Widdifield and her colleagues studied the records from health administrative databases comprising people covered by the Ontario Health Insurance Plan and in the Ontario RA administrative database (ORAD).
They found that the proportion of people aged 15 years and older who have RA increased from 0.53% to 0.84% from 1996 to 2009. Age- and sex-standardized mortality rates among the RA population were 13/1000 people in 1996 and 9.2/1000 people in 2009. The respective rates for members of the non-RA population were 8.7/1000 and 6.0/1000.
The overall mortality rates decreased from 1996 to 2009, although the excess mortality rates (ie, SMRs) were consistently higher among females than males. When the researchers used a regression model that adjusted for changes in mortality within the overall population, they found no significant reduction in SMRs among people with RA over time. They also calculated relative excess mortality over time in RA versus non-RA individuals, in the form of mortality rate ratios and found that the mortality gap has not improved over time.
- Widdifield J, Bernatsky S, Paterson JM, et al. Trends in excess mortality among patients with rheumatoid arthritis in Ontario, Canada [published online January 26, 2015]. Arthritis Care Res (Hoboken).
- Pincus T, Gibson KA, Block JA. Mortality—the neglected outcome in rheumatic diseases? [editorial] [published online January 26, 2015]. Arthritis Care Res (Hoboken).