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The National guidelines for Musculoskeletal Diseases – summary

These guidelines contain recommendations for measures relating to orthopaedic conditions. They also contain assessments of the financial and organisational consequences of the recommendations and indicators for monitoring.

The guidelines cover the following diagnostic fields:

  • osteoporosis (fragile bones)
  • osteoarthritis in the knee and hip (the breakdown of joint cartilage)
  • inflammatory spinal disease and (axial spondylartrit) and ankylosing spondylitis
  • psoriatic arthritis (a combination of psoriasis and inflammation of the joints)
  • rheumatoid arthritis (rheumatism of the joints).

Some key recommendations and their consequences

The National Board of Health and Welfare estimates that the economic impact of the recommendations generally means increased costs for healthcare. A significant part of the costs come from drug treatment with TNF inhibitors and other biological medication for rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis.

Several of the recommendations are expected to result in an improvement in the health of patients suffering from these diseases, a better quality of life, greater functional ability and a reduced number of fractures, which can lower costs in the long-term.

The National Board of Health and Welfare believes that the recommendations will lead to few organisational consequences, however.

FRAX and DXA to assess fracture risk and alendronic and zoledronic acid for very high fracture risks

When osteoporosis is suspected, the healthcare services should assess the fracture risk by means of the FRAX tool which is available on the internet and, when necessary, conduct a Bone Density Scan (DXA).

Individuals with a very high fracture risk should be treated with alendronic acid. Those individuals who have difficulty completing treatment with alendronic acid should instead be treated with zolendronic acid.

With a low fracture risk, however, the healthcare services should only treat the symptoms with these medications in exceptional cases.

The National Board of Health and Welfare estimates that the increased treatment in cases of very high fracture risk gives a total cost reduction of close to SEK 200 million per annum. The cost for the treatment is calculated to increase by approximately SEK 70 million per annum, while the reduction in the number of fractures is expected to give a cost reduction of approximately SEK 270 million per annum.

No treatment with calcium and vitamin D

The healthcare services should not prescribe calcium and vitamin D as monotherapy to women of the ages 40–79 who do not have a documented deficiency of these substances. The National Board of Health and Welfare estimates that this will lead to a cost reduction of SEK 19–29 million per annum.

No Vertebroplasty or Kyfoplasty with vertebral compression.

The healthcare services should not perform Vertebroplasty or Kyfoplasty with vertebral compression due to osteoporosis. Studies show that these surgical procedures do not have a lasting effect on pain, function, or quality of life. The use of these measures is relatively limited nowadays and the cost reduction is therefore expected to be moderate.

Physical exercise with arthritis

The healthcare services should provide supervised long-term training for individuals with arthritis of the knee and hip. Studies show that exercise has an analgesic effect that is comparable to analgesic medication. The recommendation will likely lead to a cost increase for the healthcare services.

No glucosamine, hyaluronic acid or arthroscopic surgery with joint lavage in the case of arthritis

The healthcare services should not treat with glucosamine or hyaluronic acid with arthritis of the knee or hip. These substances have no effect on pain or joint function. To cease these measures means a cost reduction of approximately SEK 85 million per annum.

Nor should the healthcare services perform arthroscopic surgery in the form of joint lavage with a meniscectomy in the case of arthritis of the knee. The measure, as treatment for arthritis, does not have a better effect on pain and function than exercise and analgesic medication. To cease this measure means a cost reduction of approximately SEK 25 million per annum.

Use TNF inhibitors when other medication have had an inadequate response with treatment of ankylosing spondylitis and psoriatic arthritis.

The healthcare services should treat with TNF inhibitors for ankylosing spondylitis when the primary treatment, known as NSAIDs, has not proven effective.

The healthcare services should also treat with TNF inhibitors for psoriatic arthritis where NSAIDs, cortisone injections and so-called disease modifying drugs have not had the desired effect. Overall, the recommendations give a cost increase of approximately SEK 480 million per annum.

Combination therapy in the early phase and with insufficient effects in the treatment of rheumatoid arthritis

The healthcare services should begin treatment with methotrexate and TNF inhibitors directly for early onset rheumatoid arthritis exhibiting high disease activity and several markers of a poor prognosis. The National Board of Health and Welfare estimates that approximately 10 per cent of those who are diagnosed with rheumatoid arthritis each year fulfil the criteria for early combination therapy. The recommendation is therefore expected to give a cost increase of SEK 84 million per annum.

An individual who has an inadequate response to only being treated with methotrexate, and has continued medium to high disease activity, should be treated with both methotrexate and THF inhibitors.

The healthcare services should treat with a combination of methotrexate and other biological medication (other TNF inhibitors, abatacept, rituximab or tocilizumab) if combination therapy with methotrexate and TNF inhibitors does not have the desired effect.

The National Board of Health and Welfare estimates that these recommendations give the greatest cost increase within all treatment for rheumatoid arthritis. The cost increase is difficult to calculate as there is no data on the size of this group. A rough estimate is that the costs for healthcare services increase by SEK 150–250 million per annum.

Importance of diagnostics, exercise and fall prevention

The guidelines also contain other important recommendations. These include recommendations for diagnostics or physical exercise for certain conditions, as well as preventative measures for older individuals who are in assisted-living facilities or hospital. For these measures, the National Board of Health and Welfare has not conducted any analysis of the consequences for the healthcare services, as they are considered either to be too small or difficult to calculate.

Monitoring is an important aspect of the guidelines

The National Board of Health and Welfare considers monitoring of the guidelines to be an essential tool for implementation. The Board will closely monitor and report on the indicators that have been developed within the framework of the guidelines. During 2012–2013, the National Board of Health and Welfare intends to commence the evaluation of healthcare processes, results and costs for orthopaedic conditions.

The Board has developed more than 40 indicators for monitoring the healthcare of individuals with orthopaedic conditions. Of these, more than half are allocated to monitoring at a national level.

A major problem within some of these areas is that there is currently no data, particularly within primary care. This means that it is not yet possible to continuously monitor a number of the indicators at a national level, even if it can be achieved at the local and regional level.