Capturing all of the costs in NICE appraisals: the impact of inflammatory rheumatic diseases on productivity

Inflammatory rheumatic diseases are common. It is estimated that similar to 2.1% of the population has an inflammatory rheumatic disease (Andrianakos A, Trontzas P, Christoyannis F et al. Prevalence of rheumatic diseases in Greece: a cross-sectional population based epidemiological study. The ESORDIG Study. J Rheumatol 2003;30:1589-601). For diseases such as RA, PsA and AS, onset is most frequent between the ages of 30 and 50 years. The impact of inflammatory rheumatic diseases on physical functioning can be significant. Patients can suffer from swollen joints that cause pain and disability. This can reduce sufferers' ability to lead fully productive lives. This has major financial consequences for sufferers and their families and there is an economic impact on society. The National Institute for Health and Clinical Excellence (NICE) technology appraisal process has typically ignored any improvements in productivity that may result from treatment. There have been calls to extend the perspective of economic evaluations to include productivity costs as one aspect of wider social effects. However, there are a number of issues that must be resolved before productivity costs can become a routine input into the calculation of cost-effectiveness of treatments. First, there is limited agreement regarding the practical details and appropriate methods for their inclusion in economic evaluation. Second, there are issues that must be addressed regarding society's preference for equity. This issue arises when considering individual's economic productivity, that is to say, how we weigh individuals who are more productive (e.g. those in employment) against those who are less so (e.g. the unemployed). Finally, it is important to consider cross-budgetary effects, since productivity has cost and benefit implications outside of health.