Treatment adherence and disease burden of individuals with rheumatic diseases admitted as outpatients to a large rheumatology center in Shanghai, China

Figures & data

Table 1 Demographic and clinical characteristics of outpatients with rheumatic diseases (n=252)

Sociodemographic characteristics	n (%)
Age (years), mean (SD)	40.13 (15.39)
Sex, female	185 (73.41)
Marital status
Married	193 (76.58)
Other marital status	59 (23.41)
Education level
Primary (0–6 years)	25 (9.92)
Secondary (7–12 years)	141 (55.95)
Higher (>12 years)	86 (34.12)
Employment
Employed	154 (61.11)
Unemployed	98 (38.89)
Work activity
Low level of activity (office etc)	201 (79.76)
Light or moderate activity (assembly line work, installers etc)	45 (17.85)
Heavy-activity (steelmaking, agriculture etc)	6 (2.38)
Monthly per capita income
<1,000 CNY	13 (5.16)
1,000–5,999 CNY	129 (51.19)
6,000–9,999 CNY	64 (25.40)
>10,000 CNY	46 (18.25)
Type of medical insurance
Rural cooperative medical care	20 (7.93)
Urban medical insurance	180 (71.43)
Self-funded	52 (20.64)
Disease characteristics	n (%)
Disease
SLE	121 (48.02)
RA	70 (27.78)
AS	61 (24.21)
Disease duration
<1 year	52 (20.63)
1–5 years	102 (40.47)
≥5 years	98 (38.89)
Comorbidities
0	115 (45.63)
1–2	113 (44.84)
≥3	24 (9.52)
EQ-5D index, mean (SD)	0.76 (0.17)
Treatment characteristics	n (%)
Types of pills prescribed daily, mean (SD)	4.16 (2.21)
Use of GC	159 (63.10)
Number of DMARDs, mean (SD)	1.38 (0.72)
Use of NSAIDs	66 (26.19)
Use of biological DMARDs	35 (13.89)
Daily dosing frequency
< Once daily	14 (5.56)
Once daily	27 (10.71)
Twice daily	143 (56.74)
Thrice daily	63 (25.00)
> Thrice daily	5 (1.98)
Side effects
0	66 (26.19)
1–2	164 (65.08)
≥3	22 (8.73)
CQR19, mean (SD)	75.84 (11.59)
Use of tools such as medication reminders	140 (55.56)
Use of alternative medicines	98 (38.89)

Abbreviations: AS, ankylosing spondylitis; CQR, Compliance Questionnaire for Rheumatology; DMARDs, disease modifying antirheumatic drugs; EQ-5D, EuroQol five dimensions; GC, glucocorticoid; NSAIDs, non-steroidal anti-inflammatory drugs; RA, rheumatoid arthritis; SLE, systemic lupus erythematosus.

Table 2 Disease burden and adherencea of patients with rheumatic diseases (n=252)

	Total	Adherent	Nonadherent
All patients (CNY/year)
Direct cost, mean (SD)	26,942.10 (55,455.02)	30,950.17 (70,447.23)	23,180.68 (36,043.77)
Outpatient	9,333.02 (16,367.63)	9,973.77 (15,983.10)	8,731.71 (16,759.82)
Hospitalization	14,711.51 (52,204.57)	18,250.82 (67,644.11)	11,390.00 (31,429.68)
Non-medical	2,897.57 (8,350.65)	2,725.58 (6,420.65)	3,058.98 (9,846.85)
Indirect cost, mean (SD)	6,633.73 (25,578.30)	6,235.25 (22,062.18)	7,007.69 (28,568.36)
Beyond annual household income, n (%)	24 (9.49)	14 (11.10)	10 (7.69)
SLE patients (CNY/year)
Direct cost, mean (SD)	33,899.49 (73,277.78)	37,945.14 (95,359.95)	30,049.60 (43,428.34)
Outpatient	7,009.13 (8,252.41)	7,663.05 (8,276.01)	63,86.85 (8,248.68)
Hospitalization	15,682.23 (36,911.15)	27,889.83 (94,643.66)	20,785.48 (42,642.21)
Non-medical	2,640.77 (4,861.53)	2,392.25 (4,249.73)	2,877.26 (5,404.20)
Indirect cost, mean (SD)	8,992.56 (28,139.07)	9,500.00 (29,549.13)	8,509.68 (26,962.16)
Beyond annual household income, n (%)	9 (7.37)	6 (10.00)	3 (4.84)
AS patients (CNY/year)
Direct cost, mean (SD)	21,453.59 (29,035.60)	27,609.33 (33,327.80)	15,496.42 (23,191.61)
Outpatient	13,309.54 (21,804.46)	17,871.07 (26,122.09)	8,895.16 (15,821.10)
Hospitalization	3,878.69 (9,463.41)	4,936.67 (10,049.34)	2,854.84 (8,904.30)
Non-medical	4,265.36 (13,107.43)	4,801.60 (10,979.86)	3,746.42 (15,050.08)
Indirect cost, mean (SD)	3,134.43 (10,579.71)	3,753.33 (10,480.81)	2,535.48 (10,813.00)
Beyond annual household income, n (%)	3 (4.84)	2 (6.45)	1 (3.22)
RA patients (CNY/year)
Direct cost, mean (SD)	19,698.61 (30,829.78)	21,481.15 (32,922.25)	18,108.78 (29,202.56)
Outpatient	9,884.79 (20,467.36)	6,925.70 (12,063.45)	12,523.97 (25,658.80)
Hospitalization	7,664.29 (19,058.40)	13,121.21 (24,707.99)	2,797.30 (10,093.63)
Non-medical	2,149.54 (7,799.47)	1,434.24 (2,815.46)	2,787.51 (10,424.05)
Indirect cost, mean (SD)	5,605.71 (29,730.60)	2,654.55 (10,940.78)	8,237.84 (39,656.69)
Beyond annual household income, n (%)	12 (16.90)	6 (18.18)	6 (16.21)

Note:

a Adherence was defined as 0 or 1 missed doses per month during the 2-month study period.

Abbreviations: AS, ankylosing spondylitis; RA, rheumatoid arthritis; SLE, systemic lupus erythematosus.

Table 3 Medication problems, EQ-5D score, and CQR19 score of patients with rheumatic diseases (n=252)a

MP no	AS (%)	RA (%)	SLE (%)	Total (%)
1	16.39	11.43	18.18	15.87
2	24.59	22.86	40.49	31.74
3	8.20	1.43	8.26	6.34
4	9.83	11.43	16.53	13.49
EQ-5D (mean)	0.792	0.700	0.780	0.761
CQR ≥80 (%)	49.18	47.14	48.76	48.41
Adherence (%)	31.14	38.57	48.76	41.67

Notes:

a Adherence was defined as 0 or 1 missed doses per month during the 2-month study period. MP no 1: usage error; MP no 2: missing dose; MP no 3: precautions unknown; MP no 4: adjustment of dosage or cessation of medicine.

Abbreviations: AS, ankylosing spondylitis; CQR, Compliance Questionnaire for Rheumatology; EQ-5D, EuroQol five dimensions; MP, medication problem; RA, rheumatoid arthritis; SLE, systemic lupus erythematosus.

Table 4 Demographic and clinical characteristics of adherent and nonadherent patients

Sociodemographic characteristics	Total (n=252)				SLE (n=121)				RA (n=70)		AS (n=61)
	Adherent n=122	Nonadherent n=130	P-value	SIG	Adherent n=59	Nonadherent n=62	P-value	SIG	P-value	SIG	P-value	SIG
Age (years), mean (SD)	39.66 (15.50)	40.33 (14.73)	0.6421		33.97 (11.23)	36.18 (14.22)	0.7302		0.6806		0.6503
Sex, female, n (%)	93 (76.22)	92 (76.22)	0.4021		56 (94.91)	58 (93.54)	1.0000		0.8613		0.3737
Marital status, n (%)			0.5643				1.0000		1.0000		0.3549
Married	91 (74.50)	102 (78.46)			41 (69.45)	43 (69.27)
Other	31 (25.50)	28 (21.53)			18 (30.55)	19 (30.73)
Education level, n (%)			0.9396				0.3599		0.5729		0.7171
Primary (0–6 yrs)	12 (9.83)	13 (10.00)			4 (6.77)	3 (4.83)
Secondary (7–12 yrs)	71 (58.20)	70 (53.84)			33 (55.93)	38 (61.29)
Higher (>12 yrs)	39 (31.96)	47 (36.15)			22 (37.28)	21 (33.87)
Employment, n (%)			0.0681	*			1.0000		0.0848		0.0809
Employed	67 (54.91)	87 (66.92)			39 (66.45)	41 (67.27)
Unemployed	55 (45.09)	43 (33.08)			20 (33.55)	21 (32.73)
Work activity, n (%)			0.1629				0.2871		0.4112		0.5346
Less activity	98 (80.33)	103 (79.16)			50 (84.82)	52 (83.87)
Light-to-moderate activity	19 (15.57)	26 (20.00)			7 (11.18)	10 (16.12)
Heavy-activity	5 (4.09)	1 (0.76)			2 (3.38)	0 (0)
Monthly per capita income, n (%)			0.1140				0.1130		0.1718		0.5918
<1,000 CNY	7 (5.73)	6 (4.62)			3 (5.08)	3 (4.83)
1,000–5,999 CNY	65 (53.27)	61 (46.92)			29 (49.73)	32 (51.63)
6,000–9,999 CNY	30 (25.60)	30 (23.07)			20 (33.34)	14 (22.58)
>10,000 CNY	20 (16.39)	26 (20.00)			7 (11.09)	13 (20.96)
Type of medical insurance, n (%)			0.2178				0.3095		0.4185		0.8440
Rural cooperative medical care	6 (4.91)	14 (10.76)			3 (5.07)	8 (12.90)
Urban medical insurance	91 (74.59)	83 (63.85)			42 (71.18)	39 (62.90)
Self-funded	25 (20.49)	25 (19.23)			14 (23.73)	15 (24.19)
Disease characteristic
Disease duration, n (%)			0.0008	**			0.0296	*	0.1019		0.0903
<1 year	21 (17.21)	31 (23.84)			10 (16.36)	15 (24.19)
1–5 years	52 (42.62)	50 (38.46)			23 (38.98)	22 (35.36)
≥5 years	49 (40.16)	49 (37.69)			26 (44.05)	25 (40.82)
Comorbidities, n (%)			0.0106	*			0.0350	*	0.3864		0.2162
0	57 (46.72)	58 (44.61)			21 (35.45)	17 (27.41)
1–2	49 (40.16)	64 (49.23)			28 (47.45)	42 (67.75)
≥3	16 (13.11)	8 (5.38)			10 (16.94)	3 (4.83)
EQ-index, mean (SD)	0.77 (0.16)	0.75 (0.18)	0.0923		0.78 (0.14)	0.77 (0.17)	0.5629		0.3002		0.1926
Disease burden (CNY/year)
Direct cost, mean (SD)	30,950.17 (70,447.23)	23,180.68 (36,043.77)	0.5760		37,945.14 (95,359.95)	30,049.60 (43,428.34)	1		0.1042
Outpatient expenditure	9,973.77 (15,983.10)	8,731.71 (16,759.82)	0.3867		7,663.05 (8,276.01)	6,386.85 (8,248.68)	0.2623		0.6933		0.3395
Hospitalization expenditure	9,324.59 (24,104.53)	11,390.00 (31,429.68)	0.3590		27,889.83 (94,643.66)	20,785.48 (42,642.21)	0.1079		0.5395		0.2293
Non-medical cost	2,725.58 (6,420.65)	3,058.98 (9,846.85)	0.4003		2,392.25 (4,249.73)	2,877.26 (5,404.20)	0.1965		0.8774		0.5460
Indirect cost, mean (SD)	6,235.25 (22,062.18)	7,007.69 (28,568.36)	0.8468		9,500.00 (29,549.13)	8,509.68 (26,962.16)	0.3400		0.4629		0.3170
Treatment characteristic
Types of pills prescribed daily, mean (SD)	3.94 (2.25)	4.36 (2.15)	0.3065		4.64 (1.96)	4.84 (1.60)	0.6291		0.8480		0.1804
Use of GC, n (%)	42 (34.43)	50 (38.46)	0.4845		1 (1.69)	4 (6.45)	0.3914		0.5812		0.9768
Number of DMARDs, n (%)	107 (87.70)	68 (52.30)	0.0590		58 (98.31)	59 (96.36)	0.7019		0.1683		0.0314	*
Use of NSAIDs, n (%)	28 (22.95)	38 (29.23)	0.1872		10 (11.94)	6 (10.09)	0.9246		0.3563		0.0497	*
Use of a biologic DMARD, n (%)	23 (18.95)	12 (9.23)	0.0429	*	1 (1.69)	1 (1.61)	1.0000		1.0000		0.0044	**
Daily dosing frequency, n (%)			0.1373				0.6004		0.2983		0.0534
< Once daily	11 (9.01)	3 (2.30)			0 (0)	0 (0)
Once daily	19 (15.57)	8 (6.55)			3 (5.08)	1 (1.61)
Twice daily	61 (50.00)	82 (67.21)			36 (61.01)	42 (67.73)
Thrice daily	28 (22.95)	30 (23.07)			18 (30.50)	17 (27.42)
> Thrice daily	3 (2.45)	2 (1.54)			2 (3.38)	2 (3.23)
Side effects, n (%)			0.0106	*			0.0350	*	0.3864		0.2162
0	39 (31.91)	27 (20.77)			14 (23.72)	6 (9.67)
1–2	77 (63.14)	87 (66.92)			42 (65.91)	47 (75.80)
≥3	6 (4.91)	16 (12.30)			4 (6.78)	10 (16.13)
CQR, mean (SD)	79.07 (11.28)	72.81 (11.08)	0.0000	***	81.53 (11.01)	75.38 (12.23)	0.0717		0.0613		0.0030	**
Use of tools such as reminders, n (%)	88 (72.13)	52 (40.00)	0.0000	***	47 (79.65)	30 (48.38)	0.0013	**	0.0007	**	0.0951
Use of alternative medicines, n (%)	42 (34.42)	56 (43.07)	0.2011		18 (30.50)	31 (50.00)	0.0682		0.7376		0.6880

Notes:

* P<0.05;

** P<0.01;

*** P<0.001; adherence was defined as 0 or 1 missed doses per month during the 2-month study period.

Abbreviations: AS, ankylosing spondylitis; CQR, Compliance Questionnaire for Rheumatology; DMARD, disease modifying antirheumatic drug; EQ-5D, EuroQol five dimensions; GC, glucocorticoid; NSAID, non-steroidal anti-inflammatory drug; RA, rheumatoid arthritis; SIG, significance; SLE, systemic lupus erythematosus.

Table 5 Multivariable logistic regression analysis of demographic and clinical characteristics associated with adherence in patients with rheumatic diseases (n=252)

Characteristic	B	SE	P-value	SIG	Exp(B)	95% CI
Step 1a
Use of tools such as reminders	1.236	0.391	0.002	**	3.441	1.598, 7.411
CQR score	0.032	0.014	0.023	*	1.032	1.004, 1.061
Duration <1 year			0.803
1–5 years	−0.178	0.429	0.678		0.837	0.361, 1.939
≥5 years	0.101	0.334	0.762		1.106	0.575, 2.128
Side effects	−0.277	0.196	0.157		0.758	0.517, 1.113
Use of biologic	0.577	0.460	0.209		1.781	0.724, 4.384
No of DMARDs	−0.115	0.235	0.627		0.892	0.562, 1.415
Employed	−0.624	0.312	0.046	*	0.536	0.291, 0.988
EQ-5D-index	1.495	0.934	0.109		4.459	0.715, 27.814
Monthly per capita income (6,000–9,999 CNY)			0.285
Monthly per capita income (<1,000 CNY)	0.053	0.779	0.945		1.055	0.229, 4.853
Monthly per capita income (>10,000 CNY)	−0.622	0.447	0.164		0.537	0.223, 1.289
Monthly per capita income (1,000–5,999 CNY)	0.177	0.354	0.616		1.194	0.596, 2.390
Types of pills prescribed daily	−0.291	0.212	0.170		0.748	0.493, 1.133
Work activity, less activity			0.013	*
Light-to-moderate activity	−2.911	1.020	0.004	**	0.054	0.007, 0.402
Heavy-activity	−3.097	1.058	0.003	**	0.045	0.006, 0.360
Use of NSAIDs	−0.013	0.325	0.968		0.987	0.522, 1.866
Use of alternative medicines	−0.799	0.315	0.011	*	0.450	0.242, 0.834
Type of medical insurance, rural cooperative medical care			0.259
Urban medical insurance	−0.935	0.605	0.122		0.393	0.120, 1.284
Self-funded	0.142	0.369	0.701		1.152	0.559, 20,374
Comorbidities	0.243	0.152	0.132		1.258	0.933, 1.696
Hospitalization expenditure	0.243	0.193	0.208		1.276	0.873, 1.863
Step 10a
Use of tools such as reminders	1.002	0.347	0.004	**	2.724	1.381, 5.374
CQR scores	0.034	0.013	0.007	**	1.034	1.009, 1.060
Side effects	−0.355	0.157	0.023	**	0.701	0.516, 0.953
Use of biologics	0.782	0.439	0.075	*	2.185	0.925, 5.161
Employed	−0.654	0.293	0.026	**	0.520	0.293, 0.924
Work activity, less activity			0.026	**
Light-to-moderate activity	−2.202	0.845	0.009	**	0.111	0.021, 0.579
Heavy-activity	−2.379	0.895	0.008	**	0.093	0.016, 0.535
Use of alternative medicines	−0.727	0.302	0.016	*	0.483	0.267, 0.873

Notes:

* P<0.05;

** P<0.01; adherence was defined as 0 or 1 missed doses per month during the 2-month study period.

a Bachward stepwise regression was used in this analysis.

Abbreviations: CQR, Compliance Questionnaire for Rheumatology; DMARD, disease modifying antirheumatic drug; EQ, EuroQol; GC, glucocorticoid; NSAID, non-steroidal anti-inflammatory drug; SIG, significance.

Table 6 Multivariable logistic regression analysis of demographic and clinical characteristics associated with adherence in SLE patients

Characteristic	B	SE	P-value	SIG	Exp(B)	95% Cl
Step 1a
Monthly per capita income (6,000–9,999 CNY)			0.007	**
Monthly per capita income (<1,000 CNY)	−0.909	1.239	0.463		0.403	0.036, 4.567
Monthly per capita income (>10,000 CNY)	−1.889	0.763	0.013	*	0.151	0.034, 0.674
Monthly per capita income (1,000–5,999 CNY)	−0.174	0.545	0.749		0.840	0.289, 2.444
Duration <1 year			0.794
1–5 years	0.007	0.681	0.992		1.007	0.265, 3.825
≥5 years	0.315	0.514	0.540		1.370	0.501, 3.752
No of side effects	−0.314	0.269	0.242		0.731	0.432, 1.237
Use of alternative medicines	−1.636	0.541	0.003	**	0.195	0.067, 0.563
CQR scores	0.038	0.025	0.130		1.039	0.989, 1.092
Comorbidities	0.494	0.240	0.040	*	0.427	0.203, 0.896
Non-medical costs	−0.001	0.001	0.174		0.999	0.998, 1.000
Use of tools such as reminders	1.334	0.722	0.065		3.796	0.923, 15.619
Hospitalization expenditure	−0.159	0.308	0.606		0.853	0.466, 1.560
Outpatient expenditure	0.000	0.000	0.481		1.000	0.999, 1.000
Work activity, less activity			0.119
Light-to-moderate activity	−2.488	1.744	0.154		0.083	0.003, 2.533
Heavy-activity	−3.477	1.854	0.061		0.031	0.001, 1.171
Step 9a
Work activity, less activity			0.037
Light-to-moderate activity	−0.632	0.360	0.079		0.532	0.263, 1.076
Heavy-activity	−1.543	0.645	0.017	*	0.214	0.060, 0.757
Use of tools such as reminders	1.833	0.461	0.000	**	6.252	2.530, 15.444
Use of alternative medicines	−1.329	0.454	0.003	**	0.265	0.109, 0.645

Notes:

* P<0.05;

** P<0.01.

a Bachward stepwise regression was used in this analysis.

Abbreviations: CQR, Compliance Questionnaire for Rheumatology; SIG, significance; SLE, systemic lupus erythematosus.