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National and state medical expenditures and lost earnings attributable to arthritis and other rheumatic conditions--United States, 2003.

Arthritis is the leading cause of disability in the United States (i), potentially limiting affected persons from walking a few blocks or climbing a flight of stairs. Using Medical Expenditure Panel Survey (MEPS) data, CDC analyzed national and state-specific direct costs (i.e., medical expenditures) and indirect costs (i.e., lost earnings) attributable to arthritis and other rheumatic conditions (AORC) in the United States during 2003. This report describes the results of that analysis, which indicated that, in 2003, the total cost of AORC in the United States was approximately $128 billion ($80.8 billion in direct and $47.0 billion in indirect costs), equivalent to 1.2% of the 2003 U.S. gross domestic product. Total costs attributable to AORC, by state/area, ranged from $225.5 million in the District of Columbia to $12.1 billion in California. Total costs attributable to AORC have increased substantially since 1997 (2), and that increase is expected to continue because of the aging of the population and increases in obesity and physical inactivity. These findings signal the need for broader implementation of effective public health interventions, such as arthritis and chronic disease self-management programs, which can reduce medical expenditures (3) among persons with AORC.

National direct and indirect costs were derived from the household component of the 2003 MEPS (MEPS-HC), an annual household interview survey of medical conditions, medical system expenditures and utilization, and earnings and employment history (4). MEPS is designed to be representative of the U.S. civilian, noninstitutionalized population; each year's MEPS panel is a subsample of the previous year's National Health Interview Survey. The 2003 MEPS did not include a nursing home component; thus, costs among nursing home residents were excluded from the analysis. During the household interview, MEPS respondents described all medical conditions for which they had sought care from a health-care provider. Each of these medical conditions was later assigned an International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) code by medical coders. The 2003 MEPS-HC response rate was 71.9%. AORC cases in MEPS were identified using three-digit ICD-9-CM codes selected by the National Arthritis Data Workgroup * (5). The 2003 MEPS sample consisted of 23,352 participants aged [greater than or equal to] 18 years, and 4,801 participants met the case definition for AORC.

Direct per-person costs attributable to AORC were estimated using a series of four-stage regression analyses (6) that modeled the probability and magnitude of medical care expenditures among adults aged [greater than or equal to] 18 years. This modeling included adjustment for the following variables: age (18-44, 45-64, or [greater than or equal to] 65 years), sex, race (white or nonwhite), ethnicity (Hispanic or non-Hispanic), marital status (single, currently married, widowed, separated, or divorced), highest educational attainment (less than high school, high school graduate, some college, college graduate, or graduate school), health-insurance status (no insurance, public insurance only, or any private insurance), and the presence of nine other high-cost chronic conditions (hypertension, other forms of heart disease, pulmonary disease, stroke, other neurologic conditions, diabetes, cancer, mental illness, or non-AORC musculoskeletal conditions). The average per-person direct cost attributable to AORC was the difference between the observed and corresponding expected medical costs. Expected costs simulated costs among persons with AORC as if they did not have AORC (2). Average per-person direct costs were generated for overall expenditures and for each of the following four cost categories: 1) ambulatory care, 2) emergency department and inpatient services, 3) prescriptions, and 4) other costs (i.e., home health care, vision aids, dental visits, and medical devices). Finally, total national direct costs were calculated as the product of the number of persons aged [greater than or equal to] 18 years reporting AORC and the average per-person direct costs.

Indirect per-person costs attributable to AORC were derived from a similar four-stage analysis that modeled the probability of employment and the magnitude of lost earnings among persons aged 18-64 years. However, age was categorized differently (18-34, 35-44, 45-54, and 55-64 years), and no adjustment was made for health-insurance status. Total indirect costs were the product of the number of persons aged 18-64 years with AORC who had ever worked and the average lost earnings per person attributable to AORC. All analyses were conducted using statistical software that adjusted for the clustered sampling design of MEPS. The statistical methods used to derive the national direct and indirect cost estimates are described elsewhere (2).

Direct and indirect costs for each state were estimated by applying the state's proportion of overall doctor-diagnosed arthritis (from the 2003 Behavioral Risk Factor Surveillance System [BRFSS]) to the MEPS-derived national cost estimates. State-specific direct costs were estimated for those aged [greater than or equal to]18 years and lost earnings for the working-age population aged 18-64 years. The 2003 BRFSS response rates ranged from 34.4% to 80.4% among states.

In 2003, total direct costs attributable to AORC were $80.8 billion, with an estimated 46.1 million persons aged [greater than or equal to]18 years reporting AORC, and average per-person direct costs of $1,752 (Table 1). Ambulatory care accounted for the highest per-person direct costs ($914), followed by emergency department and inpatient services ($352), prescriptions ($338), and other costs ($146) (Table 1). Total indirect costs attributable to AORC were $47.0 billion; average per-person lost earnings were $1,590 among 29.5 million working-age adults. National direct and indirect costs totaled $128 billion. Among states/areas, total costs attributable to AORC ranged from $225.5 million in the District of Columbia to $12.1 billion in California; New York and Texas had the next highest total costs at $8.7 billion (Table 2).

Editorial Note: The analysis described in this report estimates total AORC-attributable costs for 2003 at $128 billion. Perperson direct and indirect estimates were derived from a regression-based econometric approach, which enabled adjustment for various confounders (e.g., comorbidities) and thus allowed estimation of the costs attributable to AORC.

National direct costs attributable to AORC increased 24% during 1997-2003, from $64.8 billion (adjusted to 2003 dollars using the medical care component of the Consumer Price Index) to $80.8 billion (2). Despite changes in the treatment of persons with AORC during 1997-2003, including introduction of expensive medications in two drug classes, the coxibs ([dagger]) (e.g., Celebrex[TM] [Pfizer Pharmaceutical Company; New York, New York]) and biologics (e.g., TNF ([section]) inhibitors), and an increase in the number of knee and hip joint replacements performed, the average per-person direct costs were similar ($1,762 in 1997 [in 2003 dollars] and $1,752 in 2003). The increase in total direct costs resulted from the increase in the number of persons (9 million) with AORC in 2003, attributable to the increase in population (predominantly in the ages 45-64 years cohort) and the increased prevalence of self-reported AORC among adults aged [greater than or equal to] 50 years (2).

The findings in this report are subject to at least two limitations. First, direct costs likely were underestimated because MEPS does not capture costs associated with complementary and alternative medicines (persons with arthritis are among the major consumers of these medicines [7]), long-term mental health services, and nondurable medical goods. Similarly, indirect costs did not capture loss of unpaid work such as homemaking, child care, and volunteer work. Other expenses associated with treatment of illness, such as transportation, accommodation, and lost wages among family members were not measured by MEPS and therefore were not included in this analysis. Second, state-specific direct and indirect cost estimates were simply derived using state-level prevalences and were not adjusted for differences among states in provider charges, treatment resources, or wage differentials. Thus, costs among states with medical expenditures or wages higher than the national mean likely are underestimated, and costs among those below the mean overestimated. Deriving cost estimates from state-level MEPS data was not possible because these data were available for only 30 of the largest states.

The substantially increased costs of AORC in 2003 were driven by an increase in number of persons with AORC. Costs likely will continue rising because the number of persons with arthritis is projected to continue to increase, with another 8 million arthritis cases anticipated during 2005-2015 (8). Without cost-reduction strategies, the economic burden of AORC will continue to increase. This trend underscores the need for wide-scale implementation of interventions that reduce medical expenditures and lost earnings among persons with AORC. Self-management programs such as the Arthritis Self-Help Program are cost-effective strategies to reduce direct costs associated with arthritis (3). Self-management programs foster skills in coordinating work accommodations and pain management (through physical activity and weight management) and are essential for reducing the economic and societal burden of AORC.


(1.) CDC. Prevalence of disabilities and associated health conditions among adults--United States, 1999. MMWR 2001 ;50:120-5.

(2.) Yelin E, Murphy L, Cisternas M, Foreman A, Pasta D, Helmick C. Medical care expenditures and earnings losses of persons with arthritis and other rheumatic conditions in 2003 with comparisons to 1997. Arthritis Rheum 2007. In Press.

(3.) Kruger JM, Helmick CG, Callahan LF, Haddix AC. Cost-effectiveness of the arthritis self-help course. Arch Intern Med 1998;158:1245-9.

(4.) Agency for Healthcare and Research Quality. Medical Expenditure Panel Survey--household. Available at survey_comp/household.jsp.

(5.) CDC. Arthritis prevalence and activity limitations--United States, 1990. MMWR 1994;43:433-8.

(6.) Duan N, Manning W, Morris C, Newhouse J. Comparison of alternative models for the demand of medical care. Journal of Business and Economic Statistics 1983; 1 : 115-26.

(7.) Quandt SA, Chen H, Grzywacz JG, Bell RA, Lang W, Arcury TA. Use of complementary and alternative medicine by persons with arthritis: results of the National Health Interview Survey. Arthritis Rheum 2005;53:748-55.

(8.) Hootman JM, Helmick CG. Projections of US prevalence of arthritis and associated activity limitations. Arthritis Rheum 2006;54:226-9.

* ICD-9-CM codes 274, 354,390, 391,443,446, 71 (1-716, 719 721, and 725 729.

([dagger]) Cyclooxygenase (COX)-2-selective inhibitors.

([section])Tumor necrosis factor.

Reported by: E Yelin, PhD, Univ of California at San Francisco; M Cisternas, MA, A Foreman, MA, D Pasta, MS, Ovation Research Group, San Francisco, California. L Murphy, Phi), CG Helmick, MD, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.
TABLE 1. National direct and indirect costs attributable to
arthritis and other rheumatic conditions (AORC), by cost
category--Medical Expenditure Panel Survey, United States,

                           No. of adults    Average       Total costs
                             affected       cost per     (in billions)
Cost category              (in millions)   person ($)         ($)

Direct (medical
    expenditures)             46.1 *         1,752      80.8 ([dagger])
  Ambulatory care               --            914            42.1
  Emergency department
    and inpatient care          --            352            16.2
  Prescription                  --            338            15.6
  Other ([section])             --            146             6.7
Indirect (lost earnings)       29.5          1,590           47.0

* Persons aged >18 years.

([dagger]) Medical costs for each of the four categories do not total
to $80.8 billion because estimates for each category were derived from
separate regression models; the discrepancy results from consolidation
of variance across regression models.

([section]) Includes home health care, vision aids, dental visits, and
medical devices.

([paragraph]) Persons aged 18-64 years with AORC who had ever worked.

TABLE 2. Direct and indirect costs attributable to arthritis and other
rheumatic conditions, by state/area--Medical Expenditure Panel Survey
and Behavioral Risk Factor Surveillance System (BRFSS), United States,

                   Direct costs (medical expenditures)

                        No. of            Costs
                   adults affected    (in millions)
State/Area         (in thousands) *   ($) ([dagger])

Alabama                       1,132          1,617.9
Alaska                          112            160.0
Arizona                       1,062          1,517.9
Arkansas                        636            908.5
California                    5,503          7,863.3
Colorado                        830          1,186.2
Connecticut                     660            943.1
Delaware                        163            232.7
  of Columbia                   103            146.7
Florida                       3,595          5,137.5
Georgia                       1,681          2,401.8
Hawaii                          171            243.9
Idaho                           248            354.2
Illinois                      1,154          1,649.0
Indiana                       1,383          1,976.6
Iowa                            583            832.7
Kansas                          490            700.1
Kentucky                      1,042          1,488.4
Louisiana                       892          1,275.0
Maine                           290            413.9
Maryland                      1,058          1,512.6
Massachusetts                 1,234          1,764.1
Michigan                      2,406          3,437.8
Minnesota                       955          1,364.2
Mississippi                     656            938.1
Missouri                      1,275          1,821.8
Montana                         179            256.0
Nebraska                        344            492.3
Nevada                          441            630.9
New Hampshire                   252            360.3
New Jersey                    1,593          2,276.8
New Mexico                      340            485.6
New York                      3,898          5,569.9
North Carolina                1,790          2,558.2
North Dakota                    130            185.2
Ohio                          2,511          3,588.3
Oklahoma                        727          1,039.5
Oregon                          716          1,023.3
Pennsylvania                  2,957          4,225.6
Rhode Island                    229            327.3
South Carolina                  927          1,324.9
South Dakota                    161            229.7
Tennessee                     1,375          1,964.7
Texas                         3,765          5,380.1
Utah                            353            504.9
Vermont                         129            183.9
Virginia                      1,484          2,121.2
Washington                    1,215          1,735.8
West Virginia                   523            746.8
Wisconsin                     1,084          1,549.0
Wyoming                         106            151.9
United States      -- ([paragraph])         80,800.0

                   Indirect costs (lost earnings)

                        No. of            Costs         Total costs
                   adults affected    (in millions)    (in millions)
State/Area         (in thousands) *   ($) ([dagger])        ($)

Alabama                         763         978.9         2,596.8
Alaska                           89         114.6           274.7
Arizona                         643         824.6         2,342.5
Arkansas                        415         532.8         1,441.3
California                    3,331       4,273.3        12,136.6
Colorado                        572         733.3         1,919.5
Connecticut                     389         499.4         1,442.5
Delaware                        102         130.7           363.4
  of Columbia                    61          78.7           225.5
Florida                       1,938       2,486.0         7,623.5
Georgia                       1,176       1,508.8         3,910.7
Hawaii                          102         131.4           375.3
Idaho                           163         209.5           563.6
Illinois                        796       1,021.1         2,670.0
Indiana                         939       1,204.4         3,180.9
Iowa                            325         417.0         1,249.7
Kansas                          316         405.8         1,106.0
Kentucky                        731         938.0         2,426.4
Louisiana                       593         761.3         2,036.3
Maine                           184         236.1           650.0
Maryland                        753         966.8         2,479.3
Massachusetts                   756         970.1         2,734.2
Michigan                      1,652       2,119.4         5,557.2
Minnesota                       630         807.8         2,171.9
Mississippi                     434         556.3         1,494.5
Missouri                        820       1,051.9         2,873.7
Montana                         109         139.6           395.6
Nebraska                        206         264.8           757.0
Nevada                          304         390.7         1,021.6
New Hampshire                   166         213.1           573.5
New Jersey                      987       1,267.0         3,543.7
New Mexico                      222         284.4           770.0
New York                      2,460       3,155.7         8,725.5
North Carolina                1,211       1,553.4         4,111.6
North Dakota                     78          99.5           284.7
Ohio                          1,681       2,156.8         5,745.0
Oklahoma                        458         588.1         1,627.7
Oregon                          457         585.7         1,609.1
Pennsylvania                  1,833       2,352.1         6,577.7
Rhode Island                    143         183.5           510.8
South Carolina                  630         808.0         2,132.9
South Dakota                     95         121.7           351.4
Tennessee                     1,018       1,306.6         3,271.3
Texas                         2,592       3,326.1         8,706.2
Utah                            246         315.0           819.9
Vermont                          83         105.9           289.8
Virginia                      1,048       1,344.7         3,465.9
Washington                      819       1,051.1         2,786.9
West Virginia                   344         441.4         1,188.2
Wisconsin                       698         895.8         2,444.9
Wyoming                          71          91.3           243.1
United States      -- ([paragraph])      47,000.0       127,800.0

* Aged [greater than or equal to] 18 years.

([dagger]) State estimates might not sum to total because of rounding.

([section]) Persons aged 18-64 years.

([paragraph]) National cost estimates were apportioned using each
state's proportion of the overall number of arthritis cases in BRFSS.
The CDC arthritis program recommends using BRFSS data for estimating
state-level measures of arthritis and National Health Interview
Survey data for national measures of arthritis.
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Author:Yelin, E.; Cisternas, M.; Foreman, A.; Pasta, D.; Murphy, L.; Helmick, C.G.
Publication:Morbidity and Mortality Weekly Report
Geographic Code:1USA
Date:Jan 12, 2007
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