title: Severity index for rheumatoid arthritis and its association with health care costs and biologic therapy use in Turkey.
abstract: OBJECTIVE
  This study aimed to apply the previously validated severity index for rheumatoid arthritis (SIFRA) to prevalent rheumatoid arthritis (RA) groups in Turkey and determine the effect of RA severity on health care costs and biologic use.
  
  
  METHODS
  This retrospective study used the Turkish national health insurance database MEDULA (June 1, 2009-December 31, 2011). Prevalent RA patients were required to be age 18 to 99, have two RA diagnoses at least 60 days apart and be continuously enrolled 1 year prior to (baseline period) and post (follow-up period) index date, which was the first RA claim during the identification period (June 1, 2010-December 31, 2010). SIFRA was calculated for the baseline period. Total health care costs and biologic use were examined for the follow-up period. The chi-square test was used to determine the association between SIFRA score terciles and outcomes. Generalized linear models were applied to determine health care costs while multivariate logistic regression determined the effect of SIFRA on outcome measures for biologic use.
  
  
  RESULTS
  A total of 1,920 patients were identified. The mean SIFRA score was 14.21, and 7.05 (49.57%) of the mean composed of clinical and functional status variables, followed by 6.32 (44.47%) for medications, 0.48 (3.40%) for radiology and laboratory findings, and 0.32 (2.25%) for extra-articular manifestation. There was a significant variation in scores across cities. After controlling for age, gender, region, and comorbidity index, patients in the high SIFRA tercile were 5.16 times more likely to be prescribed biologics (p<0.001, confidence interval [CI]: 3.46-7.69), and incurred annual health care costs that were €2,091 higher (p<0.001, CI: €1,557 - €2,625) than those in the low SIFRA score tercile.
  
  
  CONCLUSIONS
  RA severity varies throughout Turkey and is a significant determinant of health care costs and biologic therapy use. Therefore, future comparative effectiveness studies should include the severity measure in their analysis.
authors.affiliation: Internal Medicine Department, Rheumatology Division, The University of Michigan, 211 N 4th Avenue, Suite 2B, Ann Arbor, MI 48104, USA. onur@med.umich.edu.
authors.forename: Onur
authors.initials: O
authors.lastname: Baser
authors.forename: Erdem
authors.initials: E
authors.lastname: Baser
authors.forename: Akif
authors.initials: A
authors.lastname: Altinbas
authors.forename: Abdulkadir
authors.initials: A
authors.lastname: Burkan