Rheumatology 2016;55:861–868

RHEUMATOLOGY doi:10.1093/rheumatology/kev428
Advance Access publication 11 January 2016

Original article
Risk of work loss due to illness or disability in

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patients with osteoarthritis: a population-based
cohort study
Behnam Sharif1, Rochelle Garner2, Claudia Sanmartin2, William M. Flanagan2,
Deirdre Hennessy2 and Deborah A. Marshall1

Abstract
Objectives. To estimate the risk of work loss due to illness or disability in a cohort of employed persons
with OA compared with matched non-OA individuals.
Methods. We performed a population-based cohort analysis using the last six cycles of the Canadian
longitudinal National Population Health Survey from 2000 to 2010. OA cases and up to four age- and sex-
matched non-OA individuals were selected. Discrete time hazard regression models were used to esti-
mate the hazard of work loss due to illness or disability. To analyse the effect of a self-reported OA
measure on the outcome, we performed a sensitivity analyses for case selection.
Results. From 7273 employed individuals between the ages of 20 and 70 years in the National Population
Health Survey, 659 OA cases were selected and matched to 2144 non-OA individuals. The proportion of
OA cases who experienced work loss due to illness or disability during the follow-up period was 12.6%,
compared with 9.3% for non-OA individuals (P < 0.001). OA cases had a 90% [hazard ratio (HR) 1.90
(95% CI 1.36, 3.23)] higher hazard of work loss due to illness or disability compared with their matched
non-OA individuals after adjusting for sociodemographic, health and work-related status. The adjusted
HRs were 1.61 (95% CI 1.13, 2.30) and 2.04 (95% CI 1.74, 4.75) for females and males, respectively.
Conclusion. OA is independently associated with an increased risk of work loss due to illness or disability.

CLINICAL
SCIENCE
Given the high prevalence of OA in the population of working age, future research may wish to investigate
ways to improve occupational participation among OA patients.
Key words: osteoarthritis, work disability, epidemiology, workforce, cohort study

Rheumatology key messages

. OA is independently associated with an increased risk of work loss due to illness or disability.
. Risk of work loss due to illness or disability is higher among OA compared with non-OA cases for both males and
females.
. This study highlights the importance of investigating approaches to improve occupational participation in the OA
population.

1
Department of Community Health Sciences, Faculty of Medicine,
University of Calgary, Calgary, Alberta and 2Health Analysis Division,
Statistics Canada, Ottawa, Ontario, Canada
Submitted 28 July 2015; revised version accepted 23 November 2015
Correspondence to: Behnam Sharif, Department of Community Health
Sciences, Faculty of Medicine, University of Calgary, 3280 Hospital
Drive NW, Calgary, AB, Canada T2N 4Z6.
E-mail: behnam.sharif@ucalgary.ca
Introduction
OA is one of the leading causes of chronic pain and mo-
bility limitations [1, 2] and is the fastest-growing cause of
disability worldwide [3]. The onset of OA starts at an age
when people are still working [5, 6] and it has been shown
that OA is strongly associated with reduced productivity
and increased healthcare resource utilization among

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Behnam Sharif et al.
workforce participants [4–8]. OA symptoms such as pain,
disturbance of sleep and stiffness may impair occupa-
tional performance not only among those with physically
demanding jobs but also in non-manual office workers [9].
While the effect of OA on productivity loss at work [10]
and short-term sick leave [7, 11] has been established, the
association between OA and work loss is not as clear [12].
Work loss due to illness or disability can be manifested as
long-term sick leave leading to unemployment [13]. Those
OA patients who become unemployed may find new jobs,
or it can eventually lead them to move out of the work-
force [13–15]. Harris and Coggon [9] described several
studies that reported work loss among end-stage hip
OA patients. In addition, Sayre et al. [18] described that
among 688 OA patients who were selected from the ad-
ministrative data registry in British Columbia, Canada,
32% had ceased employment due to OA. There is wide
variation among current estimates of the effect of OA
on work loss, as the majority of previous studies lacked
appropriate non-OA controls [16–18] or did not control for
potential confounding factors [14].
While the majority of studies investigated the associ-
ation of OA and employment [5, 9, 18, 19] using cross-
sectional data [9, 18], few recent studies have examined
the specific association of OA and work loss using longi-
tudinal data [14, 15]. In a population-based cohort study,
Hubertsson et al. [14] showed that working age individuals
with knee OA had almost twice the rate of (long-term) sick
leave compared with the general population. In another
cohort study, Wilkie et al. [15] indicated a significant dif-
ference among those who were off work due to sickness
[15]. However, none of these studies established OA as an
independent risk factor for work loss, and it is not clear if
the higher rates between OA and non-OA individuals are
due to the differences in sociodemographic, health status
or other possible confounders. In this study, we evaluated
the association of OA and work loss due to illness or
disability in a population-based cohort design.
Methods
The Canadian National Population Health Survey (NPHS)
is a longitudinal survey administered by Statistics Canada
that interviewed the same group of 17 276 Canadian
individuals every 2 years from 1994 to 2010. The survey
collects information on health as well as the factors that
can have an influence on health [20]. We used six cycles
of NPHS from cycle 4 (2000–1) to cycle 9 (2010–11). Cycle
4 was the first NPHS cycle to include a question on arth-
ritis type, that is, OA, RA or other types, and individuals
were asked if they had doctor-diagnosed OA in any site,
that is, OA of the hip, knee, spine or other joints. All sur-
veys conducted by Statistics Canada, including NPHS
used in this study, employ informed consent and have
gone through a review process prior to implementation
[20]. The use of confidential survey data collected by
Statistics Canada was carried out in the Statistics
Canada Health Analysis Division under stringent proced-
ures for disclosure analysis to ensure that no individual
can be identified. Members of the research team received
862
security clearance and take the Statistics Canada oath
in order to use confidential data files. This study did not
require ethical approval.
Study sample
The main explanatory variable was self-reported doctor-
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diagnosed OA. We sampled from those between 20 and
70 years of age who were employed at the selection cycle.
The selection cycle was defined as the cycle in which OA
cases were first identified; it could be the baseline for
those who reported OA at baseline or any follow-up
cycle for respondents reporting OA for the first time. For
the current analysis, a respondent was identified as an OA
case if they reported OA in at least two cycles, that is, the
selection cycle and at least one follow-up cycle. The non-
exposed population was NPHS respondents who did not
report OA in any survey cycle and were employed in the
selection cycle.
All non-OA individuals were matched to OA cases ac-
cording to the selection cycle, sex and age (within 5 years
of the cases). For each OA case, we sampled up to four
age- and sex-matched non-OA individuals. Matching on
the selection cycle was performed to maintain a balanced
follow-up time among the exposed and non-exposed
population. Matching on age and sex was performed to
reduce selection bias due to the limited follow-up time
(e.g. length-time bias) [21]. However, we have also ad-
justed for both age and sex in the analysis stage due to
differential rates of loss to follow-up in our study [21, 22].
Measures
In the NPHS, respondents who were unemployed or out of
the workforce were asked the reason they were not work-
ing. Response options were their own illness/disability,
permanently unable to work, retirement, caring for chil-
dren, care for a family member, pregnancy, vacation,
labour dispute, seasonal or temporary layoff, casual job,
believes no work available, work schedule and educa-
tional leave [20]. The outcome measure for our study
was work loss due to illness/disability and includes
those who reported being unemployed due to their own
illness/disability and those who reported being perman-
ently unable to work. The latter group is defined as
those experiencing work loss due to illness/disability
who are unable to work permanently in their job category.
The outcome has been evaluated for a maximum of five
follow-up periods according to the selection cycle.
Covariate selection was based on the literature that
investigated work loss due to illness or disability [23,
24]. Among the covariates first selected, only those with
P < 0.1 in univariate analyses were included in the final
model [25]. Therefore, education level and work strain
were not included in the final model. In addition to OA
status, sociodemographic status (age, sex, children,
marriage, income adequacy), health status (BMI, chronic
conditions) and work stress were selected.
The presence of chronic conditions was based on self-
reports of doctor-diagnosed conditions. The number of
chronic conditions was summed across a standard list
www.rheumatology.oxfordjournals.org

of high-prevalence chronic diseases [26]: high blood
pressure, arthritis (other than OA), back problems, eye
problems, heart disease, osteoporosis, diabetes, urinary
incontinency, chronic obstructive pulmonary disease,
bowel disorder and stroke. The number of chronic condi-
tions was categorized as zero, one or two or more condi-
tions. The work stress variable was a continuous measure
from 0 to 48 and was calculated based on a 12-item index
selected from a larger pool of items from a validated
Karasek work stress model [27–29]. This measure reflects
respondents’ perceptions about various dimensions of
their work, including physical effort required at their job
[28]. According to the tertiles for the distribution of the job
stress variable, we categorized work stress into three
levels: low (0–16), medium (17–20) and high (21–48). BMI
was based on self-reported height and weight and obesity
was defined as a BMI 530 kg/m2. Income adequacy is a
measure that examines total household income relative to
the number of people that the income supports [20].
Statistical analysis
Differences in the prevalence of covariates for OA and
non-OA individuals were assessed using chi-square and
t-tests. For the multivariate model, we used a discrete
time hazard model [30] with a complementary log–log
link function with a linear hazard function. The proportion-
ality assumptions were assessed by interacting each cov-
ariate with time: all interactions were non-significant
(P > 0.05), indicating that all covariates upheld the propor-
tionality assumption. Due to the statistically significant
interaction between OA and sex, stratified analysis by
sex was performed. NPHS survey weights were used to
account for the sample design and adjustments for non-
response were used to provide estimates representative
of the Canadian household population. Variances were
calculated using rescaled weights and bootstrap esti-
mates according to design factors provided by Statistics
Canada. All the statistical analysis was performed in SAS
version 9.3 (SAS, Cary, NC, USA).
Sensitivity analysis
One common cause of information bias in analyses using
survey data is the use of self-reported measures [31].
Information bias may be present with regard to our main
explanatory variable of self-reported OA. For example, in
our data, some individuals reported OA in one cycle but
did not report OA in any follow-up cycles, while some re-
ported OA in all follow-up cycles. Therefore, to analyse
how the use of an OA self-reported measure may affect
the final results, we defined a base case and five alterna-
tive case definitions. The base case scenario was defined
as self-reported OA in at least two cycles, that is, the se-
lection cycle and at least one follow-up cycle. The alter-
native scenarios were defined according to the
percentage of time OA was self-reported by participants;
scenarios 1–4 were defined based on OA self-reports in at
least 25, 50, 75 or 100%, respectively, of the follow-up
cycles. In the fifth scenario, we only included those who
reported OA in two consecutive cycles. We then
www.rheumatology.oxfordjournals.org
Risk of work loss due to illness among OA patients
calculated hazard ratios (HRs) of work loss due to illness
or disability for each scenario. Comparison of results
across different scenarios would indicate the sensitivity
of the outcome with regard to the self-reported measure
of OA.
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Results
From the total sample size of 17 276 longitudinal respond-
ents in the NPHS, 659 respondents reported OA at least
twice during follow-up and were employed at their first
report of OA (the base case selection scenario). The
total number of matched non-OA individuals was 2144.
Supplementary Figure S1 (available at Rheumatology
Online) illustrates the process of case selection and
matching. OA and non-OA individuals were similar in
terms of age and sex, but differed on all other covariates
(Table 1). OA cases were more likely to be obese and less
likely to be married/common-law or to have children <12
years of age living in their household compared with non-
OA individuals. The distribution of the number of chronic
conditions, work stress levels and income adequacy also
differed between OA cases and non-OA controls.
A greater proportion of OA cases experienced work loss
due to illness or disability during follow-up (12.6%)
compared with non-OA individuals (9.3%), as shown in
Table 2. A greater proportion of OA cases (30.3%) than
non-OA individuals (24.6%) were censored as a result of
work loss due to reasons other than illness or disability.
In the univariate model, OA cases became unemployed
due to illness or disability during the follow-up period at an
HR 3.13 times higher (95% CI 2.03, 4.82) than that of non-
OA individuals.
Table 3 describes the results for the multivariate dis-
crete-time hazard models. The overall goodness of fit
was tested by the likelihood ratio test; the null hypothesis
for all models with only an intercept has been rejected
(P < 0.001). This indicates the models fit the data well.
After adjusting for other covariates in the overall model,
OA cases experienced work loss due to illness or disability
during the follow-up period at an HR 1.9 times greater than
that of non-OA individuals (95% CI 1.36, 3.23). Since the
interaction of sex and OA status was significant in the over-
all model (P < 0.05), we performed analyses separately for
males and females. According to the females-only models,
the HR of work loss due to illness or disability for OA cases
was 1.61 (95% CI 1.13, 2.30), while in the males-only model
it was 2.04 (95% CI 1.74, 4.75) after adjusting for other
relevant covariates.
OA status and income adequacy were significantly
associated with work loss due to illness or disability
(Table 3). In the female-only and male-only model, individ-
uals within the high income adequacy group had 83 and
68% lower HRs, respectively, for the outcome compared
with the low income adequacy group. Among women,
having a chronic condition (for OA cases, this was in add-
ition to OA) and being obese significantly increased the
hazard of the outcome, whereas women with children
<12 years old in the household were significantly less
likely to leave employment due to illness or disability. On
863
Behnam Sharif et al.

TABLE 1 Descriptive statistics for OA cases and non-OA stress and marriage were not significantly associated
individualsa with the outcome in any of the multivariate models.
In addition, we calculated the proportion of OA cases
and non-OA individuals who went back to work after they
Non-OA
OA cases individuals P- left their first job; 36% of OA cases went back to work
Cohort Characteristics (n = 659) (n = 2144) value compared with 42.3% of non-OA individuals (P < 0.05).

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OA cases had a lower probability of going back to work
Age, mean (s.d.), years 48.0 (8.8) 48.6 (8.7) 0.25 than non-OA individuals among males (38.9% vs 45.5%,
Sex, % 0.16 P < 0.05) and females (34.1% vs 41.5%, P < 0.05).
Female 59.6 58.1
Male 40.3 41.9
Supplementary Table S1 (available at Rheumatology
Obesity, % <0.001 Online) presents the results of the sensitivity analysis
Non-obese 74.0 82.5 and shows the unadjusted and adjusted HRs of OA
Obese 26.0 17.4 cases vs non-OA individuals in terms of the outcome
Marriage, % 0.008 across different case selection scenarios. While the result-
Married or 73.7 77.1 ing number of cases decreased from scenarios 1 to 4,
common law
Single, divorced, 26.3 23.0 unadjusted and adjusted HR estimates were all significant
widowed and were not statistically different across scenarios.
Children, % <0.001
Having a child 21.4 25.7
<12 years of age
Discussion
Having no children 78.6 74.2
<12 years of age Using the last six cycles of the NPHS from 2000 to 2010,
Work stress, % <0.001 we performed a population-based cohort analysis to esti-
Low 25.5 33.7 mate the HR of work loss due to illness or disability among
Medium 26.0 25.8 initially employed OA cases and non-OA individuals.
High 39.1 26.8 According to our results, for each 2 years of follow-up,
Missing 9.4 13.7 OA cases had a 90% higher HR [1.9 (95% CI 1.36,
Chronic conditions, % <0.001
3.23)] of work loss due to illness or disability compared
No condition 49.8 73.1
One condition 34.9 21.1 with age- and sex-matched non-OA individuals after ad-
Two or more conditions 15.2 5.8 justing for other covariates.
Income adequacy, % In a 2011 systematic review, Bieleman et al. [12] stated
High 6.7 4.5 0.034 that OA could not be proven to be a strong reason for
Middle 50.2 50.0 leaving the workforce through sick leave, as the majority
Low 36.1 35.8 of examined studies were cross-sectional and did not use
Missing 7.0 9.2 appropriate controls. However, recent studies using lon-
gitudinal cohort settings have investigated the effect of
a
All variables are measured at the selection cycle. OA on work loss, including disability pensioning [14],
long-term sick leave [14] and work loss in general [15,
TABLE 2 Outcomes over the follow-up period for OA 32], and reported a strong association between OA and
cases and non-OA individuals from 2000 to 2010 work loss. While our results are comparable to the out-
come of Hubertsson et al. [14] in terms of long-term sick
leave, they did not adjust their results for possible co-
Non-OA
Outcomes and OA cases individuals P- morbidities, sociodemographic or work factors that may
censoring measures (n = 659) (n = 2144) value confound the effect. In another study, Wilkie et al. [15]
used a combined outcome of premature work loss
Unemployed due to 12.6 9.3 <0.01 (PWL) that includes early retirement, unemployment due
illness or disability, % to health or other reasons and reported that incident of
Unemployed due to 7.2 5.0 <0.01
illness, % PWL in adults with OA was 25% over 6 years. While
Permanently unable 5.4 4.3 0.12 Wilkie et al. [15] observed no significant difference in
to work, % PWL between OA and non-OA cases, they reported that
Remained employed, % 50.3 48.7 0.61 OA patients were more likely to be off work due to sick-
Censored, % 37.1 42.0 0.04 ness compared with non-OA individuals (33.8% vs
Died, were institutionalized 6.8 17.4 <0.01
19.1%), which is in accordance with our results.
or lost to follow-up, %
Left employment for 30.3 24.6 0.03 As we have shown in this study, not all individuals who
other reasons, % experience work loss due to illness or disability are per-
manently out of the work force, and a fraction of partici-
pants may come back to work in later years. According to
the other hand, among men, high income adequacy was our results, 36% of the OA population went back to work,
significantly associated with a lower hazard of work loss which was significantly lower than non-OA individuals
due to illness or disability compared with low income ad- among both males and females. This has been shown in
equacy after adjusting for other covariates. Age, work terms of work transitions in other studies; Gignac et al.

864 www.rheumatology.oxfordjournals.org
 Risk of work loss due to illness among OA patients

TABLE 3 Hazard ratios (95% CIs) from discrete-time hazard models for all individuals (overall model), females-only and
males-only models

Characteristics
measured at Overall model Females-only Males-only
selection cyclea (n = 2803) model (n = 1165) model (n = 1638)

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OA status
OA 1.90 (1.36, 3.23)** 1.61 (1.13, 2.30)** 2.04 (1.74, 4.75)**
Non-OA 1.00 1.00 1.00
Ageb 1.00 (0.97, 1.02) 0.98 (0.94, 1.01) 1.03 (1.00, 1.07)
Sex
Female 0.77 (0.48, 1.24) — —
Male 1.00 — —
BMI
Obesec 1.25 (0.91, 1.72) 1.37 (1.03, 1.83)* 1.23 (0.64, 2.35)
Non-obese 1.00 1.00 1.00
Chronic conditions
1 conditions 1.34 (0.75, 2.41) 1.91 (1.02, 3.57)* 0.93 (0.34, 2.55)
52 conditions 1.42 (0.66, 2.35) 2.89 (1.32, 6.35)** 0.57 (0.07, 4.98)
0 conditions 1.00 1.00 1.00
Childrend
412 years 0.51 (0.23, 1.41) 0.21 (0.07, 0.66)** 1.12 (0.33, 3.73)
>12 years or no children 1.00 1.00 1.00
Marriagee
Married 1.44 (0.89, 2.32) 1.52 (0.82, 2.80) 1.20 (0.49, 2.95)
Single/divorced 1.00 1.00 1.00
Income adequacyf
Low 1.00 1.00 1.00
Middle 0.35 (0.18, 0.68)** 0.25 (0.12, 0.51)*** 0.73 (0.05, 1.80)
High 0.20 (0.08, 0.49)*** 0.17 (0.06, 0.47)*** 0.32 (0.02, 0.90)**
Work stress
Low 1.00 1.00 1.00
Medium 1.18 (0.59, 2.34) 0.76 (0.31, 1.87) 1.03 (0.75, 1.41)
High 1.36 (0.65, 2.84) 1.18 (0.58, 2.41) 1.15 (0.81, 1.65)

a
All covariates were measured at the selection cycle, that is, the cycle in which the OA cases or matched non-OA individuals
were selected. bAge was a continuous variable (between 20 and 70 years). cObesity was defined as BMI >30 kg/m2. dHaving
at least one child <12 years of age vs having no children <12 years. eSingle or divorced or widowed vs married or common-
law. fIncome adequacy is a measure that examines total household income relative to the number of people that the income
supports [22]. *P < 0.05 **P < 0.01 ***P < 0.001.

[13] recruited both RA and OA participants and used a
combined measure of work transition score that was
defined according to changes in employment status and
type of work [13]. Approximately 76% of all participants
reported work transitions that were related to subse-
quently making other work transitions or eventually leav-
ing the workforce [13].
We also found a significant interaction between sex and
OA status in our model, which is consistent with findings
in Hubertsson et al. [14], who showed that the relative risk
of receiving (long-term) sickness benefits associated with
knee OA was higher for males than females [14].
Furthermore, our results conform to those of other studies
[33, 34] in terms of the effect of sociodemographic factors
on work loss. According to our results, those in lower
income adequacy groups have a higher chance of leaving
their job due to illness among both males and females.
This may suggest poorer support for lower income groups
in terms of illness/disability [35–37]. In addition, while work
stress has been shown to be a significant factor in
predicting work loss due to health reasons [29], it was
not significantly associated with the outcome in our
study. Work stress consists of several measures, includ-
ing physical demand of a job and co-worker support,
which was shown to be a significant factor in predicting
work loss among OA patients [38]. Work stress was sig-
nificantly higher across OA cases compared with non-OA
individuals in our univariate model and therefore it was
included in the multivariate model.
While effective interventions for prevention of work loss
due to disability have been recognized in diseases such
as lower back pain [39] and SLE [40], the association of
OA and work loss is a relatively new research area and
there is a paucity in the OA literature in terms of work loss
prevention programmes [41]. Identifying which groups are
at high risk of work loss due to OA is an important first
step in developing such programmes [35–37]. Wilkie et al.
[15] showed that questions about pain’s interference with
function and workplace support could be used to identify
OA patients at risk of work loss. In a study by Gignac et al.

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Behnam Sharif et al.
[36] of 291 OA and RA patients, they demonstrated that
those patients utilizing policies allowing for short-term sick
leave, work-at-home arrangements, flexible hours or
modified work schedules had lower rates of job
disruptions compared with those who did not use these
policies. Future studies need to identify cost-effective
work interventions among the OA population not only to
increase their productivity at work, but also to prevent
work loss.
Our study was not free of limitations. Our outcome was
defined based on work loss due to illness/disability and
not due to OA, as the NPHS questionnaire did not include
disease-specific reasons for work loss. However, we con-
trolled for putative confounders including co-morbidities
and other factors in the analysis stage. Therefore our final
results reflect the association between OA and work loss
due to illness or disability after adjusting for other putative
confounders present in our dataset. Furthermore, we used
a self-reported measure for both case selection and other
covariates, which possibly exposed our results to informa-
tion bias. For instance, BMI was calculated based on self-
reported height and weight measures [42]. However, we
performed a sensitivity analysis to evaluate the robust-
ness of the outcome with regard to case selection. The
sensitivity analysis supports the robustness of the model;
the direction and magnitude of the HRs across OA cases
and non-OA individuals are similar regardless of the scen-
ario definition. Moreover, we did not include the physical
activity (PA) levels of individuals. While in our study the
indirect effect of PA on OA through BMI and its effect on
employment through BMI, chronic diseases and work
stress was adjusted for, we did not take into account
the direct effect of PA [43, 44], which exposes our results
to possible confounding bias. We did not include early
retirement in our outcome, as the NPHS data did not cap-
ture the reason for early retirement, that is, due to illness/
disability or other reasons. In addition, it has been shown
that risk factors for early retirement due to disability and
long-term sickness resulting in unemployment are dissimi-
lar; therefore, to delineate the true association between
OA and work loss these outcomes are better studied
separately [31, 45]. Finally, we did not have any measure
in the NPHS to capture the severity of OA. Future studies
need to consider severity measures among the OA popu-
lation to examine the dose–response relationship of
severity of OA and work loss.
The results of this study showed that OA is an inde-
pendent risk factor of work loss due to illness or disabil-
ity. Although a fraction of those experiencing work loss
may go back to work, periods of unemployment that are
associated with OA have a large societal burden in terms
of loss of income and psychosocial burden [41].
Considering the anticipated increase in OA prevalence
due to an ageing population, increasing obesity rates
and the objective to increase work participation among
the elderly in western countries [45], the effect of OA on
work loss will become increasingly significant among
employed populations in the future. Results of our
study highlight the importance of identifying effective
866
approaches to better sustain employment in the OA
population.
Acknowledgements
The authors would like to thank Dr Jacek Kopec for his
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help and support. The views expressed in this article are
solely those of the authors and do not reflect those of
Statistics Canada.
Funding: This work was supported by Mitacs and a
University of Calgary Eyes High postdoctoral fellowship
(10006326).
Disclosure statement: D.A.M. has received honoraria and
reimbursement of travel expenses for participating in ad-
visory boards and presentations (unrelated to any prod-
uct) from Novartis, Pfizer, AbbVie and Janssen and has
provided ad hoc consulting services regarding health eco-
nomics and outcomes research for Optum Insights. All
other authors have declared no conflicts of interest.
Supplementary data
Supplementary data are available at Rheumatology
Online.
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