Shabnam Nahani
1 
, Mohammadreza Siahi-Shadbad
2 , Afshin Gharekhani
3 , Sama Samankan
4 , Mina Golestani
5 , Zohreh Siahi-Shadbad
6 , Mehdi Jafarpour
7* 1 Student Research Committee, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
2 Food and Drug Control Department, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
3 Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
4 Clinical Pharmacy Department (Pharmacotherapy), Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
5 Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
6 Faculty of Pharmacy, Biruni University, Istanbul, Turkey
7 Connective Tissue Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
Abstract
Background. Rheumatoid arthritis (RA) is a chronic inflammatory disease that imposes a significant economic burden on patients and the health system. Cost-of-illness studies are essential tools for estimating this burden and identifying associated factors. This study aimed to estimate the costs of illness and the factors influencing the economic burden of rheumatoid arthritis in hospitalized and outpatient individuals.
Methods. This descriptive-analytical, retrospective, and single-center cost-of-illness study was conducted from the perspectives of the patient and society with a one-year time horizon (2024-2025 / 1403-1404) at Imam Reza Hospital in Tabriz. Data were gathered using medical records and a researcher-developed checklist, and all eligible patients were consecutively enrolled. Costs were estimated using a bottom-up approach. Data analysis was performed using SPSS version 26 via Shapiro-Wilk, Spearman, and Mann-Whitney U tests, considering a significance level of less than 0.05.
Results. The study evaluated 48 outpatients and 124 hospitalized patients. The average direct medical costs for hospitalized patients and outpatients were 267,784 and 23,206 thousand Rials, respectively, while direct non-medical costs were 16,250 and 1,500 thousand Rials. Hospitalization and the use of biological drugs (bDMARDs) were significantly associated with increased total costs; specifically, costs were 183 percent higher in recipients of biological drugs (P=0.045). Insurance type was also associated with costs, and the out-of-pocket payment share for patients covered by the armed forces insurance was 12.5 percent lower than other insurance groups (P<0.001).
Conclusion. Rheumatoid arthritis imposes a substantial economic burden that is significantly correlated with the type of treatment and hospitalization status. Biologic medications are primary drivers of increased costs; therefore, strengthening insurance coverage and optimizing the utilization of these drugs can assist in managing the economic burden of the disease.
Research Insights
· The costs of inpatients with rheumatoid arthritis are significantly higher than those of outpatients.
· Direct medical costs account for the largest share of the economic burden of the disease.
· The use of biologic drugs is one of the most important factors in increasing treatment costs. The type of insurance coverage has a significant impact on the amount of out-of-pocket payments for patients.
· Early management of the disease and the rational use of biologic drugs can reduce the overall economic burden of the condition.
Extended Abstract
Background
Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease associated with progressive joint damage, functional disability, and a substantial socioeconomic burden. In addition to its clinical consequences, RA imposes considerable direct and indirect costs on patients, healthcare systems, and society. Direct costs include hospitalization, physician visits, medications, laboratory testing, imaging, and rehabilitation services. Biologic disease-modifying antirheumatic drugs (bDMARDs), in particular, account for a substantial proportion of treatment costs. Indirect costs include work absenteeism, productivity loss, disability, and informal care. Despite the growing burden of RA, real-world cost-of-illness data from Iran, particularly regarding the effects of hospitalization, insurance coverage, and biologic therapies, remain limited. This study therefore aimed to estimate the economic burden of RA and identify factors associated with healthcare costs among inpatients and outpatients at a tertiary referral center in Tabriz, Iran.
Methods
This retrospective, descriptive-analytical, single-center cost-of-illness study was conducted using a prevalence-based approach from patient and societal perspectives. The study population comprised patients aged 18 years or older with RA, identified by ICD-10 codes M05 or M06, who attended Imam Reza Hospital in Tabriz between September 2024 and September 2025 and had received at least one course of biologic or non-biologic therapy.
Data were collected from medical records, prescription reviews, and structured interviews with patients or their family members using a researcher-developed checklist. Because of the limited and specialized study population, all eligible patients were enrolled consecutively. Patients with severe comorbidities, incomplete medical records, or an unconfirmed diagnosis of RA were excluded.
The checklist covered four categories: demographic and socioeconomic characteristics; direct medical costs, including hospitalization, physician visits, medications, laboratory testing, imaging, physiotherapy, and therapeutic procedures; direct nonmedical costs, including transportation, home care services, and assistive equipment; and indirect costs, including work absenteeism, productivity loss, disability, and informal care.
Costs were estimated using a bottom-up approach. Medication prices were obtained from the database of the Iran Food and Drug Administration, and healthcare service costs were calculated according to the official tariffs of the Ministry of Health for 2024 and 2025. Indirect costs were estimated using the human capital approach. To account for inflation, all costs recorded in 2024 were adjusted to 2025 values using a health-sector price index adjustment factor of 1.345.
Statistical analyses were performed using SPSS version 26. Descriptive data were reported using means, standard deviations, medians, and percentages, as appropriate. The Shapiro-Wilk test indicated that the cost variables were not normally distributed. Therefore, Spearman’s rank correlation was used to assess associations involving continuous variables, and the Mann-Whitney U test was used for between-group comparisons. A p-value of less than 0.05 was considered statistically significant.
Results
A total of 172 patients were included, comprising 124 inpatients and 48 outpatients. Most participants in both groups were women. The use of biologic therapy was significantly more frequent among inpatients than among outpatients.
The mean direct medical cost was 267,784 thousand Iranian Rials for inpatients and 23,206 thousand Iranian Rials for outpatients. The corresponding direct non-medical costs were 16,250 and 1,500 thousand Rials, respectively. Indirect costs were also significantly higher among inpatients.
The estimated total economic burden was 323,459 thousand Rials for inpatients and 28,800 thousand Rials for outpatients. Direct medical costs constituted the largest share of the economic burden in both groups, accounting for approximately 82.8% of total costs among inpatients and 79.8% among outpatients.
Out-of-pocket payments accounted for 22% of total costs among inpatients and 36% among outpatients, suggesting less comprehensive insurance coverage for outpatient care.
Analysis of cost determinants showed that biologic therapy was significantly associated with higher direct medical costs and a greater total economic burden in both groups (P<0.05). Among inpatients, those receiving biologic therapy incurred significantly higher costs across nearly all cost categories than those not receiving biologic therapy. Insurance type was significantly associated with patient-paid costs. Patients covered by Armed Forces Insurance, particularly those admitted to hospital, incurred lower out-of-pocket costs than those covered by other insurance plans. However, insurance type had a more limited effect on outpatient costs.
No statistically significant association was observed between sex and healthcare costs. Increasing age was associated with higher indirect costs only among outpatients, possibly reflecting reduced productivity and greater dependence on supportive care among older adults.
Conclusions
RA imposes a substantial economic burden on patients and the healthcare system, primarily through direct medical costs associated with hospitalization and biologic therapies. Hospitalization status, biologic therapy, and insurance coverage were major factors associated with healthcare costs. Strengthening early disease management, optimizing the use of biologic therapies, expanding outpatient insurance coverage, and promoting biosimilars may help reduce the financial burden of RA and improve the sustainability of healthcare services. These findings may support the development of more cost-effective and equitable policies for the management of RA.
Practical Implications of Research
The findings suggest that early disease management, rational use of biologic therapies, and strengthening health insurance coverage may reduce the economic burden of rheumatoid arthritis and improve healthcare resource allocation.