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Economic Cost and Epidemiological Characteristics of Fibromyalgia
To the Editor: The article by Robinson, et al1 intimates how much the diagnosis of fibromyalgia costs. So why does The Journal continue to publish articles discussing this illegitimate diagnosis as if it really existed2? Let's help the patients by abandoning this fallacious and undefined (and undefineable) diagnostic term. Any diagnosis that's characterized by "I am the evidence" should immediately be discounted. GEORGE E. EHRLICH, MD, MACR, Adjunct Professor, School of Medicine, University of Pennsylvania, Adjunct Professor of Clinical Medicine, New York University, 1101-241 South Sixth Street, Philadelphia, Pennsylvania 19106-3731, USA. E-mail: g2e@mindspring.com REFERENCES 1. Robinson RL, Birnbaum HG, Morley MA, Sisitsky T, Greenberg PE, Claxton AJ. Economic cost and epidemiological characteristics of patients with fibromyalgia claims. J Rheumatol 2003;30:1318-25. 2. Dobkin PL, De Civita M, Abrahamowicz M, et al. Patient-physician discordance in fibromyalgia. J Rheumatol 2003;30:1326-34. Ms Robinson replies To the Editor: As my colleagues and I mention in our article1, the clinical understanding of fibromyalgia (FM) is evolving, the pathophysiology is unknown, and the diagnosis is often not made correctly. While Dr. Ehrlich and others may believe that FM is not a "real" disorder, the very fact that 4699 patients had an insurance claim with an ICD-9 diagnosis of FM is obvious evidence that many physicians disagree with his opinion. By way of comparison, there was also divergence of opinion regarding the biological basis of major depressive disorder prior to the advent of effective pharmacotherapy. The point of our article was to demonstrate that patients with insurance claims related to FM are suffering and face great burdens, which include hidden costs of disability and burden to health care systems. Published data on FM have grown considerably from the time the term was coined in 1976. Medline search of "fibromyalgia" represents a growing trend in the literature, from 114 in the 1970s, 227 in the 80s, and 1144 in the 90s, and already 658 since 2000. Patients and physicians want answers. We have a responsibility to patients to gain better understanding of FM, whether or not there is complete agreement within the clinical community about its legitimacy as an illness. In fact, the uncertainty of the disease is even more reason to publish and gain understanding of this disorder in order to help patients. Patients with an ICD-9 code for FM represented 2.8% of the large-employer data we analyzed. Compared with overall beneficiaries, FM claimants had 2.6 times more medical claims, almost 3 times more prescriptions for study selected medications, and had 2 times the total health care costs. We concluded there is a great need for better understanding of FM. Where better to publish these results than with the experts in the field, rheumatologists? REBECCA ROBINSON, MS, Health Outcomes Research Scientist, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana 46285, USA. REFERENCE 1. Robinson RL, Birnbaum HG, Morley MA, Sisitsky T, Greenberg PE, Claxton AJ. Economic cost and epidemiological characteristics of patients with fibromyalgia claims. J Rheumatol 2003;30:1318-25. Drs. Dobkin and Bernatsky reply To the Editor: Dr. Ehrlich seems to advocate banishing the publication of articles pertaining to fibromyalgia (FM) in The Journal of Rheumatology. His viewpoint apparently stems from his rejection of the diagnostic label "fibromyalgia." He, among others (e.g., Ford1, Quintner and Cohen2), purports that use of the diagnostic label contributes to the spread of misinformation and perpetuation of an epidemic. Apparently, the lack of objective evidence underlying the symptoms described by patients renders research pertaining to FM unworthy of public dissemination. Yet one could easily name many health problems whereby "the patient is the evidence," e.g., low back pain, migraine headaches, etc. Without patients presenting their symptoms (via self-report) most clinicians would be unable to diagnose diseases with known pathology (e.g., systemic lupus erythematosus). So why bother investigating and reporting empirical work pertaining to the syndrome defined by the American College of Rheumatology over a decade ago? First, because it is the second most common diagnosis in rheumatology clinics3. Second, because health service utilization is high, as are the costs to society and individuals with FM4. Third, because as scientists we seek to understand the nature of the syndrome (see Pillemer, et al5 and Croft6). Fourth, because as clinicians we feel compassion for other human beings who are suffering and hope to find an effective means of treating them (see Wilke7). As a clinical psychologist I cannot help but see that the term "fibromyalgia" elicits a negative reaction in many medical doctors (among others). Why does this particular syndrome bring out the worst in some otherwise competent and caring physicians? Do time pressures experienced by doctors make it harder to fit these patients into their grueling schedules? Does the lack of effective treatment make seeing them seem futile? Even if it is true that the label "fibromyalgia" is just a new term for muscular rheumatism, or neurasthenia, or fibrositis2, or that it represents a "common distress disorder"8, the fact remains that up to 2% of the adult population complains of the symptoms consistent with FM3. The good news is the label itself does not appear to alter health status, function, or health service utilization9. PATRICIA L. DOBKIN, PhD, Associate Professor, Division of Clinical Epidemiology, Department of Medicine, McGill University, 1650 Cedar Avenue, Suite L10 417, Montreal, Quebec H3G 1A4, Canada, E-mail: patricia.dobkin@mcgill.ca; SASHA BERNATSKY, MD, McGill University. REFERENCES 1. Ford CV. Somatization and fashionable diagnoses: illness as a way of life. Scand J Work Environmental Health 1997;23:7-16. 2. Quintner JL, Cohen ML. Fibromyalgia falls foul of a fallacy. Lancet 1999;353:1092-4. 3. Goldenberg DL. Fibromyalgia syndrome a decade later: what have we learned? Arch Intern Med 1999;159:777-85. 4. Penrod J, Bernatsky S, Adam V, Baron M, Dayan N, Dobkin PL. Health service costs and their determinants in women with fibromyalgia. J Rheumatol 2004;(in press). 5. Pillemer SR, Bradley LA, Crofford LJ, Moldofsky H, Chrousos GP. The neuroscience and endocrinology of fibromyalgia. Arthritis Rheum 1997;40:1928-39. 6. Croft P. Symptoms without pathology: should we try a little tenderness? Rheumatology Oxford 2003;42:815-7. 7. Wilke W. Fibromyalgia: Recognizing and addressing the multiple interrelated factors. Postgrad Med 1996;100:153-70. 8. Henningsen P, Zimmermann T, Sattel H. Medically unexplained symptoms, anxiety, and depression: a meta-analytic review. Psychosom Med 2003;65:529-33. 9. White KP, Nielson WR, Harth M, Ostbye T, Speechley M. Does the label "fibromyalgia" alter health status, function, and health service utilization? A prospective, within-group comparison in a community cohort of adults with chronic widespread pain. Arthritis Rheum 2002;47:260-5. |