Letters to the editor / Joint Bone Spine 77 (2010) 81–89 83 [9] Gottenberg JE, Guillevin L, Lambotte O, et al. Tolerance and short-term efficacy of rituximab in 43 patients with systemic autoimmune diseases. Ann Rheum Dis 2005;64(6):913–20 [Epub 2004 Nov 18]. [10] Belkhou A, Younsi R, El Bouchti I, et al. Rituximab as a treatment alternative in sarcoidosis. Joint Bone Spine 2008;7:698–9. Virginie Dasilva a Véronique Breuil a Patrick Chevallier b Liana Euller-Ziegler a,∗ a Rheumatology department, faculté de médecine de Nice, université de Nice Sophia-Antipolis, CHU de L’Archet-I, 151, route de Saint Antoine de Ginestière, 06200 Nice, France b Radiology Department, l’Archet University, 151, route de Saint-Antoine-de-Ginestière, 06200 Nice, France ∗ Corresponding author. Tel.: +33 4 92 03 55 12; fax: +33 4 93 86 68 39. E-mail address: lziegler@unice.fr (L. Euller-Ziegler). 15 April 2009 doi:10.1016/j.jbspin.2009.11.005 The social costs of digital ulcer management in sclerodema patients: An observational Italian pilot study 1. Introduction Digital ulcers (DU), localised on the fingertips or toes, have an estimated frequency of 30–50% in patients affected with systemic sclerosis (SSc) [1]. In 1012 Italian patients, the percentage of DU was 48%, 51% in the limited and 43% in the diffuse cutaneous form, 51% in Scl70 positive and 42% in ACA positive patients [2]. Intra- venous iloprost infusions have been shown to improve healing of DU [3–5] and have reached an elevated level of evidence in the recent EUSTAR recommendations for treatment of SSc [6]. Their administration is possible only in hospital structures and for this reason these therapies are very expensive for the healthcare ser- vice. The objective of this study was to evaluate the social costs of DU management in a group of SSc patients. 2. Methods The study is a retrospective analysis on medical charts of 20 SSc patients, referred to the Rheumatology Unit of the University Hospital of Padova. Their demographic characteristics are sum- marised in Table 1. Patients showed a mean number of 3.5 DU before treatment. Sixteen patients were managed with iloprost, administered by a 6-hour infusion in cycles of 3–5 consecutive Table 1 Demographic characteristics of 20 systemic sclerosis (SSc) patients. Female 18 (90%) Male 2 (10%) Age (mean ± S.D.) 51 ± 12 yrs Raynaud duration (mean ± S.D.) 17 ± 12 yrs Disease duration (mean ± S.D.) 13 ± 10 yrs Limited cutaneous form 12 (60%) Diffuse cutaneous form 8 (40%) Anti-centromeric ANA 10 (50%) Anti-Scl70 ANA 10 (50%) days. Four patients, who didn’t tolerate iloprost, were treated with alprostadil, administered by a 3-hour infusion in cycles of 5 consec- utive days. Seventeen patients were treated in Day Hospital (DH) setting (mean number of 4.3 infusion cycles), three patients were treated in a full admission regime (mean hospitalisation duration of 13 days). Costs were calculated in healthcare service of Veneto region per- spective (DH accesses, full hospital admissions, reimbursed drugs, general practitioner and specialist visits), patient perspective (non- reimbursed drugs, medications, non-pharmacological treatments) and society perspective (the above medical and non-medical direct costs plus indirect costs related to productivity losses of patients and caregivers). Costs were also distinguished in patients with and without complications of DU and calculated in the different settings of care. 3. Results Mean costs of DU management per patient/year, with and with- out DU complications, are reported in Table 2. DU were mostly managed in the DH setting (mean cost D 20,032/patient) and the main cost driver was the number of accesses to the DH (up to D 34,693 for six cycles of infusions). In three patients DU manage- ment was performed in a full admission setting, with a cost of D 4,665/patient for each period. 4. Discussion and conclusions Very few studies have estimated the economic impact of SSc [7–10]. Our data demonstrate that DU management in SSc patients has a heavy weight for the society, especially because of the ele- vated direct costs of treatments performed in hospital structures. DU complications cause a further increase of the economic bur- den, because patients need more accesses in DH. Indirect costs are elevated because 50% of patients worked and the productivity loss accounted for about 10% of total social costs. There are some limita- tions in this work. First of all, it is a pilot study performed in a quite small number of patients. Moreover it is a retrospective study, even though the time frame of observation was extensive. Table 2 Per year costs (D ) in 20 systemic sclerosis (SSc) patients with digital ulcers (DU) – analysis per perspective. Healthcare service perspective Patient perspective Productivity Loss Society perspective SSc patients (N=20) Total cost, D 474,607 9,033 51,477 535,117 Mean/patient cost (± SD), D 23,730 (±11,409) 452 (±414) 2,574 (±3,575) 26,756 (±12,184) Patients with complications (N=17) Total cost, D 413,007 6,151 45,102 464,260 Mean/patient cost (± SD), D 24,295 (±11,849) 362 (±255) 2,652 (±3,833) 27,309 (±12,837) Patients without complications (N=3) Total cost, D 61,600 2,882 6,338 70,820 Mean/patient cost (± SD), D 20,533 (±9,762) 961 (±806) 2,125 (±1,869) 23,619 (±8,642)