78 Chapter 4 Health care utilization and costs Healthcare utilization is an important measure for public healthcare organizations. The burden is especially large in individuals with chronic pain conditions.35 One previous study examined the health care utilization and costs for patients with lateral epicondylar tendinopathy.36 Median number of annual physiotherapy visits was higher in AT patients compared to patients with lateral epicondylar tendinopathy (7 for AT versus 3 for lateral epicondylar tendinopathy), while the median number of medical specialist visits was comparable (1 for both disorders).36 Both indirect costs due to the inability to work and direct costs as a result of tendinopathy have not been extensively researched. In the United States direct semi-annual medical costs for conservatively treated patients with lateral epicondylar tendinopathy were US $168 (€151) per patient.36 The total median annual medical costs per patient were slightly higher in conservatively treated patients with lateral epicondylar tendinopathy, knee osteoarthritis, and ankylosing spondylitis compared to conservatively treated AT patients (respectively €305, €660 and €451 versus €258).36-38 Patients with fibromyalgia and chronic back pain reported slightly lower median annual medical costs for primary and secondary care compared to AT patients (respectively €190 and €131 versus €258).38 Socio-economic consequences of AT patients for the public are substantial, based on Dutch incidence rates of AT and the persisting nature of the condition.7,8 The absolute socioeconomic burden of Achilles tendinopathy in the Netherlands can be estimated at more than 21 million euros. Based on an incidence rate of 2.35 per 1,000 in general practice registered adult patients and a total of 5028 general practices (with an average of 2,095 patients per practice) in the Netherlands, the total number of annual new Dutch AT patients is estimated at 25,000.5 The total socio-economic burden can therefore be estimated at 25.000 x €840 = €21.000.000 (US $24.780.000). This is likely to be an underrepresentation, as our study shows that only 39% of these patients visit a general practitioner and it is known that in an open population of runners sustaining AT, the majority is seeking other sources of primary healthcare than general practice (e.g. physiotherapy).39 Previous research indicated that surgery is performed in up to 24% of all AT patients in some countries.40 Surgically treated AT patients were excluded in our study. Including these would lead to a significant increase in healthcare costs. Furthermore, we did not use costs of medication use and imaging in the comparison as we, contrary to the other studies, did not collect this information. An illustration of the possible impact if imaging costs were included in this study is provided in supplementary file 3. It is conceivable that work absence, healthcare utilization and healthcare costs would also be significantly higher if surgically-treated patients were included and medication use and imaging costs would have been included. Therefore, the actual impact of AT on work performance, health care utilization, and direct and indirect costs may be even larger than presented in this study.
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