eMethods
Selective literature search
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For this review article, we carried out a selective literature search of PubMed for the period from 1990 to September 2021. The search was limited to systematic reviews, meta-analyses, guidelines, randomized controlled trials, and cohort studies. The search terms used were: “polymyalgia rheumatica,” “aetiology,” “diagnostics,” “therapy,” “medical care,” and “specialist care.”
Epidemiological data
To determine the incidence, prevalence, and health care by medical specialty of polymyalgia rheumatica (PMR), we analyzed data from outpatient and inpatient medical care of persons insured with the Allgemeine Ortskrankenkasse (AOK) Baden-Württemberg during the years 2011-2019. ICD-10 codes M35.3 (polymyalgia rheumatica) and M31.5 (giant cell arteritis with polymyalgia rheumatica) were used for this purpose.
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The data were provided by the AOK Baden-Württemberg in aggregated form, and were stratified by age and sex in accordance with previously agreed inclusion criteria as described below. Apart from the number of insured persons with PMR (stratified by sex) in the various age groups, no other information on the insured persons was provided. Incidences and prevalences (both crude and standardized for age and sex) were calculated and data on specialist medical care were analyzed by the Institute of General Practice and Interprofessional Care. All analyses were performed using the statistical software R.
Incidence of PMR
The incidence of PMR was defined using diagnoses from outpatient and inpatient medical care. A diagnosis (ICD-10: M 35.3, M 31.5) from outpatient care was taken to indicate new-onset PMR if it was coded in two quarters within a year (M2Q criterion) and was coded as a confirmed diagnosis (“G”). The two diagnoses from outpatient care recorded within 1 year could differ (e.g., first diagnosis: M35.3; second diagnosis: M31.5). The year in which the first of the two diagnoses was coded was considered the year of onset. In the data from inpatient care, a PMR diagnosis coded as main or secondary diagnosis was sufficient to count as new-onset PMR. To ensure that it was indeed an incident PMR diagnosis, a 2-year pre-observation period was set that could not include any earlier PMR diagnosis. The insured persons also had to have been continuously insured with the AOK Baden-Württemberg during this two-year period.
Prevalence of PMR
For a PMR diagnosis to be included in the prevalence data, a confirmed diagnosis (“G”) from outpatient care or a main or secondary diagnosis from inpatient care sufficed.
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Standardization for age and sex
In addition to crude incidence and prevalence, the data were standardized for age and sex. The standard population comprised all persons insured in the statutory health insurance (SHI) system for the year 2019 (7).
Medical specialties providing outpatient care
To analyze which medical specialties provided care to insured persons with new-onset PMR, we used the “basic flat rates” (“Grundpauschalen”) for outpatient care billed to the AOK Baden-Württemberg on a specialty-specific basis. Unlike a doctor’s “lifetime physician number” (“LANR”), the advantage of these billing records is that they provide information on the specialty in which care was actually provided to the insured person, rather than the specialty in which the attending doctor originally trained – which may or may not be the same as his or her current area of practice. The basic flat rates for the following specialties were included: general practice, rheumatology, orthopedics, neurology, and ophthalmology. Diagnoses not made by the above-mentioned specialists were grouped together under “other medical specialty.”
To determine which medical specialties were involved in the diagnosis of PMR, we determined the frequencies of the specialist basic flat rates billed during the quarter of PMR onset and in the subsequent quarter when accompanied by a documented incident PMR diagnosis.
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