Journal article
Treatment of very early rheumatoid arthritis with symptomatic therapy, disease-modifying antirheumatic drugs, or biologic agents: a cost-effectiveness analysis.
- Finckh A Division of Rheumatology, Department of Internal Medicine, University of Geneva, Geneva, Switzerland.
- Bansback N
- Marra CA
- Anis AH
- Michaud K
- Lubin S
- White M
- Sizto S
- Liang MH
- 2009-11-04
Published in:
- Annals of internal medicine. - 2009
Anti-Inflammatory Agents, Non-Steroidal
Antirheumatic Agents
Arthritis, Rheumatoid
Cost-Benefit Analysis
Decision Support Techniques
Disease Progression
Glucocorticoids
Health Care Costs
Humans
Immunologic Factors
Methotrexate
Quality-Adjusted Life Years
Radiography
Treatment Outcome
English
BACKGROUND
Long-term control or remission of rheumatoid arthritis (RA) may be possible with very early treatment. However, no optimal first therapeutic strategy has been determined.
OBJECTIVE
To assess the potential cost-effectiveness of major therapeutic strategies for very early RA.
DESIGN
Decision analytic model with probabilistic sensitivity analyses.
DATA SOURCES
Published data, the National Data Bank for Rheumatic Diseases, and actual 2007 hospital costs.
TARGET POPULATION
U.S. adults with very early RA (symptom duration
TIME HORIZON
Lifetime.
PERSPECTIVE
Health care provider and societal.
INTERVENTION
3 management strategies were compared: a symptomatic or "pyramid" strategy with initial nonsteroidal anti-inflammatory drugs, patient education, pain management, and low-dose glucocorticoids, and disease-modifying antirheumatic drugs (DMARDs) at 1 year for nonresponders; early DMARD therapy with methotrexate; and early therapy with biologics and methotrexate.
OUTCOME MEASURES
Cost per quality-adjusted life-year (QALY) gained.
RESULTS OF BASE-CASE ANALYSIS
By reducing the progression of joint erosions and subsequent functional disability, both early intervention strategies increase quality-adjusted life more than the pyramid strategy and save long-term costs. When the cost of very early intervention is factored in, the cost-effectiveness ratio of the early DMARD strategy is $4849 per QALY (95% CI, $0 to $16 354 per QALY) compared with the pyramid strategy, whereas the benefits gained through the early biologic strategy come at a substantial incremental cost. The early DMARD strategy maximizes the effectiveness of early DMARDs and reserves the use of biologics for patients with more treatment-resistant disease of longer duration, for which the incremental benefit of biologics is greater.
RESULTS OF SENSITIVITY ANALYSIS
The early biologic strategy becomes more cost-effective if drug prices are reduced, risk for death is permanently lowered through biologic therapy, patients experience drug-free remission, responders can be selected before therapy initiation, or effective alternative antirheumatic agents are available for patients for whom several biologics have failed.
LIMITATIONS
Data on the long-term effect of very early therapeutic interventions on the natural progression in disability and joint erosions are limited. The study considered only tumor necrosis factor inhibitors and not the newer biologics.
CONCLUSION
According to the most objective measures of RA progression, very early intervention with conventional DMARDs is cost-effective. The cost-effectiveness of very early intervention with biologics remains uncertain.
Long-term control or remission of rheumatoid arthritis (RA) may be possible with very early treatment. However, no optimal first therapeutic strategy has been determined.
OBJECTIVE
To assess the potential cost-effectiveness of major therapeutic strategies for very early RA.
DESIGN
Decision analytic model with probabilistic sensitivity analyses.
DATA SOURCES
Published data, the National Data Bank for Rheumatic Diseases, and actual 2007 hospital costs.
TARGET POPULATION
U.S. adults with very early RA (symptom duration
TIME HORIZON
Lifetime.
PERSPECTIVE
Health care provider and societal.
INTERVENTION
3 management strategies were compared: a symptomatic or "pyramid" strategy with initial nonsteroidal anti-inflammatory drugs, patient education, pain management, and low-dose glucocorticoids, and disease-modifying antirheumatic drugs (DMARDs) at 1 year for nonresponders; early DMARD therapy with methotrexate; and early therapy with biologics and methotrexate.
OUTCOME MEASURES
Cost per quality-adjusted life-year (QALY) gained.
RESULTS OF BASE-CASE ANALYSIS
By reducing the progression of joint erosions and subsequent functional disability, both early intervention strategies increase quality-adjusted life more than the pyramid strategy and save long-term costs. When the cost of very early intervention is factored in, the cost-effectiveness ratio of the early DMARD strategy is $4849 per QALY (95% CI, $0 to $16 354 per QALY) compared with the pyramid strategy, whereas the benefits gained through the early biologic strategy come at a substantial incremental cost. The early DMARD strategy maximizes the effectiveness of early DMARDs and reserves the use of biologics for patients with more treatment-resistant disease of longer duration, for which the incremental benefit of biologics is greater.
RESULTS OF SENSITIVITY ANALYSIS
The early biologic strategy becomes more cost-effective if drug prices are reduced, risk for death is permanently lowered through biologic therapy, patients experience drug-free remission, responders can be selected before therapy initiation, or effective alternative antirheumatic agents are available for patients for whom several biologics have failed.
LIMITATIONS
Data on the long-term effect of very early therapeutic interventions on the natural progression in disability and joint erosions are limited. The study considered only tumor necrosis factor inhibitors and not the newer biologics.
CONCLUSION
According to the most objective measures of RA progression, very early intervention with conventional DMARDs is cost-effective. The cost-effectiveness of very early intervention with biologics remains uncertain.
- Language
-
- English
- Open access status
- closed
- Identifiers
-
- DOI 10.7326/0003-4819-151-9-200911030-00006
- PMID 19884622
- Persistent URL
- https://sonar.ch/global/documents/170997
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