T.R. Zijlstra

Treating to the target of remission in early rheumatoid arthritis is cost-effective: results of the DREAM registry.

BackgroundWhere health economic studies are frequently performed using modelling, with input from randomized controlled trials and best guesses, we used real-life data to analyse the cost-effectiveness and cost-utility of a treatment strategy aiming to the target of remission compared to usual care in early rheumatoid arthritis (RA).MethodsWe used real-life data from comparable cohorts in the Dutch Rheumatoid Arthritis Monitoring (DREAM) registry: the DREAM remission induction cohort (treat-to-target, T2T) and the Nijmegen early RA inception cohort (usual care, UC). Both cohorts were followed prospectively using the DREAM registry methodology. All patients fulfilled the American College of Rheumatology criteria for RA and were included in the cohort at the time of diagnosis. The T2T cohort was treated according to a protocolised strategy aiming at remission (Disease Activity Score in 28 joints (DAS28) < 2.6). The UC cohort was treated without DAS28-guided treatment decisions. EuroQol-5D utility scores were estimated from the Health Assessment Questionnaire. A health care perspective was adopted and direct medical costs were collected. The incremental cost effectiveness ratio (ICER) per patient in remission and incremental cost utility ratio (ICUR) per quality-adjusted life year (QALY) gained were calculated over two and three years of follow-up.ResultsTwo year data were available for 261 T2T patients and 213 UC patients; an extended follow-up of three years was available for 127 and 180 patients, respectively. T2T produced higher remission percentages and a larger gain in QALYs than UC. The ICER was € 3,591 per patient in remission after two years and T2T was dominant after three years. The ICUR was € 19,410 per QALY after two years and T2T was dominant after three years.ConclusionsWe can conclude that treating to the target of remission in early RA is cost-effective compared with UC. The data suggest that in the third year, T2T becomes cost-saving.

The rheumatoid arthritis articular damage score: first steps in developing a clinical index of long term damage in RA

Objective: To design and validate a clinical method for scoring irreversible long term articular damage in rheumatoid arthritis (RA). Methods: The rheumatoid arthritis articular damage score (RAAD score) is based on examination of 35 large and small joints. Concise definitions were formulated to score each joint on a three point scale (0, no irreversible damage; 1, partially damaged; 2, severe damage, ankylosis, or prosthesis). The RAAD score was determined for 121 patients with RA with a large range of disease duration. Interobserver agreement was studied in 39 patients scored by three observers. Data on disease duration, Health Assessment Questionnaire, disease activity score, and Larsen score were collected for 121, 78, 47, and 45 patients, respectively. Results: The RAAD score correlated well with the Larsen score (rs=0.81) and disease duration (rs=0.68) and (as intended) not with disease activity (rs=0.10). Good interobserver agreement was found for total scores and individual joints. The wide range of RAAD scores for patients with the same disease duration suggested good discriminating power, especially after >10 years. Conclusion: The RAAD score is a quick and feasible method for measuring the long term articular damage in large RA populations. It has good reliability and construct validity and deserves further study to assess its discriminant validity.

Determinants of Perceived Health Nonimprovement in Early Rheumatoid Arthritis Patients With Favorable Treatment Outcomes

To explore the association between achieving favorable clinical outcomes and patients’ perceived change in overall health status after 12 months of treat‐to‐target in patients with early rheumatoid arthritis (RA) and to identify determinants of subjective nonimprovement.

An Economic Evaluation of Stopping Versus Continuing Tumor Necrosis Factor Inhibitor Treatment in Rheumatoid Arthritis Patients With Disease Remission or Low Disease Activity: Results From a Pragmatic Open-Label Trial

To evaluate, from a societal perspective, the incremental cost‐effectiveness of withdrawing tumor necrosis factor inhibitor (TNFi) treatment compared to continuation of these drugs within a 1‐year, randomized trial among rheumatoid arthritis patients with longstanding, stable disease activity or remission.

An economic evaluation of stopping versus continuing TNF-inhibitor treatment in rheumatoid arthritis patients in remission or low disease activity: results from the POET randomized trial.

To evaluate, from a societal perspective, the incremental cost‐effectiveness of withdrawing tumor necrosis factor inhibitor (TNFi) treatment compared to continuation of these drugs within a 1‐year, randomized trial among rheumatoid arthritis patients with longstanding, stable disease activity or remission.

Cost-Effectiveness and Cost-Utility Analysis of Treat-to-Target Versus Usual Care in Early Rheumatoid Arthritis: Results of the DREAM Registry

Background Treat-to-target (T2T) has proven to be more effective in achieving remission in early rheumatoid arthritis (RA) patients than usual care [1]. However, T2T has not been fully implemented in daily clinical practice yet. Moreover, it is unknown whether T2T is cost-effective. Objectives To analyse the cost-effectiveness and cost-utility of a T2T strategy aiming at remission (Disease Activity Score in 28 joints (DAS28) <2.6) compared to usual care in early RA over the first two years of the disease. Methods Two early RA inception cohorts including patients who fulfilled the ACR 1987 criteria were compared. The T2T group (n=261) consisted of patients from the DREAM remission induction cohort and was treated according to a protocolized treatment strategy aiming at DAS28 remission. The usual care group (n=213) consisted of patients from the Nijmegen early RA inception cohort and was treated without DAS28-guided, protocolized treatment decisions. For both groups, direct medical costs were collected and compared with gain in effectiveness (DAS28 remission) and quality adjusted life years (QALYs) (EQ-5D utility estimated from the HAQ) over two years of follow-up. Results T2T produced a higher remission percentage (64.4% vs. 34.7%) and a larger gain in QALYs (median (IQR) 1.45 (1.24-1.55) vs. 1.39 (1.18-1.53), p=0.037) than usual care. The total mean (SD) costs per patient were €4.807 (7.434) in the T2T group and €3.806 (5.761) in the usual care group. The incremental cost-effectiveness ratio was €3.340 per patient in remission. The incremental cost-utility ratio was €18.259 per QALY. The figure presents the cost planes which show the relation between A) the differences in effectiveness and costs and B) the differences in utility and costs of T2T versus usual care. Anti-TNF therapy was given to more T2T patients (21.5% vs. 15.0%) and was prescribed earlier in the disease process, compared to usual care. Conclusions This quasi-experiment showed that over the first two years of treatment, T2T is associated with higher costs but also with substantial higher effectiveness. We conclude that T2T is cost-effective in daily clinical practice. References [1] Schipper et al, Ann Rheum Dis. 2011 (In press). Disclosure of Interest None Declared