Background Nowadays treat-to-target by means of tight-control is generally accepted as the standard treatment principle in early rheumatoid arthritis (RA) (Schoels et.al.). However, this requires frequent (monthly) visits including comprehensive clinical measurement of disease activity which is often not feasible in rheumatology outpatient clinics. The handscan is a non-invasive imaging system for monitoring the inflammatory status of RA patients and might be a solution in terms of quick, easy and objective measurement of disease activity of patients. No studies have reported on the cost effectiveness of such a tight-control strategy as compared to a non-tight control strategy.
Objectives To evaluate the cost-effectiveness of a tight-control treatment strategy with the use of the handscan (TCHS) compared to tight-control using only clinical assessments (TC) and compared to a general non-tight-control treatment strategy (usual care; UC) in early RA.
Methods Data from 299 early RA patients from the computer-assisted management in early RA (CAMERA) trial was used. Clinical outcomes were extrapolated to Quality Adjusted Life Years (QALYs) and costs using a Markov model. These were compared between the TC and UC arms of CAMERA and a third simulated strategy TCHS. This last strategy was based on a modification of the intensive strategy from the CAMERA trial. Incremental cost-effectiveness ratio's (ICERs) were calculated and several scenario analyses performed. The scenarios included full rheumatologist visit instead of half, increase and decrease in handscan cost, using adalimumab instead of cyclosporine, increasing and decreasing effectiveness of handscan and increasing efectiveness of UC. All analyses were performed probabilistically to obtain confidence intervals.
Results In TCHS, €4,660 (95% CI -€11,516 to €2,045) was saved and 0.06 (95% CI 0.01 to 0.11) QALYs were gained, when compared to UC, with an ICER of €77,670 saved per QALY gained. This resulted in 91% simulation in the quadrant less expensive with QALY gain. The probability of cost effectiveness was above 99% at a willingness to pay (WTP) of €20,000 per QALY. TCHS resulted in only limited savings compared to TC, €642 (95% CI -€6,903 to €5,601). TCHS was found to be dominant in only 31% of simulations and in 23% inferior (i.e. more expensive and less effective) as compared to TC. The different scenarios also found TCHS and TC to be highly cost effective when compared to UC. The scenarios regarding increasing clinical effectiveness of TCHS, UC and the use of adalimumab instead of cyclosporine had the largest influence on cost-effectiveness results when comparing TCHS and UC.
Conclusions A tight control treatment strategy is highly cost-effective compared to a non-tight control approach in early RA. Using the handscan as a monitoring device in a tight control treatment strategy might facilitate implementation of tight control with similar costs and effects, which should be investigated further.
Schoels M, Knevel R, Aletaha D, et al. Evidence for treating rheumatoid arthritis to target: results of a systematic literature search. Annals of the rheumatic diseases. 2010;69:638-43. Epub 2010/03/20.
Acknowledgements This research was supported and reviewed by the Center for Translational Molecular Medicine (CTMM) and the Reumafonds (TRACER). We would like to thank all the participating rheumatologists, patients and research nurses of the CAMERA trial for their specific contribution. We would also like to thank Hemics for their contribution to this work.
Disclosure of Interest None declared