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Abstract
Background Treating to target (T2T) of remission has proven to be the most efficacy strategy to achieve clinical remission in patients with early rheumatoid arthritis (RA), resulting cost-effective after three years. It involves monitoring disease activity, adjusting drugs to approved protocol and aiming at a predefined target. However there is not enough clinical evidence in established and persistent RA and it has not been established the target treatment strategy.
Objectives The objective was to estimate the cost-effectiveness of three strategies in real-life conditions from the Health Service perspective. T2T of remission versus achievement of low disease activity (LDA) and versus satisfactory disease control (SDC) after two years of treatment
Methods All patients diagnosed of RA according to the American College of Rheumatology who started biologic therapy between January 2007 and December 2012 were included in the Create registry.
A multidisciplinary care team composed by rheumatologists, hospital pharmacists, nurse and statistical personal from a tertiary hospital was the responsible for making the decision about the treatment-choice.
A T2T strategy aiming at remission (DAS28<2,6) was applied to all patients. This included standardised and protocolised treatment adjustment. Patients were followed up and evaluated at least every two months.
Measurements Effectiveness was evaluated using the DAS28 value. Three different results were compared:
Strategy 1 (S1): Clinical Remission (CR). DAS28<2,6 at two years.
Strategy 2 (S2): Patients at CR or at least with LDA (DAS28<3,2) at two years.
Strategy 3 (S3): Patients from S2 and also those patients with a DAS28>3,2 at two years, but whose disease activity is judged by both the rheumatologist and patient to be low enough not to require switch of treatment (SDC).
Care and cost Direct health care costs were assessed from the hospital perspective and included the official drug acquisition costs, diagnostic tests, rheumatologist visits, hospital admission and use of day-care facilities for intravenous drug administration. Data were retrieved from hospital information system and electronic case reports forms. Data of two year follow-up were analysed.
Cost-effectiveness It was calculated dividing total direct healthcare mean costs by percentage of patients achieving the target clinical result for each strategy.
Results 144 patients were included. After two years, 32,6% of patients achieved target for S1 (DAS28<2,6), 57,6% of patients reached at least DAS28 value<3,2 (S2) and 90,9% of patients reached a SDC (S3).
Direct health mean cost after two years was 25,976.05 € (IC95%:23,888.16-28,063.93).
T2T of remission was the least cost-effective strategy: 79,681.14€ per clinical remission (SD ±38,880.43€), versus 45,097€/LDA (±22,00.,24€) and 28,545.11€/SDC (±13,958.59€), (p<0,001 in both cases S1 vs S2 and S1 vs S3). Similarly, S2 was less cost-effective than S3 (p<0,001).
Conclusions T2T of remission strategy with biologic therapy in established RA and in real-life conditions is less cost-effective than T2T of low disease activity or satisfactory disease control.
Disclosure of Interest None declared