A treat-to-target strategy for treating early rheumatoid arthritis yielded better patient outcomes and long-term cost savings than did usual care for patients in the multicenter Dutch Rheumatoid Arthritis Monitoring registry.
"Treat-to-target" refers to a treatment regime whose goal is to reach and maintain remission in patients as quickly as possible using regular monitoring of disease activity and a fixed protocol for adjusting medication.
"After 2 years of treatment, treat-to-target is cost-effective as it comes with higher costs but also with substantially higher effectiveness," reported Marloes Vermeer, a PhD student at the University of Twente in Enschede, the Netherlands, and her colleagues in (BMC Musculoskelet. Disord. 2013 Dec. 13 [doi:10.1186/1471-2474-14-350]). "Our study suggests that treating to the target of remission is the preferred strategy over usual care in early rheumatoid arthritis," they wrote.
The researchers used the incremental cost-effectiveness ratio (ICER) and the incremental cost-utility ratio (ICUR) to analyze costs after determining the participants’ volume of care and the cost for each volume of consumption, based on the Dutch Guideline for Cost Analyses and the Dutch Board of Health Insurances. The ICER, found in this study to be 3,591 euros (about US $4,900), represents the costs per one more patient in remission while the ICUR, found to be 19,410 euros (US $26,530) in this study, represents the costs per quality-adjusted life-year (QALY) gained. For both the second and third years of follow-up, the treat-to-target strategy was dominant.
The researchers followed two cohorts of rheumatoid arthritis patients from initial diagnosis through at least 2 years of follow-up at 11 centers participating in the Dutch Rheumatoid Arthritis Monitoring registry (DREAM). Both the target-to-treat and usual care groups had been diagnosed according to American College of Rheumatology 1987 classification criteria with symptoms for less than a year and no past treatment with disease-modifying antirheumatic drugs (DMARDs). Comparable age, sex, rheumatoid factor positivity, number of tender joints, and erythrocyte sedimentation rate characteristics existed among both groups.
The treat-to-target cohort, initially composed of 261 patients diagnosed between January 2006 and February 2009, involved initial treatment with methotrexate monotherapy and then sulfasalazine, which was replaced with antitumor necrosis factor (TNF) agents if disease activity continued. Remission was defined as a Disease Activity Score in 28 joints (DAS28) of less than 2.6, after which medication was not changed until remission had been sustained for at least 6 months. After 6 months of remission, medication use was gradually discontinued. After clinic visits every 1-3 months for the first year, patients were assessed every 3 months in the second and third years.
In the usual care group, initially composed of 213 patients diagnosed between January 2000 and February 2009, DAS28 was assessed every 3 months by rheumatology nurses but not usually provided to the treating rheumatologist. Medication regimes were determined without a set protocol by the rheumatologist, most frequently involving "step-up or sequential monotherapy with conventional DMARDs and/or biologic, notably anti-TNF."
Among the patients in the treat-to-target cohort, 64.4% of 261 patients were in remission after 2 years, and 59.8% of 127 patients were in remission after 3 years (P less than .001). Among the patients in the usual care cohort, 34.7% of 213 patients were in remission after 2 years, and 35% of 180 patients were in remission after 3 years (P less than .001). The median QALYs in both the second and third years were higher for the treat-to-target cohort, rising from 1.45 in the second year (compared with 1.39 in the usual care group, P = .04) to 2.19 in the third year (compared with 2.04 in the usual care group, P = .05).
Direct costs per patient after 2 years were initially greater in the treat-to-target group, at 4,791 per patient, than in the usual care group, costing 3,727 euros per patient, a difference driven primarily by hospitalization and anti-TNF therapy costs. The treat-to-target group included 21.5% of patients receiving anti-TNF therapy over the first 2 years, with a mean time of 58 weeks until the first anti-TNF agent was started. Meanwhile, 15% of the usual care group received anti-TNF therapy over the first 2 years, with a mean time of 80 weeks until the first anti-TNF agent was started.
By the third year of follow-up, however, the 6,872 euro costs per patient in the usual care group exceeded the 6,410 euro costs per patient in the treat-to-target group, a difference driven primarily by hospitalization costs. The treat-to-target strategy was determined to be dominant in both the second and third years of follow-up.
Ms. Vermeer and her colleagues wrote that they expected cost savings with the treat-to-target regime to continue increasing over the long term, with better, earlier disease control also allowing for work participation and productivity within society and overall improved quality of life for patients. "Our expectation is that the extra effort and time spent in the first years of the disease ultimately result in a reduction of the number of consultations later in the disease course and the possibility of tapering and discontinuing medication in case of sustained remission, thereby diminishing costs," they wrote.