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Value Propositions

VBCR - April 2014, Volume 3, No 2 - Value Propositions

Nurse-Led Methotrexate Clinic Efficient, Cost-Effective
To facilitate the transition to subcutaneous methotrexate, study investigators sought to introduce a nurse-led methotrexate clinic into a district general hospital and thereby make the best use of the advanced knowledge and skills of rheumatology specialty nurses, as well as empower patients and improve their experience, and contribute to cost-savings for a hospital trust.

As part of the project, pharmacists, clinicians, and administrative and support staff met during the span of 4 months and discussed ways to introduce changes, procedures to follow, and safety issues for patients. Services were reviewed 1 year prior and 1 year after the implementation of the initiative. The investigators found that the number of patients with rheumatoid arthritis who switched to methotrexate increased by 80% (P = .049).

“This project demonstrated that not only do nurse specialists have the skills to make clinical decisions and judgments, prescribe medications and escalate therapies with no detriment to the patient, but also that this practice can lead to a more efficient and effective service, at reduced cost,” the investigators concluded. Fitzgerald P, et al. Musculoskeletal Care. 2014 Apr 7; Epub ahead of print


Taking Patient Preferences into Account When Selecting Anti-TNF
Using anti–tumor necrosis factor (TNF) medications for the treatment of patients with rheumatoid arthritis, as well as other chronic inflammatory conditions such as psoriasis, represent a large and growing healthcare expenditure.

As part of a cross-sectional survey and claims study based on claims in the HealthCore Integrated Research Database, investigators examined patient preferences regarding anti-TNF agents and mode of administration options. Patients were identified based on whether they received infliximab (intravenous group) or adalimumab, etanercept, or certolizumab pegol (subcutaneous group). Patients were diagnosed with conditions for which these agents were indicated by the US Food and Drug Administration between March 2012 and August 2012.

Patients in the subcutaneous group had a higher preference for the administration route they were using compared with patients in the intravenous group. Specifically, 89.9% of the subcutaneous group preferred the subcutaneous route of administration, whereas 71.8% of the intravenous group preferred the intravenous route (P <.001). The global treatment satisfaction scores were similar in both groups, and the reported likelihood of patients discussing alternative anti-TNF options with their physician was low (P = .366).

“An opportunity for patient education exists, because conversations with physicians about alternative anti-TNF therapies and administration appear to be lacking,” according to the investigators. There was a strong correlation between the route of administration in use and the preference. Results showed that patients had stronger preferences for subcutaneous routes than for intravenous routes. Sylwestrzak G, et al. Am Health Drug Benefits. 2014;7(2):71-81


Alternate RA Therapy Shows Promise in Animal Model
Although tumor necrosis factor (TNF)-alpha inhibitors are associated with significant relief among patients with rheumatoid arthritis (RA), a need exists for safe, oral, cost-effective therapy.

A group of investigators evaluated the anti-inflammatory and anti-arthritic effects of a polyherbal formulation (BV-9238) and its ability to inhibit TNF-alpha and nitric oxide (NO) production in lipopolysaccharide-stimulated RAW 264.7 mouse macrophage cell line. Overall, it was found that the compound reduced TNF-alpha and NO production without cytotoxic effects and, when tested in adjuvant-induced arthritis and carrageenan-induced paw edema rat animal models, significantly reduced arthritic scores in both models.

This compound may be promising as an alternate therapy for inflammatory disorders, such as RA, where TNF-alpha and NO play significant roles, according to the study authors. Debendranath D, et al. Phytother Res. 2014 Apr 7; Epub ahead of print


HCQ Lipid Profile, Toxicity, and Costs Favorable in RA
In a cohort from the Veterans Affairs Rheumatoid Arthritis (VARA), investigators sought to examine lipid profiles among patients with rheumatoid arthritis (RA) who used hydroxychloroquine (HCQ) compared with patients who did not use it.

Participants of the VARA cohort tended to be predominantly elderly, white men; 1011 had lipid profiles. Overall, 11.6% used statins, 33.5% had diabetes mellitus, and 31.2% had cardiovascular events. The investigators observed that patients who used HCQ (n = 150) tended to be older, had longer RA disease, and lower disease activity compared with nonusers. In addition, HCQ users had more frequent optimum lipid profiles including total cholesterol/high-density lipoprotein (HDL), and HDL/low-density lipoprotein (LDL) ratios (P ≤.001), but not including HDL. Other measures evaluated, including National Cholesterol Education Program Adult Treatment Panel III target levels, were reached by more patients taking HCQ compared with nonusers.

HCQ use over the course of 3 months is associated with better lipid profiles, relatively lower costs and toxicity in patients with RA, according to recently published data. Continued use, the investigators added, regardless of treatment regimen, should be taken under consideration. Kerr G, et al. Arthritis Care Res (Hoboken). 2014 Apr 1; Epub ahead of print


Shared Decision-Making in JIA
As the number of treatment options increases for the treatment of patients with juvenile idiopathic arthritis (JIA), there is a need for improved clinician–parent communication.

Using shared decision-making, clinicians can share information about options available, while patients and their parents can discuss their goals and preferences. “Together, a treatment plan is developed that is the best fit for the individual and their family,” according to the investigators.

Using the Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN)—a network aimed at improving outcomes of JIA care using quality improvement methods—the investigators developed tools to facilitate shared decision-making for patients with JIA and their families. In particular, issue cards were developed based on qualitative interviews with clinicians and care providers, as well as direct observation of clinical encounters. Prototype issue cards were introduced in the clinic using Plan-Do-Study-Act (PDSA) cycles. Feedback for revisions was solicited from PR-COIN members using electronic surveys, webinars, and direct observations.

How soon therapies will take effect, how often they are given, in addition to side effects, costs, and how long patients will need to stay on the medication, as well as other considerations were the most important attributes identified to discuss. Overall, 18 revisions were made to the issue cards, at which point they were deemed acceptable for regular use.

“Our ultimate goal is to drive improvement in child JIA outcomes by reliably engaging patients/parents in [shared decision-making] to select a medication that is a good fit,” the investigators concluded. Dewitt EM, et al. Arthritis Rheumatol. 2014;66(Suppl 11):S232-S233

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Last modified: May 21, 2015
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