Pathway of Care Algorithms Feasible in RA

And other news from ISPOR 2014
VBCR - June 2014, Volume 3, No 3 - ISPOR Annual Meeting

Montreal, Quebec—The healthcare costs associated with rheumatoid arthritis (RA) have been a growing cause of concern because of the chronic aspect of the disease, treatment costs, and variability in patterns of care, according to researchers. To address these costs, Bruce A. Feinberg, DO, Vice President and Chief Medical Officer, Cardinal Health Specialty Solutions, Dublin, OH, and colleagues evaluated pathway programs as a way to reduce cost variability and improve the quality and cost of care.

“High-level pathway program adoption suggests feasibility of this approach,” they found (Feinberg BA, et al. Rheumatoid arthritis pathway program impact on patterns of care. 2014. Poster PSH 170). “Opportunity exists to improve biologic use compliance.”

Feinberg and colleagues evaluated the feasibility of a collaborative, evidence-based, consensus-driven RA pathway to determine levels of participation for network rheumatology providers and assess the adoption of an online decision-support tool. Provider compliance to an RA pathway was also evaluated.

Together with CareFirst BlueCross BlueShield, Cardinal Health worked with rheumatologists in the CareFirst network to develop a payer-sponsored, collaborative RA pathway program, the investigators explained. Although participation was voluntary, reimbursement enhancements were offered to mitigate the cost of provider adoption and compliance. In addition, a preplanned consensus set the pathway compliance threshold to 70% and 80% for the first and second years, respectively. The RA pathway was created by a steering committee of 12 physicians. Several requirements were used to create it, including obligatory use of a real-time, decision-support, and data-capture tool; use of disease-modifying antirheumatic drugs (DMARDs) as first-line treatment for at least 12 weeks before use of a biologic agent; requirement that the dose, schedule, and adjustments for biologic agents follow package label prescribing guidelines; and requirement for a Clinical Disease Activity Index at each physician visit.

Overall, 80 physicians from 37 Care­First community network practices participated in the study, including 1800 unique patients with RA in the first year. The study authors found that the Clinical Disease Activity Index exceeded 70% of the visits, and adherence to the pathway was without a consequent increase in the index scores. In addition, compliance to the DMARD rule yielded an 8% reduction in the use of biologic agents. Claims-­validated compliance with the package label for the initial infused dose and schedule of the biologic agent increased from 40% to 53%.

Evidence-based algorithms do not risk patient outcomes, Feinberg and colleagues found, as this analysis indicated that the use of label-based prescription of DMARDs and biologic agents do not increase the Clinical Disease Activity Index.

Productivity Similar in Patients with RA, with and without Previous Anti-TNF Therapy
Certolizumab pegol (CZP) improves workplace and household productivity, as well as social participation in patients with RA, with and without previous exposure to anti–tumor necrosis factors (TNF).

“Limited data is available for the burden RA places on work and household productivity, comparing patients with and without prior anti-TNF exposure,” Arthur F. Kavanaugh, MD, Division of Rheumatology Allergy and Immunology, University of California, San Diego, and colleagues explained (Kavanaugh A, et al. Effect of tertolizumab pegol on workplace and household productivity in US patients with rheumatoid arthritis with or without prior anti-TNF exposure: results from the PREDICT study. 2014. Poster PMS66). “The data presented here [report], for the first time, the effect of CZP on work and household productivity in patients with prior anti-TNF exposure.”

As part of the PREDICT trial, the investigators sought to determine the effect of CZP treatment on workplace and household productivity, as well as on social participation in US patients with RA who were and were not exposed to anti-TNF. The trial compared the effect of CZP in this patient population and evaluated Routine Assessment of Patient Index Data 3 (RAPID3) and the investigator-based Clinical Disease Activity Index tools.

The study design dictated that patients receive a loading dose of 400 mg CZP during weeks 0, 2, and 4 of the trial, followed by 200 mg of CZP every second weeks until week 50. The workplace and household productivity were assessed using the arthritis-specific Work Productivity Survey, which estimates productivity limitations associated with the disease on paid jobs outside of the home, on work within the home, as well as participation in social activities in the preceding month.

Among 733 randomized patients, 55.5% were previously exposed to anti-TNF; of these patients, 33.3% reported using 1 anti-TNF drug, 17.6% reported using 2 anti-TNF drugs, and 4.5% reported using >2 anti-TNF drugs.

Patient demographics and disease characteristics were similar between the study groups, the study authors reported. Overall, patients who were previously exposed to an anti-TNF therapy had a higher mean disease duration, higher disease activity based on RAPID3, and a greater proportion of the patients were rheumatoid factor positive.

At the start of the study, 43.5% of the patients were employed outside of the home—38.8% in the group of patients who took anti-TNF drugs and 49.3% in the group of patients who did not take anti-TNF drugs. Because of arthritis in patients with previous exposure to anti-TNF, a higher proportion of patients work disabled, the study investigators noted.

In addition, both groups of patients reported high RA disease burden in workplace and household productivity, as well as social participation; the disease burden was slightly higher in patients who were previously exposed to anti-TNF drugs.

The study authors observed improvements with CZP in both patients with and without previous anti-TNF exposure. By week 4, employed patients reported reductions in workplace absenteeism, presenteeism, and in the level of RA interference with work productivity; these improvements were sustained through the completion of the study at week 52. Both groups also had substantial improvements in household productivity and social participation.

Related Items
A New Approach to Estimating Healthcare Costs in Rheumatology
VBCR - August 2012, Volume 1, No 3 published on September 20, 2012 in ISPOR Annual Meeting
Patient-Reported Outcomes Support the Treat-to-Target Paradigm in RA
VBCR - August 2012, Volume 1, No 3 published on September 20, 2012 in ISPOR Annual Meeting
Incorporating Patient-Reported Data into the Pharma Sales Story
VBCC - September 2010, Volume 1, No 4 published on October 7, 2010 in ISPOR Annual Meeting
Moving Targets: Personalized Medicine and Targeted Therapies
VBCC - July/August 2010, Volume 1, No 3 published on September 9, 2010 in ISPOR Annual Meeting
Medicare, a Major P(l)ayer, Not Ready for New Payment Policy Evidence
VBCC - July/August 2010, Volume 1, No 3 published on September 8, 2010 in ISPOR Annual Meeting
Do End-of-Life Products Deserve Special Treatment?
VBCC - July/August 2010, Volume 1, No 3 published on September 7, 2010 in ISPOR Annual Meeting
Last modified: May 21, 2015
  • Rheumatology Practice Management
  • American Health & Drug Benefits
  • Value-Based Cancer Care
  • Value-Based Care in Myeloma
  • Value-Based Care in Neurology