Value Propositions - April 2016

VBCR - April 2016, Vol 5, No 2 - Value Propositions

In This Article

Rapid Access Rheumatology Consultations Feasible, Beneficial

Rapid access services in the rheumatology care setting is feasible and has a high diagnostic accuracy, according to results published in The Journal of Rheumatology. A significant huge hurdle exists in timely delivery of rheumatology care, such as wait times for first appointments, explained study authors Rudolf Puchner, MD, Centre of Excellence in Medicine, Linz, Austria, and colleagues.

By offering short initial assessments to patients with musculoskeletal problems, and 6-month follow-up through a union of office-based rheumatologists, they asserted that an immediate access network could be established to improve access to care.

Dr Puchner and colleagues examined 335 patients at initial presentation in 6 cooperating practices and at follow-up 6 months later during dedicated office hours. A total of 124 (38%) patients had symptom duration for <3 months; among patients with rheumatoid arthritis, 43% had symptoms lasting <3 months, and this proportion was 70% for patients with rheumatoid arthritis who were self-referred.

At 6 months postinitial assessment, 325 patients were available for follow-up; of these patients, 88% had initially suspected diagnoses confirmed. For patients with rheumatoid arthritis and spondyloarthritis, confirmation rates were 93% (n = 59) and 84% (n = 46), respectively. The visual analog scale for pain had decreased considerably in patients with rheumatoid arthritis at the 6-month follow-up, from a median of 70 to 27.5; a decrease from 65 to 30 was observed in patients with spondyloarthritis, the study authors noted.

Use of a rapid access clinic gave rise to significant improvements in access to rheumatology assessments; more than one-third of the patients involved in the study presented <3 months following symptom onset, and in approximately 90% of patients, suspected diagnoses of inflammatory rheumatic diseases were confirmed.

“This initiative demonstrates the feasibility of a rapid access service and indicates high diagnostic accuracy in such a setting,” Dr Puchner and colleagues concluded. “In particular, with respect to early access, it compares favorably with similar hospital-based approaches.”

Puchner R, Janetschko R, Kaiser W, et al. J Rheumatol. 2016 Apr 1. Epub ahead of print.

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Etanercept plus MTX More Cost-Effective than Monotherapy in Patients with Severe JIA

Although etanercept plus methotrexate (MTX) as first-line treatment is costly compared with MTX in patients with juvenile idiopathic arthritis (JIA), the treatment may be cost-effective for patients with more severe disease, researchers found.

With evidence pointing to a lack of knowledge about the optimal timing of biologic treatment in patients with polyarticular JIA, authors of a recent study examined the cost and impact of first-line treatment with etanercept versus stepwise therapy in patients with JIA.

Using a cohort state-transition model of newly diagnosed patients, the researchers compared the use of MTX plus etanercept as first-line therapy (ie, etanercept-first) and MTX monotherapy followed by etanercept (ie, etanercept-second) during 5 years, among patients aged 11 years, who weighed 40 kg, and had active joints totaling ≥5.

Results of the study, which were sensitive to cost of etanercept, the model’s time frame, and efficacy estimates of first-line therapies, demonstrated that, compared with etanercept-second, etanercept-first generated a reduced, incremental cost of $16,893 (95% confidence interval [CI], $9348-$25,310), incremental quality-adjusted life-years (QALYs) of 0.19 (95% CI, 0.08-0.32), and an incremental cost-effectiveness ratio of $88,815 per QALY gained. In patients with severe JIA, the cost per QALY for treating them was $33,960.

“First-line therapy of [etanercept] and MTX is relatively expensive compared to MTX alone, but may be economically attractive for more severely affected patients,” the study authors concluded. “More research is needed regarding the efficacy of first-line anti-TNFα agents.”

Luca NJ, Burnett HF, Ungar WJ, et al. Arthritis Care Res (Hoboken). 2016 Apr 5. Epub ahead of print.

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Higher Costs Linked to Lower DMARD Initiations, Refills in MAPD Members with RA

Patients with rheumatoid arthritis (RA), who are members of a national Medicare Advantage and Prescription Drug (MAPD) plan that has higher out-of-pocket costs, may be less likely to initiate or refill a biologic disease-modifying antirheumatic drug (DMARD) therapy, data suggest.

Sari Hopson, MSPH, PhD, lead author of the study and Research Scientist, Comprehensive Health Insights, Louisville, KY, and colleagues assessed MAPD members with adjudicated claims for a biologic DMARD from July 1, 2007, to December 31, 2012, and retrospectively followed MAPD members with RA to their first adjudicated claim date identified as the index date.

Using these data, the investigators examined associations between initial prescription abandonment rates, out-of-pocket costs, and factors influencing the refill of DMARD therapy through multivariate regression models and based on pharmacy claims.

Among the 864 MAPD members included in the final sample size, the majority were women (77.4%), and mean age was 63.5 years. During the preindex phase of the study, most patients (78%) had conventional nonbiologic DMARD use. For biologic DMARDs, the overall initial abandonment rate was 18.2%, ranging from 1.3% for the group with the lowest out-of-pocket costs ($0-$250), to 32.7% for the group with the highest out-of-pocket costs (>$550), the study authors found. For patients with out-of-pocket costs of $250.01-$400.00, $400.01-$550.00, and >$550.00, odds ratios [ORs] for abandonment rose from 18.4 to 32.7 to 41.2, respectively. For the index claim, meeting the catastrophic coverage limit and specialty pharmacy use were associated with a decreased likelihood of therapy abandonment (OR = 0.29 and OR = 0.14, respectively). In a subset of patients with paid claims (n = 533), 82.4% had ≥1 postindex refills.

“This study suggests that the higher the member [out-of-pocket] cost, the less likely an MAPD member is to initiate or refill a biologic DMARD therapy for RA,” Dr Hopson and colleagues concluded. “Further research is needed to understand reasons for initial [prescription] abandonment and lack of refills, including benefit design and adverse events.”

Hopson S, Saverno K, Liu LZ, et al. J Manag Care Spec Pharm. 2016;22:122-130.

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Higher Social Support Associated with Less Depression in Older Patients with RA

Pain fluctuations and symptoms of depression are common among older adults with chronic arthritis pain, according to authors of a recent study evaluating the stability and covariation of arthritis pain and symptoms of depression.

Arthritis pain and depression are widespread physical and psychological disorders co-occurring frequently in late life. As such, the investigators, who sought to determine the constancy and covariation of these symptoms in addition to examining the influence cognitive functioning and social support have on the relationship between pain and depressive symptoms, performed a longitudinal study of 299 older, retirement community–dwelling participants based in Florida.

After testing the roles that cognitive functioning and social support play in the association between arthritis pain and depressive symptoms, the researchers observed—even after controlling for a time effect—considerable within-person disparity with regard to symptoms of pain and depression (between 58% and 65%) across 4 years. Following control for arthritis pain, however, participants with higher social support and cognitive functioning reported lower levels of depressive symptoms.

“[Our] findings suggest that fluctuations in pain and depressive symptoms are common for older adults,” the investigators concluded. “Furthermore, social support and intact cognitive functioning may serve as useful resources, as they buffer the negative impact of arthritis pain on depressive symptoms.”

Lee JE, Kahana B, Kahana E. Aging Ment Health. 2016;20:370-379.

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Last modified: May 27, 2016
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