Background/Purpose: Previous studies have shown that using Triple Therapy (a combination of 3 generic drugs) prior to a biologic, is the most cost-effective strategy for patients with rheumatoid arthritis. While studies also find that many patients would prefer to trial Triple Therapy prior to a biologic, fewer than 5% of patients do so in the US. We determined the potential value of an intervention that promotes informed shared decision-making between patients and clinicians around triple therapy use after failure of methotrexate.

Methods: We developed an economic model that compared a strategy where patient preferences for triple therapy use were integrated into treatment decisions, versus usual care. A previous study suggests that 59% of patients would choose triple therapy first if provided the comparative evidence of benefits, potential adverse events and dosing schedule. We assumed a cost of $50 for a shared decision making intervention such as a patient decision aid. Patient’s trialling triple therapy first were assumed to switch to a sequence of biologics upon withdrawal. We extrapolated the influence of the initial treatment decision on subsequent disease progression, resource use such as hospitalizations, quality of life, mortality and Quality Adjusted Life Years (QALYs). Various sensitivity analyses were performed. A scenario that incorporated the value patients assign to the process of shared decision-making was also considered.

Results: Incorporating patient preferences into the decision was estimated to reduce average costs for a patient by $40,000 over a lifetime through delaying the introduction of biologic therapy. Even under the most pessimistic assumptions regarding the potential for earlier biologic use delaying joint erosions, only 0.08 QALYs (28 days of full health) over a lifetime were estimated to be lost. The consequent incremental cost-effectiveness ratio for usual care vs the patient preference strategy is over $500,000/QALY. Sensitivity analysis supported this finding. Incorporating the process of shared decision-making offsets the negative QALYs, implying the patient preference strategy saves costs and increases QALYs.

Conclusion: This study demonstrates that systematically giving patients with rheumatoid arthritis who fail methotrexate an informed choice between triple therapy and a biologic as the initial treatment is cost-saving and can even provide more ‘benefits’ to the patient. This strategy allows patients who prefer biologic therapy to choose it, but saves costs by delaying the biologic initiation in patients who choose triple therapy first. The results suggest that strategies used elsewhere for increasing shared decision-making such as building infrastructure for implementing patients decision aids, or introducing fee codes for shared decision-making, could be cost-effective and should be explored to promote value based prescribing in rheumatology.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/the-potential-value-of-a-shared-decision-making-intervention-for-choices-regarding-triple-therapy-in-rheumatoid-arthritis/