Session Information
Date: Monday, November 6, 2017
Title: Health Services Research Poster II: Osteoarthritis and Rheumatoid Arthritis
Session Type: ACR Poster Session B
Session Time: 9:00AM-11:00AM
Background/Purpose:
Autonomic nervous system (ANS) testing with heart rate variability (HRV) has been shown to predict 52-week anti-TNF therapeutic outcomes in rheumatoid arthritis (RA).1 HRV testing could be combined with the three currently available putative ANS biologic pathways (vagal nerve stimulation,2 obstructive sleep apnea,3 and restless leg [RLS] medications4) to improve treatment response for RA patients. We explored the potential costs and health outcomes of introducing HRV testing into RA treatment, both without vs. with ANS optimization.
Methods:
A decision tree exploratory economic model compared HRV testing to standard care in moderate-to-severe biologic-eligible patients over a 10-year time horizon. Patients were stratified by HRV test scores into “low probability of response” and “moderate to high probability of response” (parasympathetic HRV<=vs. >0.12) with positive predictive value (PPV)=33% and negative predictive value (NPV)=100%.5 We then explored adding ANS optimization (RLS method4) based on HRV score, with patients stratified into parasympathetic <=vs. >0.19, PPV=0.63, NPV=0.88.5 Finally we explored a hypothetical scenario expanding the eligible population to all RA patients using hypothetically analogous ANS-prediction and ANS-enhancement of non-biologic treatment (no study yet done) over a range of potential PPV values (10-25%). We also evaluated model outcomes when biologic utilization was assumed to increase from current 26%6 of eligible patients to 35-55%. Costs and quality-adjusted life-years (QALYs) per patient and for the US population were estimated. Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) below $150,000/QALY.
Results:
HRV testing in biologic-eligible patients decreased non-effective biologic use, reducing US costs by $9.8B over 10 years with QALYs unchanged. When combined with ANS optimization in biologic-eligible patients, HRV testing could increase costs by $1.5 billion over 10 years and save 102,000 QALYs (ICER $14,000/QALY). Our hypothetical analysis estimated that, among all RA patients, HRV testing with ANS optimization could save $15-20 billion and 780,000 QALYs over 10 years, depending on PPV of the HRV test. In this scenario, if biologic use increased from current uptake, costs could increase from $13 to 98 billion, ICER maintained <$150,000/QALY.
| Standard of Care | Incremental Change with HRV Testing | Standard of Care | Incremental Change with HRV Testing | Standard of Care | Incremental Change with HRV Testing | ||||||
| HRV testing vs. no testing (10 year total) | |||||||||||
| Biologics utilization 26% (current) | Biologics utilization 35% | Biologics utilization 45% | |||||||||
| Total costs | $57.33 bil | -$9.30 bil | — | — | — | — | |||||
| Biologics | $36.07 bil | -$9.84 bil | — | — | — | — | |||||
| QALYs | 2,228,036 | 0 | — | — | — | — | |||||
| ICER | — | — | — | — | — | — | |||||
| HRV testing + ANS optimization vs. no testing or optimization, biologic eligible patients (10 year total) | |||||||||||
| Biologics utilization 26% (current) | Biologics utilization 35% | Biologics utilization 45% | |||||||||
| Total costs | $57.33 bil | $1.45 bil | $57.33 bil | $14.20 bil | $57.33 bil | $28.39 bil | |||||
| Biologics | $36.07 bil | $0.03 bil | $36.07 bil | $12.55 bil | $36.07 bil | $26.48 bil | |||||
| QALYs | 2,228,036 | 101,765 | 2,228,036 | 163,444 | 2,228,036 | 232,054 | |||||
| ICER | — | $14,244/QALY | — | $86,894/QALY | — | $122,330/QALY | |||||
| HRV testing + ANS optimization vs. no testing or optimization, all patients (10 year total), hypothetical analysis | |||||||||||
| Biologics utilization 26% (current) | Biologics utilization 35% | Biologics utilization 45% | |||||||||
| PPV 10% | Total costs | $207.38 bil | -$15.36 bil | $207.38 bil | $19.66 bil | $207.38 bil | $58.58 bil | ||||
| Biologics | $122.27 bil | -$23.08 bil | $122.27 bil | $11.28 bil | $122.27 bil | $49.47 bil | |||||
| QALYs | 9,348,102 | 780,335 | 9,348,102 | 852,805 | 9,348,102 | 933,359 | |||||
| ICER | — | — | — | $23,049/QALY | — | $62,759/QALY | |||||
| PPV 25% | Total costs | $207.38 bil | -$19.98 bil | $207.38 bil | $13.30 bil | $207.38 bil | $50.29 bil | ||||
| Biologics | $122.27 bil | -$27.99 bil | $122.27 bil | $4.66 bil | $122.27 bil | $40.96 bil | |||||
| QALYs | 9,348,102 | 946,503 | 9,348,102 | 1,015,410 | 9,348,102 | 1,092,002 | |||||
| ICER | — | — | — | $13,100/QALY | — | $46,055/QALY | |||||
Conclusion:
The potential US health economic impact of introducing HRV testing and ANS optimization into RA treatment appears substantial and is possibly cost-effective. Additional rigorous studies are warranted in larger patient samples, particularly investigation into non-biologic therapeutic applications.
1. Holman, Arthritis Rheum. 2015;67 (suppl 10) #1571
2. Koopman, Proc Natl Acad Sci. 2016;113(29)
3. Shimizu, Arthritis Rheum. 2003
4. Holman, Arthritis Rheum. 2015;67 (suppl 10) #422
5. Holman, Auton Neurosci. 2008;143(1-2)
6. Yazici, Bull NYU Hosp Jt Dis. 2008;66(2)
To cite this abstract in AMA style:
Zimmermann M, Vodicka E, Holman AJ, Garrison LP. Heart Rate Variability Testing with Autonomic Nervous System Optimization: Could It Change the Course of Spending for Rheumatoid Arthritis Patients in the U.S.? an Exploratory Minimal Model Analysis [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10). https://acrabstracts.org/abstract/heart-rate-variability-testing-with-autonomic-nervous-system-optimization-could-it-change-the-course-of-spending-for-rheumatoid-arthritis-patients-in-the-u-s-an-exploratory-minimal-model-analysis/. Accessed .« Back to 2017 ACR/ARHP Annual Meeting
ACR Meeting Abstracts - https://acrabstracts.org/abstract/heart-rate-variability-testing-with-autonomic-nervous-system-optimization-could-it-change-the-course-of-spending-for-rheumatoid-arthritis-patients-in-the-u-s-an-exploratory-minimal-model-analysis/