Background/Purpose: Despite the establishment of the innovative rheumatology nurse-led clinics (NLC) in the UK, the evidence of their cost-effectiveness is unknown. This study aimed at determining the cost effectiveness of NLC in patients with rheumatoid arthritis (RA).

Methods: This was a 10-centre, RCT where patients were randomized to either NLC or rheumatologist-led clinic (RLC). Adults with both stable and active RA were recruited. The interventions were delivered by 9 clinical nurse specialists (Mdn experience = 10 years) and 10 rheumatologists (Mdn experience = 9 years).

The primary outcome was the average change (from baseline) in disease activity score (DAS28) assessed at weeks 13, 26, 39 & 52. The EQ-5D was used to derive Quality-of-Life-Adjusted-Year (QALY) utility values.

Mean differences (MD) between the groups were estimated using linear models controlling for baseline covariates following per-protocol (PP) and intention-to-treat (ITT) strategies. The economic evaluation jointly estimated cost relative to quality adjusted life years (QALYs) and DAS28. Only ITT results are reported here: missing data being accounted through multiple imputation. Joint parameterization was achieved via bootstrap evaluation of the imputed datasets, and estimates plotted using cost-effectiveness planes and cost effectiveness acceptability curves.

Results: Demographics and baseline characteristics of patients under NLC (n = 91) were comparable to those under RLC (n = 90). They had a mean age (SD) of 58.5 (11.6), disease duration of 9.9 (10.7) years and 74% were female.

Average DAS28 change scores were higher in the NLC group (MD = -0.15, 95%CI = -0.45, 0.14) while average QALYs were higher in the RLC group (MD = 0.018, 95%CI = -0.037, 0.073).

Overall mean healthcare and National Health Service costs (UK-pounds) were higher in the RLC group compared to the NLC group (MD = 230, 95%CI = -406, 865 and MD = 223, 95%CI = -405, 850 respectively (approx. 360 US-dollars per person).

Figure 1 shows cost utility planes for healthcare costs. NLC was ‘dominant’ in respect of costs relative to change in DAS28 but not in respect of cost relative to QALY. Cost-effectiveness of NLC in relation to QALY is dependent on willingness-to-pay (WTP); this being the most likely cost-effective strategy for a WTP not in excess of £12,777 (i.e. 20,073 US-Dollars) for the healthcare perspective, and slightly less for the NHS perspective.

Conclusion: This was the first economic evaluation of rheumatology NLC in the UK. While the findings indicate that NLC is likely to be a cost-efficient service under a cost-minimisation approach, we are not able to draw firm conclusions on cost-effectiveness given the variation in results between DAS28 and QALY.

Figure 1: Economic evaluation (healthcare costs – ITT results).