Background/Purpose:

Assessment of the total cost of care requires clinical, epidemiological, patient-centered, and economic data. However, barriers to a value-driven outcome assessment include the resource-intensive nature of activity-based costing. One aspect of the total cost of care is direct costs. Government-based outpatient care enables an analysis that controls for all direct costs apart from medication costs. The aim of our study is to understand one aspect of the direct cost of care upon a given steroid decrement.

Methods:

We reversed the Branching Decision Tree for identification of expenses attributable to clinical care by restricting our assessment to a given steroid taper. Our analysis identifies drug costs over the preceding 10 weeks as the basis for allocating direct care costs to specific encounters. This timeframe is chosen because it is the average interval between outpatient appointments. We identified patients for analysis at the time that they were instructed by the rheumatologist to reduce prednisone dosage. Patients were enrolled over a 6-month period at a community outpatient clinic. Captured data included diagnosis, current and new prednisone dose, and other rheumatology medications. We extended our analysis to a 10-week prospective durability ascertainment of the success of the intervention. We stratified the analysis based upon a diagnosis of Rheumatoid Arthritis (RA) or Other Autoimmune diseases (OTHER).

Results:

Direct costs invested over a ten-week period for all patients tapering prednisone were $1659.30 (Table 1), which normalizes to $434.37/mg decrement (Table 1). A greater normalized cost was invested per patient for RA as compared to OTHER. There was a 97% completion rate for data collection in the prospective arm of the study. We observe a 76% durability response towards maintaining the recommended reduced steroid dose 10 weeks after the incident date in RA patients as compared to 85% for OTHER patients (Table 1). In general, a two or three-fold greater direct investment antecedent to steroid decrement was associated with a durable response over the ensuing ten weeks for either disease category.

Conclusion:

Our analysis demonstrates that outpatient drug costs for RA are most fruitful to target when looking to contain direct health care costs. On the other hand, the prospective arm of the study suggests that higher direct costs are associated with durable steroid decrement outcomes regardless of inflammatory disease classification. The advantage of this study is that reimbursement, coverage levels, and access to care are all controlled for because our protocol-based health care delivery model renders this a unique opportunity to assess relatively pure direct costs. A disadvantage of this study is that indirect costs are not analyzed. Future research is needed to ascertain whether the higher invested direct costs are offset by the drop in future indirect costs consequent to a durable steroid-sparing benefit.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/identifying-the-investment-needed-to-generate-a-durable-prednisone-dose-decrement/