Background/Purpose: Results from cost-effectiveness analysis (CEAs) comparing treatment options for patients with rheumatoid arthritis (RA) who have an inadequate response to an initial tumor necrosis factor inhibitor (TNFi) have been inconclusive. Our objective was to systematically review the modelling approaches and quality of economic evaluations comparing the cost-effectiveness, cost-utility, or cost-minimization of subsequent TNFi (cycling) versus a therapy with a different mode of action (swapping) in order to understand their discrepant results.

Methods: We searched seven electronic databases until 2016, sources of gray literature and the references of relevant publications. Two independent reviewers screened retrieved citations, including studies published in English-language and economic evaluations comparing second line biological treatments in RA patients. We excluded reviews, conference abstracts and poster presentations. Data extraction was done by one reviewer and crosschecked by another. Reporting quality was evaluated based on the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Reported incremental cost-effectiveness ratios (ICERs) were synthetized and adjusted to 2016 US dollars according to rules specified by the Panel on Cost-Effectiveness in Health and Medicine.

Results: Of 4,563 citations, ten economic evaluations comprising 21 comparisons and representing six European countries, Canada and the United States were included. Most studies (8 of 10) were funded by the pharmaceutical industry. There were two discrete event simulations, three microsimulations, two Markov cohort models, two decision trees and one single study-based evaluation. The most common time horizons were lifetime (6/10) and one year (2/10). Seven studies were from a payer perspective. The cohorts were predominantly female (78%), on average aged 53.4 years, disease duration of 10.2 years and baseline health assessment questionnaire (HAQ) of 2.3. Adherence to reporting standards was good with seven studies scoring ≥26 out of 36. The most common failing point was justification of modelling choices. One study did not report any sensitivity analysis, but most performed probabilistic as well as one-way sensitivity analysis. Common influential parameters include rituximab dosing schedule as well as assumptions regarding HAQ progression and conversion to utilities. In the cost-utility analyses, the median ICER was US$25,617 for the swapping strategy, rituximab dominated in half of the comparisons. Of the CEA comparisons, tofacitinib dominated adalimumab while the ICER for abatacept versus infliximab was $20,803 and $27,976 per case of low disease activity and remission respectively. The single cost-minimization study found in favor of rituximab.

Conclusion: Despite disparate modelling approaches it appears that swapping to a targeted agents with an alternative mechanism of action is cost-effective at the $50,000/QALY threshold as ICER’s ranged between $9,323 to 41,467/QALY, dominating in 8 of 20 comparisons.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/systematic-review-of-modelling-approaches-and-quality-for-the-cost-effectiveness-of-sequential-targeted-therapy-in-patients-with-rheumatoid-arthritis-that-show-an-inadequate-response-to-at-least-one-t/