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VBCR - April 2017, Vol 6, No 1 - Value Propositions

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Integrated Care and Workplace Interventions Not Cost-Effective in Patients with Rheumatoid Arthritis

Integrated care and participatory workplace interventions for patients with rheumatoid arthritis (RA) do not improve quality of life or productivity enough to justify the additional costs of such services, according to the results of a recent economic evaluation.

In an effort to evaluate the cost-effectiveness and -utility of using integrated care interventions and participatory workplace interventions to increase productivity among workers with RA, Cindy Noben, PhD, Faculty of Health, Medicine and Life Sciences, Caphri School for Public Health and Primary Care, Maastricht University, the Netherlands, and colleagues conducted a 12-month follow-up at specialized rheumatology treatment centers, in addition to a randomized controlled trial that was carried out between 2011 and 2013.

“The current intervention...includes an integrated care intervention and participatory workplace intervention provided to workers with RA currently at work (no more than three months sick leave at time of inclusion) to improve their work productivity,” they said.

Integrated care was provided using case management protocol by a multidisciplinary team comprising a clinical occupational physician, an occupational therapist, and the patient’s rheumatologist. The participatory workplace intervention was coordinated by the occupational therapist, and relied on the active participation of the patient, and, if appropriate, his or her supervisor.

Patients in the trial were given the opportunity to partake in both intervention types. Cost-effectiveness and -utility were evaluated to determine the incremental costs and benefits that came with each additional unit of effect, and were included in subgroup and sensitivity analyses.

Over the course of 2 weeks, patients who received the intervention had approximately 4.6 hours of productivity loss, whereas those who received care as usual clocked approximately 3.5 hours. Quality-of-life differences between the groups were insignificant. Following the 12-month follow-up, total average costs were highest among patients who received interventions (ie, €7437.76) compared with those who did not (ie, €5758.23). Noben C, et al. J Occup Health. 2017 Apr 5. Epub ahead of print.

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Wellness Coaching in Patients with Fibromyalgia Improves Quality of Life, Reduces Utilization

Adding a health and wellness coaching intervention to the pharmacologic management of fibromyalgia led to significantly improved results in patient quality-of-life measures, reduction in pain severity and interference, and markedly reduced healthcare utilization, researchers behind a recent study have found.

Kevin V. Hackshaw, MD, Associate Professor, Division of Rheumatology & Immunology, The Ohio State University, Columbus, and colleagues recruited 9 women with fibromyalgia who were willing to receive a health and wellness coaching intervention, and followed them for 1 year. Protocol for the health and wellness coaching intervention comprised 2 modules, which participants received via phone over the course of 12 months. Taking into account the patient’s preference for scheduling and frequency, trained health and wellness coaches met with patients individually during the 12-month study period. Each patient also took part in bimonthly and monthly group classes for self-coaching strategies. Health and quality of life were measured, as were pain scores, and rate of healthcare utilization.

All patients completed the health and wellness coaching intervention; Revised Fibromyalgia Impact Questionnaire scores improved by 35%, Brief Pain Inventory-Short Form scores were reduced by 32% overall, with 31% for severity and 44% for interference, and healthcare utilization rates decreased by 86%. These favorable results suggest that the use of health and wellness coaching interventions in this patient population can significantly improve health and quality of life.

“Such improvements do not typically occur spontaneously in FM [fibromyalgia] patients, suggesting that HWC [health and wellness coaching] deserves further consideration as an intervention for FM,” Dr Hackshaw and colleagues stated. Hackshaw KV, et al. BMC Musculoskelet Disord. 2016;17:457.

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Nonadherence to DMARD Therapy Correlates Positively with Healthcare Costs, Anxiety

Nonadherence to DMARD use in patients with early arthritis was associated with increased healthcare costs during the first year of therapy, as well as an increase in baseline anxiety, according to the results of a recent multicenter cohort trial. “Non-adherence can be expected to cause either more or less health care costs. Usually, the relation in which non-adherence leads to ineffective treatment and higher costs due to substituting expensive treatment, is emphasized,” said Annelieke Pasma, MSc, Department of Rheumatology, University Medical Center Rotterdam, the Netherlands, and colleagues.

Using a time frame of 1 year for follow-up, Dr Pasma and colleagues measured nonadherence (ie, the number of days when a negative difference between expected and observed jar openings occurred) continuously via electronically monitored medication jars. Measurements for cost pertained to hospital costs during the first year, and included consultations, visits to the emergency department, hospitalizations, medical procedures, imaging modalities, costs of medications, and laboratory tests. Costs were gleaned from patient medical files.

Using multivariate regression analyses, Dr Pasma and colleagues determined the association between costs and nonadherence, and between costs and other variables (eg, age, sex, baseline disease activity, socioeconomic status, anxiety, and depression). Among the 206 willing participants of the trial, 74.2% had RA, 20.9% had psoriatic arthritis, and 4.9% had undifferentiated arthritis. Over the course of the 1-year follow-up period, a nonadherence rate of >20% was seen in 23.7% of patients. Nonadherence and anxiety were both found to be positively related to cost, suggesting that an improvement in adherence would be associated not only with better cost-savings, but with better health outcomes.

“Our findings address the need to improve adherence, because money is being wasted and potentially beneficial medication is discarded. It is important to study which patients are at risk for non-adherence, so that interventions to improve adherence can be targeted. While there remains uncertainty about which patients are at risk and how to intervene on adherence behavior, rheumatologists should at least be aware that patients might be non-adherent to therapy,” Dr Pasma and colleagues concluded. Pasma A, et al. PLoS One. 2017;12:e0171070.

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Sequential Therapy with Biologic DMARDs Cost-Effective, Adds Clinical Benefits

Use of sequential treatments with biologic disease-modifying antirheumatic drugs (DMARDs) in US patients with RA is cost-effective and is associated with increased clinical benefit, researchers have found.

Seeking to determine whether providing treatment with biologic DMARDs in a sequential manner is more cost-effective than conventional DMARD use in US patients with moderately to severely active RA whose disease responded inadequately to conventional DMARDs, Jeroen Paul Jansen, PhD, MSc, Adjunct Assistant Professor of Public Health and Community Medicine, Tufts University, Boston, MA, and colleagues developed an individual patient model that simulates outcomes using a cycle length of 6 months.

Through the use of clinical trial data and real-world evidence, the model evaluates the impact treatments have on disease. Treatment sequences began with etanercept, adalimumab, certolizumab, or abatacept—and were then compared with conventional DMARDs. The incremental cost, quality-adjusted life-years, and cost-effectiveness ratios were calculated for each individual therapy sequence in relation to conventional DMARD use. The cost-effectiveness of each strategy was measured using a US willingness-to-pay threshold of $150,000 per quality-adjusted life-year.

Greater treatment benefit, lower loss of productivity costs, and greater treatment-related costs were associated with biologic DMARD treatment sequences than with conventional DMARD use. For biologic DMARD sequences, expected incremental cost-effectiveness ratios fell below the US willingness-to-pay threshold, ranging from $126,000 to $140,000 for every quality-adjusted life-year. Similar incremental cost-effectiveness ratios were seen in alternative situations assessing dose increases, increased hospitalization costs for patients who are severely physically impaired, and a lower baseline Health Assessment Questionnaire Disability Index score.

“Sequential bDMARDs [biologic DMARDs] for treatment of patients with moderately to severely active RA and inadequate response to cDMARDs [conventional DMARDs] can be considered cost-effective from the US societal perspective,” Dr Jansen and colleagues concluded. Jansen JP, et al. J Med Econ. 2017 Apr 5. Epub ahead of print.

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