Cost-utility analysis of treatment strategies in patients with recent-onset rheumatoid arthritis
Objective. To evaluate societal costs and quality-adjusted life years (QALYs) of treatment strategies for patients with recent-onset active rheumatoid arthritis (RA). Methods. Patients (n = 508) were randomly allocated to 1 of 4 treatment strategy groups: sequential monotherapy, step-up combination therapy, initial combination therapy with prednisone, or initial combination therapy with infliximab. For 2 years, patients reported cost and utility measures. Results. Average QALYs (ideally 2.00) for groups 1-4 were 1.29, 1.31, 1.32, and 1.41, respectively, for the British EuroQol (P ≤ 0.05 for group 4 versus groups 1-3); 1.41, 1.43, 1.44, and 1.52, respectively, for the Dutch EuroQol (P ≤ 0.05 for group 4 versus groups 1-3); and 1.38, 1.38, 1.39, and 1.44, respectively, for the Short Form 6D (P ≤ 0.05 for group 4 versus groups 1-3). The Time Trade-Off showed no significant differences. In the primary analysis, using the friction cost method to value productivity, the cost-utility ratio for group 4 against the next best alternative was estimated at €130,000 (95% confidence interval €27,000, €3,000,000) per QALY. Using the human capital method, the value of sustained productivity in group 4 largely compensated for the extra medication costs. Conclusion. Initial combination therapy with infliximab for patients with recent-onset active RA resulted in significantly better quality of life than other strategies. Using the friction cost method, costs to achieve this improvement are generally considered too high, and initial combination therapy with prednisone should be preferred. However, depending on the extent to which productivity is valued, infliximab costs could be largely compensated for by savings on productivity. Since patterns of infliximab use had not yet stabilized after 2 years, longer followup may change the economic conclusions.