Triple Therapy Versus Biologic Therapy for Active Rheumatoid Arthritis A Cost-Effectiveness Analysis
Triple Therapy Versus Biologic Therapy for Active Rheumatoid Arthritis A Cost-Effectiveness Analysis
复制标题
活动性类风湿关节炎的三联疗法与生物疗法的成本效益分析
DOI：
10.7326/m16-0713
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发表时间：
2017-07-04
影响因子：
39.2
通讯作者：
Anis, Aslam H.
中科院分区：
文献类型：
--
作者：
Bansback, Nick;Phibbs, Ciaran S.;Anis, Aslam H.
背景：RACAT（类风湿关节炎活性疗法比较）试验发现，对于活动性类风湿关节炎 (RA) 患者，三联疗法并不劣于依那西普-甲氨蝶呤。目的：确定依那西普-甲氨蝶呤与三联疗法作为一线策略的成本效益。设计：基于 RACAT 试验中 353 名参与者的试验内分析以及推断的终生分析使用决策分析队列模型来评估成本和结果。数据来源：RACAT 试验和文献来源。目标人群：尽管接受了至少 12 周的甲氨蝶呤治疗，但仍然患有活动性 RA 的患者。时间范围：24 周和终生。视角：社会和医疗保险。干预：首先依那西普-甲氨蝶呤与首先三联疗法。结果衡量：增量成本、质量调整生命年(QALY) 和增量成本效益比 (ICER)。 基础案例分析结果：试验内分析发现，依那西普-甲氨蝶呤作为一线治疗提供了稍多的 QALY，但累积的药物成本却显着升高。策略之间其他成本的差异可以忽略不计。一线依那西普-甲氨蝶呤和三联疗法在 24 周和 48 周内的 ICER 分别为每 QALY 270 万美元和每 QALY 98 万美元。生命周期分析表明，一线依那西普-甲氨蝶呤将导致生命周期 QALY 延长 0.15 倍，但这一收益将增加 77 290 美元，导致每位患者每个 QALY 的 ICER 为 521 520 美元。敏感性分析结果：从长远角度考虑，即使在乐观的假设下，与首先使用三联疗法相比，具有相似成本和疗效的依那西普-甲氨蝶呤和生物制剂的初始策略也不太可能具有成本效益。局限性：三联疗法的长期获益数据尚不确定。结论：在不首先尝试三联疗法的情况下启动生物疗法会增加成本，同时提供最小的增量收益。
Background: The RACAT (Rheumatoid Arthritis Comparison of Active Therapies) trial found triple therapy to be noninferior to etanercept-methotrexate in patients with active rheumatoid arthritis (RA).Objective: To determine the cost-effectiveness of etanercept-methotrexate versus triple therapy as a first-line strategy.Design: A within-trial analysis based on the 353 participants in the RACAT trial and a lifetime analysis that extrapolated costs and outcomes by using a decision analytic cohort model.Data Sources: The RACAT trial and sources from the literature.Target Population: Patients with active RA despite at least 12 weeks of methotrexate therapy.Time Horizon: 24 weeks and lifetime.Perspective: Societal and Medicare.Intervention: Etanercept-methotrexate first versus triple therapy first.Outcome Measures: Incremental costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs).Results of Base-Case Analysis: The within-trial analysis found that etanercept-methotrexate as first-line therapy provided marginally more QALYs but accumulated substantially higher drug costs. Differences in other costs between strategies were negligible. The ICERs for first-line etanercept-methotrexate and triple therapy were $2.7 million per QALY and $0.98 million per QALY over 24 and 48 weeks, respectively. The lifetime analysis suggested that first-line etanercept-methotrexate would result in 0.15 additional lifetime QALY, but this gain would cost an incremental $77 290, leading to an ICER of $521 520 per QALY per patient. Results of SensitivityAnalysis: Considering a long-term perspective, an initial strategy of etanercept-methotrexate and biologics with similar cost and efficacy is unlikely to be cost-effective compared with using triple therapy first, even under optimistic assumptions.Limitation: Data on the long-term benefit of triple therapy are uncertain.Conclusion: Initiating biologic therapy without trying triple therapy first increases costs while providing minimal incremental benefit.