What is the added value of ultrasound joint examination for monitoring synovitis in rheumatoid arthritis and can it be used to guide treatment decisions? A systematic review and cost-effectiveness analysis.
What is the added value of ultrasound joint examination for monitoring synovitis in rheumatoid arthritis and can it be used to guide treatment decisions? A systematic review and cost-effectiveness analysis.
复制标题
超声关节检查对于监测类风湿性关节炎滑膜炎有什么附加价值，可以用来指导治疗决策吗？
DOI：
10.3310/hta22200
复制
发表时间：
2018
影响因子：
3.6
通讯作者：
R. Wakefield
中科院分区：
文献类型：
--
作者：
E. Simpson;E. Hock;M. Stevenson;Ruth Wong;N. Dracup;A. Wailoo;P. Conaghan;C. Estrach;C. Edwards;R. Wakefield
背景
类风湿性关节炎（RA）中的滑膜炎（关节滑膜衬里发炎）可以通过临床检查（CE）或超声（US）进行评估。
目的
在临床有效性和成本效益方面，研究US与单独CE相比在RA滑膜炎中的附加值。
数据源
检索了从开始到2015年10月的电子数据库，包括MEDLINE、EMBASE和科克伦数据库。
复习方法
一项系统性综述寻找了比较额外US与CE的RA研究。研究在干预、对照和结局方面的异质性排除了荟萃分析。对成本-效果研究和美国研究以及治疗减量研究（不一定包括美国）进行了系统检索。
数学模型
构建了一个模型，估计对于考虑药物减量的患者，疾病缓解抗风湿药物（DMARD）和严重感染的成本降低，其中增加US的每质量调整生命年（QALY）成本增加了20，000英镑和30，000英镑。此外，还估计了美国成为成本中性时DMARD成本的降低。对于正在考虑剂量递增的患者，估计增加US治疗后每QALY成本增加20，000英镑和30，000英镑的患者数量和严重感染数量减少。还估计了美国升级治疗以实现成本中性的患者数量减少。
结果
纳入了58项研究。两项随机对照试验比较了在早期RA患者的基于疾病活动评分（DAS）的达标治疗策略中添加US。在早期风湿性关节炎靶向滑膜炎（TaSER）试验中，将能量多普勒超声（PDUS）添加到基于疾病活动性评分28关节的靶向治疗策略中，导致疾病活动性评分44关节（DAS 44）的变化无显著组间差异。本研究发现，PDUS组中达到DAS 44缓解的患者显著更多（p = 0.03）。ARCTIC试验发现，在基于DAS的策略中添加PDUS和灰阶超声（GSUS）在主要终点方面没有产生显著的组间差异：复合DAS <1.6，关节无肿胀，货车der Heijde改良总Sharp评分（vdHSS）无进展。ARCTIC试验确实发现vdHS的糜烂评分明显优于US组（p = 0.04）。在TaSER试验中，侵蚀没有显著的组间差异。其他研究表明，PDUS与放射学进展显著相关，并且US对腕关节和手关节而不是足关节和踝关节有附加价值。试验之间的异质性使结论不确定。未发现报告超声监测滑膜炎的成本效益的研究。该模型估计，生物DMARD成本平均降低2.5%将足以抵消3个月US的成本。如果只使用口服甲氨蝶呤，这笔钱就无法收回。
限制
试验的异质性排除了荟萃分析。因此，未获得效应的汇总估计值。未纳入与逐渐减量或疾病进展后复发相关的额外费用和健康相关生活质量下降。美国加强监测的可行性尚未得到评估。
结论
有限的证据表明，超声监测滑膜炎可以提供一种具有成本效益的方法来选择RA患者进行治疗减量或升级避免。所有结论都存在很大的不确定性。未来的研究重点包括在纵向临床研究中评估RA滑膜炎的US监测。
研究注册
本研究注册为PROSPERO CRD 42015017216。
资金
国家卫生研究所卫生技术评估方案。
BACKGROUND
Synovitis (inflamed joint synovial lining) in rheumatoid arthritis (RA) can be assessed by clinical examination (CE) or ultrasound (US).
OBJECTIVE
To investigate the added value of US, compared with CE alone, in RA synovitis in terms of clinical effectiveness and cost-effectiveness.
DATA SOURCES
Electronic databases including MEDLINE, EMBASE and the Cochrane databases were searched from inception to October 2015.
REVIEW METHODS
A systematic review sought RA studies that compared additional US with CE. Heterogeneity of the studies with regard to interventions, comparators and outcomes precluded meta-analyses. Systematic searches for studies of cost-effectiveness and US and treatment-tapering studies (not necessarily including US) were undertaken.
MATHEMATICAL MODEL
A model was constructed that estimated, for patients in whom drug tapering was considered, the reduction in costs of disease-modifying anti-rheumatic drugs (DMARDs) and serious infections at which the addition of US had a cost per quality-adjusted life-year (QALY) gained of £20,000 and £30,000. Furthermore, the reduction in the costs of DMARDs at which US becomes cost neutral was also estimated. For patients in whom dose escalation was being considered, the reduction in number of patients escalating treatment and in serious infections at which the addition of US had a cost per QALY gained of £20,000 and £30,000 was estimated. The reduction in number of patients escalating treatment for US to become cost neutral was also estimated.
RESULTS
Fifty-eight studies were included. Two randomised controlled trials compared adding US to a Disease Activity Score (DAS)-based treat-to-target strategy for early RA patients. The addition of power Doppler ultrasound (PDUS) to a Disease Activity Score 28 joints-based treat-to-target strategy in the Targeting Synovitis in Early Rheumatoid Arthritis (TaSER) trial resulted in no significant between-group difference for change in Disease Activity Score 44 joints (DAS44). This study found that significantly more patients in the PDUS group attained DAS44 remission (p = 0.03). The Aiming for Remission in Rheumatoid Arthritis (ARCTIC) trial found that the addition of PDUS and grey-scale ultrasound (GSUS) to a DAS-based strategy did not produce a significant between-group difference in the primary end point: composite DAS of < 1.6, no swollen joints and no progression in van der Heijde-modified total Sharp score (vdHSS). The ARCTIC trial did find that the erosion score of the vdHS had a significant advantage for the US group (p = 0.04). In the TaSER trial there was no significant group difference for erosion. Other studies suggested that PDUS was significantly associated with radiographic progression and that US had added value for wrist and hand joints rather than foot and ankle joints. Heterogeneity between trials made conclusions uncertain. No studies were identified that reported the cost-effectiveness of US in monitoring synovitis. The model estimated that an average reduction of 2.5% in the costs of biological DMARDs would be sufficient to offset the costs of 3-monthly US. The money could not be recouped if oral methotrexate was the only drug used.
LIMITATIONS
Heterogeneity of the trials precluded meta-analysis. Therefore, no summary estimates of effect were available. Additional costs and health-related quality of life decrements, relating to a flare following tapering or disease progression, have not been included. The feasibility of increased US monitoring has not been assessed.
CONCLUSION
Limited evidence suggests that US monitoring of synovitis could provide a cost-effective approach to selecting RA patients for treatment tapering or escalation avoidance. Considerable uncertainty exists for all conclusions. Future research priorities include evaluating US monitoring of RA synovitis in longitudinal clinical studies.
STUDY REGISTRATION
This study is registered as PROSPERO CRD42015017216.
FUNDING
The National Institute for Health Research Health Technology Assessment programme.
ACR 和 EULAR 改善标准在类风湿性关节炎试验中具有相当的有效性。
DOI：
--
发表时间：
1999
期刊：
The Journal of rheumatology
影响因子：
--
作者：
vanGestel,AM;Anderson,JJ;vanRiel,PL;Boers,M;Haagsma,CJ;Rich,B;Wells,G;Lange,ML;Felson,DT
通讯作者：
Felson,DT
评估风湿病治疗的有效性和安全性：障碍和建议的解决方案。
DOI：
10.1002/art.11087
发表时间：
2003
期刊：
Arthritis and rheumatism.
影响因子：
--
作者：
Felson,DavidT
通讯作者：
Felson,DavidT