Cost-utility of different treatment strategies after the failure of tumour necrosis factor inhibitor in rheumatoid arthritis in the Finnish setting

Abstract

Objective: To evaluate the cost-utility of different treatment strategies in severe RA after TNF-inhibitor failure.

Methods: The cost-effectiveness of treatment strategies was compared in a group of hypothetical Finnish RA patients. Initially, the patients received either best supportive care (BSC) or one of the following treatments before BSC: adalimumab (ADAL), abatacept (ABAT), etanercept (ETAN), infliximab (INFL) or rituximab (RTX). Further treatments were added to the most cost-effective strategy in a stepwise manner. The analysis was performed on an Excel-based Markov state transition model using the probabilistic approach. The clinical outcomes related to treatments were estimated from published clinical trials. The gained quality-adjusted life-years (QALYs) were estimated based on Health Utilities Index (HUI-3) and disease severity scores (HAQ). The resource use and costs were obtained from the Finnish treatment practice, one published study, the Finnish Unit Cost list and Finnish Medicine Tariffs.

Results: Treatment with RTX was more effective and less costly than treatment with ADAL, ABAT or ETAN after TNF-inhibitor failure. An additional QALY gained with RTX costs 30,248 euros compared with BSC. The incremental cost-effectiveness ratios (ICERs) are 50,941, 50,372, 36,121 and 67,003 euros per QALY gained for adding ADAL, ETAN, INFL and ABAT to the RTX strategy, respectively. According to the cost-effectiveness acceptability frontier (CEAF), only BSC or treatments with RTX or RTX followed by INFL should be considered after TNF-inhibitor failure, if willingness to pay is between 0 and 50,000 euros per QALY gained.

Conclusions: Treatment with RTX is a cost-effective treatment strategy in RA patients in Finland.

Fig. 1

The cost-effectiveness efficiency frontier (CEEF) represents the most efficient choices among the compared treatment strategies. The average costs and QALYs gained with BSC are given in the origin.

Fig. 2

The CEAF represents the probability of cost-effectiveness of optimal treatments (i.e. treatments with the highest expected net benefit) with different WTP levels.