The total fixed costs of treating patients with rheumatoid arthritis (RA) in Sweden increased by 32% between 1990 and 2010, years that encompass the time period when biologic therapies became available. These results of a large, population-based registry study suggest that hospitalization and other indirect costs associated with RA have not been reduced enough to offset the increased cost of more expensive drugs (Kalkan A, et al. Rheumatology [Oxford]. 2014;53:153-160).
Identifying the Source of the Costs
Despite the availability of guidelines in Sweden, as in the United States, the final selection of treatment for a patient with RA is made by the treating physician, explained lead author Almina Kalkan, PhDc, Linköping University, Linköping, Sweden.
“Our study shows that the costs of RA have increased, despite lowered use of healthcare and sick leave/disability pension by RA patients,” she told Value-Based Care in Rheumatology. “The amount of indirect costs has decreased and direct costs have increased. This implies that the costs to the societal insurance system for this disease have increased relative to the costs to the healthcare system.”
“We purposefully chose 10 years before and 10 years after the introduction of biologics for our study that retrospectively measures on a national level, with all data available, how the indirect costs have changed,” she continued. “One needs to ask whether these increased costs [of biologics] are accompanied by large increases in quality-of-life.”
Although studies show trends toward large initial quality-of-life benefits for biologics versus traditional triple therapy with disease-modifying antirheumatic drugs (DMARDs), in the longer term, there is little if any difference in quality of life between the treatments. Targets of treatment in RA, including remission/low disease activity and improved functional status, can be achieved with both expensive and less expensive antirheumatic drugs, she stated, citing recent research (Sokka T, et al. Clin Exp Rheumatol. 2013;31:409-414).
“Because of the large initial benefit with biologics, some physicians may increasingly choose to skip the phase with triple therapy but jump directly to biologics,” she said.
Costs and Benefits of Treatment
Using comprehensive national databases for the study, the investigators analyzed both current and fixed prices. Fixed prices were adjusted for inflation using the Consumer Price Index and a healthcare price index reflecting changes.
The direct costs included inpatient and outpatient care, as well as cost of drugs. Indirect costs included sick leave due to RA and disability pensions for patients with RA. Throughout the study period, utilization of inpatient care for RA decreased, with a more pronounced decline between 1994 and 2000, than after 2000. Outpatient care for RA remained relatively unchanged during the study period.
The number of days of sick leave due to RA decreased by 50% after the mid-1990s, while newly granted disability pensions due to RA fluctuated, closely mirroring the pattern for the populations with other diagnoses.
The fixed costs of RA doubled between 1990 and 2010. These price increases largely outweighed any reductions in other costs. Total fixed costs increased by 32% over the study period. Inflation adjustments showed a noticeable downturn in all costs except drug costs.
“The benefits of biologic treatment should be weighed against the considerable costs of biologic drugs compared with traditional DMARDs,” according to Ms Kalkan and colleagues. n