Evaluating the consequences of rheumatoid arthritis.

Patients and non-patients tend to attach different utility values to the state of suffering from specific illnesses. This observation naturally leads to the question whose utility values should be used as the basis in cost-effectiveness analysis (CEA). Intuitively, one would presume that patients are better informed about the consequences of their illness, and public authorities should, therefore, use the patients' utility values in CEA. Contrary to this presumption, it has been argued that society at large should determine which values are to be used and not the patients because, in the end, it is societal resources that are to be allocated. Against this background, we use data from a discrete choice experiment (DCE) that was completed by patients of rheumatoid arthritis (RA) and non-patients to explore the discrepancies between the two groups' utility estimates for typical consequences of RA. Our results indicate that both groups attach remarkably similar part-worth utilities to the symptoms pain, fatigue, and functional limitations. However, non-patients significantly undervalue the ability to work when compared to patients.

Biologic TNF inhibiting agents for treatment of rheumatoid arthritis: persistence and dosing patterns in Germany.

OBJECTIVE: To obtain detailed real-world data on persistence and dosing patterns in the utilisation of the TNF inhibitors adalimumab, etanercept, and infliximab in rheumatoid arthritis (RA) patients treated in Germany. METHODS: In this retrospective observational study claims data of a major German health insurance fund between 2005 and 2008 were analysed. Patients receiving at least one prescription of adalimumab, etanercept or infliximab were identified and categorised as "TNF inhibitor naive" or "TNF inhibitor continuing". For the calculation of TNF inhibitor persistence a survival analysis with the Kaplan-Meier estimator was used. A Cox regression was used to analyse, if any relevant factors were influencing persistence. Dosage increase rates were analysed for adalimumab, etanercept and infliximab. Sensitivity analyses based on variations in gap length were conducted. RESULTS: A total of 2,201 RA patients were identified. 1,468 of these patients were TNF inhibitor naive patients and 733 were defined as TNF inhibitor continuing patients. There were no significant differences in the treatment persistence rates between adalimumab, etanercept and infliximab for TNF inhibitor naive and continuing patients. The persistence rate after three years was 22.47% for adalimumab, 24.27% for etanercept and 21.49% for infliximab naive patients. For continuing patients, the persistence rate after three years was 32.88% for adalimumab, 30.95% for etanercept, and 33.90% for infliximab, respectively. Gender, medication and Charlson Comorbidities Index did not influence the persistence significantly. Dosage increase occurred in 7.3% adalimumab, 1.4% etanercept, and 17.2% infliximab naive patients and 5.8%, 1.1% and 11.9% respectively in the continuing patients. CONCLUSIONS: In this study, there were no significant differences in persistence among adalimumab, etanercept and infliximab treated patients. Consistent with previous research, there was a higher dose escalation for infliximab than for the two subcutaneous treatments, adalimumab or etanercept.

Cost effectiveness of preventive screening programmes for type 2 diabetes mellitus in Germany.

BACKGROUND: As in several other industrialized countries, Germany's statutory health insurance (SHI) is facing rising healthcare costs as well as the challenges caused by a double-aging society. The early detection and prevention of chronic diseases is considered a possible way to reduce the impact of these developments. However, controversy surrounds the costs and effects in terms of medical and financial outcomes of such programmes. OBJECTIVE: To examine the cost effectiveness of screening for type 2 diabetes mellitus (T2DM) from the perspective of the German SHI. The screening programme was compared with the current status quo (i.e. diagnosis of T2DM in routine clinical care or after the occurrence of the first clinical symptoms). Prevention strategies after diagnosis of pre-diabetes encompassed lifestyle and metformin interventions. METHODS: Effects of introducing screening for T2DM were assessed based on a Markov Monte Carlo microsimulation model. In contrast to a cohort model, this approach easily allows for detailed subgroup analysis accounting for the different characteristics of the general German population that would be targeted by the screening programme. Assessed endpoints included quality of life, lifetime costs, age at diabetes diagnosis, and incidence and age at occurrence of diabetes-related complications such as myocardial infarction, stroke, renal failure and blindness. RESULTS: Screening for T2DM was cost effective in the general population by all commonly applied standards (euro562.54 per QALY for lifestyle intervention, euro325.44 per QALY for prevention with metformin [year 2006 values]) and even cost saving in the subgroup diagnosed with pre-diabetes and treated preventively. Occurrence of diabetes-related adverse events was reduced significantly and life expectancy was increased compared with no screening. CONCLUSIONS: These results suggest that early detection and disease prevention may be cost effective in the long term. However, additional political measures are necessary to support implementation, as the German SHI is currently lacking the necessary long-term incentives to support preventive screening programmes.