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Chang S, Rivellese F, Payne K, Ide Z, Barton A, Pitzalis C, Gavan SP. Ultrasound-guided synovial tissue biopsy for people with rheumatoid arthritis: a micro-costing study. Rheumatol Adv Pract 2025; 9:rkaf011. [PMID: 40007859 PMCID: PMC11855308 DOI: 10.1093/rap/rkaf011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2024] [Accepted: 01/08/2025] [Indexed: 02/27/2025] Open
Abstract
Objective Identify and quantify the resource use and cost per patient of performing a US-guided synovial tissue biopsy for people with RA within a routine healthcare setting. Method A micro-costing study was performed from a healthcare system perspective (National Health Service England). A service pathway conceptual model described how the procedure will be embedded within routine care to inform management decisions. Consumables were estimated from existing standard operating procedures for synovial biopsies. Staff time was estimated by expert input (clinical rheumatologist and patient). The time for tissue sample acquisition was obtained from data within the biopsy-driven R4RA trial. Unit costs were sourced from historic purchase prices, published salary scales and public-facing list prices. One-way sensitivity analysis identified key drivers of total cost per patient. Scenario analyses explored the cost impact if less senior healthcare staff performed the biopsy or if an additional outpatient appointment was required to identify joint suitability. Results The total cost of US-guided synovial tissue biopsy was £356.24/patient (best-case estimate: £185.30; worst-case estimate: £812.46). The key driver of total cost was the time taken to perform tissue sample acquisition. The total cost was lower if a registrar performed the biopsy (£294.24) and higher if an additional outpatient appointment was required for joint selection (£438.98). Conclusion Interventions requiring synovial tissue samples to inform treatment selection or prognosis are emerging. The findings can inform cost parameters for future cost-effectiveness analyses. These results will help resource allocation and clinical decisions to improve the value of treatments for RA.
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Affiliation(s)
- Sainan Chang
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Felice Rivellese
- Department of Rheumatology, Mile End Hospital, Barts Health NHS Trust and NIHR Barts Biomedical Research Centre, London, UK
- Centre for Experimental Medicine and Rheumatology, Queen Mary University of London, London, UK
| | - Katherine Payne
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Zoë Ide
- Patient Researcher, University of Manchester, Manchester, UK
| | - Anne Barton
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Versus Arthritis Centre for Genetics and Genomics, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Costantino Pitzalis
- Department of Rheumatology, Mile End Hospital, Barts Health NHS Trust and NIHR Barts Biomedical Research Centre, London, UK
- Centre for Experimental Medicine and Rheumatology, Queen Mary University of London, London, UK
| | - Sean P Gavan
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Towards Personalising the Use of Biologics in Rheumatoid Arthritis: A Discrete Choice Experiment. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2021; 15:109-119. [PMID: 34142326 PMCID: PMC8739310 DOI: 10.1007/s40271-021-00533-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/26/2021] [Indexed: 11/27/2022]
Abstract
Introduction There have been promising developments in technologies and associated algorithm-based prescribing (‘stratified approach’) to target biologics to sub-groups of people with rheumatoid arthritis (RA). The acceptability of using an algorithm-guided approach in practice is likely to depend on various factors. Objective This study quantified preferences for an algorithm-guided approach to prescribing biologics (termed ‘biologic calculator’). Methods An online discrete choice experiment (DCE) was designed to elicit preferences from patients and the public for using a ‘biologic calculator’ compared with conventional prescribing. Treatment approaches were described by five attributes: delay to starting treatment; positive and negative predictive value (PPV/NPV); risk of infection; and cost saving to the UK national health service. Each survey contained six choice sets asking respondents to select their preferred option from two hypothetical biologic calculators or conventional prescribing. Background questions included sociodemographics, health status and healthcare experiences. DCE data were analysed using mixed logit models. Results Completed choice data were collected from 292 respondents (151 patients with RA and 142 members of the public). PPV, NPV and risk of infection were the most highly valued attributes to respondents deciding between prescribing strategies. Conclusion Respondents were generally receptive to personalised medicine in RA, but researchers developing personalised approaches should pay close attention to generating evidence on both the PPV and the NPV of their technologies. Supplementary Information The online version contains supplementary material available at 10.1007/s40271-021-00533-z.
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Koduri GM, Gullick NJ, Hayes F, Dubey S, Mukhtyar C. Patient perceptions of co-morbidities in inflammatory arthritis. Rheumatol Adv Pract 2021; 5:rkaa076. [PMID: 33615128 PMCID: PMC7884022 DOI: 10.1093/rap/rkaa076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/19/2020] [Indexed: 11/21/2022] Open
Abstract
Objective Longer life expectancy has resulted in people living with an increasing number of co-morbidities. The average individual with inflammatory arthritis has two co-morbidities, which contribute to higher mortality, poorer functional outcomes and increased health-care utilization and cost. A number of studies have investigated the prevalence of co-morbidities, whereas this study was designed to look at patient perspectives. Methods The study comprised two parts: a patient questionnaire and an interview. Individuals with physician-verified inflammatory arthritis along with one or more Charlson co-morbidities were invited to participate. In-depth data were obtained by interviews with 12 willing participants. Results One hundred and forty-six individuals were recruited; 50 (35%) had one co-morbidity, 69 (48%) had two and 25 (17%) had more than four co-morbidities. Seventy-seven individuals (53%) reported that co-morbidities affected their health as much as their arthritis, and 82 (56%) reported dependence on others for activities of daily living. Lack of education was highlighted by 106 (73%) participants. Qualitative data provided further support for the challenges, with participants highlighting the lack of time to discuss complex or multiple problems, with no-one coordinating their care. This, in turn, led to polypharmacy and insufficient discussion around drug and disease interactions, complications and self-help measures. Conclusion This study highlights the challenges for individuals with inflammatory arthritis who suffer with multiple co-morbidities. The challenges result from limited resources or support within the current health-care environments. Individuals highlighted the poor quality of life, which is multifactorial, and the need for better educational strategies and coordination of care to improve outcomes.
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Affiliation(s)
- Gouri M Koduri
- Rheumatology Department, Southend University Hospital, Westcliff-on-Sea
| | - Nicola J Gullick
- Rheumatology Department, University Hospitals Coventry & Warwickshire NHS Trust, Coventry
| | - Fiona Hayes
- Rheumatology Department, Southend University Hospital, Westcliff-on-Sea
| | - Shirish Dubey
- Rheumatology Department, University Hospitals Coventry & Warwickshire NHS Trust, Coventry
| | - Chetan Mukhtyar
- Rheumatology Department, Norfolk and Norwich University Hospital, Norwich, UK
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Sutcliffe M, Radley G, Barton A. Personalized medicine in rheumatic diseases: how close are we to being able to use genetic biomarkers to predict response to TNF inhibitors? Expert Rev Clin Immunol 2020; 16:389-396. [DOI: 10.1080/1744666x.2020.1740594] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Megan Sutcliffe
- Versus Arthritis Centre for Genetics and Genomics, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
| | - Gemma Radley
- Versus Arthritis Centre for Genetics and Genomics, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
| | - Anne Barton
- Versus Arthritis Centre for Genetics and Genomics, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
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Argollo M, Gilardi D, Peyrin-Biroulet C, Chabot JF, Peyrin-Biroulet L, Danese S. Comorbidities in inflammatory bowel disease: a call for action. Lancet Gastroenterol Hepatol 2019; 4:643-654. [PMID: 31171484 DOI: 10.1016/s2468-1253(19)30173-6] [Citation(s) in RCA: 137] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/17/2019] [Accepted: 03/18/2019] [Indexed: 02/06/2023]
Abstract
Inflammatory bowel disease (IBD) is a chronic systemic inflammatory condition. Previously, the focus has been on extraintestinal manifestations of IBD, including arthritis, psoriasis, and uveitis. Although comorbidities have long been the subject of intensive research in other chronic inflammatory diseases such as rheumatoid arthritis, the concept of comorbidities is only beginning to emerge in IBD. Several comorbid conditions have been proposed to be related to IBD, including cardiovascular disease, neuropsychological disorders, and metabolic syndrome. Recognition of these conditions and their treatment could lead to better management of IBD. This Review aims to explore current knowledge regarding classic and emerging comorbidities related to IBD.
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Affiliation(s)
- Marjorie Argollo
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Centre, Milan, Italy; Universidade Federal de São Paulo, São Paulo, Brazil
| | - Daniela Gilardi
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Centre, Milan, Italy
| | | | - Jean-Francois Chabot
- Department of Pneumology, Nancy University Hospital, Lorraine University, Nancy, France
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, Nancy, France
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Centre, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy.
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Jani M, Gavan S, Chinoy H, Dixon WG, Harrison B, Moran A, Barton A, Payne K. A microcosting study of immunogenicity and tumour necrosis factor alpha inhibitor drug level tests for therapeutic drug monitoring in clinical practice. Rheumatology (Oxford) 2016; 55:2131-2137. [PMID: 27576368 PMCID: PMC5144665 DOI: 10.1093/rheumatology/kew292] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 06/29/2016] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To identify and quantify resource required and associated costs for implementing TNF-α inhibitor (TNFi) drug level and anti-drug antibody (ADAb) tests in UK rheumatology practice. METHODS A microcosting study, assuming the UK National Health Service perspective, identified the direct medical costs associated with providing TNFi drug level and ADAb testing in clinical practice. Resource use and costs per patient were identified via four stages: identification of a patient pathway with resource implications; estimation of the resources required; identification of the cost per unit of resource (2015 prices); and calculation of the total costs per patient. Univariate and multiway sensitivity analyses were performed using the variation in resource use and unit costs. RESULTS Total costs for TNFi drug level and concurrent ADAb testing, assessed using ELISAs on trough serum levels, were £152.52/patient (range: £147.68-159.24) if 40 patient samples were tested simultaneously. For the base-case analysis, the pre-testing phase incurred the highest costs, which included booking an additional appointment to acquire trough blood samples. The additional appointment was the key driver of costs per patient (67% of the total cost), and labour accounted for 10% and consumables 23% of the total costs. Performing ELISAs once per patient (rather than in duplicate) reduced the total costs to £133.78/patient. CONCLUSION This microcosting study is the first assessing the cost of TNFi drug level and ADAb testing. The results could be used in subsequent cost-effectiveness analyses of TNFi pharmacological tests to target treatments and inform future policy recommendations.
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Affiliation(s)
- Meghna Jani
- Centre for Musculoskeletal Research
- Arthritis Research UK Centre for Epidemiology, Institute of Inflammation and Repair
| | - Sean Gavan
- Manchester Centre for Health Economics, Institute of Population Health, Manchester Academic Health Science Centre University of Manchester
- National Institute of Health Research Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust Manchester Academic Health Science Centre, Manchester
| | - Hector Chinoy
- Centre for Musculoskeletal Research
- National Institute of Health Research Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust Manchester Academic Health Science Centre, Manchester
- Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford
| | - William G Dixon
- Centre for Musculoskeletal Research
- Arthritis Research UK Centre for Epidemiology, Institute of Inflammation and Repair
- Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford
| | - Beverley Harrison
- Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford
| | | | - Anne Barton
- Centre for Musculoskeletal Research
- National Institute of Health Research Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust Manchester Academic Health Science Centre, Manchester
- Kellgren Centre for Rheumatology, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Katherine Payne
- Manchester Centre for Health Economics, Institute of Population Health, Manchester Academic Health Science Centre University of Manchester,
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van Onna M, Boonen A. The challenging interplay between rheumatoid arthritis, ageing and comorbidities. BMC Musculoskelet Disord 2016; 17:184. [PMID: 27118031 PMCID: PMC4845363 DOI: 10.1186/s12891-016-1038-3] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Accepted: 04/15/2016] [Indexed: 11/30/2022] Open
Abstract
Background The incidence of rheumatoid arthritis (RA) is expected to increase over the next 10 years in the European Union because of the increasing proportion of elderly people. As both RA and ageing are associated with emerging comorbidities such as cardiovascular disease, malignancies and osteoporosis, these factors will have a profound effect on the management of RA. In addition, both increasing age and comorbidities may independently alter commonly used RA-specific outcome measures. Discussion Age-related decline in immune cell functions (immunosenescence), such as a decrease in T-cell function, may contribute to the development of RA, as well as comorbidity. The chronic immune stimulation that occurs in RA may also lead to premature ageing and comorbidity. The interplay between RA, ageing and (emerging) comorbidities is interesting but complex. Cardiovascular disease, lung disease, malignancies, bone and muscle wasting and neuropsychiatric disease all occur more frequently in RA patients as compared to the general population. It is unclear how RA should be managed in ‘today’s world of multiple comorbidities’. Evidence that treatment of RA improves comorbidities is currently lacking, although some promising indirect observations are available. On the other hand, there is limited evidence that medication regularly prescribed for comorbidities, such as statins, might improve RA disease activity. Both ageing and comorbidity have an independent effect on commonly used outcome measures in the RA field, such as the Health Assessment Questionnaire (HAQ) and the clinical disease activity index (CDAI). Prospective studies, that also account for the presence of comorbidity in (elderly) RA patients are therefore urgently needed. To address gaps in knowledge, future research should focus on the complex interdependencies between RA, ageing and comorbidity. In addition, these findings should be integrated into daily clinical practice by developing and testing integrated and coordinated health care services. Adaptation of management recommendations is likely required. Summary The elderly RA patient who also deals with (emerging) comorbidities presents a unique challenge to treating clinicians. A paradigm shift from disease-centered to goal-oriented approach is needed to develop adequate health care services for these patients.
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Affiliation(s)
- Marloes van Onna
- Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Center, School for Public Health and Primary Care (CAPHRI), Maastricht University, P. Debyelaan 25, Maastricht, 6202 AZ, The Netherlands.
| | - Annelies Boonen
- Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Center, School for Public Health and Primary Care (CAPHRI), Maastricht University, P. Debyelaan 25, Maastricht, 6202 AZ, The Netherlands
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