A study presented at the European League Against Rheumatism Annual Congress (EULAR 2016) revealed that several factors not related to cost might influence the prescription of TNF inhibitors for patients with rheumatoid arthritis (RA).
Although the National Institute of Health and Care Excellence (NICE) guidance recommends that RA patients in England should be treated with less costly anti-TNF, the study suggests that a series of other factors influence treatment choice.
Most anti-TNF therapies at an average cost of 9,000 euros for a one year course but only a few brand distinctions exist with differences in prices accentuated by different patient access programs.
There are currently several different anti-TNF therapies that NICE recommends as treatment options for RA. Usually combined with methotrexate when it is tolerated and not contraindicated, treatment is only advised in the face of severe disease and if the disease has not responded to intensive therapy with a combination of conventional disease-modifying anti-rheumatic drugs (DMARDs).
First, the study asked physicians about what influences their significant treatment decisions.
Most rheumatologists responded that cost rarely factored in their choice of first-line anti-TNF treatment, unless the least-expensive option was imposed by local authorities. But the physicians maintained cautious optimism when discussing the use of anti-TNF generics on the grounds of potential cost-saving. Patient involvement in the decision-making was often sacrificed when the cheapest option was required by law.
Regarding the interpretation of NICE guidance, the interviewees reported distinct standpoints – some claimed it was too restrictive while others thought it was flexible and beneficial.
Many of the participants claimed that manipulation of DAS28 disease activity score was a way to maintain clinical autonomy; anti-TNF therapy was only prescribed if they thought the treatment was appropriate for specific RA patients whose disease did not meet the NICE-imposed threshold.
Additionally, those interviewed reported negotiated local exceptions as a facilitator of clinical autonomy and that advancements in clinical evidence were commonly used to justify deviation from NICE guidelines. The influence of clinical evidence was also less important in dose-optimization decisions in RA patients in remission, to whom guidance is more limited.
“With so many factors for a consultant rheumatologist to consider when he or she is choosing which anti-TNF therapy to prescribe, this is likely to contribute to a wide variability in treatment received by RA patients in England,” study’s lead author, Sean Gavan, of Manchester Centre for Health Economics, said in a press release. “Emergence of evidence, interpretation of clinical guidelines, patient involvement in decision-making, desire for clinical autonomy and the involvement of clinical service commissioners have all been identified as influencing factors. We now need further research to explore whether these deviations from NICE guidance lead to differences in patient outcomes, or cost-effectiveness of care.”