A test-based strategy is more cost effective than empiric dose escalation for patients with Crohn's disease who lose responsiveness to infliximab.
OBJECTIVE
Patients with Crohn's disease who become unresponsive to therapy with tumor necrosis factor antagonists are managed initially with either empiric dose escalation or testing-based strategies. The comparative cost effectiveness of these 2 strategies is unknown. We investigated whether a testing-based strategy is more cost effective than an empiric dose-escalation strategy.


METHODS
A decision analytic model that simulated 2 cohorts of patients with Crohn's disease compared outcomes for the 2 strategies over a 1-year time period. The incremental cost-effectiveness ratio of the empiric strategy was expressed as cost per quality-adjusted life-year (QALY) gained, compared with the testing-based strategy. We performed 1-way, probabilistic, and prespecified secondary analyses.


RESULTS
The testing strategy yielded similar QALYs compared with the empiric strategy (0.801 vs 0.800, respectively) but was less expensive ($31,870 vs $37,266, respectively). In sensitivity analyses, the incremental cost-effectiveness ratio of the empiric strategy ranged from $500,000 to more than $5 million per QALY gained. Similar rates of remission (63% vs 66%) and response (28% vs 26%) were achieved through differential use of available interventions. The testing-based strategy resulted in a higher percentage of surgeries (48% vs 34%) and lower percentage use of high-dose biological therapy (41% vs 54%).


CONCLUSIONS
A testing-based strategy is a cost-effective alternative to the current strategy of empiric dose escalation for managing patients with Crohn's disease who have lost responsiveness to infliximab. The basis for this difference is lower cost at similar outcomes.
Division of Gastroenterology and Hepatology, University of California, San Francisco, California 94115, USA. fernando.velayos@ucsf.edu
Fernando S
FS
Velayos
James G
JG
Kahn
William J
WJ
Sandborn
Brian G
BG
Feagan
D000465:Algorithms; D000911:Antibodies, Monoclonal / Q000191:economics / Q000627:therapeutic use*; D003365:Costs and Cost Analysis; D003424:Crohn Disease / Q000188:drug therapy*; D003661:Decision Support Techniques; D006801:Humans; D007155:Immunologic Factors / Q000191:economics / Q000627:therapeutic use*; D000069285:Infliximab; D017211:Treatment Failure
D000911:Antibodies, Monoclonal; D007155:Immunologic Factors; D000069285:Infliximab