title: The Cost-effectiveness of Sequences of Biological Disease-modifying Antirheumatic Drug Treatment in England for Patients with Rheumatoid Arthritis Who Can Tolerate Methotrexate.
abstract: To ascertain whether strategies of treatment with a biological disease-modifying antirheumatic drug (bDMARD) are cost-effective in an English setting. Results are presented for those patients with moderate to severe rheumatoid arthritis (RA) and those with severe RA.
  
  
  
  An economic model to assess the cost-effectiveness of 7 bDMARD was developed. A systematic literature review and network metaanalysis was undertaken to establish relative clinical effectiveness. The results were used to populate the model, together with estimates of Health Assessment Questionnaire (HAQ) score following European League Against Rheumatism response; annual costs, and utility, per HAQ band; trajectory of HAQ for patients taking bDMARD; and trajectory of HAQ for patients using nonbiologic therapy (NBT). Results were presented as those associated with the strategy with the median cost-effectiveness. Supplementary analyses were undertaken assessing the change in cost-effectiveness when only patients with the most severe prognoses taking NBT were provided with bDMARD treatment. The costs per quality-adjusted life-year (QALY) values were compared with reported thresholds from the UK National Institute for Health and Care Excellence of £20,000 to £30,000 (US$24,700 to US$37,000).
  
  
  
  In the primary analyses, the cost per QALY of a bDMARD strategy was £41,600 for patients with severe RA and £51,100 for those with moderate to severe RA. Under the supplementary analyses, the cost per QALY fell to £25,300 for those with severe RA and to £28,500 for those with moderate to severe RA.
  
  
  
  The cost-effectiveness of bDMARD in RA in England is questionable and only meets current accepted levels in subsets of patients with the worst prognoses.
authors.affiliation: From the School of Health and Related Research, University of Sheffield, Sheffield; Department of Rheumatology, West Hertfordshire Hospitals National Health Service (NHS) Trust, Hertfordshire; Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK. m.d.stevenson@shef.ac.uk.|M.D. Stevenson, PhD, Professor of Health Technology Assessment, School of Health and Related Research, University of Sheffield; A.J. Wailoo, PhD, Professor of Health Economics, School of Health and Related Research, University of Sheffield; J.C. Tosh, PhD, Research Fellow in Health Economics, School of Health and Related Research, University of Sheffield; M. Hernandez-Alava, PhD, Senior Research Fellow in Econometrics, School of Health and Related Research, University of Sheffield; L.A. Gibson, PhD, Research Associate in Econometrics, School of Health and Related Research, University of Sheffield; J.W. Stevens, PhD, Reader in Decision Science, School of Health and Related Research, University of Sheffield; R.J. Archer, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; E.L. Simpson, PhD, Research Fellow, School of Health and Related Research, University of Sheffield, E.S. Hock, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; A. Young, FRCP, Professor of Clinical Rheumatology, Centre for Lifespan and Chronic Illness Research, University of Hertfordshire; D.L. Scott, MD, FRCP, Professor of Clinical Rheumatology, Department of Rheumatology, King's College Hospital NHS Foundation Trust. m.d.stevenson@shef.ac.uk.
authors.forename: Matt D
authors.initials: MD
authors.lastname: Stevenson
authors.affiliation: From the School of Health and Related Research, University of Sheffield, Sheffield; Department of Rheumatology, West Hertfordshire Hospitals National Health Service (NHS) Trust, Hertfordshire; Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK.|M.D. Stevenson, PhD, Professor of Health Technology Assessment, School of Health and Related Research, University of Sheffield; A.J. Wailoo, PhD, Professor of Health Economics, School of Health and Related Research, University of Sheffield; J.C. Tosh, PhD, Research Fellow in Health Economics, School of Health and Related Research, University of Sheffield; M. Hernandez-Alava, PhD, Senior Research Fellow in Econometrics, School of Health and Related Research, University of Sheffield; L.A. Gibson, PhD, Research Associate in Econometrics, School of Health and Related Research, University of Sheffield; J.W. Stevens, PhD, Reader in Decision Science, School of Health and Related Research, University of Sheffield; R.J. Archer, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; E.L. Simpson, PhD, Research Fellow, School of Health and Related Research, University of Sheffield, E.S. Hock, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; A. Young, FRCP, Professor of Clinical Rheumatology, Centre for Lifespan and Chronic Illness Research, University of Hertfordshire; D.L. Scott, MD, FRCP, Professor of Clinical Rheumatology, Department of Rheumatology, King's College Hospital NHS Foundation Trust.
authors.forename: Allan J
authors.initials: AJ
authors.lastname: Wailoo
authors.affiliation: From the School of Health and Related Research, University of Sheffield, Sheffield; Department of Rheumatology, West Hertfordshire Hospitals National Health Service (NHS) Trust, Hertfordshire; Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK.|M.D. Stevenson, PhD, Professor of Health Technology Assessment, School of Health and Related Research, University of Sheffield; A.J. Wailoo, PhD, Professor of Health Economics, School of Health and Related Research, University of Sheffield; J.C. Tosh, PhD, Research Fellow in Health Economics, School of Health and Related Research, University of Sheffield; M. Hernandez-Alava, PhD, Senior Research Fellow in Econometrics, School of Health and Related Research, University of Sheffield; L.A. Gibson, PhD, Research Associate in Econometrics, School of Health and Related Research, University of Sheffield; J.W. Stevens, PhD, Reader in Decision Science, School of Health and Related Research, University of Sheffield; R.J. Archer, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; E.L. Simpson, PhD, Research Fellow, School of Health and Related Research, University of Sheffield, E.S. Hock, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; A. Young, FRCP, Professor of Clinical Rheumatology, Centre for Lifespan and Chronic Illness Research, University of Hertfordshire; D.L. Scott, MD, FRCP, Professor of Clinical Rheumatology, Department of Rheumatology, King's College Hospital NHS Foundation Trust.
authors.forename: Jonathan C
authors.initials: JC
authors.lastname: Tosh
authors.affiliation: From the School of Health and Related Research, University of Sheffield, Sheffield; Department of Rheumatology, West Hertfordshire Hospitals National Health Service (NHS) Trust, Hertfordshire; Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK.|M.D. Stevenson, PhD, Professor of Health Technology Assessment, School of Health and Related Research, University of Sheffield; A.J. Wailoo, PhD, Professor of Health Economics, School of Health and Related Research, University of Sheffield; J.C. Tosh, PhD, Research Fellow in Health Economics, School of Health and Related Research, University of Sheffield; M. Hernandez-Alava, PhD, Senior Research Fellow in Econometrics, School of Health and Related Research, University of Sheffield; L.A. Gibson, PhD, Research Associate in Econometrics, School of Health and Related Research, University of Sheffield; J.W. Stevens, PhD, Reader in Decision Science, School of Health and Related Research, University of Sheffield; R.J. Archer, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; E.L. Simpson, PhD, Research Fellow, School of Health and Related Research, University of Sheffield, E.S. Hock, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; A. Young, FRCP, Professor of Clinical Rheumatology, Centre for Lifespan and Chronic Illness Research, University of Hertfordshire; D.L. Scott, MD, FRCP, Professor of Clinical Rheumatology, Department of Rheumatology, King's College Hospital NHS Foundation Trust.
authors.forename: Monica
authors.initials: M
authors.lastname: Hernandez-Alava
authors.affiliation: From the School of Health and Related Research, University of Sheffield, Sheffield; Department of Rheumatology, West Hertfordshire Hospitals National Health Service (NHS) Trust, Hertfordshire; Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK.|M.D. Stevenson, PhD, Professor of Health Technology Assessment, School of Health and Related Research, University of Sheffield; A.J. Wailoo, PhD, Professor of Health Economics, School of Health and Related Research, University of Sheffield; J.C. Tosh, PhD, Research Fellow in Health Economics, School of Health and Related Research, University of Sheffield; M. Hernandez-Alava, PhD, Senior Research Fellow in Econometrics, School of Health and Related Research, University of Sheffield; L.A. Gibson, PhD, Research Associate in Econometrics, School of Health and Related Research, University of Sheffield; J.W. Stevens, PhD, Reader in Decision Science, School of Health and Related Research, University of Sheffield; R.J. Archer, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; E.L. Simpson, PhD, Research Fellow, School of Health and Related Research, University of Sheffield, E.S. Hock, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; A. Young, FRCP, Professor of Clinical Rheumatology, Centre for Lifespan and Chronic Illness Research, University of Hertfordshire; D.L. Scott, MD, FRCP, Professor of Clinical Rheumatology, Department of Rheumatology, King's College Hospital NHS Foundation Trust.
authors.forename: Laura A
authors.initials: LA
authors.lastname: Gibson
authors.affiliation: From the School of Health and Related Research, University of Sheffield, Sheffield; Department of Rheumatology, West Hertfordshire Hospitals National Health Service (NHS) Trust, Hertfordshire; Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK.|M.D. Stevenson, PhD, Professor of Health Technology Assessment, School of Health and Related Research, University of Sheffield; A.J. Wailoo, PhD, Professor of Health Economics, School of Health and Related Research, University of Sheffield; J.C. Tosh, PhD, Research Fellow in Health Economics, School of Health and Related Research, University of Sheffield; M. Hernandez-Alava, PhD, Senior Research Fellow in Econometrics, School of Health and Related Research, University of Sheffield; L.A. Gibson, PhD, Research Associate in Econometrics, School of Health and Related Research, University of Sheffield; J.W. Stevens, PhD, Reader in Decision Science, School of Health and Related Research, University of Sheffield; R.J. Archer, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; E.L. Simpson, PhD, Research Fellow, School of Health and Related Research, University of Sheffield, E.S. Hock, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; A. Young, FRCP, Professor of Clinical Rheumatology, Centre for Lifespan and Chronic Illness Research, University of Hertfordshire; D.L. Scott, MD, FRCP, Professor of Clinical Rheumatology, Department of Rheumatology, King's College Hospital NHS Foundation Trust.
authors.forename: John W
authors.initials: JW
authors.lastname: Stevens
authors.affiliation: From the School of Health and Related Research, University of Sheffield, Sheffield; Department of Rheumatology, West Hertfordshire Hospitals National Health Service (NHS) Trust, Hertfordshire; Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK.|M.D. Stevenson, PhD, Professor of Health Technology Assessment, School of Health and Related Research, University of Sheffield; A.J. Wailoo, PhD, Professor of Health Economics, School of Health and Related Research, University of Sheffield; J.C. Tosh, PhD, Research Fellow in Health Economics, School of Health and Related Research, University of Sheffield; M. Hernandez-Alava, PhD, Senior Research Fellow in Econometrics, School of Health and Related Research, University of Sheffield; L.A. Gibson, PhD, Research Associate in Econometrics, School of Health and Related Research, University of Sheffield; J.W. Stevens, PhD, Reader in Decision Science, School of Health and Related Research, University of Sheffield; R.J. Archer, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; E.L. Simpson, PhD, Research Fellow, School of Health and Related Research, University of Sheffield, E.S. Hock, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; A. Young, FRCP, Professor of Clinical Rheumatology, Centre for Lifespan and Chronic Illness Research, University of Hertfordshire; D.L. Scott, MD, FRCP, Professor of Clinical Rheumatology, Department of Rheumatology, King's College Hospital NHS Foundation Trust.
authors.forename: Rachel J
authors.initials: RJ
authors.lastname: Archer
authors.affiliation: From the School of Health and Related Research, University of Sheffield, Sheffield; Department of Rheumatology, West Hertfordshire Hospitals National Health Service (NHS) Trust, Hertfordshire; Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK.|M.D. Stevenson, PhD, Professor of Health Technology Assessment, School of Health and Related Research, University of Sheffield; A.J. Wailoo, PhD, Professor of Health Economics, School of Health and Related Research, University of Sheffield; J.C. Tosh, PhD, Research Fellow in Health Economics, School of Health and Related Research, University of Sheffield; M. Hernandez-Alava, PhD, Senior Research Fellow in Econometrics, School of Health and Related Research, University of Sheffield; L.A. Gibson, PhD, Research Associate in Econometrics, School of Health and Related Research, University of Sheffield; J.W. Stevens, PhD, Reader in Decision Science, School of Health and Related Research, University of Sheffield; R.J. Archer, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; E.L. Simpson, PhD, Research Fellow, School of Health and Related Research, University of Sheffield, E.S. Hock, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; A. Young, FRCP, Professor of Clinical Rheumatology, Centre for Lifespan and Chronic Illness Research, University of Hertfordshire; D.L. Scott, MD, FRCP, Professor of Clinical Rheumatology, Department of Rheumatology, King's College Hospital NHS Foundation Trust.
authors.forename: Emma L
authors.initials: EL
authors.lastname: Simpson
authors.affiliation: From the School of Health and Related Research, University of Sheffield, Sheffield; Department of Rheumatology, West Hertfordshire Hospitals National Health Service (NHS) Trust, Hertfordshire; Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK.|M.D. Stevenson, PhD, Professor of Health Technology Assessment, School of Health and Related Research, University of Sheffield; A.J. Wailoo, PhD, Professor of Health Economics, School of Health and Related Research, University of Sheffield; J.C. Tosh, PhD, Research Fellow in Health Economics, School of Health and Related Research, University of Sheffield; M. Hernandez-Alava, PhD, Senior Research Fellow in Econometrics, School of Health and Related Research, University of Sheffield; L.A. Gibson, PhD, Research Associate in Econometrics, School of Health and Related Research, University of Sheffield; J.W. Stevens, PhD, Reader in Decision Science, School of Health and Related Research, University of Sheffield; R.J. Archer, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; E.L. Simpson, PhD, Research Fellow, School of Health and Related Research, University of Sheffield, E.S. Hock, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; A. Young, FRCP, Professor of Clinical Rheumatology, Centre for Lifespan and Chronic Illness Research, University of Hertfordshire; D.L. Scott, MD, FRCP, Professor of Clinical Rheumatology, Department of Rheumatology, King's College Hospital NHS Foundation Trust.
authors.forename: Emma S
authors.initials: ES
authors.lastname: Hock
authors.affiliation: From the School of Health and Related Research, University of Sheffield, Sheffield; Department of Rheumatology, West Hertfordshire Hospitals National Health Service (NHS) Trust, Hertfordshire; Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK.|M.D. Stevenson, PhD, Professor of Health Technology Assessment, School of Health and Related Research, University of Sheffield; A.J. Wailoo, PhD, Professor of Health Economics, School of Health and Related Research, University of Sheffield; J.C. Tosh, PhD, Research Fellow in Health Economics, School of Health and Related Research, University of Sheffield; M. Hernandez-Alava, PhD, Senior Research Fellow in Econometrics, School of Health and Related Research, University of Sheffield; L.A. Gibson, PhD, Research Associate in Econometrics, School of Health and Related Research, University of Sheffield; J.W. Stevens, PhD, Reader in Decision Science, School of Health and Related Research, University of Sheffield; R.J. Archer, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; E.L. Simpson, PhD, Research Fellow, School of Health and Related Research, University of Sheffield, E.S. Hock, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; A. Young, FRCP, Professor of Clinical Rheumatology, Centre for Lifespan and Chronic Illness Research, University of Hertfordshire; D.L. Scott, MD, FRCP, Professor of Clinical Rheumatology, Department of Rheumatology, King's College Hospital NHS Foundation Trust.
authors.forename: Adam
authors.initials: A
authors.lastname: Young
authors.affiliation: From the School of Health and Related Research, University of Sheffield, Sheffield; Department of Rheumatology, West Hertfordshire Hospitals National Health Service (NHS) Trust, Hertfordshire; Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK.|M.D. Stevenson, PhD, Professor of Health Technology Assessment, School of Health and Related Research, University of Sheffield; A.J. Wailoo, PhD, Professor of Health Economics, School of Health and Related Research, University of Sheffield; J.C. Tosh, PhD, Research Fellow in Health Economics, School of Health and Related Research, University of Sheffield; M. Hernandez-Alava, PhD, Senior Research Fellow in Econometrics, School of Health and Related Research, University of Sheffield; L.A. Gibson, PhD, Research Associate in Econometrics, School of Health and Related Research, University of Sheffield; J.W. Stevens, PhD, Reader in Decision Science, School of Health and Related Research, University of Sheffield; R.J. Archer, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; E.L. Simpson, PhD, Research Fellow, School of Health and Related Research, University of Sheffield, E.S. Hock, PhD, Research Fellow, School of Health and Related Research, University of Sheffield; A. Young, FRCP, Professor of Clinical Rheumatology, Centre for Lifespan and Chronic Illness Research, University of Hertfordshire; D.L. Scott, MD, FRCP, Professor of Clinical Rheumatology, Department of Rheumatology, King's College Hospital NHS Foundation Trust.
authors.forename: David L
authors.initials: DL
authors.lastname: Scott
mesh_terms: D018501:Antirheumatic Agents / Q000191:economics* / Q000627:therapeutic use; D001172:Arthritis, Rheumatoid / Q000188:drug therapy* / Q000191:economics; D001688:Biological Products / Q000191:economics* / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D004739:England; D006801:Humans; D008727:Methotrexate / Q000191:economics* / Q000627:therapeutic use
chemical_list: D018501:Antirheumatic Agents; D001688:Biological Products; D008727:Methotrexate
keywords: ANTIRHEUMATIC AGENTS; COST-BENEFIT ANALYSIS; MEDICAL ECONOMICS; RHEUMATOID ARTHRITIS