LEDDEGIGT – - Sundhedsstyrelsen

heumatology specialist capacity in Denmark, with the ratio of specialists to
inhabitants ranging from 1:47,000 to 1:13,000. In areas where specialist coverage
is low, rheumatoid arthritis patients are largely dependent on treatment
by general practitioners. The differences in specialist capacity are also reflected
in the waiting time for both inpatient and outpatient treatment.
The general practitioners should offer patients with joint swelling a follow-up
control no later than six weeks after the first examination. If the
joint swelling persists, the patient should be referred to a specialist in
rheumatology on suspicion of rheumatoid arthritis.
Irrespective of what treatment the patient receives, it is important that
the treatment is conducted by multidisciplinary teams so as to ensure
optimal conditions for early diagnosis, treatment, care and rehabilitation.
Patients who are treated in the primary sector should be offered
relevant physiotherapy and occupational therapy, and should be ensured
easy access to evaluation for surgical treatment.
Economic factors
The additional cost to the Counties for the treatment of rheumatoid arthritis
patients relative to age-corrected control groups is calculated to be DKK 278
million. This is not an unequivocal estimate of the costs, however, among
other reasons because unequivocal identification of rheumatoid arthritis patients
via registers is not possible. Moreover, a number of important costs
cannot be calculated and incorporated, and the cost estimate must therefore
be considered as a minimum figure.
The TNF-alpha antagonists are presently considerably more expensive than
the traditional anti-rheumatic drugs. Even though the price is expected to fall
in step with the introduction of more biological drugs on the market, their
use will still entail considerable additional costs.
The additional costs of treatment with infliximab and etanercept,
which are usually administered in combination with methotrexate, are
calculated relative to the cost of treatment with methotrexate alone.
With infliximab administered in standard doses the costs amount to an
average of DKK 73,000 per patient the first year. With etanercept the
additional costs amount to DKK 110,300 per patient in the first year
and subsequent years. Concerning infliximab the treatment is dearer the
first year than the following due to the initial more frequent influsions.
The additional cost calculations do not take into account the expected
savings resulting from the less severe course of the disease.
Three possible treatment models
Three theoretical models have been established for future organization of
medical treatment of rheumatoid arthritis. In this connection, treatment
plans have been drawn up and the models have been characterized from the
medical, patient, organizational and economic perspectives.
Model A describes the treatment of rheumatoid arthritis solely by
means of the slowly-acting anti-rheumatic drugs. Referral practice and
diagnosis are assumed to remain unchanged. Model A is intended as
the baseline for comparison with models B and C. The model is no
longer a reality since the use of TNF-alpha antagonists has already been
initiated in Denmark, and they are presently estimated to be administered
to approximately 400 patients (May 2002).
Model B describes a course whereby the new drugs are offered to all newly
diagnosed patients as well as to other patients attended by rheumatologists
in whom the slowly-acting anti-rheumatic drugs are ineffective.
The model entails early referral and diagnosis.
Model C describes a course whereby the new drugs are not generally offered
until the slowly-acting anti-rheumatic drugs have not had an adequate
effect. This model also presumes early referral and diagnosis.
Based on current treatment standards it is expected that of rheumatoid arthritis
patients attended by rheumatologists, the slowly-acting anti-rheumatic
drugs will be ineffective in an estimated 10-20% of those with longstanding
disease and 10% of those who are diagnosed and treated after introduction of
early diagnosis.
Model A: slowly-acting anti-rheumatic drugs
Slowly-acting anti-rheumatic drugs only have an effect while treatment is
maintained, thus necessitating long-term treatment. With most of these
drugs (except methotrexate), few patients remain responsive and can tolerate
the treatment for more than 2 years. This necessitates frequent change of
medication and long periods with insufficient control of the disease due to
the slow onset of action of these anti-rheumatic drugs.
Due to the absence of TNF-alpha antagonists in this model, a group of unresponsive
patients (an estimated 10-20% of the population of rheumatoid
arthritis patients attended by rheumatologists) will not have access to a modern
treatment. Similarly, the treatment benefits of early referral and diagnosis
will be denied these patients. This model entails the lowest costs.
30 LEDDEGIGT – medicinsk teknologivurdering af diagnostik og behandling
LEDDEGIGT – medicinsk teknologivurdering af diagnostik og behandling 31