Harnessing Decision Support Tools to Improve RA Treatment
Rheumatoid arthritis (RA) is a chronic autoimmune disease affecting approximately 1.5 million adults in the United States. This debilitating disease results in joint damage and causes disability and impairs quality of life with disease progression, and premature death. Furthermore, RA is a heterogeneous disease, and therefore, response to treatment is variable among patients. Given its complex presentation, RA presents a challenge for clinicians to manage and results in a substantial economic burden. Estimates place the annual health care expenditures at $128 billion in the United States.
The 2015 American College of Rheumatology (ACR) guidelines for RA recommend a treat-to-target strategy focused at achieving targets of low remission or low disease activity. Management of RA includes conventional and targeted synthetic disease-modifying antirheumatic drugs (DMARDs) and biologics that have multiple mechanisms of action (MOA).
Why Decision Support Tools Are Needed
Because the goal of therapy is to administer the appropriate therapy to the individual patient, decision support tools may aid health care providers with treatment sequencing in RA. First Report Managed Care spoke with stakeholders for their insights and experience with decision support tools.
“Decision support tools are needed in RA due to lack of guidelines (which drug is appropriate for which patient), lack of comparative clinical trials, and lack of objective measurable outcomes that providers can actually use in practice,” said Jeffrey Dunn, PharmD, MBA, chief clinical officer/senior vice president, VRx Pharmacy Services, noting that ACR guidelines, for example, are a clinical trial tool rather than a practice tool. “And importantly, due to the high cost of treatments, we need tools that can predict response and measure whether a drug is working; and if it isn’t, when and what should be done (ie, switch to a different MOA drug after 12 weeks).”
Bruce Feinberg, DO, vice president medical affairs, chief medical officer, Cardinal Health Specialty Solutions, explained that decision support tools are a very practical tool for addressing the challenges of treating RA.
“Real-time, up-to-date content, decision support tools represent an elegant methodology to aggregate and present the most relevant information on a given clinical scenario to the provider as the treatment intervention is considered,” Dr Feinberg, told First Report Managed Care.
However, its use in treatment sequencing in RA has had a slow uptake, which S Russell Spjut, PharmD, formulary management pharmacist, MagellanRx Management, said may be related to low availability or knowledge that the tools exist.
“Most of the cost of RA is due to the high cost of biologic drugs,” added Dr Dunn. “We don’t have good support tools to help determine if a drug is not working, and then what to switch to.”
Decision Support Tools for RA
Dr Spjut said he was aware of at least two or three studies in RA, and a number of studies in other disease states, that have shown many improvements in treatment when decision support tools are used, ranging from improved medical outcomes to improved prescriber and patient education to decreases in adverse effects experienced by the patient.
For example, a study of a clinical pathway for RA developed by Cardinal Health found that the treatment support tool was valuable at assessing and improving biologic-related costs and efficacy.
The Cardinal Health pathway requires patients with RA visit rheumatologists every 3 to 6 months to measure for clinical disease activity index scores. Patients cannot be started on a biologic therapy unless they received 3 months of nonbiologic DMARD treatment. Biologic utilization is relegated to indications and dosing within the package insert guideline; although, the pathway does not specify which biologics should be used. Additionally, the pathway does not require that patients with continued disease activity step up to a biologic therapy; however, patients must be in remission based on clinical disease activity index measurements in order to initiate, switch, or increase biologic therapy. The pathway also requires that nonhospital sites are used for administration of biologics.
The researchers concluded that the pathway is a “powerful model to assess and improve cost and effectiveness of treatment strategies for [RA].”
According to Dr Spjut, comparative effectiveness research (CER) is a decision support tool used in RA, but it poses challenges for stakeholders.