Treatment of very early rheumatoid arthritis with symptomatic therapy, disease-modifying antirheumatic drugs, or biologic agents: a cost-effectiveness analysis.

BACKGROUND: Long-term control or remission of rheumatoid arthritis (RA) may be possible with very early treatment. However, no optimal first therapeutic strategy has been determined. OBJECTIVE: To assess the potential cost-effectiveness of major therapeutic strategies for very early RA. DESIGN: Decision analytic model with probabilistic sensitivity analyses. DATA SOURCES: Published data, the National Data Bank for Rheumatic Diseases, and actual 2007 hospital costs. TARGET POPULATION: U.S. adults with very early RA (symptom duration

Efficacy of systemic treatments for moderate to severe plaque psoriasis: systematic review and meta-analysis.

AIMS: To compare the efficacy of psoriasis treatments through a systematic literature review and meta-analysis. METHODS: Randomized controlled trials evaluating the Psoriasis Area and Severity Index (PASI) were identified and assessed for quality. PASI responses were modeled using a mixed-treatment comparison, which enabled the estimation of the relative effectiveness of several treatments. Sensitivity analyses were performed. RESULTS: Twenty-two trials were included. Tumor necrosis factor (TNF) inhibitors were most likely to achieve PASI 75, with a mean relative risk (RR) of 15.57 (95% CI 12.46-19.25) versus mean RRs of 9.24 (95% CI 5.33-13.91) for systemic and 5.65 (95% CI 3.74-7.97) for T-cell therapies. Infliximab (81%) and adalimumab (71%) had greater probabilities of achieving PASI 75 than etanercept (50%). Dosage was an important determinant of outcome. CONCLUSIONS: TNF inhibitors were more effective than T cell agents; adalimumab and infliximab were more effective than systemic therapies and etanercept. Evidence-based comparisons support patient and physician decisions.

The effect of direct-to-consumer genetic tests on anticipated affect and health-seeking behaviors: a pilot survey.

PURPOSE: Numerous websites offer direct-to-consumer (DTC) genetic testing, yet it is unknown how individuals will react to genetic risk profiles online. The objective of this study was to determine the feasibility of using a web-based survey and conjoint methods to elicit individuals' interpretations of genetic risk profiles by their anticipated worry/anxiousness and health-seeking behaviors. METHODS: A web-based survey was developed using conjoint methods. Each survey presented 12 hypothetical genetic risk profiles describing genetic test results for four diseases. Test results were characterized by the type of disease (eight diseases), individual risk (five levels), and research confidence (three levels). After each profile, four questions were asked regarding anticipated worry and health-seeking behaviors. Probabilities of response outcomes based on attribute levels were estimated from logistic regression models, adjusting for covariates. RESULTS: Overall, 319 participants (69%) completed 3828 unique genetic risk profiles. Across all profiles, most participants anticipated making doctor's appointments (63%), lifestyle changes (57%), and accessing screening (57%); 40% anticipated feeling more worried and anxious. Higher levels of disease risk were significantly associated with affirmative responses. CONCLUSION: Conjoint methods may be used to elicit reactions to genetic information online. Preliminary results suggest that genetic information may increase worry/anxiousness and health-seeking behaviors among consumers of DTC tests. Further research is planned to determine the appropriateness of these affects and behaviors.

Economic evaluation of biologic therapies for the treatment of moderate to severe psoriasis in the United States.

BACKGROUND: New biologic therapies are available for moderate to severe psoriasis. OBJECTIVE: To determine the most cost-effective sequence of biologic treatments. METHODS: Through modeling of the clinical pathway of biologic agents, adalimumab, alefacept, efalizumab, etanercept, and infliximab, the costs and benefits (quality-adjusted life-years [QALYs]) were determined. A decision rule determined the optimal treatment sequence comparing costs and QALYs. RESULTS: While infliximab was found to provide the most incremental QALY and etanercept was found to be the least costly, on balance, the incremental cost-effectiveness ratio of adalimumab was the most favorable (ICER = $544/QALY). Consequently, the optimal sequence would begin with adalimumab and be followed by etanercept, infliximab, efalizumab, and alefacept, respectively. The limitations of this study are that evidence was based on indirect comparisons of biologic effectiveness, and toxicities were not included in the model. CONCLUSIONS: In consideration of cost-effectiveness in prescribing biologics for moderate to severe psoriasis, the optimal sequence would begin with adalimumab.