Suter Lisa G, Fraenkel Liana, Braithwaite R Scott
Section of Rheumatology, Department of Internal Medicine, Yale University School of Medicine, 300 Cedar St, Room TAC S541, PO Box 208031, New Haven, CT 06520-8031, USA.
Arch Intern Med. 2011 Apr 11;171(7):657-67. doi: 10.1001/archinternmed.2011.115.
Early, aggressive treatment of rheumatoid arthritis (RA) improves outcomes but confers increased risk. Risk stratification to target aggressive treatment of high-risk individuals with early RA is considered important to optimize outcomes while minimizing clinical and monetary costs. Some advocate the addition of magnetic resonance imaging (MRI) to standard RA risk stratification with clinical markers for patients early in the disease course. Our objective was to determine the incremental cost-effectiveness of adding MRI to standard risk stratification in early RA.
Using a decision analysis model of standard risk stratification with or without MRI, followed by escalated standard treatment protocols based on treatment response, we estimated 1-year and lifetime quality-adjusted life-years, RA-related costs, and incremental cost-effectiveness ratios (with MRI vs without MRI) for RA patients with fewer than 12 months of disease and no baseline radiographic erosions. Inputs were derived from the published literature. We assumed a societal perspective with 3.0% discounting.
One-year and lifetime incremental cost-effectiveness ratios for adding MRI to standard testing were $204,103 and $167,783 per quality-adjusted life-year gained, respectively. In 1-way sensitivity analyses, model results were insensitive to plausible ranges for every variable except MRI specificity, which published data suggest is below the threshold for MRI cost-effectiveness. In probabilistic sensitivity analyses, most simulations produced lifetime incremental cost-effectiveness ratios in excess of $100,000 per quality-adjusted life-year gained, a commonly cited threshold.
Under plausible clinical conditions, adding MRI is not cost-effective compared with standard risk stratification in early-RA patients.
类风湿关节炎（RA）的早期积极治疗可改善预后，但会增加风险。对早期RA高危个体进行风险分层以针对性地进行积极治疗，被认为对于优化预后同时将临床和经济成本降至最低很重要。一些人主张在疾病早期阶段，将磁共振成像（MRI）添加到基于临床指标的标准RA风险分层中。我们的目标是确定在早期RA中，将MRI添加到标准风险分层中的增量成本效益。
使用有或没有MRI的标准风险分层决策分析模型，随后根据治疗反应采用逐步升级的标准治疗方案，我们估算了病程少于12个月且无基线放射学侵蚀的RA患者的1年和终生质量调整生命年、RA相关成本以及增量成本效益比（有MRI与无MRI相比）。数据来源于已发表的文献。我们采用社会视角，贴现率为3.0%。
将MRI添加到标准检测中的1年和终生增量成本效益比分别为每获得一个质量调整生命年204,103美元和167,783美元。在单因素敏感性分析中，模型结果对除MRI特异性外的每个变量的合理范围均不敏感，已发表的数据表明MRI特异性低于MRI成本效益的阈值。在概率敏感性分析中，大多数模拟得出的终生增量成本效益比超过每获得一个质量调整生命年100,000美元，这是一个常用的阈值。
在合理的临床条件下，与早期RA患者的标准风险分层相比，添加MRI不具有成本效益。
