Curtis Jeffrey R, Chen Lang, Greenberg Jeffrey D, Harrold Leslie, Kilgore Meredith L, Kremer Joel M, Solomon Daniel H, Yun Huifeng
University of Alabama at Birmingham, Birmingham, AL, USA.
NYU School of Medicine, New York, NY.
Pharmacoepidemiol Drug Saf. 2017 Mar;26(3):310-319. doi: 10.1002/pds.4126. Epub 2016 Dec 28.
Treat to target guidelines recommend achieving remission or low disease activity in rheumatoid arthritis (RA). However, the reduction in adverse events and costs associated with lower disease activity is unclear.
We used Corrona linked to Medicare data to identify RA patients. Time varying disease activity was measured using Clinical Disease Activity Index (CDAI); outcomes included all-cause hospitalization, a composite of hospitalization or emergency department (ED) visits, mortality, and medical costs. Outcome-specific Cox proportional models evaluated the adjusted hazard ratios between disease activity and outcomes, controlling for potential confounders including comorbidities grouped into four patient phenotypes. Costs were analyzed with mixed models using a Gaussian distribution with log transformation.
Depending on outcome, 4593 RA patients contributed up to 12 001 person years. Median age was 71 years, 75% women. At baseline, approximately 50-60% of patients were in remission or low disease activity. There was a dose-response relationship between RA disease activity (remission, low, moderate, and high) and the incidence of hospitalizations (13.1, 17.8, 21.2, 27.5 per 100 py, respectively); all adjusted hazard ratios were significant: 0.68 (remission), 0.87 (low), and 1.24 (high) compared with moderate disease activity. Similar trends were observed for ED visits and mortality. The crude difference in annual medical costs between remission ($11 145) and moderate disease activity ($17 646) was $-6 500; the adjusted difference (95%CI) was $-3133 (-4737.72, -1528.43).
Leveraging the benefits of linking registry and administrative data together, lower disease activity in RA was associated with incrementally reduced risks of all-cause hospitalization, ED visits, mortality, and medical costs in a dose-dependent fashion. Copyright © 2016 John Wiley & Sons, Ltd.
治疗达标指南建议在类风湿关节炎（RA）中实现缓解或低疾病活动度。然而，与较低疾病活动度相关的不良事件减少和成本降低情况尚不清楚。
我们使用与医疗保险数据相关联的Corrona来识别RA患者。使用临床疾病活动指数（CDAI）测量随时间变化的疾病活动度；结局包括全因住院、住院或急诊就诊的综合情况、死亡率和医疗费用。特定结局的Cox比例模型评估疾病活动度与结局之间的调整后风险比，控制包括合并症在内的潜在混杂因素，合并症分为四种患者表型。使用高斯分布并进行对数转换的混合模型分析成本。
根据结局不同，4593例RA患者贡献了高达12001人年的数据。中位年龄为71岁，75%为女性。基线时，约50 - 60%的患者处于缓解或低疾病活动度。RA疾病活动度（缓解、低、中、高）与住院发生率之间存在剂量反应关系（分别为每100人年13.1、17.8、21.2、27.5次）；所有调整后风险比均具有统计学意义：与中度疾病活动度相比，缓解组为0.68，低疾病活动度组为0.87，高疾病活动度组为1.24。急诊就诊和死亡率也观察到类似趋势。缓解组（11145美元）和中度疾病活动度组（17646美元）的年度医疗费用粗略差值为 - 6500美元；调整后差值（95%CI）为 - 3133美元（ - 4737.72， - 1528.43）。
利用将登记数据和行政数据相结合的优势，RA中较低的疾病活动度与全因住院、急诊就诊、死亡率和医疗费用的风险以剂量依赖方式逐步降低相关。版权所有© 2016约翰威立父子有限公司。
