Effectiveness and Costs of TNF-Alpha Blocker Use for Patients with Rheumatoid Arthritis

Background: Rheumatoid arthritis (RA) is ranked among the highest of all chronic diseases in terms of its adverse impact on health-related quality of life, limitations in physical function, increased pain and fatigue, and diminished work performance and attendance compared with other debilitating chronic conditions. Objective: To compare healthcare expenditures, utilization, and productivity-related outcomes for patients with RA using tumor necrosis factor (TNF)-alpha blockers compared with patients with mild, moderate, or severe RA who are not using these medications. Design and Methods: Patients with RA were identified from the 1998-2007 Medical Expen-d-iture Panel Survey database, using International Classification of Diseases, Ninth Revision, Clinical Modification codes (714.xx); the patients were classified as (1) TNF-alpha blocker users, identified on the basis of pharmacy or intravenous therapy utilization, or (2) TNF-alpha blocker nonusers (but could be using other RA-related medications). Patients who were not using TNF-alpha blockers were subclassified as having mild, moderate, or severe RA; nonusers were not subclassified by disease severity. An algorithm was created for this study that combined and ranked 5 patient-reported health-related outcomes used to classify RA severity in the TNF-alpha blocker nonusers group. The main outcome measures included healthcare expenditures, medical service utilization, and work-related productivity for patients with RA. Results: A total of 1152 patients were included in this study. TNF-alpha blocker users (N = 65) were found to have lower odds of being unemployed compared with nonusers who had moderate (N = 159) or severe (N = 208) RA, using patients with mild RA as the reference group (N = 720; P <.01 for both comparisons). Only significant results were included in this study. There were no differences between patients with mild RA who were TNF-alpha blocker users versus nonusers with regard to all-cause emergency department visits, hospitalizations, and average length of hospital stay. The medical, prescription, and total healthcare costs were higher for TNF-alpha blocker users than for patients with mild RA who did not use these agents. Patients with moderate or severe RA who did not use TNF-alpha blockers also had higher incremental annual medical expenditures ($1088 and $1640, respectively) than nonusers with mild RA; these incremental cost differences were lower than the difference in users of TNF-alpha blockers ($2096). Conclusions: Based on this study, the use of TNF-alpha blocker treatment had a positive impact on employment status and was associated with fewer hospitalizations compared with other RA medications and compared with patients who did not use TNF-alpha blockers in patients with moderate or severe RA. The determination of RA severity may be biased, because it was based on patient self-reports and not on provider assessments; however, self-reporting is a common, validated method of assessing RA severity.