• Nick Bansback, Ciaran S Phibbs, Huiying Sun, James R O'Dell, Mary Brophy, Edward C Keystone, Sarah Leatherman, Ted R Mikuls, Aslam H Anis, and CSP 551 RACAT Investigators.
• From University of British Columbia and St Paul's Hospital, Vancouver, British Columbia, Canada; Palo Alto Veterans Affairs (VA) Health Care System, Palo Alto, and Stanford University School of Medicine, Stanford, California; VA Nebraska-Western Iowa Health Care Center and University of Nebraska Medical Center, Omaha, Nebraska; Boston University School of Medicine, Boston, Massachusetts; and University of Toronto and Mount Sinai Hospital, Toronto, Ontario, Canada.
• Ann. Intern. Med. 2017 Jul 4; 167 (1): 8-16.

BackgroundThe RACAT (Rheumatoid Arthritis Comparison of Active Therapies) trial found triple therapy to be noninferior to etanercept-methotrexate in patients with active rheumatoid arthritis (RA).ObjectiveTo determine the cost-effectiveness of etanercept-methotrexate versus triple therapy as a first-line strategy.DesignA within-trial analysis based on the 353 participants in the RACAT trial and a lifetime analysis that extrapolated costs and outcomes by using a decision analytic cohort model.Data SourcesThe RACAT trial and sources from the literature.Target PopulationPatients with active RA despite at least 12 weeks of methotrexate therapy.Time Horizon24 weeks and lifetime.PerspectiveSocietal and Medicare.InterventionEtanercept-methotrexate first versus triple therapy first.Outcome MeasuresIncremental costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs).Results Of Base Case AnalysisThe within-trial analysis found that etanercept-methotrexate as first-line therapy provided marginally more QALYs but accumulated substantially higher drug costs. Differences in other costs between strategies were negligible. The ICERs for first-line etanercept-methotrexate and triple therapy were $2.7 million per QALY and $0.98 million per QALY over 24 and 48 weeks, respectively. The lifetime analysis suggested that first-line etanercept-methotrexate would result in 0.15 additional lifetime QALY, but this gain would cost an incremental $77 290, leading to an ICER of $521 520 per QALY per patient.Results Of Sensitivity AnalysisConsidering a long-term perspective, an initial strategy of etanercept-methotrexate and biologics with similar cost and efficacy is unlikely to be cost-effective compared with using triple therapy first, even under optimistic assumptions.LimitationData on the long-term benefit of triple therapy are uncertain.ConclusionInitiating biologic therapy without trying triple therapy first increases costs while providing minimal incremental benefit.Primary Funding SourceThe Cooperative Studies Program, Department of Veterans Affairs Office of Research and Development, Canadian Institutes for Health Research, and an interagency agreement with the National Institutes of Health-American Recovery and Reinvestment Act.

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