Is symptom duration before DMARD therapy a determinant of direct and indirect costs in DMARD-naive RA patients? A systematic review

Objective Early treatment of RA improves clinical outcomes; however, the impact on health economic outcomes is unclear. This review sought to investigate the relationship between symptom/disease duration and resource utilization/costs and the responsiveness of costs following RA diagnosis. Methods A systematic search was performed on Pubmed, EMBASE, CINAHL and Medline. Studies were eligible if patients were DMARD-naive and fulfilled 1987 ACR or 2010 ACR/EULAR RA classification criteria. Studies had to report symptom/disease duration and resource utilization or direct/indirect costs as health economic outcomes. The relationships between symptom/disease duration and costs were explored. Results Three hundred and fifty-seven records were identified in a systematic search; nine were eligible for analysis. The mean/median of symptom/disease duration in studies ranged between 25 days and 6 years. Annual direct costs of RA following diagnosis showed a U-shaped distribution in two studies. Longer symptom duration before starting a DMARD (>180 days) was associated with lower health-care utilization in the first year of RA diagnosis in one study. Annual direct and indirect costs 6 months before RA diagnosis were higher in patients with shorter symptom duration (<6 months) in one study. Given the clinical and methodological heterogeneities, the association between symptom/disease duration and costs after diagnosis was not computed. Conclusion The association between symptom/disease duration at the time of DMARD initiation and resource utilization/cost in patients with RA remains unclear. Health economic modelling with clearly defined symptom duration, resource utilization and long-term productivity is vital to address this evidence gap.Lay Summary What does this mean for patients? We studied the extent to which the cost of health care varies depending on how quickly patients with rheumatoid arthritis (RA) receive treatment after diagnosis. This is important to allow long-term financial planning within the health-care service. This is a systematic review study, which means we collect information from published papers that meet a set of criteria to see whether there is a clear pattern emerging across multiple papers. In this study, we selected papers that included patients with a diagnosis of RA and with no previous treatment for their RA. We then studied whether there is any clear link between the delay in starting treatment for RA and costs of treating RA. In two selected studies, the costs of RA treatment (e.g. medication costs, consultation costs) showed a U-shaped distribution; that means costs were high in the initial years after starting treatment, then dropped before subsequently rising again. It was not possible to assess further whether there is a clear link between the delay in starting treatment for RA and costs of treating RA, because each study used different criteria to assess treatment delay and costs of treatment. Therefore, this study highlights that there is a need for further economic modelling studies in RA.