Costs and Utilization of Treat-to-Target Guideline Compliance in VA Patients with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by inflammation of synovial tissues that leads to joint pain, swelling, stiffness, and progressive joint destruction. There is no cure for RA, so treatment tactics often concentrate on managing symptoms. If RA is left untreated, the major adverse consequences such as joint damage, physical disability and premature mortality could occur. In 2010, guidelines of treating RA to target were developed for achieving optimal therapeutic outcomes of clinical remission or low disease activity (LDA) in patients with RA. The treat-to-target (T2T) guidelines recommend frequent disease monitoring by physicians. Little has been studied on the economic implications and healthcare utilization of treating RA to target. Veterans using the US Department of Veterans Affairs (VA) healthcare systems have a high prevalence of rheumatoid arthritis and tend to use most of their healthcare within the VA. Therefore, it was a population to examine these questions. This study evaluated how costs and utilization differ among the VA patients with RA treated in compliance with T2T guidelines regarding patient follow-up and those who were not. The study also examined the prevalence of the VA patients with RA, patients’ descriptive statistics and health status. The study design was a retrospective study using Veterans Health Administration (VHA) data from 2004 to 2010. RA diagnosis was identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Code 714.xx. A total of 4,577 patients who were >= 18 and < 65 years of age were identified with 962 (21.02%) being selected as compliant and 3,615 (78.98%) non-compliant. The average age was 53.9 and 84.82% were male. Multivariable generalized linear models (GLMs) were used to compare medical service costs and utilization. Within the year between 3 months and 15 months after the first DMARD was prescribed, the total study population, the compliant and non-compliant groups spent the average inpatient admission utilization of 0.26±0.01, 0.20±0.02 and 0.28±0.02 visits respectively, and the average outpatient utilization of 8.39±0.20, 8.86±0.33 and 8.18±0.23 visits respectively. The compliant cohort spent statistically significant 0.09 less inpatient admissions (P value < 0.05) and 1.76 more outpatient counts than the non-compliant cohort (P value < 0.05). The one-year average total medical service costs of these three groups were $17,848.43±426.49, $16,727.25±763.09 and $18,154.13±475.98 respectively, the average inpatient costs $4,667.7±403.29, $3,760.92±585.38, $4,912.78±482.48 respectively, the average outpatient costs (not including outpatient pharmacy costs) $10,525.23±165.78, $9,849.19±335.87, and $10,708.44±192.44 respectively, and the outpatient pharmacy costs $2,833.92±68.36, $2,708.64±136.77, and $2,869.15±80.44 respectively. There was no significant difference in the average total medical service costs, the average inpatient costs and the average outpatient pharmacy costs between the compliant and non-compliant cohorts (P value > 0.05). However, the compliant cohort spent statistically significant $880 less outpatient medical service costs than the non-compliant cohort (P value < 0.05).