What is the added value of ultrasound joint examination for monitoring synovitis in rheumatoid arthritis and can it be used to guide treatment decisions? A systematic review and cost-effectiveness analysis

• Published in: Health Technology Assessment
• Main Authors: Simpson, E.L., Hock, E.S., Stevenson, M.D., Wong, R., Dracup, N., Wailoo, A., Conaghan, P.G., Estrach, C., Edwards, C.J., Wakefield, R.J.
• Other Authors: NIHR journals
• Format: Article in Journal/Newspaper
• Language: English
• Published: NIHR Health Technology Assessment Programme 2018
• Subjects: Arctic
• Online Access: https://eprints.whiterose.ac.uk/120676/; https://eprints.whiterose.ac.uk/120676/10/3013793.pdf; https://doi.org/10.3310/hta22200

Background Synovitis (inflamed joint synovial lining), in rheumatoid arthritis (RA) can be assessed by clinical examination (CE) or ultrasound (US). Objective To investigate the added value of US, compared to CE alone, in RA synovitis, to clinical and cost-effectiveness. Data sources Electronic databases, inception-October 2015, including MEDLINE, EMBASE and Cochrane Databases. Review methods A systematic review sought RA studies, comparing additional US with CE. Heterogeneity in intervention, comparators and outcomes precluded meta-analyses. Systematic searches of costeffectiveness and US, and treatment-tapering studies (not necessarily including US) were undertaken. Mathematical model A model was constructed that estimated, for patients in whom drug tapering was considered, the reduction in costs of disease modifying drugs (DMARDs) and serious infections, at which the addition of US had a cost per quality adjusted life year (QALY) gained of £20,000 and £30,000. Further, the reduction in the costs of DMARDs at which US become cost-neutral was also estimated. For patients in whom dose escalation was being considered, the reduction in patients not escalating treatment and in serious infections at which the addition of US had a cost per QALY gained of £20,000 and £30,000 was estimated. The reduction in patients escalating treatment for US to become cost-neutral was also estimated. Results Fifty-eight studies were included. Two RCTs compared adding US to a DAS-based treat-to-target strategy for early RA patients. The addition of PDUS to DAS28 based treat-to-target strategy in TaSER reported no significant between group difference for change in DAS44. This study found the PDUS group had significantly more patients attaining DAS44 remission (p=0.03). ARCTIC found the addition of PDUS and GSUS to a DAS based strategy did not produce a significant between group difference in the primary endpoint: composite DAS<1.6, no swollen joints, and no progression in van der Heijde-modified total Sharp Score (vdHSS). ARCTIC did ...