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 (Winchester, England) England), 2018-04, Vol.22 (20), p.1-258
• Main Authors: Simpson, Emma, Hock, Emma, Stevenson, Matt, Wong, Ruth, Dracup, Naila, Wailoo, Allan, Conaghan, Philip, Estrach, Cristina, Edwards, Christopher, Wakefield, Richard
• Format: Article
• Language: English
• Subjects: Antirheumatic Agents - administration & dosage; Antirheumatic Agents - adverse effects; Antirheumatic Agents - therapeutic use; Arthritis, Rheumatoid - drug therapy; biologic treatment; Clinical Decision-Making; Cost-Benefit Analysis; cost-effectiveness analysis; Dose-Response Relationship, Drug; Drug Administration Schedule; Humans; Models, Econometric; Physical Examination; Quality of Life; Quality-Adjusted Life Years; rheumatoid arthritis; Synovitis - diagnostic imaging; Synovitis - drug therapy; systematic review; Technology Assessment, Biomedical; treatment decisions; Ultrasonography - economics; ultrasound joint examination
• ISSN: 1366-5278; 2046-4924
• DOI: 10.3310/hta22200

Synovitis (inflamed joint synovial lining) in rheumatoid arthritis (RA) can be assessed by clinical examination (CE) or ultrasound (US). To investigate the added value of US, compared with CE alone, in RA synovitis in terms of clinical effectiveness and cost-effectiveness. Electronic databases including MEDLINE, EMBASE and the Cochrane databases were searched from inception to October 2015. A systematic review sought RA studies that compared additional US with CE. Heterogeneity of the studies with regard to interventions, comparators and outcomes precluded meta-analyses. Systematic searches for studies of cost-effectiveness and US and treatment-tapering studies (not necessarily including US) were undertaken. A model was constructed that estimated, for patients in whom drug tapering was considered, the reduction in costs of disease-modifying anti-rheumatic 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. Furthermore, the reduction in the costs of DMARDs at which US becomes cost neutral was also estimated. For patients in whom dose escalation was being considered, the reduction in number of patients 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 number of patients escalating treatment for US to become cost neutral was also estimated. Fifty-eight studies were included. Two randomised controlled trials compared adding US to a Disease Activity Score (DAS)-based treat-to-target strategy for early RA patients. The addition of power Doppler ultrasound (PDUS) to a Disease Activity Score 28 joints-based treat-to-target strategy in the Targeting Synovitis in Early Rheumatoid Arthritis (TaSER) trial resulted in no significant between-group difference for change in Disease Activity Score 44 joints (DAS44). This study found that significantly more patients in the PDUS group attained DAS44 remission (  = 0.03). The Aiming for Remission in Rheumatoid Arthritis (ARCTIC) trial found that the addition of PDUS and grey-scale ultrasound (GSUS) to a DAS-based strategy did not produce a significant between-group difference in the primary end point: composite DAS of