English Rheumatoid Arthritis care standards out of step with Europe

A 12-country comparative analysis of rheumatoid arthritis (RA) treatment guidelines reveals that there is considerable variation in patient access to care, with England out of step with standards adopted by its European counterparts.

The findings from a new research report by the Policy Analysis Centre/London School of Economics, released today at the start of the European League Against Rheumatism’s (EULAR) annual meeting, reveal the disparities between national guidelines when compared with those from EULAR.1

Representing one of the most in-depth analyses to compare variations in clinical guidelines for the treatment of RA, the research, commissioned and funded by MSD shows that, despite best practice guidelines by EULAR, restrictive guidelines in England are limiting access to biologic therapies for patients who need them, when compared with other countries.1

Biologic therapies such as anti-tumour necrosis factors (anti-TNFs) have the potential to not only control the inflammation of RA, but also to prevent or slow irreversible damage to the joints.2

The research shows that healthcare systems in Europe have created a variation in  patients' access to biologic therapies depending on which country they live in.  England is one of the most restrictive, with a high threshold for treatment eligibility with a biologic and that patients need to have failed to respond to two DMARDs (disease-modifying anti-rheumatic drugs).

Sweden is the most flexible, with guidelines offering specialists a significant degree of autonomy in their shared decision-making with individual patients.1

Tony Hockley, co-author of the report commented: 'Our study reveals no logic to explain the huge variations in treating this disease. The postcode lottery of care that confronts patients according to where they live has no clear basis in local economic considerations or in the local burden of disease. The potential to tackle rheumatoid arthritis and limit the burden of the disease is now well established, but the will to do so in some countries appears to be weak. Of the 12 countries studied, this lack of will is most evident in England, where access to modern, biologic therapies is heavily restricted until a patient’s burden of disease has become severe. Compared with other European countries this seems to be too little, too late.'     

In England, NICE restricts biologics to those only with severe RA (classified on the disease activity score, DAS-28, as 5.1 or greater) before treatment with biologics is initiated; this contrasts greatly with Sweden, Netherlands and Spain where a threshold of 3.2 is set – seen as more moderate disease levels, and in Slovenia where the threshold is 4.2.1

In England, NICE also stipulates that patients need to have received treatment with two rounds of standard disease-modifying anti-rheumatic drugs (DMARDs) before biologics are initiated, over a minimum period of six months.

This compares with Sweden where patients with high disease activity need only receive one round of standard DMARD prior to treatment with biologics being given; and France, Spain and The Netherlands where biologics can be initiated after three months’ treatment with standard DMARDs. 

As few as 6% of RA patients in England are on anti-TNF therapy; Spain, Sweden and the Netherlands in comparison have higher uptakes at 8%, 11% and 12%, respectively.3

In new patient research released alongside the report findings, of 471 UK patients with RA surveyed through the National Rheumatoid Arthritis Society (NRAS) less than half (43%) are completely satisfied with their care.4

Nearly one in five (17%) of patients felt national healthcare practices delayed their access to a rheumatologist, and just under a quarter (24%) felt current practices in the UK delayed their access to a biologic treatment.4

Ailsa Bosworth, CEO of National Rheumatoid Arthritis Society, said: 'We have known for some considerable time that we lag behind most of the rest of Europe when it comes to access to biologics. We also know that people with a DAS score falling between 3.2 and 5.1 do just as badly long term as those with a DAS of greater than 5.1 and these patients are expensive to the NHS when their disease is not well controlled. It’s false economy not to allow clinicians and patients to tackle uncontrolled disease in the most appropriate way and it is us patients and the NHS who are paying the price.'

Around 580,000 people in England have RA, with an estimated 26,000 new cases diagnosed each year.5 RA costs the NHS £560 million annually, with additional costs to the economy due to sickness absence from work and aspects of work-related disability estimated at £1.6 billion a year,5 although the National Rheumatoid Arthritis Society estimates that total costs could amount to nearly £8 billion a year.6   In the survey of NRAS’ members, more than a quarter (27%) said they had to stop working as a direct result of their RA, 11% changed from full to part-time, and 7% changed their occupation or type of work.4

Though regularly reviewed every three years, NICE has recently announced no changes will be made to their current guideline recommendations for RA for 2012.7 However, there is agreement and support by the British Society of Rheumatology  that treatment of RA with a biologic therapy should be started earlier, specifically in patients who fail to achieve DAS-28 of 3.2 or below with standard DMARDs.3

References:

1.     Costa-Font, J., Hockley, T.  A Common Disease with an Uncommon Treatment: European Guideline Variations and Access to Innovative Therapies for Rheumatoid Arthritis.  Policy Analysis Centre. May 2012. http://www.policy-centre.com/projects.html
2.     Breedveld, F.C., Combe, B. Understanding emerging treatment paradigms in rheumatoid arthritis. Arthritis Research & Therapy 2011, 13 (1):S3.
3.     Deighton, C., Hyrich, K., Ding, T. et al. BSR and BHPR rheumatoid arthritis guidelines on eligibility criteria for the first biological therapy. Rheumatology 2010; 49: 1197-99.
4.     Rheumatoid Arthritis Patient Experience Survey. May 2012. Merck data on file.  
5.     National Audit Office. Services for People with Rheumatoid Arthritis. Available from: http://www.nao.org.uk/publications/0809/services_for_people_with_rheum.aspx Accessed 16 May 2012
6.     National Rheumatoid Arthritis Society (NRAS). Economic Burden of RA Report, March 2010
7.     Rheumatoid Arthritis: the management of rheumatoid arthritis in adults, CG79. http://www.nice.org.uk/CG79
8.     National Rheumatoid Arthritis Society (NRAS). What is RA? Available at:. http://www.nras.org.uk/about_rheumatoid_arthritis/what_is_ra/what_is_ra.aspx  Accessed 17 May 2012.