Cost-Effectiveness of Tight Control for Crohn’s Disease With Adalimumab-Based Treatment: Economic Evaluation of the CALM Trial From a Canadian Perspective

Abstract

Crohn’s disease (CD) is associated with reduced quality of life, increased absenteeism and high direct medical costs resulting from frequent hospitalizations and surgeries. Tumor necrosis factor–alpha inhibitors (TNFi’s) have transformed the therapeutic landscape and enabled a shift from a symptom control to a treat-to-target strategy. The Effect of Tight Control Management on Crohn’s Disease (CALM) trial demonstrated tight control (TC), with TNFi dose changes informed by biochemical markers of inflammation, achieved higher mucosal healing rates compared with conventional management (CM) based on symptoms. A Markov model compared TC and CM strategies from the perspective of the Canadian public payer using patient-observation data from the CALM trial. A regression model estimated weekly CD Activity Index–based transition matrices over a 5-year horizon and included covariates to improve extrapolation of outcomes beyond the 48-week trial assessment period. Costs of CD-related hospitalizations, biomarker tests and adalimumab injections were sourced from public data. Other direct medical costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated. Absenteeism was monetized and included in a sensitivity analysis. Over the 5-year time horizon, TC reduced hospitalization costs by 64% compared with CM. Other direct medical costs were reduced by 22%; adalimumab costs increased by 38%, generating an ICER of $35,168 per QALY gained. Absenteeism costs were reduced by 54%, and, when that was included in the model, TC became dominant compared with CM. Management of CD with TC is cost-effective compared with CM in Canada and is dominant if indirect costs associated with absenteeism are included. Trial registration number: NCT01235689.

Treat‐to‐target and sequencing therapies in Crohn's disease

“…However, there are some data showing its costeffectiveness. 9 Additionally, as shown in the STARDUST trial, the treat-to-target strategy may not be appropriate for all patients. The Selecting Therapeutic Targets in Inflammatory Bowel Disease Endpoints (STRIDE) consortium has provided consensus on the various goals or targets when developing a treatment and monitoring strategy with the patient.…”

“…However, there are some data showing its cost‐effectiveness. 9 Additionally, as shown in the STARDUST trial, the treat‐to‐target strategy may not be appropriate for all patients.…”

“…Taken together, this should also reduce health-related costs and burden on the health system. 9 Multiple studies have investigated whether a treat-to-target strategy can achieve improved outcomes when compared with routine clinical management. One of the first studies introducing this concept in CD was a retrospective study by Bouguen et al In this study, the authors investigated whether adjusting therapy based on the presence of endoscopic lesions resulted in higher rates of endoscopic healing, defined as no ulcerations.…”

“…It is thought that using a proactive treatment and monitoring strategy will increase the likelihood of achieving disease control, endoscopic healing, and disease‐related complications. Taken together, this should also reduce health‐related costs and burden on the health system 9 …”

“…The possible limitations of the treat‐to‐target strategy include that it can be labor intensive and costly in terms of the repeated testing and the time patients need to invest in the treatment and monitoring plans. However, there are some data showing its cost‐effectiveness 9 . Additionally, as shown in the STARDUST trial, the treat‐to‐target strategy may not be appropriate for all patients.…”