Exploring the impact of the national tender system on the use of costly drugs treating rheumatoid arthritis patients in ten rheumatology centers in Norway (2010-2019)

BACKGROUND

Biologic and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) are highly effective in treating rheumatoid arthritis (RA), albeit high drug cost has restricted their use in many countries. As a countermeasure, Norway implemented pharmaceutical tendering as a cost-reducing strategy. The aim of this study was to assess the annual proportion of different b/tsDMARDs registered to treat RA patients under the influence of a Norwegian pharmaceutical tendering between 2010 and 2019.

METHOD

The data is collected from ten Norwegian outpatient centers. The included patients are categorized as naïve, non-naïve, and current b/tsDMARD users. 13 individual b/tsDMARDs are assessed and compared with the tender rankings from each year. Overview of subcutaneous (sc) with per oral vs. intravenous (iv) and biosimilars vs. non-biosimilar are also described.

RESULT

The tender-winning b/tsDMARD was the most or second most used drug in nine out of ten years for naïve users, seven for non-naïve users, and twice for current users. The average sum of the highest and second highest proportion among naïve, non-naïve, and current b/tsDMARD users were 75%, 53%, and 50% during the ten years, respectively. The tender-winning drug was iv in eight out of ten years. However, the average total proportion of sc and per oral b/tsDMARDs was about 70% for naïve b/tsDMARD users, 50% for non-naïve b/tsDMARD users, and 60% for current b/tsDMARD users. The main contributors to sc and per oral b/tsDMARD were etanercept (reference and biosimilar) and certolizumab pegol. The main contributors to iv b/tsDMARD were rituximab reference and infliximab biosimilar. Despite low-ranking offers, rituximab reference (offered as a second-line drug) often achieved a high proportion among non-naïve and current b/tsDMARD users. After the introduction of biosimilars, their average proportion was about 40%, 40%, and 20% for naïve, non-naïve, and current b/tsDMARD users, respectively.

CONCLUSION

Based on observed data, a higher tender rank was associated with a higher proportion among naïve and non-naïve b/tsDMARD users. However, in most cases, sc b/tsDMARDs achieved a higher proportion with lower tender ranks than iv b/tsDMARDs with higher tender ranks.

Antibiotic hyper-resistance in a class I aminoacyl-tRNA synthetase with altered active site signature motif

Antibiotics target key biological processes that include protein synthesis. Bacteria respond by developing resistance, which increases rapidly due to antibiotics overuse. Mupirocin, a clinically used natural antibiotic, inhibits isoleucyl-tRNA synthetase (IleRS), an enzyme that links isoleucine to its tRNAIle for protein synthesis. Two IleRSs, mupirocin-sensitive IleRS1 and resistant IleRS2, coexist in bacteria. The latter may also be found in resistant Staphylococcus aureus clinical isolates. Here, we describe the structural basis of mupirocin resistance and unravel a mechanism of hyper-resistance evolved by some IleRS2 proteins. We surprisingly find that an up to 103-fold increase in resistance originates from alteration of the HIGH motif, a signature motif of the class I aminoacyl-tRNA synthetases to which IleRSs belong. The structural analysis demonstrates how an altered HIGH motif could be adopted in IleRS2 but not IleRS1, providing insight into an elegant mechanism for coevolution of the key catalytic motif and associated antibiotic resistance.

Long-term temporal trends in incidence rate and case fatality of sepsis and COVID-19-related sepsis in Norwegian hospitals, 2008-2021: a nationwide registry study

OBJECTIVES

To estimate temporal trends in incidence rate (IR) and case fatality during a 14-year period from 2008 to 2021, and to assess possible shifts in these trends during the COVID-19 pandemic.

SETTING

All Norwegian hospitals 2008-2021.

PARTICIPANTS

317 705 patients ≥18 year with a sepsis International Classification of Diseases 10th revision code retrieved from The Norwegian Patient Registry.

PRIMARY AND SECONDARY MEASURES

Annual age-standardised IRs with 95% CIs. Poisson regression was used to estimate changes in IRs across time, and logistic regression was used to estimate ORs for in-hospital death.

RESULTS

Among 12 619 803 adult hospitalisations, a total of 317 705 (2.5%) hospitalisations in 222 832 (70.0%) unique patients met the sepsis criteria. The overall age-standardised IR of a first sepsis admission was 246/100 000 (95% CI 245 to 247), whereas the age-standardised IR of all sepsis admissions was 352/100 000 (95% CI 351 to 354). In the period 2009-2019, the annual IR for a first sepsis episode was stable (IR ratio (IRR) per year, 0.999; 95% CI 0.994 to 1.004), whereas for recurrent sepsis the IR increased (annual IRR, 1.048; 95% CI 1.037 to 1.059). During the COVID-19 pandemic, the IRR for a first sepsis was 0.877 (95% CI 0.829 to 0.927) in 2020 and 0.929 (95% CI 0.870 to 0.992) in 2021, and for all sepsis it was 0.870 (95% CI 0.810 to 0.935) in 2020 and 0.908 (95% CI 0.840 to 0.980) in 2021, compared with the previous 11-year period. Case fatality among first sepsis admissions declined in the period 2009-2019 (annual OR 0.954 (95% CI 0.950 to 0.958)), whereas case fatality increased during the COVID-19 pandemic in 2020 (OR 1.061 (95% CI 1.001 to 1.124) and in 2021 (OR 1.164 (95% CI 1.098 to 1.233)).

CONCLUSION

The overall IR of sepsis increased from 2009 to 2019, due to an increasing IR of recurrent sepsis, and indicates that sepsis awareness with updated guidelines and education must continue.

Remission or Not Remission, That's the Question: Shedding Light on Remission and the Impact of Objective and Subjective Measures Reflecting Disease Activity in Rheumatoid Arthritis

Introduction

The inclusion of certain variables in remission formulas for rheumatoid arthritis (RA) may give rise to discrepancies. An increase in patient global assessment (PGA), a variable showing the patient's self-evaluation of their disease activity, may alone tilt a patient out of remission when using certain remission-assessing methods. This study aimed to explore differences in remission rates among various formulas and the impact of PGA and other clinical variables on the calculation of remission.

Methods

Data were collected from RA patients monitored during the years 2015–2019 at an outpatient clinic in southern Norway. Linear and logistic regression assessed associations between PGA, other RA-related variables, and remission-assessing methods.

Results

Remission rates were 23%, 65%, and 73% in 2019 when assessing the same 502 RA patients using Boolean remission, Boolean remission without PGA, and the disease activity score (DAS) with C-reactive peptide [DAS28(3)-CRP] method, respectively. Among the same population that year, 27% reported PGA ≤ 10, 74% had a tender joint count of ≤ 1, 85% had a swollen joint count of ≤ 1, and 86% had CRP ≤ 10. Pain (standardized coefficient β = 0.7, p < 0.001) was most strongly associated with PGA. Pain, fatigue, and morning stiffness were substantially associated with the remission-assessing methods that incorporated PGA.

Conclusions

Since PGA is strongly associated with the patient’s perception of pain and may not reflect the inflammatory process, our study challenges the application of remission-assessing methods containing PGA when monitoring RA patients in the outpatient clinic. We recommend using measures that are less likely to be associated with noninflammatory pain and psychosocial factors.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-022-00490-5.

POS0108 REMISSION OR NOT REMISSION? THAT’S THE QUESTION, BUT WHAT’S THE ANSWER? - ILLUMINATING ON REMISSION IN ORDINARY OUTPATIENT CLINICAL RHEUMATOID ARTHRITIS PATIENTS

Background

A recent meta-analysis by Ferreira et al. (2020) has questioned the validity of using Patient Global Assessment (PGA) to define remission in the Boolean remission criteria (4-variable remission, 4vR) [1]. This is because PGA, which presumptively reflects a patient’s perception of disease activity, is influenced by both inflammatory and non-inflammatory mechanisms, thus questioning the validity of PGA-related remission definitions when treating patients to target using anti-inflammatory drugs. Further, the impact of PGA differs in the various definitions and algorithms developed to define remission in rheumatoid arthritis (RA).

Objectives

This study aims to examine remission rates by applying different definitions of remission in an outpatient cohort of RA patients and illuminate the impact of PGA on Boolean remission.

Methods

Data were obtained during 2019 from RA patients followed at an outpatient clinic in Southern Norway. The composite disease activity scores simple disease activity index (SDAI), clinical disease activity index (CDAI), and disease activity score with 28 joint count with C-reactive peptide (DAS28(3) and with PGA DAS28(4)), as well as Boolean 4vR and without PGA the 3-variable remission (3vR) were used to define remission. Cut-off remission values for CDAI, SDAI, and DAS28 are ≤2.8, ≤3.2, and ≤2.6, respectively. 4vR is attained when PGA ≤10, C-reactive peptide (CRP) ≤10 mg/L, SJC28 ≤1, and TJC28 ≤1, while 3vR when CRP ≤10 mg/L, TJC28 and SJC28 ≤1 [2]. Remission rates for 4vR were also calculated with the PGA cut-offs of ≤20, 30, 40, 50, 60, 70, 80, 90.

Results

In Figure 1, proportion rates of remission for DAS28(3), DAS28(4), CDAI, SDAI, 3vR, and 4vR with different PGA cut-offs are presented. The proportion of remission were 73% for DAS28(3), 67% for DAS28(4), 37% for CDAI, 38% for SDAI, 23% for 4vR, 65% for 3vR. When comparing the different remissions proportion rate with various cut-offs of PGA in 4vR, SDAI and CDAI lie between a cut-off of ≤20 and ≤30, while DAS28(3), DAS28(4), and 3vR all lies beyond a cut-off of ≤90.

Figure 1.

Remission rates using different definitions of remission in an outpatient cohort of 502 rheumatoid arthritis patients

Conclusion

Our data highlights that there is a great variation in remission rates for the different remission definitions, with DAS28(3) having the highest (73%) and the original Boolean remission the lowest (23%) remission rate. While RA patients in DAS28 remission may still have swollen joints, RA patients with no swollen and tender joints and normal CRP may not achieve Boolean remission because of even a minor elevation of PGA above ten, which may not only reflect inflammatory mechanisms. We question the value of using remission definitions where PGA has a large impact when used in ordinary clinical practice to treat patients to remission. Further studies are warranted to illuminate which remission definitions should be used both in studies and in ordinary clinical practice when treating patients with anti-inflammatory drugs.

Is it time for a paradigm shift to focus more on objective than subjective measures reflecting disease status and disease activity when aiming for remission daily clinical practice?

References

[1]Ferreira RJO, Welsing PMJ, Jacobs JWG, Gossec L, Ndosi M, Machado PM, et al. Revisiting the use of remission criteria for rheumatoid arthritis by excluding patient global assessment: an individual meta-analysis of 5792 patients. Ann Rheum Dis. 2020.

[2]Felson DT, Smolen JS, Wells G, Zhang B, van Tuyl LH, Funovits J, et al. American College of Rheumatology/European League Against Rheumatism provisional definition of remission in rheumatoid arthritis for clinical trials. Arthritis Rheum. 2011;63(3):573-86.

Acknowledgements

To all patients, nurses, and doctors who contributed to the data collection

Disclosure of Interests

None declared

Exploring drug cost and disease outcome in rheumatoid arthritis patients treated with biologic and targeted synthetic DMARDs in Norway in 2010-2019 - a country with a national tender system for prescription of costly drugs

Background

In Norway, an annual tender system for the prescription of biologic and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) has been used since 2007. This study aimed to explore annual b/tsDMARDs costs and disease outcomes in Norwegian rheumatoid arthritis (RA) patients between 2010 and 2019 under the influence of the tender system.

Methods

RA patients monitored in ordinary clinical practice were recruited from 10 Norwegian centers. Data files from each center for each year were collected to explore demographics, disease outcomes, and the prescribed treatment. The cost of b/tsDMARDs was calculated based on the drug price given in the annual tender process.

Results

The number of registered RA patients increased from 4909 in 2010 to 9335 in 2019. The percentage of patients receiving a b/tsDMARD was 39% in 2010 and 45% in 2019. The proportion of b/tsDMARDs treated patients achieving DAS28 remission increased from 42 to 67%. The estimated mean annual cost to treat a patient on b/tsDMARDs fell by 47%, from 13.1 thousand euros (EUR) in 2010 to 6.9 thousand EUR in 2019. The mean annual cost to treat b/tsDMARDs naïve patients was reduced by 75% (13.0 thousand EUR in 2010 and 3.2 thousand EUR in 2019).

Conclusions

In the period 2010–2019, b/tsDMARD treatment costs for Norwegian RA patients were significantly reduced, whereas DAS28 remission rates increased. Our data may indicate that the health authorities’ intention to reduce treatment costs by implementing a tender system has been successful.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07425-w.

Decentralizing healthcare in Norway to improve patient-centered outpatient clinic management of rheumatoid arthritis - a conceptual model

A growing population of older adults and improved effective treatments for inflammatory rheumatic diseases will increase the demand for more healthcare resources that already struggle with staggering outpatient clinic waiting times. Transformative delivery care models that provide sustainable healthcare services are urgently needed to meet these challenges. In this mini-review article, a proposed Lifelong Treatment Model for a decentralized follow-up of outpatient clinic patients living with rheumatoid arthritis is presented and discussed.Our conceptual model follows four steps for a transformative care delivery model supported by an Integrated Practice Unit; (1) Diagnosis, (2) Treatment, (3) Patient Empowered Disease Management, and (4) Telehealth. Through an Integrated Practice Unit, a multidisciplinary team could collaborate with patients with rheumatoid arthritis to facilitate high-value care that addresses most important outcomes of the patients; (1) Early Remission, (2) Decentralization, (3) Improved Quality of Life, and (4) Lifelong Sustain Remission.The article also addresses the growing challenges for the healthcare delivery system today for patients with rheumatoid arthritis and proposes how to reduce outpatient clinic visits without compromising quality and safety.

OP0238 DRUG COST FOR BIOLOGIC AND TARGETED SYNTHETIC DMARDS FOR RHEUMATOID ARTHRITIS PATIENTS IN NORWAY FROM 2010 TO 2019 - A COUNTRY WITH A NATIONAL TENDER SYSTEM FOR DRUG PRESCRIPTION

Background:

Biologic and Target Synthetic disease-modifying antirheumatic drugs (BTSs) have caused a paradigm shift in the treatment of patients with inflammatory joint disorders, e.g., rheumatoid arthritis (RA), where remission is now attainable [1]. The high cost of BTSs has caused restrictions on use and prescription, contributing to inequality of care worldwide [2]. An annual tender system was introduced in 2008 in Norway to reduce the costs of these drugs [3].

Objectives:

Explore changes in drug costs for BTSs for RA patients treated at Norwegian rheumatology outpatient clinics between 2010 and 2019.

Methods:

The project BioRheuma (BIOlogic treatment of patients suffering from inflammatory RHEUMAtic disorders in Norway) aimed to monitor patients treated with BTSs while using a designed computer program. Anonymized data files from the ten participating centers were merged and analyzed (EXCEL and SPSS). For each year in the ten-year period, the annual total cost for BTSs and mean BTS cost for treatment of one patient was calculated for all current BTSs users, for all those who started BTSs, and for patients starting naïve to BTSs. The cost was calculated based on price offers given at the annual tender process for the different years.

Results:

The number of registered RA patients in the databases increased from 4909 in 2010 to 9335 in 2019. Simultaneously, the number of patients treated with BTSs increased from 1959 (39.9%) in 2010 to 4209 (45.1%) in 2019. The total treatment expenditure of these BTS treated patients was lowest in 2010 with 226 million Norwegian Kroner (NOK), highest in 2014 (350 million NOK) treating 3448 patients, and second-lowest in 2019 (255 million NOK).

The number of BTSs used for each year (Figure 1) is shown for all current users, all who started new BTSs treatment, and those starting BTSs naïve to BTSs. The same figure also reports the average cost of treating one RA patient with BTSs in these three groups. For the current users of BTSs, when the number of treated patients during follow-up doubled, the mean cost to treat one patient with BTSs was reduced by approximately 50% (decreasing from 115497 NOK in 2010 to 60701 NOK in 2019). The number of patients starting on BTSs approximately doubled, while keeping a steady small increase for the naïve patients to BTSs (382 in 2010 to 405 in 2019). The average starting treatment cost decreased from 114549 NOK in 2010 to 37384 NOK in 2019, and from 114987 NOK in 2010 to 28249 NOK in 2019, for patients starting on BTSs and for patients naïve to BTSs, respectively.

Figure 1.

A ten-year overview of treating RA patient with BTSs

Conclusion:

Our data shows that the average annual costs of treating a Norwegian RA patient on a current BTS, with a national tender system, were reduced by approximately 50% over the ten years 2010-19. For patients starting on a BTS, the average annual cost was reduced by approximately 75%. The consequence for the payers is that treatment can be offered at a lower price, and thus costly drugs may become more available for patients. We believe that mechanisms like the Norwegian tender system enforced upon the commercial pharmaceutical market improve competition and increase availability and use of costly drugs.

References:

[1]Smolen JS, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis 2020;79;685-99.

[2]Bergstra SA, et al. Inequity in access to bDMARD care and how it influences disease outcomes across countries worldwide: results from the METEOR-registry. Ann Rheum Dis 2018;77:1413–20.

[3]Norwegian Hospital Procurement. (Jan 2021). Available from: https://sykehusinnkjop.no.

Acknowledgements:

To all members of the BioRheuma project

Disclosure of Interests:

None declared

Heparanase link between vasculogenesis and angiogenesis as well as a predictive factor of a shorter survival rate

Heparanase concentration is low in normal epithelia cells but its overexpression is reported in many carcinomas, including sarcomas and haematological malignancies. The purpose of this study was to investigate the association with selected angiogenic parameters as well as in the number of circulating endothelial progenitors (EPCs) in respect to low, moderate and high concentrations of heparanase. Also, we estimated the diagnostic usefulness of the heparanase concentration for disease recurrence prediction in breast cancer cases. Eighty-six patients with IA-IIB stage invasive breast carcinoma who passed a comprehensive clinicopathologic evaluation were included in the study. The median tumour diameter was 1.5 cm. Twenty cases showed lymph node metastasis (N1). Follow-up was completed in all patients a median follow-up was 33.5 months with a 11.6% recurrence rate. An immunoassay of selected angiogenic parameters, heparanase, as well as an immunohistochemistry of oestrogen and progesterone receptors, human epidermal growth factor receptor 2 (HER2), Ki67 and E-cadherin was performed in all cases. Circulating EPCs were determined by flow cytometry. Higher levels of heparanase in oestrogen and progesterone receptor negative cancers than in positive ones were noted. A higher concentration of heparanase was observed in T2 cases than T1 subjects. Significant positive associations between circulating EPCs, soluble forms of VEGF receptors and increasing plasma levels of heparanase were obtained. Follow-up revealed a significantly higher incidence of disease relapse in breast cancer patients with high baseline concentrations of heparanase. Heparanase was the most accurate biomarker with an AUC^ROC = 0.72. The cut-off value of 213.74 pg/mL was identified in order to discriminate between disease recurrence patients and those without disease relapse. We suggest, that a high concentration of heparanase next to tumour size and oestrogen and progesterone receptor expression may serve as an indicator of a more an aggressive character of tumour cells and a shorter survival rate.

Increased number of endothelial progenitors in peripheral blood as a possible early marker of tumour growth in post-menopausal breast cancer patients

The aim of the study was to evaluate the number of circulating endothelial progenitor cells (circulating EPCs) in the blood of patients diagnosed with breast cancer and to make an attempt at finding associations with the number of circulating EPCs and selected clinic-pathological factors; TNM and histological grading, molecular subtype of breast cancer, hormonal status, the expression of Ki-67 and the size of tumour. The study involved 96 Caucasian ethnicity post-menopausal women. Sixty-six women aged 48 - 63 (mean age 55) with breast cancer diagnosis without distant metastases (M0). The median value of the tumour diameter was 1.51 cm. The control group consisted of 30 healthy, non-smoking, post-menopausal women, mean age 49, range 44 - 54 years of age. The exclusion criteria for all the participants were hypertension, hyperlipidaemia, and hyperglycaemia, acute and chronic infection. With regard to the fresh blood samples the number of circulating endothelial progenitors was determined using flow cytometry. The fluorescence of 100,000 cells was measured during the analysis. Circulating EPCs were identified with the immune-phenotype CD45^-, CD34⁺, CD133⁺, CD31⁺. A significantly higher number of circulating EPCs in the study group, as compared to the controls (P = 0.0001) and a significantly higher number of circulating EPCs in women over 60 with breast cancer than in the younger women (P = 0.0029) were reported. A positive correlation was noted between circulating EPCs and age as well as between circulating EPCs and HER-2 (P = 0.0231, P = 0.0414, respectively), and a negative correlation between circulating EPCs and histological grading of breast cancer (P = 0.0272). The study has shown a higher number of circulating EPCs in breast cancer patients, which indicates stimulation of neovascularization. Additionally, since bone morrow-derived circulating EPCs are more intensively mobilised in older and overweight breast cancer patients, we can speculate that more aggressive neo-angiogenesis can occur in those patients.

C1-INH and its Effect on Infarct Size and Ventricular Function in an Acute Pig Model of Infarction, Cardiopulmonary Bypass, and Reperfusion

BACKGROUND

Recent studies suggest that complement inhibition reduces reperfusion injury. A clinical setting with local application of a C1 esterase inhibitor (C1-INH) has been modeled in an animal study in order to further investigate these findings.

METHODS

In 21 pigs, the left anterior descending coronary artery (LAD) was occluded distally to the first diagonal branch for 2 hours (h), including 1 h of cardioplegic arrest during CPB. After release of the coronary snare, C1-INH or NaCl (control) was applied to the aortic root. Thereafter, the aortic cross-clamp was removed and the heart was reperfused for 30 minutes before weaning from CPB. Left ventricular pressure volume analysis was performed by a multielectrode conductance catheter and the area at risk and infarct size were determined from excised hearts.

RESULTS

The following data were observed (mean+/-SEM) for the control group and the C1-INH group, respectively, after 1-h ligation of the LAD: heart rate (HR) 86+/-3 and 93+/-6 beats/min, stroke volume (SV) 1.2+/-0.1 and 1.2+/-0.1 ml/kg, aortic pressure (AoP) 83+/-6 and 87+/-5 mmHg, left ventricular end-diastolic pressure (LVedP) 12+/-1 and 11+/-2 mmHg; two hours after weaning from CPB: HR 106+/-9 and 123+/-4 beats/min, SV 0.9+/-0.1 and 0.9+/-0.1 ml/kg, AoP 65+/-5 and 79+/-7 mmHg, LVedP 9+/-1 and 8+/-1 mmHg. Conductance catheter measurements showed no improved left ventricular performance after C1-INH application. Infarct size to area at risk ratio was 61.5+/-4.2% for controls and 61.4+/-4.8% for C1-INH.

CONCLUSIONS

Intracoronary application of complement inhibitor in an acute infarction model, which mimicked a clinical setting of urgent coronary bypass grafting after ischemia, has been shown to neither influence the area of infarction, nor the ventricular function.