Harnessing Decision Support Tools to Improve RA Treatment


“I think many who work within the medical community are still unsure how to use CER,” He explained. “Head-to-head trials are usually pretty well accepted by providers and I think can provide good information especially when one of the drugs is clearly superior to the other. They often help providers differentiate between drugs on a general basis and can help with population management overall. The downside is that sometimes a drug that is shown to be inferior is actually still the better option for a subset of patients. If providers only remember the overall inferiority of a product, they may miss an opportunity to use it in a patient that could really benefit from it.”

Dr Dunn has seen some improvement with CER in recent years. “We have started to compare drugs based on value (ie, net cost per ACR70 response). However, formularies are still dictated by contracting by drug, not by disease state/indication, number of indications, and utilization.” He noted that progress is being made to re-contract by indication.

While clinical pathways are being used in oncology, there is evidence of its value in RA, according clinical studies of Cardinal Health Specialty  Solutions’ Clinical Pathways program.

“Our published evidence as well as research done by others suggest that decision support tools can help achieve the triple aim of better health through better health care at a lower cost,” said Dr Feinberg.

Dr Feinberg and colleagues research was part of a pilot program with CareFirst BlueCross BlueShield. The program involved having physicians establish an evidence-based algorithm to guide treatment and incorporate that algorithm into clinical pathways.

“In our research, decision support tool compliance at initiation of DMARD and pre-biologic use provided the most value reducing cost without detriment to clinical outcomes,” he said, noting that the pharmacy benefit management program (PBM) program was suspended for the duration of the pilot. “It is unclear if decision support tools will have the same benefit if superimposed on a PBM program that challenges the guidance of the decision support.”

Formulary Hurdles

Drs Dunn and Spjut agreed that formulary restrictions are contributing to decision support tools not having a big impact in treatment sequencing in RA.

“Most of the current decision making is due to formularies, which are dictated by contracting,” Dr Dunn said. “We need better tools that would aid providers in objectively determining if a drug is working and, if not, when to switch. Ideally, formularies would be based on comparative cost-effectiveness but we need to have contracting flexibility and willingness to sequence based on value.”

“Within the PBM world, we realize that our step requirements in this space do not always align with the best treatment patterns for patients,” Dr Spjut added. “Most of this is driven by rebate contracts which are a necessary component of formulary design in this space because of the high cost of treatment of the specialty products. We are seeing a shift in available contracting though, so hopefully in the next 12 to 24 months we will begin to see formularies align more with the decisions that come out of these decision support tools.”

Dr Spjut wants to see these tools become an important part of medical care.

“When developed and presented correctly, decision support tools will help patients experience better outcomes and usually help in minimizing the medical costs,” he concluded. “I really hope that the familiarity and use of decision support tools will continue to grow and become an integral part of medical practice.”

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