Inequality of access to advanced therapies for patients with inflammatory arthritis: a postcode lottery?

Abstract

Objectives Advanced therapies (AT), including biologics, biosimilars and Janus kinase inhibitors, have dramatically improved the quality of life of patients with RA, PsA and axial spondyloarthritis (axSpA). Evidence-based criteria for prescribing these drugs in England and Wales is formulated by the National Institute for Health and Care Excellence (NICE) through health technology appraisals and guidelines, with the aim of providing equitable access to AT for patients with severe or resistant disease. Similar bodies exist in some, but not all European countries, with disparities in AT access between countries for RA. We examined whether this disparity was mirrored in England for RA, PsA and axSpA despite the National Health Service in England and Wales being legally obliged to provide funding for AT recommended by NICE’s Health Technology Appraisal board, through the commissioning bodies, the clinical commissioning groups (CCGs). Methods We requested AT pathways from CCGs in England. Where these were not available, individual hospital Trusts were contacted using freedom of information requests. Results We found marked variability in the way that CCGs in England interpret NICE guidance. We found 41, 29 and 25 different pathways for RA, PsA and axSpA, respectively. Similar disparities existed with sequential prescribing where one AT did not work, with limits on the numbers of sequential AT in 54%, 59% and 59% of CCGs for RA, PsA and axSpA, respectively, and with these limits being different for the same condition between CCGs. Conclusion Although patients at identical stages of their disease course should have access to the same NICE-approved AT, we found this is not the case for large parts of England. Inequality of access was found between regions, mirroring the variability that occurs between countries throughout Europe. Harmonization of access needs to be addressed by policymakers to ensure fairness in the way that clinicians and patients can access AT.

Effectiveness of sequential biologic and targeted disease modifying anti-rheumatic drugs for rheumatoid arthritis

“…Many healthcare providers and systems limit the number of trials of different high-cost b/tsDMARDs for an individual patient. For example, some UK commissioning bodies have set the maximum to four [ 6 , 7 ]. Very few studies have examined treatment outcomes beyond the third line [ 12 ]; such decisions may in part be influenced by earlier evidence that showed linearly reduced effectiveness from first- to third-line TNFi [ 13 ].…”

“…beyond three) lines of therapy is lacking, making it difficult to weigh against risk of adverse events, yet the opportunities for this continues to increase as more b/tsDMARDs, with different mechanisms of action, are approved. In the absence of such evidence, many healthcare providers or systems, implicitly or explicitly, limit the number of trials of high-cost b/tsDMARDs that any individual patient may have [ 6 , 7 ].…”

Approaches to optimising access to NICE-approved biologic anti-TNFs for patients with rheumatoid arthritis with moderately active disease

“…The coronavirus disease 2019 (COVID-19) pandemic continues to challenge our healthcare system and has impacted how we care for patients in the UK; moreover, it has also emphasised differences in care across post codes [17]. When government restrictions on movement and activity were in place to reduce COVID-19 spread, it affected all aspects of the daily life of the general population.…”