Heart rate variability testing: could it change spending for rheumatoid arthritis patients in the United States? An exploratory economic analysis

Figures & data

Figure 1. Decision tree of RA patient journey with current standard care (A), and with HRV testing for biologic-eligible patients (B). *Disease control defined as ACR70. References: (a) Ollendorf et al.²⁸, (b) Kim et al.³⁰, (c) Holman and Ng²¹.

Table 1. Costs data inputs and sources.

Cost category	Value	Source
Biologic drug costs, annual	$34,144	Average annual drug cost for 6 commonly used RA biologics^28
RLS therapy costs, annual	$224	Annual cost of benzodiazepine^31
HRV testing costs, per test	$155	Inmedix administrative data: $91 for clinician test administration and $64 for reporting test results
Underlying healthcare costs, annual	$5,232	Costs for methotrexate, hospitalizations, emergency visits, and doctor visits for 1 year^32
RA specific mortality^b
Disease control	1.33^0.58	Mortality multiplier exponentiated by the HAQ^a score for disease control^33^,^34
No disease control	1.33^1.33	Mortality multiplier exponentiated by the HAQ^a score for no disease control^33^,^34
Quality-of-life utility
Disease control	0.84	Visual Analog Scale utility score for ACR70^35
No disease control	0.53	Visual Analog Scale utility score for no disease improvement^35

^aHAQ, the Health Assessment Questionnaire³⁶, which measures quality-of-life based on the ability to perform daily activities in several domains, including dressing, arising, eating, walking, hygiene, reach, grip, and general activities. Higher HAQ scores indicate greater disability, controlled disease HAQ = 0.58, uncontrolled disease HAQ = 1.54³⁶.

^bMortality multipliers are multiplied by mortality rates from US life tables to calculate RA-specific mortality rates.

Figure 2. RA patient journey with HRV testing and ANS optimization for biologic-eligible patients. *Disease control defined as ACR70. References: (a) Ollendorf et al.²⁸, (b) Holman and Ng²¹, (c) Kim et al.³⁰, (d) Holman and Ng^20,24.

Figure 3. Hypothetical RA patient journey with HRV tasting and ANS optimization for all patients. *Disease control defined as ACR70. References: (a) Holman and Ng²¹, (b) Holman and Ng^20,24, (c) Kim et al.³⁰.

Table 2. Results for HRV testing compared to standard care for patients with moderate-to-severe RA eligible for biologic treatment.

	Per patient			US population
	Standard care	HRV	Difference	Standard care	HRV	Difference
Total costs	$321,122	$249,291	–$71,831	$154.8 B	$120.2 B	–$34.6 B
Biologics	$276,951	$201,419	–$75,532	$133.5 B	$97.1 B	–$36.4 B
HRV	$0	$3,701	$3,701	$0. B	$1.8 B	$1.8 B
Healthcare	$44,172	$44,172	$0	$21.3 B	$21.3 B	$0.0 B
QALYs	5.05	5.05	0.00	2,433,056	2,433,115	59
ICER	–	–	Cost-saving	–	–	Cost-saving

Abbreviations. HRV, heart rate variability; QALYs, quality-adjusted life-years; ICER, incremental cost-effectiveness ratio.

Table 3. Results for HRV testing + ANS optimization compared to standard care for patients with moderate-to-severe RA in the US.

	Standard care	HRV	Difference
Patients eligible for biologic treatment
Total costs	$154.8 B	$158.4 B	$3.6 B
Biologics	$133.5 B	$133.9 B	$0.4 B
RLS	$0.0 B	$0.7 B	$0.7 B
HRV	$0.0 B	$2.4 B	$2.4 B
Healthcare	$21.3 B	$21.4 B	$0.07 B
QALYs	2,433,056	2,811,162	378,106
ICER	–	–	$9,551/QALY
All patients
PPV 40%
Total costs	$168.9 B	$172.3 B	$3.4 B
Biologics	$126.1 B	$123.2 B	–$3.0 B
RLS	$0.0 B	$1.4 B	$1.4 B
HRV	$0.0 B	$5.0 B	$5.0 B
Healthcare	$42.8 B	$42.8 B	$0.0 B
QALYs	5,782,159	5,804,700	22,541
ICER	–	–	$150,691/QALY
PPV 50%
Total costs	$168.9 B	$166.2 B	–$2.7 B
Biologics	$126.1 B	$117.1 B	–$9.1 B
RLS	$0.0 B	$1.4 B	$1.4 B
HRV	$0.0 B	$5.0 B	$5.0 B
Healthcare	$42.8 B	$42.8 B	$0.0 B
QALYs	5,782,159	5,851,024	68,865
ICER	–	–	Cost-saving
PPV 60%
Total costs	$168.9 B	$160.1 B	–$8.8 B
Biologics	$126.1 B	$111.0 B	–$15.2 B
RLS	$0.0 B	$1.4 B	$1.4 B
HRV	$0.0 B	$5.0 B	$5.0 B
Healthcare	$42.8 B	$42.8 B	$0.0 B
QALYs	5,782,159	5,897,366	115,207
ICER	–	–	Cost-saving

Abbreviations. HRV, heart rate variability; QALYs, quality-adjusted life-years; ICER, incremental cost-effectiveness ratio; PPV, positive predictive value.

Figure 4. Tornado diagram for one-way sensitivity analysis for the ICER for HRV testing + ANS optimization for biologic eligible patients (top), and for the incremental costs of HRV testing + ANS optimization for all patients (bottom), compared to standard care.

Figure 5. Results of the probabilistic sensitivity analysis: incremental costs and incremental QALYs for the US population for HRV testing + ANS optimization for biologic-eligible and for all patients compared to standard care.

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