Treatment patterns and economic outcomes in patients with juvenile idiopathic arthritis

Figures & data

Figure 1 Patient attrition flow charts for (A) JIA cases and matched controls and (B) identification of JIA DMARD treatment subcohorts.

Abbreviations: DMARD, disease-modifying antirheumatic drugs; JIA, juvenile idiopathic arthritis.

Notes: ^aControl patients were randomly assigned an index date maintaining the index date distribution of the qualified JIA cohort. ^bCannot have >1 biologic DMARD on the same day that could be considered as an index DMARD claim. ^cSystemic lupus erythematosus and other connective tissue disease, vasculitis, and sarcoidosis. ^dChronic lymphocytic leukemia, Crohn’s disease, polyarteritis nodosa, Non-Hodgkin’s lymphoma, plaque psoriasis, ulcerative colitis, or Wegener’s granulomatosis. ^ePatients may qualify as both biologic and non-biologic users. ^fComprised of all JIA patients not included in the 3 treatment subcohorts.

Table 1 Baseline demographic and clinical characteristics

	All JIA patients	Treatment subcohorts				Matched controls
		Biologic only	Biologic & non-biologic	Non-biologic only	Other JIA cases^a
	n=3,815	n=873	n=407	n=734	n=1,801	n=11,535
Age, mean (SD)	10 (4.5)	11 (4.5)	12 (3.8)	11 (4.2)	9 (4.6)	10 (4.5)
Age group, years, n (%)
2–5	740 (19.4%)	127 (14.6%)	28 (6.9%)	100 (13.6%)	485 (26.9%)	2,235 (19.4%)
6–10	981 (25.7%)	194 (22.2%)	103 (25.3%)	178 (24.3%)	506 (28.1%)	2,970 (25.8%)
11–15	1,543 (40.5%)	371 (42.5%)	203 (49.9%)	340 (46.3%)	629 (34.9%)	4,653 (40.3%)
16–17	551 (14.4%)	181 (20.7%)	73 (17.9%)	116 (15.8%)	181 (10.1%)	1,677 (14.5%)
Female, n (%)	2,631 (69.0%)	616 (70.6%)	278 (68.3%)	539 (73.4%)	1,198 (66.5%)	7,956 (69.0%)
Health plan type, n (%)
Comprehensive/Indemnity	55 (1.4%)	16 (1.8%)	2 (0.5%)	13 (1.8%)	24 (1.3%)	165 (1.4%)
EPO/PPO	2,261 (59.3%)	513 (58.8%)	227 (55.8%)	422 (57.5%)	1,099 (61.0%)	6,837 (59.3%)
POS/POS w/capitation	344 (9.0%)	78 (8.9%)	38 (9.3%)	72 (9.8%)	156 (8.7%)	1,041 (9.0%)
HMO	661 (17.3%)	151 (17.3%)	81 (19.9%)	146 (19.9%)	283 (15.7%)	1,992 (17.3%)
CDHP/HDHP	381 (10.0%)	92 (10.5%)	49 (12.0%)	62 (8.5%)	178 (9.9%)	1,158 (10.0%)
Other/Unknown	113 (3.0%)	23 (2.6%)	10 (2.5%)	19 (2.6%)	61 (3.4%)	342 (3.0%)
Region, n (%)
Northeast	714 (18.7%)	140 (16.0%)	76 (18.7%)	118 (16.1%)	380 (21.1%)	2,151 (18.7%)
North Central	1,021 (26.8%)	199 (22.8%)	118 (29.0%)	251 (34.2%)	453 (25.2%)	3,087 (26.8%)
South	1,239 (32.5%)	341 (39.1%)	113 (27.8%)	215 (29.3%)	570 (31.7%)	3,741 (32.4%)
West	775 (20.3%)	178 (20.4%)	93 (22.9%)	136 (18.5%)	368 (20.4%)	2,358 (20.4%)
Unknown	66 (1.7%)	15 (1.7%)	7 (1.7%)	14 (1.9%)	30 (1.7%)	198 (1.7%)
DCCI, mean (SD)	0.23 (0.49)	0.30 (0.59)	0.27 (0.52)	0.24 (0.50)	0.18 (0.42)	0.08 (0.31)
Comorbid conditions, n (%)
ADHD	133 (3.5%)	32 (3.7%)	17 (4.2%)	21 (2.9%)	63 (3.5%)	299 (2.6%)
Anxiety	138 (3.6%)	37 (4.2%)	19 (4.7%)	22 (3.0%)	60 (3.3%)	180 (1.6%)
Asthma	341 (8.9%)	83 (9.5%)	42 (10.3%)	61 (8.3%)	155 (8.6%)	722 (6.3%)
Depression	85 (2.2%)	33 (3.8%)	14 (3.4%)	14 (1.9%)	24 (1.3%)	181 (1.6%)
Diabetes	35 (0.9%)	11 (1.3%)	4 (1.0%)	6 (0.8%)	14 (0.8%)	38 (0.3%)
Concomitant medications, n (%)
ADHD Medications	234 (6.1%)	57 (6.5%)	27 (6.6%)	47 (6.4%)	103 (5.7%)	602 (5.2%)
Anti-depressants	307 (8.1%)	97 (11.1%)	52 (12.8%)	55 (7.5%)	103 (5.7%)	460 (4.0%)
Anti-diabetic agents	48 (1.3%)	14 (1.6%)	5 (1.2%)	11 (1.5%)	18 (1.0%)	61 (0.5%)
Anxiolytics	296 (7.8%)	93 (10.7%)	43 (10.6%)	57 (7.8%)	103 (5.7%)	372 (3.2%)
Corticosteroids	1,675 (43.9%)	477 (54.6%)	246 (60.4%)	358 (48.8%)	594 (33%)	1,843 (16.0%)
NSAIDs	2,864 (75.1%)	608 (69.6%)	347 (85.3%)	609 (83.0%)	1,300 (72.2%)	721 (6.3%)
Opioids	901 (23.6%)	251 (28.8%)	118 (29.0%)	180 (24.5%)	352 (19.5%)	1,345 (11.7%)

Note: ^aOther JIA subcohort contains all JIA patients not included in the treatment subcohorts.

Abbreviations: ADHD, attention-deficit hyperactivity disorder; CDHP, consumer-driven health plan; DCCI, Deyo-Charlson comorbidity index; EPO, exclusive provider organization; HDHP, high-deductible health plan; HMO, health maintenance organization; JIA, juvenile idiopathic arthritis; NSAIDs, nonsteroidal anti-inflammatory drugs; POS, point of service; PPO, preferred provider organization; SD, standard deviation.

Table 2 DMARD treatment patterns

	All biologic users	All non-biologic users^a
	n=1,280	n=1,124
Adherence, n (%)	597 (46.6%)	373 (33.2%)
Persistence, n (%)	526 (41.1%)	638 (56.8%)
Switching^b within class, n (%)	191 (14.9%)	132 (11.7%)
Months to DMARD initiation,^c mean (SD)	15.4 (18.3)	4.5 (10.2)

Notes: ^aSeventeen patients who received non-biologics had multiple drugs on their non-biologic treatment start date and were excluded from the treatment pattern analysis. ^bConverting route of administration did not constitute a switch in therapy. ^cNumber of months between index date and treatment start date for patients who received both biologic and non-biologic DMARDs.

Abbreviations: DMARD, disease modifying anti-rheumatic drug; SD, standard deviation.

Table 3 First DMARD used by each treatment subcohort

	Biologic only users	Biologic & non-biologic users	Non-biologic only users	All treated patients
	n=873	n=407	n=734	n=2,014
Biologics, n (%)
Abatacept	15 (1.7%)	6 (1.5%)	-	21 (1.0%)
Adalimumab	188 (21.0%)	106 (25.7%)	-	294 (14.4%)
Anakinra	43 (4.8%)	9 (2.2%)	-	52 (2.5%)
Etanercept	523 (58.4%)	259 (62.7%)	-	782 (38.3%)
Infliximab	71 (7.9%)	20 (4.8%)	-	91 (4.5%)
Intravenous immunoglobulin	17 (1.9%)	1 (0.2%)	-	18 (0.9%)
Tocilizumab	16 (1.8%)	6 (1.5%)	-	22 (1.1%)
Non-biologics, n (%)
Hydroxychloroquine	-	31 (7.5%)	149 (20.2%)	180 (8.8%)
Methotrexate	-	341 (82.6%)	506 (68.8%)	847 (41.4%)
Sulfasalazine	-	42 (10.2%)	75 (10.2%)	117 (5.7%)
Other (azathioprine, leflunomide)	-	5 (1.2%)	15 (2.0%)	20 (1.0%)

Abbreviation: DMARD, disease-modifying anti-rheumatic drug.

Table 4 All-cause and JIA-related health care resource utilization

	All JIA patients	Treatment subcohorts				Controls
		Biologic only users	Biologic & non-biologic users	Non-biologic only users	Other JIA cases
	n=3,815	n=873	n=407	n=734	n=1,801	n=11,535
All-cause health care utilization
Patients with inpatient admission, n (%)	177 (4.6%)	72 (8.3%)	15 (3.7%)	25 (3.4%)	65 (3.6%)	167 (1.5%)
Patients with emergency room visit, n (%)	1,003 (26.3%)	265 (30.4%)	104 (25.6%)	174 (23.7%)	460 (25.5%)	1,871 (16.2%)
Average office visits per patient, mean (SD)	10.8 (6.6)	12.1 (7.4)	12.8 (7.2)	10.7 (6.0)	9.7 (6.0)	3.1 (3.2)
Average outpatient prescriptions per patient, mean (SD)	19.0 (17.8)	26.5 (21.1)	30.8 (19.8)	22.9 (15.3)	11.2 (11.9)	3.7 (6.2)
JIA-related health care utilization
Patients with inpatient admission, n (%)	25 (0.7%)	15 (1.7%)	2 (0.5%)	5 (0.7%)	3 (0.2%)	n/a
Patients with emergency room visit, n (%)	213 (5.6%)	61 (7.0%)	24 (5.9%)	48 (6.5%)	80 (4.4%)	n/a
Average office visits per patient, mean (SD)	4.6 (3.5)	5.0 (4.4)	6.0 (3.8)	4.9 (3.2)	4.0 (2.9)	n/a
Average outpatient prescriptions per patient, mean (SD)	4.3 (5.9)	8.4 (5.9)	10.1 (6.9)	5.9 (5.1)	0.3 (1.7)	n/a

Abbreviations: JIA, juvenile idiopathic arthritis; n/a, not applicable; SD, standard deviation.

Figure 2 Annual unadjusted all-cause and JIA-related health care costs for (A) JIA patients and matched controls and (B) treatment subcohorts.

Note: Numbers in brackets above the bars represent the standard deviation values.

Abbreviations: ER, emergency room; JIA, juvenile idiopathic arthritis.

Table 5 Treatment costs for the 12 months post-treatment initiation with a biologic DMARD

Category	First agent used	n	Mean	Median	Cumulative costs	% of cumulative costs	Total % by category
TNFi	Adalimumab	188	$26,938	$15,495	$5,064,410	26.1%	87.1%
	Etanercept	523	$17,083	$15,545	$8,934,571	46.0%
	Infliximab	71	$41,136	$26,236	$2,920,667	15.0%
Non-TNFi	Abatacept	15	$21,825	$17,129	$327,371	1.7%	8.7%
	Anakinra	43	$20,523	$13,349	$882,504	4.5%
	Tocilizumab	16	$30,175	$20,269	$482,795	2.5%
Other	Intravenous immunoglobulin	17	$48,048	$36,297	$816,818	4.2%	4.2%
Totals	Biologic only users	873			$19,429,134

Abbreviations: DMARD, disease modifying anti-rheumatic drug; TNFi, tumor necrosis factor inhibitor.

Table 6 Estimates of annual health care resource utilization and costs for JIA patients vs matched controls

JIA cohort vs matched controls	Point estimator	Lower 95% CL	Upper 95% CL	P-value
Total all-cause costs	CR=6.58	6.17	7.02	<0.0001
Inpatient costs	CR=5.39	4.64	6.27	<0.0001
Probability of inpatient admission	OR =1.69	1.23	2.33	0.0012
Emergency room costs	CR=1.27	1.13	1.43	<0.0001
Probability of emergency room visit	OR =1.07	0.93	1.22	0.3376
Office visit costs	CR=3.44	3.24	3.64	<0.0001
Number of office visits	VR =2.62	2.53	2.71	<0.0001
Other outpatient services costs^a	CR=6.54	6.06	7.06	<0.0001
Outpatient prescription costs	CR=16.19	14.82	17.70	<0.0001
Outpatient prescription fills	FR =3.24	3.06	3.43	<0.0001

Notes: Adjusted for age, sex, geographic region, health plan, urbanicity, index year, DCCI, comorbid conditions, and concomitant medications; In all cases, ratios were calculated as [JIA]/[controls]; ^aOther outpatient services consist of laboratory, radiology, and hospital outpatient facility costs.

Abbreviations: CL, confidence level; CR, cost ratio; OR, odds ratio; FR, prescription fill ratio; VR, visits ratio.