Payers' views on treating-to-target in rheumatoid arthritis: an English perspective.

OBJECTIVES Delivering treat-to-target strategies in rheumatoid arthritis (RA) involves commitments from both providers and payers for healthcare. We have summarised the perspectives of payers from England, where the National Health Service (NHS) provides universal care that is without cost for patients. METHODS We reviewed the literature - including that from the NHS and National Institute for Health and Clinical Excellence (NICE) - concerning payers views on the clinical effectiveness and cost-effectiveness of treat-to-target strategies for RA. RESULTS Commissioners pay for government-funded English healthcare and providers (divided between General Practitioners (GPs) and Hospital Consultants) and deliver it according to NICE guidance. Treat-to-target using intensive disease-modifying drug (DMARD) combinations with glucocorticoids are recommended for early active RA. Treatment tapering is recommended when disease control is achieved. Some aspects of treat-to-target are recommended in established RA, including the early management of flares and the use of biologics in persistently active RA that is non-responsive to DMARDs. However, treat-to-target is not widely recommended in established RA, mainly because the evidence base is incomplete. English healthcare is moving towards quality care becoming the main driver and is adopting 'integrated care' involving both GPs and consultants for most long-term disorders; RA is likely to be included within these approaches, which are unlikely to focus specifically on treat-to-target. CONCLUSIONS Payers strongly support treat-to-target in early RA. In established disease there is limited enthusiasm; without stronger evidence for efficacy and cost-effectiveness this is unlikely to change.