Is early intervention worth it?

Historically, the largest components of costs associated with rheumatoid arthritis (RA), the most common inflammatory rheumatic disease, were hospitalizations, principally for joint replacement surgery, and work loss. Thus, for expensive interventions such as biological agents to be "worthwhile," they must reduce the prevalence of joint replacement and assist persons with RA in maintaining employment. However, joint replacement surgery and work losses tend to occur at least several years after onset of disease, even in severe cases. Assessing the cost-effectiveness of expenditures becomes computationally and politically difficult when the expenditure and the outcome are separated in time. The computational issue concerns the translation of future benefits--surgeries avoided and jobs held onto years from now--into present monetary values. The computational issue may be even more complex when the benefits are less tangible than surgery and wages; for example, when measured by quality-adjusted life-years. The political issue concerns the disjuncture between the agents making the expenditures--provincial health insurance in Canada or an employer's health plan in the US--and the agents reaping the benefits, a private disability insurance company or provincial or state workers' compensation fund. In addition, there is an ethical dilemma. In the US, many of the advances in the care for RA such as the biological agents derive, at least in part, from federal research expenditures. Such expenditures are financed by increasingly regressive taxes. Yet the individuals bearing an increasing share of the tax burden find themselves relegated to more restrictive health insurance plans less likely to provide access to those agents. Thus, whether expenditures for early interventions are worthwhile may turn on such issues as how long the expenditure and the benefits are separated in time, how well the interests of the agent making the expenditure and the agent reaping the rewards are aligned, and how equitable the financing of the benefit and the access to it.