A comparison of the administration regimens for two rheumatoid arthritis drugs across three hospital day units has highlighted an opportunity for substantial time savings for healthcare providers and patients.
The combined results in this analysis are taken from two studies and could have an important impact on rheumatology day unit capacity. Our results show that overall rituximab administration required substantially less hospital staff resources and patient time than infliximab administration during the 43 week assessment period.
This is due to the fact that the longer individual visit time for rituximab was outweighed by the greater frequency of visits required for infliximab. The average staff time used was two hours less when caring for patients who received rituximab than for those who received infliximab.
Additionally, patients who received rituximab spent an average of 11 fewer hours in hospital compared with those who received infliximab.
Biological agents such as infliximab and rituximab are used to treat rheumatoid arthritis when other disease-modifying drugs have failed, with rituximab currently reserved for use after failure of an anti-TNF biological agent such as etanercept.
Although they are both given by intravenous infusion, they have different administration schedules.
Following a pilot real world study looking at the frequency of visits and time required for each visit to administer rituximab or infliximab to inform local capacity planning decisions at the Norfolk and Norwich University Hospitals Foundation Trust, a multi-centre study involving two further centres (Aintree University Hospitals Foundation Trust and Southend University Hospital Foundation Trust) was conducted to see whether the results seen at NNUH could be repeated.
The study had two components at each centre: retrospective review of the medical records of patients who had received infliximab or rituximab for rheumatoid arthritis, to see how many visits to hospital and investigations were involved for each drug, and a prospective “time and motion” study in the day units, to observe how much staff time, patient time and other resources were needed per visit.
While infliximab is given according to a regimen with a set frequency of infusions, rituximab is given as an initial course of two infusions, with subsequent infusions given only when the patient has a disease flare, which is expected usually to be between six and 12 months after the initial course.
So the first aim of the study was to find out from patients’ records how long on average it was in normal clinical practice before patients had to return for the repeat course of rituximab.
This average interval was then set as the period over which the number of visits for infliximab administration was counted, so that a fair comparison could be made. Numbers of hospital admissions, outpatient clinic visits and investigations were also counted for both drugs over the same period.
The review of patients’ records, which involved 18 patients who had received rituximab, showed that the average time between rituximab courses was 43 weeks.
Over this period, in which two courses of rituximab were needed, the 26 studied patients receiving infliximab needed, on average, 6.9 infusions. This was very similar in all three foundation trusts, with a range of only 6.8 to 7.0 average number of visits across the centres.
The groups of patients receiving each drug were similar in terms of age and sex distribution and in terms of the other drugs they were taking for rheumatoid arthritis and any co-existing conditions. This means that any differences can reasonably be attributed to the rituximab or infliximab they were receiving.
While the numbers of outpatient clinic visits, inpatient bed days and investigations were similar for patients receiving either drug, the greater number of infusions required for infliximab meant that patients had to come to the day unit 6.9 times vs twice for rituximab.
The time and motion study showed that each visit for administration of rituximab (12 patients) required on average 87 minutes of staff activity time to prepare, administer and monitor the infusion, compared with just 46 minutes per visit for infliximab (13 patients).
Most of the activities that made up this total staff time took longer for rituximab than for infliximab, but notably the preparation and administration of a pre-medication (rituximab 6.4 minutes vs infliximab 0.4 minutes) and consultation time (rituximab 7.1 minutes vs infliximab 3.5 minutes).
However, even with the longer visit time, overall rituximab required fewer hospital resources than infliximab, because the longer visit time for rituximab administration was outweighed by the greater frequency of visits for infliximab. Over the whole 43 weeks, infliximab required 317 minutes of staff time, while rituximab needed only 174 minutes, a saving of 143 minutes.
Similarly for patients, although the duration of each visit was longer for those receiving rituximab (420 minutes) than for those receiving infliximab (220 minutes), the less frequent visits for rituximab translated into an even greater time-saving overall of 675 minutes (more than 11 hours).
The potential impact of these differences on service planning and delivery may depend on whether the day unit where infusions are given is for rheumatoid arthritis patients only or whether patients come from other specialties as well.
Gill Marflitt, manager of the medical day ward at Aintree University Hospitals Foundation Trust explains: “Since many day units are not solely for rheumatoid arthritis patients, planning patients in group sessions of those having the same drug can be of benefit for the management of admission for infusions (which may favour the use of infliximab, with its predictable dosing schedule). However, if patients were on a less frequent infusion (such as rituximab), appointments could be freed up for admission of patients from other disciplines.”
She added: “A drug requiring less frequent infusions may also give the day unit some flexibility in capacity for patients who need urgent referral, avoiding patients feeling overcrowded. The most important consideration is to ensure the patients’ needs are met and they are receiving optimum service. A drug with varying dosing schedules will have an impact on service planning and capacity, but the patients’ needs in terms of lifestyle must be taken into account. Some patients will be grateful for less frequent infusions, while others may prefer a predictable, if more frequent dosing schedule.”
Gill Grundy, rheumatology nurse specialist at Aintree University Hospitals Foundation Trust, said that in an increasingly demanding NHS, it is important to consider the patients’ journey, the quality of the service provided and the financial implications of treatments and services.
She added: “Information from this study does indicate that offering rituximab may be less intrusive in terms of inconvenience and time. However, as the effectiveness and side effect profile of individual treatments can vary between patients, they should be given a choice as to which treatment is most likely to suit their condition and their lifestyle.”
This study provides information which will help clinicians and patients to make that choice and managers to plan the services needed to deliver the chosen treatment.
- Prof D Scott - Norfolk and Norwich University Hospital NHS Trust
- M Somerville - Norfolk and Norwich University Hospital NHS Trust
- Prof B Dasgupta - Southend University Hospital NHS Foundation Trust
- Prof R Moots - Aintree University Hospitals NHS Foundation Trust
- F Percival - pH Associates
- M De la Orden - Roche Products Ltd
Marie Keetley is project manager at pH Associates.