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N-of-1 Trials of Expensive Biological TherapiesA Third Way?
Richard L. Kravitz, MD, MSPH;
Naihua Duan, PhD;
Richard H. White, MD
Arch Intern Med. 2008;168(10):1030-1033.
In developing policies for use of expensive agents, such as those used for the treatment of rheumatoid arthritis, managed care organizations have invoked "stepped care," in which physicians and patients must first try more established and less costly agents. N-of-1 clinical trials are multiple crossover trials in a single patient. In this cost-minimization analysis, we show that offering patients with rheumatoid arthritis the opportunity to participate in an n-of-1 trial comparing methotrexate with etanercept could save costs relative to open access while preserving clinical freedom relative to mandatory stepped care. In the primary model, the n-of-1 trial option was 15% more expensive than stepped care but 47% cheaper than open access to etanercept. More research is needed on the acceptability, safety, and generalizability of this promising approach.
Author Affiliations: Division of General Medicine and Center for Healthcare Policy and Research, University of California, Davis, School of Medicine, Sacramento (Drs Kravitz and White); and Division of Biostatistics, Department of Psychiatry, Columbia University Medical Center, New York, New York (Dr Duan).
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