Centers of excellence implementation for treating rheumatoid arthritis in Colombia: A cost-analysis

Background: Health systems need to optimize the use of resources, especially in high-cost diseases as rheumatoid arthritis (RA). We aimed to evaluate the efficiency of using centers of excellence (CoE) as a strategy for improving RA treatment in Colombia. Methods: A cost description analysis was car...

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Autores:: Santos-Moreno, Pedro
ALVIS-ZAKZUK, NELSON J.
Villarreal-Peralta, Laura
Carrasquilla Sotomayor, Maria
de la Hoz Restrepo, Fernando
Alvis-Guzmán, Nelson

Tipo de recurso:: Article of journal

Fecha de publicación:: 2021

Institución:: Corporación Universidad de la Costa

Repositorio:: REDICUC - Repositorio CUC

Idioma:: eng

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repository_id_str
dc.title.spa.fl_str_mv	Centers of excellence implementation for treating rheumatoid arthritis in Colombia: A cost-analysis
title	Centers of excellence implementation for treating rheumatoid arthritis in Colombia: A cost-analysis
spellingShingle	Centers of excellence implementation for treating rheumatoid arthritis in Colombia: A cost-analysis rheumatoid arthritis treat to target cost-savings cost-analysis
title_short	Centers of excellence implementation for treating rheumatoid arthritis in Colombia: A cost-analysis
title_full	Centers of excellence implementation for treating rheumatoid arthritis in Colombia: A cost-analysis
title_fullStr	Centers of excellence implementation for treating rheumatoid arthritis in Colombia: A cost-analysis
title_full_unstemmed	Centers of excellence implementation for treating rheumatoid arthritis in Colombia: A cost-analysis
title_sort	Centers of excellence implementation for treating rheumatoid arthritis in Colombia: A cost-analysis
dc.creator.fl_str_mv	Santos-Moreno, Pedro ALVIS-ZAKZUK, NELSON J. Villarreal-Peralta, Laura Carrasquilla Sotomayor, Maria de la Hoz Restrepo, Fernando Alvis-Guzmán, Nelson
dc.contributor.author.spa.fl_str_mv	Santos-Moreno, Pedro ALVIS-ZAKZUK, NELSON J. Villarreal-Peralta, Laura Carrasquilla Sotomayor, Maria de la Hoz Restrepo, Fernando Alvis-Guzmán, Nelson
dc.subject.spa.fl_str_mv	rheumatoid arthritis treat to target cost-savings cost-analysis
topic	rheumatoid arthritis treat to target cost-savings cost-analysis
description	Background: Health systems need to optimize the use of resources, especially in high-cost diseases as rheumatoid arthritis (RA). We aimed to evaluate the efficiency of using centers of excellence (CoE) as a strategy for improving RA treatment in Colombia. Methods: A cost description analysis was carried out using the standard costing technique. We estimated the costs of medical consultations, laboratories, images, and medications for RA. Categories of care standards stratified by severity were defined using the disease activity score in 28 joints (DAS28). We evaluated the impact, in terms of costs (US dollars), for providing RA clinical care for a previously described cohort using the CoE approach. Statistical analyses were performed in Microsoft Excel®, and R. Results: Expenditure on therapeutic drugs increases as the severity of RA increases. Drugs represent 53.6% of the total cost for the low disease activity (LDA) stage, 75.2% for moderate disease activity (MDA), 88.5% for severe disease activity (SDA) and 97% for SDA with biologic treatment (SDA+Biologic). Treating 968 patients would cost US$612,639 (US$487,978– 1,220,160) at baseline, per year. After a year of follow-up at the CoE, treating the same patients would cost US$388,765 (US$321,710– 708,476), which implies potential cost-savings of up to US$223,874 per year. Conclusion: The strategy of providing clinical care for RA through CoE can save US$231.3 per patient-per year. The results of our study show that CoE could greatly impact the public policies dealing with treatment of RA in Colombia. Applying the CoE model in our country would both improve health outcomes, as well as being more efficient in terms of costs.
publishDate	2021
dc.date.accessioned.none.fl_str_mv	2021-07-27T13:29:41Z
dc.date.available.none.fl_str_mv	2021-07-27T13:29:41Z
dc.date.issued.none.fl_str_mv	2021
dc.type.spa.fl_str_mv	Artículo de revista
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dc.identifier.doi.spa.fl_str_mv	https://doi.org/10.2147/CEOR.S308024
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dc.relation.references.spa.fl_str_mv	Nell VPK, Machold KP, Eberl G, Stamm TA, Uffmann M, Smolen JS. Benefit of very early referral and very early therapy with disease-modifying anti-rheumatic drugs in patients with early rheumatoid arthritis. Rheumatology. 2004;43(7):906–914. doi:10.1093/rheumatology/keh199 van der Linden MPM, Le Cessie S, Raza K, et al. Long‐term impact of delay in assessment of patients with early arthritis. Arthritis Rheumatol. 2010;62(12):3537–3546. doi:10.1002/art.27692 Puchner R, Hochreiter R, Pieringer H, Vavrovsky A. Improving patient flow of people with rheumatoid arthritis has the potential to simultaneously improve health outcomes and reduce direct costs. BMC Musculoskelet Disord. 2017;18(1):7. doi:10.1186/s12891-016-1362-7 Hogan DR, Stevens GA, Hosseinpoor AR, Boerma T. Monitoring universal health coverage within the Sustainable Development Goals: development and baseline data for an index of essential health services. Lancet Glob Heal. 2018;6(2):e152–68. doi:10.1016/S2214-109X(17)30472-2 Evans DB, Etienne C. Health systems financing and the path to universal coverage. Bull World Health Organ. 2010;88(6):402. doi:10.2471/BLT.10.078741 Amaya-Lara JL. Catastrophic expenditure due to out-of-pocket health payments and its determinants in Colombian households. Int J Equity Health. 2016;15(1):182. doi:10.1186/s12939-016-0472-z Castro-Rodríguez A, Machado-Duque ME, Gaviria-Mendoza A, Medina-Morales DA, Álvarez-vera T, Machado-Alba JE. Factors related to excessive polypharmacy (≥15 medications) in an outpatient population from Colombia. Int J Clin Pract. 2018;e13278. doi:10.1111/ijcp.13278 Santos-Moreno P, Castañeda O, Garro B, Flores D, Sánchez G, Castro C. From the model of integral attention to the creation of centers of excellence in rheumatoid arthritis. Clin Rheumatol. 2015;34(S1):71–77. doi:10.1007/s10067-015-3017-8 Santos-Moreno P, Galarza-Maldonado C, Caballero-Uribe CV, et al. REAL-PANLAR project for the implementation and accreditation of centers of excellence in rheumatoid arthritis throughout Latin America. JCR J Clin Rheumatol. 2015;21(4):175–180. doi:10.1097/RHU.0000000000000247 Smolen JS, Aletaha D, Bijlsma JWJ, et al. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis. 2012;69:631–637. doi:10.1136/ard.2009.123919 Smolen JS, Breedveld FC, Burmester GR, et al. Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force. Ann Rheum Dis. 2015;1–13. Cuenta de Alto Costo. Situación de la artritis reumatoide en Colombia [Internet]. 2017. ISSN: 2590–9037. Available from: https://cuentadealtocosto.org/site/download/situacion-de-la-artritis-reumatoide-en-colombia-2017/. Ministerio de Salud y Protección Social. Guía de Práctica Clínica para la detección temprana, diagnóstico y tratamiento de la artritis reumatoide. 2014. Alemao E, Al MJ, Boonen AA, et al. Conceptual model for the health technology assessment of current and novel interventions in rheumatoid arthritis. Nurmohamed M, editor. PLoS One. 2018;13(10):e0205013. doi:10.1371/journal.pone.0205013 Santos-Moreno P, Alvis-Zakzuk NJ, Villarreal-Peralta L, Carrasquilla-Sotomayor M, Paternina-Caicedo A, Alvis-Guzmán N. A comprehensive care program achieves high remission rates in rheumatoid arthritis in a middle-income setting. Experience of a Center of Excellence in Colombia. Rheumatol Int. 38(3):499–505. doi:10.1007/s00296-017-3903-2. Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the Economic Evaluation of Health Care Programmes. Oxford university press; 2015:445. Rovira J, Antoñanzas F. Economic analysis of health technologies and programmes. Pharmacoeconomics. 1995;8(3):245–252. doi:10.2165/00019053-199508030-00007 Hjelmgren J, Berggren F, Andersson F. Health economic guidelines—similarities, differences and some implications. Value Heal. 2001;4(3):225–250. doi:10.1046/j.1524-4733.2001.43040.x Loras C, Mayor V, Fernández-Bañares F, Esteve M. Study of the standard direct costs of various techniques of advanced endoscopy. Comparison with surgical alternatives. Dig Liver Dis. 2018;50(7):689–697. doi:10.1016/j.dld.2018.03.002 Amat O, Soldevila P, Aguilà S Contabilidad y gestión de costes. Profit; 2011. Instituto de Evaluación Tecnológica en Salud-IETS. Manual para la elaboración de evaluaciones económicas en salud. Bogotá - Colombia: Instituto de Evaluación Tecnológica en Salud; 2014. Instituto de Evaluación Tecnológica en Salud. Qué es el IETS. 2018. SISPRO. Sistema Integral de Información de la Protección Social. de la República B. Tasa de cambio representativa del mercado (TRM). Available from: https://www.banrep.gov.co/es/estadisticas/trm. Accessed May 17, 2021. Viegas Brenol C, Mendonça Silva da Chakr R, Pamplona Bueno Andrade N, et al. Daily practice feasibility and effectiveness of treating long-standing rheumatoid arthritis to target with synthetic disease-modifying antirheumatic drugs: a prospective cohort study. Clin Rheumatol. 2015;34(10):1781–1785. doi:10.1007/s10067-015-2915-0 Santos-Moreno PI, De La Hoz-valle J, Villarreal L, Palomino A, Sánchez G, Castro C. Treatment of rheumatoid arthritis with methotrexate alone and in combination with other conventional DMARDs using the T2T strategy. A cohort study. Clin Rheumatol. 2015;34(2):215–220. doi:10.1007/s10067-014-2794-9 Ling E, Ofer-Shiber S, Goren O, Molad Y. Outcome of patients with rheumatoid arthritis: cross-sectional study of a single-center real-world inception cohort. Isr Med Assoc J. 2013;15(12):758–762. Machado-Alba JE, Ruiz AF, Machado-Duque ME. Effectiveness of treatment with biologic- and disease-modifying antirheumatic drugs in rheumatoid arthritis patients in Colombia. Int J Clin Pract. 2016;70(6):506–511. doi:10.1111/ijcp.12809 Ministerio de Trabajo. Decreto número 2552 de 2015. 2015. Available from: https://www.funcionpublica.gov.co/eva/gestornormativo/norma.php?i=67555. Accessed May 17, 2021. Gamboa-Cárdenas RV, Ugarte-Gil MF, Loreto M, et al. Clinical predictors of remission and low disease activity in Latin American early rheumatoid arthritis: data from the GLADAR cohort. Clin Rheumatol. 2019;38(10):2737–2746. doi:10.1007/s10067-019-04618-x Hresko A, Lin T-C, Solomon DH. Medical care costs associated with rheumatoid arthritis in the US: a systematic literature review and meta-analysis. Arthritis Care Res (Hoboken). 2018;70(10):1431–1438. doi:10.1002/acr.23512 Baser O, Baser E, Altinbas A, Burkan A. Severity index for rheumatoid arthritis and its association with health care costs and biologic therapy use in Turkey. Health Econ Rev. 2013;3(1):5. doi:10.1186/2191-1991-3-5 Lakomek H-J, Krause A. “Treat-to-Target“ (T2T) aus der Sicht der stationären Rheumatologie. Z Rheumatol. 2011;70(8):656–663. doi:10.1007/s00393-011-0765-y Voshaar MJH, Nota I, Van De Laar MAFJ, Van Den Bemt BJF. Patient-centred care in established rheumatoid arthritis. Best Pract Res Clin Rheumatol. 2015;29(4–5):643–663. doi:10.1016/j.berh.2015.09.007 Bidaut-Russell M, Gabriel SE. Adverse gastrointestinal effects of NSAIDs: consequences and costs. Best Pract Res Clin Gastroenterol. 2001;15(5):739–753. doi:10.1053/bega.2001.0232 Instituto Nacional de Salud - Observatorio Nacional de Salud. Quinto Informe ONS: Carga de enfermedad por enfermedades crónicas no transmisibles y discapacidad en Colombia. (Pág. 160). Bogotá, DC: Imprenta Nacional de Colombia; 2015. Lenz-alcayaga R. Análisis de costos en evaluaciones económicas en salud: aspectos introductorios. 2010;138(Supl2):88–92. Bernal-Aguirre C, Carvajal-Sierra H, Alvis-Zakzuk NJ. Costos económicos de la infección respiratoria aguda en un Municipio de Colombia. Rev La Univ Ind Santander Salud. 2017;49(3):470–477. Rice DP. Estimating the Cost-Of-Illness. Washington, DC: US Department of Health, Education, and Welfare, Public Health Service; 1966.
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spelling	Santos-Moreno, PedroALVIS-ZAKZUK, NELSON J.Villarreal-Peralta, LauraCarrasquilla Sotomayor, Mariade la Hoz Restrepo, FernandoAlvis-Guzmán, Nelson2021-07-27T13:29:41Z2021-07-27T13:29:41Z2021https://hdl.handle.net/11323/8489https://doi.org/10.2147/CEOR.S308024Corporación Universidad de la CostaREDICUC - Repositorio CUChttps://repositorio.cuc.edu.co/Background: Health systems need to optimize the use of resources, especially in high-cost diseases as rheumatoid arthritis (RA). We aimed to evaluate the efficiency of using centers of excellence (CoE) as a strategy for improving RA treatment in Colombia. Methods: A cost description analysis was carried out using the standard costing technique. We estimated the costs of medical consultations, laboratories, images, and medications for RA. Categories of care standards stratified by severity were defined using the disease activity score in 28 joints (DAS28). We evaluated the impact, in terms of costs (US dollars), for providing RA clinical care for a previously described cohort using the CoE approach. Statistical analyses were performed in Microsoft Excel®, and R. Results: Expenditure on therapeutic drugs increases as the severity of RA increases. Drugs represent 53.6% of the total cost for the low disease activity (LDA) stage, 75.2% for moderate disease activity (MDA), 88.5% for severe disease activity (SDA) and 97% for SDA with biologic treatment (SDA+Biologic). Treating 968 patients would cost US$612,639 (US$487,978– 1,220,160) at baseline, per year. After a year of follow-up at the CoE, treating the same patients would cost US$388,765 (US$321,710– 708,476), which implies potential cost-savings of up to US$223,874 per year. Conclusion: The strategy of providing clinical care for RA through CoE can save US$231.3 per patient-per year. The results of our study show that CoE could greatly impact the public policies dealing with treatment of RA in Colombia. Applying the CoE model in our country would both improve health outcomes, as well as being more efficient in terms of costs.Santos-Moreno, Pedro-will be generated-orcid-0000-0001-7802-0317-600Alvis-Zakzuk, Nelson J-will be generated-orcid-0000-0001-9382-214X-600Villarreal-Peralta, LauraCarrasquilla Sotomayor, Mariade la Hoz Restrepo, FernandoAlvis-Guzmán, Nelson-will be generated-orcid-0000-0001-9458-864X-600application/pdfengAttribution-NonCommercial-NoDerivatives 4.0 Internationalhttp://creativecommons.org/licenses/by-nc-nd/4.0/info:eu-repo/semantics/openAccesshttp://purl.org/coar/access_right/c_abf2ClinicoEconomics and Outcomes Researchhttps://www.dovepress.com/centers-of-excellence-implementation-for-treating-rheumatoid-arthritis-peer-reviewed-fulltext-article-CEORrheumatoid arthritistreat to targetcost-savingscost-analysisCenters of excellence implementation for treating rheumatoid arthritis in Colombia: A cost-analysisArtículo de revistahttp://purl.org/coar/resource_type/c_6501http://purl.org/coar/resource_type/c_2df8fbb1Textinfo:eu-repo/semantics/articlehttp://purl.org/redcol/resource_type/ARTinfo:eu-repo/semantics/acceptedVersionNell VPK, Machold KP, Eberl G, Stamm TA, Uffmann M, Smolen JS. Benefit of very early referral and very early therapy with disease-modifying anti-rheumatic drugs in patients with early rheumatoid arthritis. Rheumatology. 2004;43(7):906–914. doi:10.1093/rheumatology/keh199van der Linden MPM, Le Cessie S, Raza K, et al. Long‐term impact of delay in assessment of patients with early arthritis. Arthritis Rheumatol. 2010;62(12):3537–3546. doi:10.1002/art.27692Puchner R, Hochreiter R, Pieringer H, Vavrovsky A. Improving patient flow of people with rheumatoid arthritis has the potential to simultaneously improve health outcomes and reduce direct costs. BMC Musculoskelet Disord. 2017;18(1):7. doi:10.1186/s12891-016-1362-7Hogan DR, Stevens GA, Hosseinpoor AR, Boerma T. Monitoring universal health coverage within the Sustainable Development Goals: development and baseline data for an index of essential health services. Lancet Glob Heal. 2018;6(2):e152–68. doi:10.1016/S2214-109X(17)30472-2Evans DB, Etienne C. Health systems financing and the path to universal coverage. Bull World Health Organ. 2010;88(6):402. doi:10.2471/BLT.10.078741Amaya-Lara JL. Catastrophic expenditure due to out-of-pocket health payments and its determinants in Colombian households. Int J Equity Health. 2016;15(1):182. doi:10.1186/s12939-016-0472-zCastro-Rodríguez A, Machado-Duque ME, Gaviria-Mendoza A, Medina-Morales DA, Álvarez-vera T, Machado-Alba JE. Factors related to excessive polypharmacy (≥15 medications) in an outpatient population from Colombia. Int J Clin Pract. 2018;e13278. doi:10.1111/ijcp.13278Santos-Moreno P, Castañeda O, Garro B, Flores D, Sánchez G, Castro C. From the model of integral attention to the creation of centers of excellence in rheumatoid arthritis. Clin Rheumatol. 2015;34(S1):71–77. doi:10.1007/s10067-015-3017-8Santos-Moreno P, Galarza-Maldonado C, Caballero-Uribe CV, et al. REAL-PANLAR project for the implementation and accreditation of centers of excellence in rheumatoid arthritis throughout Latin America. JCR J Clin Rheumatol. 2015;21(4):175–180. doi:10.1097/RHU.0000000000000247Smolen JS, Aletaha D, Bijlsma JWJ, et al. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis. 2012;69:631–637. doi:10.1136/ard.2009.123919Smolen JS, Breedveld FC, Burmester GR, et al. Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force. Ann Rheum Dis. 2015;1–13.Cuenta de Alto Costo. Situación de la artritis reumatoide en Colombia [Internet]. 2017. ISSN: 2590–9037. Available from: https://cuentadealtocosto.org/site/download/situacion-de-la-artritis-reumatoide-en-colombia-2017/.Ministerio de Salud y Protección Social. Guía de Práctica Clínica para la detección temprana, diagnóstico y tratamiento de la artritis reumatoide. 2014.Alemao E, Al MJ, Boonen AA, et al. Conceptual model for the health technology assessment of current and novel interventions in rheumatoid arthritis. Nurmohamed M, editor. PLoS One. 2018;13(10):e0205013. doi:10.1371/journal.pone.0205013Santos-Moreno P, Alvis-Zakzuk NJ, Villarreal-Peralta L, Carrasquilla-Sotomayor M, Paternina-Caicedo A, Alvis-Guzmán N. A comprehensive care program achieves high remission rates in rheumatoid arthritis in a middle-income setting. Experience of a Center of Excellence in Colombia. Rheumatol Int. 38(3):499–505. doi:10.1007/s00296-017-3903-2.Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the Economic Evaluation of Health Care Programmes. Oxford university press; 2015:445.Rovira J, Antoñanzas F. Economic analysis of health technologies and programmes. Pharmacoeconomics. 1995;8(3):245–252. doi:10.2165/00019053-199508030-00007Hjelmgren J, Berggren F, Andersson F. Health economic guidelines—similarities, differences and some implications. Value Heal. 2001;4(3):225–250. doi:10.1046/j.1524-4733.2001.43040.xLoras C, Mayor V, Fernández-Bañares F, Esteve M. Study of the standard direct costs of various techniques of advanced endoscopy. Comparison with surgical alternatives. Dig Liver Dis. 2018;50(7):689–697. doi:10.1016/j.dld.2018.03.002Amat O, Soldevila P, Aguilà S Contabilidad y gestión de costes. Profit; 2011.Instituto de Evaluación Tecnológica en Salud-IETS. Manual para la elaboración de evaluaciones económicas en salud. Bogotá - Colombia: Instituto de Evaluación Tecnológica en Salud; 2014.Instituto de Evaluación Tecnológica en Salud. Qué es el IETS. 2018.SISPRO. Sistema Integral de Información de la Protección Social.de la República B. Tasa de cambio representativa del mercado (TRM). Available from: https://www.banrep.gov.co/es/estadisticas/trm. Accessed May 17, 2021.Viegas Brenol C, Mendonça Silva da Chakr R, Pamplona Bueno Andrade N, et al. Daily practice feasibility and effectiveness of treating long-standing rheumatoid arthritis to target with synthetic disease-modifying antirheumatic drugs: a prospective cohort study. Clin Rheumatol. 2015;34(10):1781–1785. doi:10.1007/s10067-015-2915-0Santos-Moreno PI, De La Hoz-valle J, Villarreal L, Palomino A, Sánchez G, Castro C. Treatment of rheumatoid arthritis with methotrexate alone and in combination with other conventional DMARDs using the T2T strategy. A cohort study. Clin Rheumatol. 2015;34(2):215–220. doi:10.1007/s10067-014-2794-9Ling E, Ofer-Shiber S, Goren O, Molad Y. Outcome of patients with rheumatoid arthritis: cross-sectional study of a single-center real-world inception cohort. Isr Med Assoc J. 2013;15(12):758–762.Machado-Alba JE, Ruiz AF, Machado-Duque ME. Effectiveness of treatment with biologic- and disease-modifying antirheumatic drugs in rheumatoid arthritis patients in Colombia. Int J Clin Pract. 2016;70(6):506–511. doi:10.1111/ijcp.12809Ministerio de Trabajo. Decreto número 2552 de 2015. 2015. Available from: https://www.funcionpublica.gov.co/eva/gestornormativo/norma.php?i=67555. Accessed May 17, 2021.Gamboa-Cárdenas RV, Ugarte-Gil MF, Loreto M, et al. Clinical predictors of remission and low disease activity in Latin American early rheumatoid arthritis: data from the GLADAR cohort. Clin Rheumatol. 2019;38(10):2737–2746. doi:10.1007/s10067-019-04618-xHresko A, Lin T-C, Solomon DH. Medical care costs associated with rheumatoid arthritis in the US: a systematic literature review and meta-analysis. Arthritis Care Res (Hoboken). 2018;70(10):1431–1438. doi:10.1002/acr.23512Baser O, Baser E, Altinbas A, Burkan A. Severity index for rheumatoid arthritis and its association with health care costs and biologic therapy use in Turkey. Health Econ Rev. 2013;3(1):5. doi:10.1186/2191-1991-3-5Lakomek H-J, Krause A. “Treat-to-Target“ (T2T) aus der Sicht der stationären Rheumatologie. Z Rheumatol. 2011;70(8):656–663. doi:10.1007/s00393-011-0765-yVoshaar MJH, Nota I, Van De Laar MAFJ, Van Den Bemt BJF. Patient-centred care in established rheumatoid arthritis. Best Pract Res Clin Rheumatol. 2015;29(4–5):643–663. doi:10.1016/j.berh.2015.09.007Bidaut-Russell M, Gabriel SE. Adverse gastrointestinal effects of NSAIDs: consequences and costs. Best Pract Res Clin Gastroenterol. 2001;15(5):739–753. doi:10.1053/bega.2001.0232Instituto Nacional de Salud - Observatorio Nacional de Salud. Quinto Informe ONS: Carga de enfermedad por enfermedades crónicas no transmisibles y discapacidad en Colombia. (Pág. 160). Bogotá, DC: Imprenta Nacional de Colombia; 2015.Lenz-alcayaga R. Análisis de costos en evaluaciones económicas en salud: aspectos introductorios. 2010;138(Supl2):88–92.Bernal-Aguirre C, Carvajal-Sierra H, Alvis-Zakzuk NJ. 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Centers of excellence implementation for treating rheumatoid arthritis in Colombia: A cost-analysis

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