Maxime Verhoeven

163 Editorial; unravelling the cost of biological strategies in RA but also on the eye and interests of the beholder, i.e., stakeholder (see Figure). Of course, their interests are also determining choices in study design and methodology. For a Dutch hospital, financial data on prescribed bDMARD for outpatients, including biosimilars, are relevant. This would be different for hospitals in other countries, where bDMARDs are not paid for and delivered to outpatients by the hospital, or were bDMARD prices are set per region or the entire country, and all medication cost are reimbursed by the National Health Service system. 8,9 For RA patients, if they do not have to pay extra (i.e., beyond their health insurance) for the medications, quality of life and anti-disability effects of bDMARD strategy studies are the most relevant. For the Ministry of Health, control of the health budget, especially for the duration of its administration, is important, and probably most interesting will be results of budget impact analyses. For the government as a whole, as for the tax paying population, comprehensive cost-utility studies incorporating also indirect cost would be important. However, because reduction of expenditures for unemployment and for absenteeism, let alone for presenteeism, as a result of increased adequate use of bDMARD by RA patients is very difficult to estimate, and also because this would take an adequate period of many years to assess it fully, often not all indirect cost can be taken into account in these analyses. In conclusion, Müskens et al. are to be complemented with their study on real-world medication cost with relevant results for a Dutch hospital. The authors report a negative study result. However, the study might have had positive results with a more stable bDMARD prescription policy, and especially with a broader scope, which we would prefer, next to health-economic evaluations of novel treatment strategies. 8