Rheumatology

Rheumatoid Arthritis

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Randomized Controlled Trial Examining a Treat‐to‐Target Strategy in Rheumatoid Arthritis

clinical study insights by Vibeke Strand, MD, MACR, FACP

Overview

Clinical Study Title:
Implementation of Treat-to-Target for Rheumatoid Arthritis in the US: Analysis of Baseline Data From a Randomized Controlled Trial

Clinical Study Abstract:
OBJECTIVE: A treat-to-target (TTT) strategy is recommended in rheumatoid arthritis (RA). However, health care providers’ adherence to TTT in clinical practice remains unclear. We examined adherence to TTT in RA at US rheumatology sites.

METHODS: We used baseline information from the randomized controlled Treat-to-Target in RA: Collaboration to Improve Adoption and Adherence trial, which recruited 641 patients from 46 providers practicing at 11 US sites. We obtained data on the implementation of TTT, patient covariates, provider characteristics, and site variables. We examined the implementation of TTT using 4 cardinal features: recording a disease target, recording a disease activity measure, engaging in shared decision-making, and changing treatment if not at disease target. These features were assessed across sites and providers. We calculated a TTT implementation score as the percentage of features noted. We examined the association between patient, provider, and site covariates and TTT implementation score using proportional odds models.

RESULTS: The implementation of TTT at baseline was suboptimal: 64.3% of visits had none of the TTT components present, 33.1% had 1 component, 2.3% had 2 components, and 0.3% had all components. The implementation of TTT was significantly different across providers and sites (P < 0.0001 for all). In the multivariable model, we observed that more experience as a rheumatologist was associated with a higher implementation score (P = 0.01 for trend). Compared with fellows, providers with >20 years of experience in practice were more likely to have more TTT components recorded (odds ratio 7.68 [95% confidence interval 1.46-40.52]).

CONCLUSION: We found that adherence to a TTT strategy in RA was suboptimal, and it differed across providers and sites. 

Reference:
Yu Z, Lu B, Agosti J, et al. Implementation of treat-to-target for rheumatoid arthritis in the US: analysis of baseline data from a randomized controlled trial. Arthritis Care Res (Hoboken).2018;70(5):801-806.

Expert Commentary

Vibeke Strand, MD, MACR, FACP

Adjunct Clinical Professor, Division of Immunology/Rheumatology
Stanford University School of Medicine
Biopharmaceutical Consultant
Palo Alto, CA

“These data are disappointing but not surprising in that we understand some of the sources of TTT nonimplementation.” 

Vibeke Strand, MD

In the present analysis, TTT implementation rates were suboptimal, although researchers reported substantial variability in these rates, which may have been a reflection of the mix of different practice settings and practitioner characteristics. For instance, more experienced rheumatologists had higher rates of TTT implementation.

These data are disappointing but not surprising in that we understand some of the sources of TTT nonimplementation. For example, we have seen that patient-provider communication is often poor with respect to goal setting at the time of addition or changes in therapy. We published survey results in 2015 suggesting that many patients with RA have difficulty communicating their disease burden and treatment goals to their health care provider and that providers often do not discuss treatment goals or rationales for changes in therapy with their patients in sufficient detail. Despite this, patients do set goals for their treatment. Changing therapy is considered “a big deal” for many patients, and they usually take a benefit-risk approach to treatment changes.

There are multiple reasons why health care providers are not using TTT. In the present study, only 4 of 11 sites reported using disease activity measures at baseline. Thus, many clinicians lack an accurate baseline from which to gage the treatment target. It is possible, however, that assessments are actually being done without documentation, which would not be captured in most studies. There can be inconsistency, ambiguity, and inefficiency introduced with the use of the electronic medical record (EMR) to input disease activity measures. This is complicated by the fact that documentation requirements differ by country and by health care system (eg, prerequisites for biologic use). The Simple Disease Activity Index is fairly easy to perform once you have experience using it. However, it incorporates C-reactive protein (CRP), which may create inefficiencies because this requires subsequent data entry in the EMR. The Clinical Disease Activity Index and the Routine Assessment of Patient Index Data 3 (RAPID3) may offer easier and more convenient options, as they do not incorporate CRP or erythrocyte sedimentation rate. In fact, patients can complete the RAPID3 quickly while in the waiting room, and it takes only 5 seconds to calculate the score, so this may be a more practical tool for measuring disease activity in busy clinical settings.

References

Aletaha D, Smolen J. The Simplified Disease Activity Index (SDAI) and the Clinical Disease Activity Index (CDAI): a review of their usefulness and validity in rheumatoid arthritis. Clin Exp Rheumatol. 2005;23(5 Suppl 39):S100-S108.

Pincus T, Yazici Y, Bergman MJ. RAPID3, an index to assess and monitor patients with rheumatoid arthritis, without formal joint counts: similar results to DAS28 and CDAI in clinical trials and clinical care. Rheum Dis Clin North Am. 2009;35(4):773-778, viii.

Solomon DH, Lee SB, Zak A, et al. Implementation of treat-to-target in rheumatoid arthritis through a Learning Collaborative: rationale and design of the TRACTION trial. Semin Arthritis Rheum. 2016;46(1):81-87.

Strand V, Wright GC, Bergman MJ, Tambiah J, Taylor PC. Patient expectations and perceptions of goal-setting strategies for disease management in rheumatoid arthritis. J Rheumatol. 2015;42(11):2046-2054.

Vibeke Strand, MD, MACR, FACP

Adjunct Clinical Professor, Division of Immunology/Rheumatology
Stanford University School of Medicine
Biopharmaceutical Consultant
Palo Alto, CA

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