This report by Leslie R. Harrold, MD, MPH, and colleagues is an interesting analysis that I think everybody should read. The authors examined contemporary outcomes in patients with rheumatoid arthritis (RA) using the Consortium of Rheumatology Researchers of North America (CORRONA) database, comparing treat-to-target (TTT) care with standard of care. TTT exploits the benefits of early, aggressive treatment, whereby the clinician is sufficiently aggressive with advancing treatment to achieve sequentially monitored goals, such as remission or low disease activity.

Top-line results from the present study show that today, in the United States, where novel therapies are readily available and widely used and where patient visits occur relatively frequently, it is actually difficult to discern outcome differences between “usual care” and TTT care.

While TTT principles are ensconced in routine clinical practice for entities such as diabetes, hypertension, and hyperlipidemia, questions arise about the appropriate translation of TTT care to RA. Further, while there is a growing consensus that a TTT approach optimizes clinical outcomes in patients with RA, the seminal studies demonstrating the effectiveness of this type of care were performed in a previous treatment era. Further, many of them were conducted in Europe in accordance with health care systems and patient-physician constructs that, at times, can be quite distinct from those here in the United States. The question then becomes what to make of these findings. One possibility is that usual care today in the United States is essentially TTT-like care. Indeed, Harrold and colleagues noted that the number of visits among individuals in the usual care group suggests that many of them were actually receiving TTT-like care. Additionally, whether the approach is considered usual care or TTT, the continued need for advancing therapy and for switching therapy seems to transcend these definitions. That is, patients with RA do not stay on a specific therapy for longer than approximately 2 years, with some fairly uncommon exceptions. In usual care settings, one might expect to find less of a focus on achieving such stringently defined assessments of tight disease control. And yet, we still see that many patients are not able to stay on a given therapy for a number of years—and this is true across settings. 

Still, this topic is an interesting one that deserves further investigation and discussion. Results of this study may be a good indication that we are doing a fairly good job taking care of our patients with RA, at least in terms of meeting targets and controlling core disease manifestations.