Dataset Information

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

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.

SUBMITTER: Yu Z

PROVIDER: S-EPMC5823714 | biostudies-literature | 2018 May

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

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

Yu Zhi Z Lu Bing B Agosti Jenifer J Bitton Asaf A Corrigan Cassandra C Fraenkel Liana L Harrold Leslie R LR Losina Elena E Katz Jeffrey N JN Solomon Daniel H DH

Arthritis care & research 20180412 5

<h4>Objective</h4>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.<h4>Methods</h4>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 imple ...[more]

PMID: 28834390

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Project description:IntroductionMagnetic resonance imaging (MRI) is increasingly used in patients with rheumatoid arthritis (RA) to determine residual inflammation after treatment and as a predictor of structural damage progression. Establishing an optimal threshold of inflammatory activity that predicts lower risk of structural damage progression may inform treatment decisions. This post hoc analysis investigated whether patients with RA at low risk of structural damage progression can be identified based on MRI inflammation thresholds.MethodsHand and wrist MRI was performed at baseline, and at months 6 and 12 in a phase 3b, randomized, active-controlled, double-blind trial of abatacept in early RA (AVERT). Pathologies were scored using the OMERACT RA MRI Score. Data were stratified into two risk subgroups (less and more severe inflammation) for structural damage progression (erosion change > 0.5) based on baseline inflammation. In this post hoc analysis, log odds ratios of probability of progression {adjusted for baseline Disease Activity Score in 28 joints [C-reactive protein; DAS28 (CRP)]} were compared between subgroups to test the performance of inflammation thresholds.ResultsThere were 351 randomized and treated patients with baseline MRIs, of whom 276 (78.6%) and 235 (67.0%) had MRIs available at months 6 and 12, respectively. The DAS28 (CRP)-adjusted probabilities of progression from baseline to month 12 based on scores at baseline, and from months 6 to 12 based on month 6 scores, were significantly lower among patients with less inflammation (P < 0.0001-0.0459), independent of clinical disease activity. Predefined thresholds of synovitis ≤ 3 (total score 21), osteitis ≤ 3 (total score 69) and total inflammation score (osteitis double-weighted) ≤ 9 were associated with a lower likelihood of structural damage progression in unadjusted analyses.ConclusionLevels of MRI-determined inflammatory activity below defined thresholds were independently associated with a lower risk of structural damage progression in early RA, providing a potential trial endpoint for levels of inflammation not associated with progression.Trial registrationClinicalTrials.gov identifier, NCT01142726.FundingBristol-Myers Squibb.

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Project description:IntroductionIn collaboration with the Alberta Medical Association's Physician Learning Program we developed individualized physician reports and held a group feedback session on rheumatoid arthritis (RA) performance measures (PM) to facilitate treat-to-target (T2T) strategies and evaluated physician experiences with this process.Methods5 PMs addressing T2T concepts from an established Canadian quality framework were operationalized for physician practice reports at 2 university-affiliated rheumatology clinics. Rheum4U, a quality improvement and research platform, was the data source. The audit results were reviewed in a facilitated group feedback session. Rheumatologists provided experiential feedback on the process through survey and/or an interview. Transcripts from interviews were analyzed using a 6-step thematic analysis.Results11 of 12 eligible rheumatologists consented to receive practice reports and provided feedback through surveys (n = 5) and interviews (n = 6). The practice reports from Rheum4U (n = 448 patients) revealed high rates of yearly follow-up (> 85%, PM1) and 100% performance on documentation of disease activity at ≥ 50% of visits (PM2). Only 34% of patients were seen within 3 months if not in remission (PM3) with 62% (2017) and 69% (2018) of those with active RA achieving a LDA state within 6 months (PM4). Approximately 70% of patients were in remission at any time point (PM5). All survey respondents agreed or strongly agreed comparison to peers was valuable and helped them reflect on their practice. Several strategies for improvement were identified, including but not limited to, leveraging of electronic records for future audit and feedback reports, providing additional granularity of results, additional stratification of results, and using high-performing peers as the comparator rather than the group mean.ConclusionsAudit and feedback was perceived by clinicians as a useful strategy for evaluating T2T efforts in RA. Future work will focus on longitudinal evaluation of the clinical impact of this quality improvement initiative.

Dataset Information

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

Objective

Methods

Results

Conclusion

Publications

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

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