User login
Adjustment of disease-modifying antirheumatic drug (DMARD) therapy is not happening quickly enough for a substantial minority of rheumatoid arthritis patients with moderate to high disease activity, according to the findings of a registry study that is the first to evaluate this association.
Investigators led by Yomei Shaw, PhD, a research fellow with the National Data Bank for Rheumatic Diseases, retrospectively analyzed data from 538 patients in the university’s Rheumatoid Arthritis Comparative Effectiveness Research (RACER) registry who had moderate to high disease activity. Dr. Shaw conducted the study as a doctoral student in the department of health policy and management at the University of Pittsburgh.
In 40% of patients who had persistent disease activity of this severity, clinicians waited more than the 90 days recommended by treat-to-target (T2T) guidelines to adjust DMARDs, according to published results (Arthritis Care Res. 2017 Sep 21. doi: 10.1002/acr.23418). Such delay was more common for certain groups, including those on biologics and those who had rheumatoid arthritis (RA) for longer.
Compared with peers whose therapy was adjusted sooner, patients with such delayed adjustment were about one-quarter less likely to achieve low disease activity or remission during follow-up.
“The results of our survival analyses suggest that delays in DMARD adjustment of more than 3 months are common among RA patients with [moderate to high disease activity], highlighting an important potential gap in quality of care for these patients,” Dr. Shaw and her colleagues wrote.
They acknowledge that some of the delays in adjustment may have been unavoidable. For example, patients on biologic DMARDs may have needed insurance approval to start a new biologic, and patients with long-standing disease may have had fewer options remaining or symptoms that clinicians attributed to irreversible joint damage.
The study’s findings provide additional evidence of the importance of timely, guideline-adherent DMARD adjustment in reducing the amount of time patients spend in moderate to high disease activity, the investigators further contend.
“Promoting T2T in clinical practice requires coordinated change at the system, rheumatology practice, and individual levels,” such as consistently documenting the treatment target, assessing disease activity at every visit, and mandating a minimum visit frequency, they conclude.
Dr. Shaw and her colleagues studied patients having moderate to high disease activity, defined according to the 28-joint Disease Activity Score with C-reactive protein criteria (score of greater than 3.2).
The investigators reported a median time to adjustment of DMARD therapy of 154 days during 943.5 patient-years of follow-up. These adjustments could be adding, switching, or increasing the dose of a DMARD medication (excluding corticosteroids).
In multivariate analysis, patients had a longer time to DMARD adjustment if they were aged 75 years or older (subdistribution hazard ratio, 0.61; P = .02), had lower baseline disease activity (0.72; P less than .01), had longer duration of rheumatoid arthritis (0.98; P less than .01), or were receiving a biologic DMARD at baseline (0.71; P less than .01).
The median time to achieving low disease activity or remission was 301 days for the entire cohort. Patients had a longer time to achieve this goal if their DMARD therapy was not adjusted within 90 days (hazard ratio, 0.76; P = .01) or if they were African American (0.63; P = .01) or had higher baseline disease activity (0.75; P less than .01). They had a shorter time if they had better mental health (1.01; P = .03) or physical health (1.01; P = .02) as assessed with the 12-item Short Form Health Survey.
One of the study authors received research funding from Genentech and is currently employed by AbbVie. The registry used was funded by the National Institutes of Health and Genentech.
Randomized controlled trials demonstrate that statin lipid–lowering drugs reduce repeat cardiovascular events. Based on this evidence, clinicians agree that the vast majority of patients should receive statin lipid-lowering drugs after a CV event, and that providers not prescribing statins to these patients are providing suboptimal care.
By analogy, the data provided in this new analysis by Shaw and her colleagues suggests that many rheumatologists are providing suboptimal care. Many randomized, controlled trials testing a treat-to-target (T2T) paradigm demonstrate the clinical benefits of changing treatments for patients with rheumatoid arthritis who are in moderate or high disease activity. Yet, this analysis found many patients do not change treatments despite poor disease control. While the current study does not examine the reasons for suboptimal care, some correlates include:
• Patient preference to not change treatment;
• Provider desire to give treatments more time to work; and
• Health system issues such as drug payment complexities.
Continuing medical education may be necessary, but it is not a sufficient lever to push providers to implement T2T. Audit and feedback – providing individual providers with their performance metrics – alerts rheumatic disease providers when improvement is necessary. Yet, most providers need specific strategies within their practice to implement T2T. Collaborative learning between providers with a common purpose and coaches that understand the complexities of implementing T2T have been shown in the recently published TRACTION trial to produce improvements (Arthritis Rheumatol. 2017;69[7]:1374-80). The article by Shaw and her colleagues should sound the alarm to rheumatic disease providers: Care for RA needs improving if we want to produce optimal outcomes.
Daniel H. Solomon, MD, is a professor of medicine at Harvard University, and chief of the section of clinical sciences in the division of rheumatology at Brigham and Women’s Hospital, both in Boston. He has no relevant disclosures.
Randomized controlled trials demonstrate that statin lipid–lowering drugs reduce repeat cardiovascular events. Based on this evidence, clinicians agree that the vast majority of patients should receive statin lipid-lowering drugs after a CV event, and that providers not prescribing statins to these patients are providing suboptimal care.
By analogy, the data provided in this new analysis by Shaw and her colleagues suggests that many rheumatologists are providing suboptimal care. Many randomized, controlled trials testing a treat-to-target (T2T) paradigm demonstrate the clinical benefits of changing treatments for patients with rheumatoid arthritis who are in moderate or high disease activity. Yet, this analysis found many patients do not change treatments despite poor disease control. While the current study does not examine the reasons for suboptimal care, some correlates include:
• Patient preference to not change treatment;
• Provider desire to give treatments more time to work; and
• Health system issues such as drug payment complexities.
Continuing medical education may be necessary, but it is not a sufficient lever to push providers to implement T2T. Audit and feedback – providing individual providers with their performance metrics – alerts rheumatic disease providers when improvement is necessary. Yet, most providers need specific strategies within their practice to implement T2T. Collaborative learning between providers with a common purpose and coaches that understand the complexities of implementing T2T have been shown in the recently published TRACTION trial to produce improvements (Arthritis Rheumatol. 2017;69[7]:1374-80). The article by Shaw and her colleagues should sound the alarm to rheumatic disease providers: Care for RA needs improving if we want to produce optimal outcomes.
Daniel H. Solomon, MD, is a professor of medicine at Harvard University, and chief of the section of clinical sciences in the division of rheumatology at Brigham and Women’s Hospital, both in Boston. He has no relevant disclosures.
Randomized controlled trials demonstrate that statin lipid–lowering drugs reduce repeat cardiovascular events. Based on this evidence, clinicians agree that the vast majority of patients should receive statin lipid-lowering drugs after a CV event, and that providers not prescribing statins to these patients are providing suboptimal care.
By analogy, the data provided in this new analysis by Shaw and her colleagues suggests that many rheumatologists are providing suboptimal care. Many randomized, controlled trials testing a treat-to-target (T2T) paradigm demonstrate the clinical benefits of changing treatments for patients with rheumatoid arthritis who are in moderate or high disease activity. Yet, this analysis found many patients do not change treatments despite poor disease control. While the current study does not examine the reasons for suboptimal care, some correlates include:
• Patient preference to not change treatment;
• Provider desire to give treatments more time to work; and
• Health system issues such as drug payment complexities.
Continuing medical education may be necessary, but it is not a sufficient lever to push providers to implement T2T. Audit and feedback – providing individual providers with their performance metrics – alerts rheumatic disease providers when improvement is necessary. Yet, most providers need specific strategies within their practice to implement T2T. Collaborative learning between providers with a common purpose and coaches that understand the complexities of implementing T2T have been shown in the recently published TRACTION trial to produce improvements (Arthritis Rheumatol. 2017;69[7]:1374-80). The article by Shaw and her colleagues should sound the alarm to rheumatic disease providers: Care for RA needs improving if we want to produce optimal outcomes.
Daniel H. Solomon, MD, is a professor of medicine at Harvard University, and chief of the section of clinical sciences in the division of rheumatology at Brigham and Women’s Hospital, both in Boston. He has no relevant disclosures.
Adjustment of disease-modifying antirheumatic drug (DMARD) therapy is not happening quickly enough for a substantial minority of rheumatoid arthritis patients with moderate to high disease activity, according to the findings of a registry study that is the first to evaluate this association.
Investigators led by Yomei Shaw, PhD, a research fellow with the National Data Bank for Rheumatic Diseases, retrospectively analyzed data from 538 patients in the university’s Rheumatoid Arthritis Comparative Effectiveness Research (RACER) registry who had moderate to high disease activity. Dr. Shaw conducted the study as a doctoral student in the department of health policy and management at the University of Pittsburgh.
In 40% of patients who had persistent disease activity of this severity, clinicians waited more than the 90 days recommended by treat-to-target (T2T) guidelines to adjust DMARDs, according to published results (Arthritis Care Res. 2017 Sep 21. doi: 10.1002/acr.23418). Such delay was more common for certain groups, including those on biologics and those who had rheumatoid arthritis (RA) for longer.
Compared with peers whose therapy was adjusted sooner, patients with such delayed adjustment were about one-quarter less likely to achieve low disease activity or remission during follow-up.
“The results of our survival analyses suggest that delays in DMARD adjustment of more than 3 months are common among RA patients with [moderate to high disease activity], highlighting an important potential gap in quality of care for these patients,” Dr. Shaw and her colleagues wrote.
They acknowledge that some of the delays in adjustment may have been unavoidable. For example, patients on biologic DMARDs may have needed insurance approval to start a new biologic, and patients with long-standing disease may have had fewer options remaining or symptoms that clinicians attributed to irreversible joint damage.
The study’s findings provide additional evidence of the importance of timely, guideline-adherent DMARD adjustment in reducing the amount of time patients spend in moderate to high disease activity, the investigators further contend.
“Promoting T2T in clinical practice requires coordinated change at the system, rheumatology practice, and individual levels,” such as consistently documenting the treatment target, assessing disease activity at every visit, and mandating a minimum visit frequency, they conclude.
Dr. Shaw and her colleagues studied patients having moderate to high disease activity, defined according to the 28-joint Disease Activity Score with C-reactive protein criteria (score of greater than 3.2).
The investigators reported a median time to adjustment of DMARD therapy of 154 days during 943.5 patient-years of follow-up. These adjustments could be adding, switching, or increasing the dose of a DMARD medication (excluding corticosteroids).
In multivariate analysis, patients had a longer time to DMARD adjustment if they were aged 75 years or older (subdistribution hazard ratio, 0.61; P = .02), had lower baseline disease activity (0.72; P less than .01), had longer duration of rheumatoid arthritis (0.98; P less than .01), or were receiving a biologic DMARD at baseline (0.71; P less than .01).
The median time to achieving low disease activity or remission was 301 days for the entire cohort. Patients had a longer time to achieve this goal if their DMARD therapy was not adjusted within 90 days (hazard ratio, 0.76; P = .01) or if they were African American (0.63; P = .01) or had higher baseline disease activity (0.75; P less than .01). They had a shorter time if they had better mental health (1.01; P = .03) or physical health (1.01; P = .02) as assessed with the 12-item Short Form Health Survey.
One of the study authors received research funding from Genentech and is currently employed by AbbVie. The registry used was funded by the National Institutes of Health and Genentech.
Adjustment of disease-modifying antirheumatic drug (DMARD) therapy is not happening quickly enough for a substantial minority of rheumatoid arthritis patients with moderate to high disease activity, according to the findings of a registry study that is the first to evaluate this association.
Investigators led by Yomei Shaw, PhD, a research fellow with the National Data Bank for Rheumatic Diseases, retrospectively analyzed data from 538 patients in the university’s Rheumatoid Arthritis Comparative Effectiveness Research (RACER) registry who had moderate to high disease activity. Dr. Shaw conducted the study as a doctoral student in the department of health policy and management at the University of Pittsburgh.
In 40% of patients who had persistent disease activity of this severity, clinicians waited more than the 90 days recommended by treat-to-target (T2T) guidelines to adjust DMARDs, according to published results (Arthritis Care Res. 2017 Sep 21. doi: 10.1002/acr.23418). Such delay was more common for certain groups, including those on biologics and those who had rheumatoid arthritis (RA) for longer.
Compared with peers whose therapy was adjusted sooner, patients with such delayed adjustment were about one-quarter less likely to achieve low disease activity or remission during follow-up.
“The results of our survival analyses suggest that delays in DMARD adjustment of more than 3 months are common among RA patients with [moderate to high disease activity], highlighting an important potential gap in quality of care for these patients,” Dr. Shaw and her colleagues wrote.
They acknowledge that some of the delays in adjustment may have been unavoidable. For example, patients on biologic DMARDs may have needed insurance approval to start a new biologic, and patients with long-standing disease may have had fewer options remaining or symptoms that clinicians attributed to irreversible joint damage.
The study’s findings provide additional evidence of the importance of timely, guideline-adherent DMARD adjustment in reducing the amount of time patients spend in moderate to high disease activity, the investigators further contend.
“Promoting T2T in clinical practice requires coordinated change at the system, rheumatology practice, and individual levels,” such as consistently documenting the treatment target, assessing disease activity at every visit, and mandating a minimum visit frequency, they conclude.
Dr. Shaw and her colleagues studied patients having moderate to high disease activity, defined according to the 28-joint Disease Activity Score with C-reactive protein criteria (score of greater than 3.2).
The investigators reported a median time to adjustment of DMARD therapy of 154 days during 943.5 patient-years of follow-up. These adjustments could be adding, switching, or increasing the dose of a DMARD medication (excluding corticosteroids).
In multivariate analysis, patients had a longer time to DMARD adjustment if they were aged 75 years or older (subdistribution hazard ratio, 0.61; P = .02), had lower baseline disease activity (0.72; P less than .01), had longer duration of rheumatoid arthritis (0.98; P less than .01), or were receiving a biologic DMARD at baseline (0.71; P less than .01).
The median time to achieving low disease activity or remission was 301 days for the entire cohort. Patients had a longer time to achieve this goal if their DMARD therapy was not adjusted within 90 days (hazard ratio, 0.76; P = .01) or if they were African American (0.63; P = .01) or had higher baseline disease activity (0.75; P less than .01). They had a shorter time if they had better mental health (1.01; P = .03) or physical health (1.01; P = .02) as assessed with the 12-item Short Form Health Survey.
One of the study authors received research funding from Genentech and is currently employed by AbbVie. The registry used was funded by the National Institutes of Health and Genentech.
FROM ARTHRITIS CARE & RESEARCH
Key clinical point:
Major finding: In 40% of patients who had persistent disease activity of this severity, clinicians waited more than the 90 days recommended by treat-to-target guidelines to adjust DMARDs.
Data source: A retrospective cohort study of 538 patients with RA having moderate to high disease activity.
Disclosures: One of the study authors received research funding from Genentech and is currently employed by AbbVie. The study registry used was funded by the National Institutes of Health and Genentech.