Prescribing practices in a US cohort of rheumatoid arthritis patients before and after publication of the American College of Rheumatology treatment recommendations

Challenges in implementing treat-to-target in rheumatoid arthritis: a perspective from Brazilian rheumatologists

BACKGROUND

Patient management in rheumatoid arthritis (RA) has evolved to a "treat-to-target" (T2T) approach, which entails intensive treatment and regular follow-up with the goal of achieving low levels of disease activity or clinical remission. Even though a T2T approach is endorsed by professional organizations and yields superior outcomes, its implementation remains incomplete. EVEREST (EleVatE care in RhEumatoid arthritiS with Treat-to-target) is a quality-improvement initiative designed to improve the widespread implementation of a personalized T2T strategy and enable patients with RA to reach their full potential for remission. We describe the Brazilian results from the Global T2T Survey, first part of the EVEREST program.

METHODS

Between June and September 2022, we conducted an online survey targeting rheumatologists in Brazil. Our objective was to evaluate the barriers and knowledge gaps hindering the effective implementation of T2T strategies. To achieve this, we employed a set of multiple-choice questions specifically crafted to elicit responses categorized in a structured order.

RESULTS

166 rheumatologists participated in the survey, 51% of them with more than 21 years of experience in rheumatology. Regarding the perceived challenges in the management of RA in clinical practice, the highest percentage of agreement/strong agreement among the participants was related to the contradictory results of disease activity measures (60%). In terms of the main barriers to assess the disease activity in clinical practice, the lack of adherence to treatment and contradictory assessments between patient-reported outcomes and composite measures were indicated by 75% and 59% of the participants, respectively, as a moderate/serious barrier. The most frequently knowledge and skill gaps related to the management of RA pointed out by the participants were on the difficulty to assess patients' health literacy (54% stated to have no more than intermediate knowledge on standardized methods to assess it and 43% no more than intermediate skills on determining the level of health literacy of the patients). In general, the use of tools to support the management of RA patients in clinical practice was indicated to be unusual by the participants. Self-reflection questionnaires, patient education materials and treatment consideration checklists were pointed out as the least frequently used tools (85%, 64% and 62% of the participants stated to use them never, rarely, or only sometimes, respectively).

CONCLUSIONS

Our findings indicate a greater need for design, selection, and uptake of practical strategies to further improve communication between healthcare providers and patients with RA, as well as for promoting well-informed, collaborative decision-making in their care.

Understanding Heterogeneity in Patients' Conceptualisation of Treatment for Rheumatoid Arthritis: A Cluster Analysis

OBJECTIVE

Uptake of treat-to-target (TTT) strategies for rheumatoid arthritis (RA) management is low. Our objective was to understand the heterogeneity in patients' conceptualisation of RA treatment to inform interventions improving TTT uptake.

DESIGN

Eligible participants recruited from an online research registry rated 56 items (on 5-point scales) reflecting concepts raised from patient interviews. Using items describing adhering to physician recommendations to create a binary criterion variable for medication adherence, we conducted a principal components analysis on the remaining items using Varimax rotation, describing how these factors predict adherence over and above demographic characteristics. We further use optimal sets in regression to identify the individual concepts that are most predictive of medication adherence.

RESULTS

We found significant heterogeneity in patients' conceptualisation of RA treatment among 621 persons with RA. A scree plot revealed a four-factor solution explained 38.4% of the variance. The four factors expected to facilitate TTT uptake were (% variance explained): (1) Access to high quality care and support (11.3%); (2) low decisional conflict related to changing disease-modifying antirheumatic drugs (DMARDs) (10.1%); (3) endorsement of a favourable DMARD risk/benefit ratio (9.9%); and (4) confidence that testing reflects disease activity (7.2%). These factors account for 13.8% of the variance in full medication adherence, fully explaining the only significant demographic predictor, age of the patient. The individual items most predictive of poor adherence centre on the lack of effective patient-physician communication, specifically insufficient access to information from rheumatologists, along with the need to seek information elsewhere.

CONCLUSION

Patients' conceptualisation of RA treatment varies; however, almost all patients have difficulty escalating DMARDs, even with access to quality information and an understanding of the benefits of TTT. Tailored interventions are needed to address patient hesitancy to escalate DMARDs.

Rheumatologist and Patient Mental Models for Treatment of Rheumatoid Arthritis Help Explain Low Treat-to-Target Rates

OBJECTIVE

Despite proven benefits, less than half of patients with rheumatoid arthritis (RA) are treated using a treat-to-target (TTT) strategy. Our objective was to identify critical discrepancies between rheumatologist and patient mental models related to the treatment of RA to inform interventions designed to increase implementation of TTT.

METHODS

We developed rheumatologist and patient mental models using the Mental Models Approach to Risk Communication. We conducted semistructured interviews to elicit views related to RA treatment decisions with 14 rheumatologists and 30 patients with RA. We also included responses (n = 284) to an open-ended question on a survey fielded to augment qualitative descriptions from the interviews. Interviews were transcribed and coded independently by two members of the research team.

RESULTS

Rheumatologist and patient mental models for RA treatment are significantly more complex than the TTT model. Both consider domains (system factors and patient readiness) outside of disease activity measurement, target setting, and risk versus benefit assessment in their decision-making. Furthermore, specific factors were found to be unique to each model. For example, the physician model stresses the importance of evaluating disease activity over time and patient adherence. In contrast, patients discussed the impact of chronic disease weariness, medication-related fatigue, the importance of feeling adequately informed, and stress associated with changing medications.

CONCLUSION

We found several discrepancies primarily related to information gaps and differences in how patients and physicians value trade-offs that can serve as specific targets to improve patient-physician communication and ultimately inform interventions to improve uptake of TTT.

Treating-to-target in rheumatology: Theory and practice

Despite its inclusion in current treatment recommendations, adherence to the treat-to-target strategy (T2T) is still poor. Among the issues are the definition(s) of target, especially the caveats of the patient global assessment (PGA), included in all recommended definitions of remission. The PGA is poorly related to inflammation, especially at low levels of disease activity, rather being a measure of the disease impact. Up to 60% of all patients otherwise in remission still score PGA at >1 and as high as 10. These patients (PGA-near-remission) are exposed to overtreatment if current recommendations are strictly followed and will continue to endure significant impact, unless adjuvant measures are implemented. A proposed method to overcome both these risks is to systematically pursue two targets: one focused on the disease process (the biological target) and another focused on the symptoms and impact (the impact target), the dual-target strategy. Candidate instruments to define each of these targets are discussed.

Evaluation of an Intervention to Support Patient-Rheumatologist Conversations About Escalating Treatment in Patients with Rheumatoid Arthritis: A Proof-of-Principle Study

Objective

This study’s objective was to test whether an online video intervention discussing appropriate treatment escalation improves willingness to change treatment in people living with rheumatoid arthritis (RA).

Methods

We conducted a controlled, randomized trial among patients with RA enrolled in ArthritisPower, a United States patient registry. We recruited participants by email and surveyed their assessment of disease activity (patient global), satisfaction with disease control (patient acceptable symptom state), attitudes about RA medications, decisional conflict (decisional conflict scale), and willingness to modify RA treatment (choice predisposition scale, higher scores are better) if or when recommended by their rheumatologist. Intervention groups watched educational videos relevant to a treat‐to‐target (T2T) strategy, whereas control groups viewed vaccination‐related videos as an “attention control.” We compared the between‐group difference in patients’ willingness to modify RA treatment (primary outcome) and difference in decisional conflict about changing RA treatment (secondary outcome) after watching the videos using t tests.

Results

Participants with self‐reported RA (n = 208) were 90% White and 90% women, with a mean (standard deviation) age of 50 (11) years, and 52% reported familiarity with the RA T2T strategy. We found a significant improvement in between‐group difference in willingness to change RA treatment among intervention versus control participants (0.49 [95% confidence interval 0.09‐0.88], P = 0.02). The effect size (Glass’s delta) for the intervention was 0.48. Decisional conflict about treatment change decreased, but the between‐group difference was not significant.

Conclusion

This novel educational patient‐directed intervention discussing appropriate treatment escalation was associated with improved willingness to change RA treatment if or when recommended by a rheumatologist. Further studies should evaluate whether this change in patients’ predisposition translates into actual treatment escalation.

Rheumatoid arthritis serotype and synthetic disease-modifying anti-rheumatic drugs in patients with periodontitis: A case-control study

Patients with rheumatoid arthritis (RA) experience a higher prevalence of periodontitis. This study aimed to examine the variation of periodontitis experienced with different serotypes suffered by RA patients and to examine the relationship between the different medications taken for RA that may influence this relationship. Two hundred and sixty RA and control participants underwent standardized periodontal examinations. Medical, serological and radiological (Sharp/van der Heijde) records were assessed. Functional status was assessed using the administered Health Assessment Questionnaire. Moreover, disease parameters, including disease activity (DAS28-ESR) and anti-citrullinated protein antibodies (ACPA) and rheumatoid factor (RF) seropositivity were evaluated. Periodontitis was higher in RA (71.54%) compared with controls (54.62%). The stage of periodontitis experienced by ACPA-positive participants were higher than APCA-negative participants. The probing pocket depth and recession experienced by RF-positive participants were higher than those who were RF-negative. RA participants on methotrexate had lower clinical attachment loss and lower periodontal probing depth compared with participants on a combination methotrexate and other disease-modifying antirheumatic drugs. Participants taking corticosteroids had lower gingival index scores. The association between seropositivity and the type of medications taken with periodontal health parameters in this group of patients suggests that both seropositivity and medications taken are important modifiers in the relationship between periodontitis and RA.

Co-Design of a Disease Activity Based Self-Management Approach for Patients with Rheumatoid Arthritis

Objective:

The systematic development of an intervention to improve disease activity-based management of rheumatoid arthritis (RA) in daily clinical practice that is based on patient-level barriers.

Methods:

The self-management strategy was developed through a step-wise approach, in a process of co-design with all stakeholders and by addressing patient level barriers to RA management based on disease activity.

Results:

The resulting DAS-pass strategy consists of decision supportive information and guidance by a specialised rheumatology nurse. It aims to increase patients’ knowledge on DAS28, to empower patients to be involved in disease management, and to improve patients’ medication beliefs. The decision supportive information includes an informational leaflet and a patient held record. The nurse individualises the information, stimulates patients to communicate about disease activity, and offers the opportunity for questions or additional support.

Conclusion:

The DAS-pass strategy was found helpful by stakeholders. It can be used to improve RA daily clinical practice. Our systematic approach can be used to improve patient knowledge and self-management on other RA related topics. Also, it can be used to improve the management of other chronic conditions. We therefore provide a detailed description of our methodology to assist those interested in developing an evidence-based strategy for educating and empowering patients.

Rheumatoid Arthritis Real-world Management Over 20 Years

Clinical trials show which treatments improve rheumatoid arthritis (RA), whereas observational studies show how patients are managed in routine practice. Prospective cohort studies give the most detailed information about what happens to patients, but being a part of a prospective study influences patient management because patients are no longer routine cases.

A patient-centered knowledge translation tool for treat-to-target strategy in rheumatoid arthritis: Patient and rheumatologist perspectives

AIM

Implementation of treat-to-target (T2T) for rheumatoid arthritis (RA) presents many challenges and an evidence-practice gap has emerged. This study assessed clinician and patient barriers to the implementation of an RA-T2T strategy and developed a knowledge translation (KT) tool for use in "real-life" clinical settings.

METHODS

Surveys of patients and rheumatologists measured agreement with RA-T2T recommendations and use in daily practice. Patient knowledge and perceptions were assessed as was clinician willingness to alter practice and barriers to RA-T2T using visual analog scales. An electronic KT-tool was developed and a two-phase usability trial undertaken to assess use in clinical interactions.

RESULTS

Ninety-one percent of patients had no prior knowledge of RA-T2T but agreed with the recommendations showing mean level agreement scores (8.39-9.54, SD 2.37-1.54). Ninety percent were willing to try RA-T2T, 49% felt their treatment could be improved and 28% wanted more involvement in treatment decisions. Rheumatologists agreed with RA-T2T recommendations (7.30-9.27, SD 2.59-0.91). Barriers to implementation identified by rheumatologists included time, appointment availability and perceived patient reluctance to escalate medications. Usability experiences with the KT-tool were tracked and clinicians reported it was easy to use (100%), resulted in a discussion of RA-T2T (73%) and a target being set for 63% of consults. Patients reported they read (92%) and understood (87%) the information in the KT-tool, and that a target was set in 62% of interactions.

CONCLUSIONS

RA-T2T uptake in clinical practice may be improved through understanding local clinician and patient barriers and an implementation strategy utilizing a patient-driven KT-tool.

Validation of the adjusted multi-biomarker disease activity score as a prognostic test for radiographic progression in rheumatoid arthritis: a combined analysis of multiple studies

BACKGROUND

The multi-biomarker disease activity (MBDA) test measures 12 serum protein biomarkers to quantify disease activity in RA patients. A newer version of the MBDA score, adjusted for age, sex, and adiposity, has been validated in two cohorts (OPERA and BRASS) for predicting risk for radiographic progression. We now extend these findings with additional cohorts to further validate the adjusted MBDA score as a predictor of radiographic progression risk and compare its performance with that of other risk factors.

METHODS

Four cohorts were analyzed: the BRASS and Leiden registries and the OPERA and SWEFOT studies (total N = 953). Treatments included conventional DMARDs and anti-TNFs. Associations of radiographic progression (ΔTSS) per year with the adjusted MBDA score, seropositivity, and clinical measures were evaluated using linear and logistic regression. The adjusted MBDA score was (1) validated in Leiden and SWEFOT, (2) compared with other measures in all four cohorts, and (3) used to generate curves for predicting risk of radiographic progression.

RESULTS

Univariable and bivariable analyses validated the adjusted MBDA score and found it to be the strongest, independent predicator of radiographic progression (ΔTSS > 5) compared with seropositivity (rheumatoid factor and/or anti-CCP), baseline TSS, DAS28-CRP, CRP SJC, or CDAI. Neither DAS28-CRP, CDAI, SJC, nor CRP added significant information to the adjusted MBDA score as a predictor, and the frequency of radiographic progression agreed with the adjusted MBDA score when it was discordant with these measures. The rate of progression (ΔTSS > 5) increased from < 2% in the low (1-29) adjusted MBDA category to 16% in the high (45-100) category. A modeled risk curve indicated that risk increased continuously, exceeding 40% for the highest adjusted MBDA scores.

CONCLUSION

The adjusted MBDA score was validated as an RA disease activity measure that is prognostic for radiographic progression. The adjusted MBDA score was a stronger predictor of radiographic progression than conventional risk factors, including seropositivity, and its prognostic ability was not significantly improved by the addition of DAS28-CRP, CRP, SJC, or CDAI.

Using Process Improvement and Systems Redesign to Improve Rheumatology Care Quality in a Safety Net Clinic

OBJECTIVE

To develop and evaluate interventions to improve quality of care in 4 priority areas in an urban safety net adult rheumatology clinic serving a racially/ethnically and socioeconomically diverse patient population.

METHODS

The Institute for Healthcare Improvement's Model for Improvement was used to redesign clinical processes to achieve prespecified benchmarks in the following areas from 2015 to 2017: 13-valent pneumococcal conjugate vaccine (PCV13) administration among immunocompromised patients; disease activity monitoring with the Clinical Disease Activity Index (CDAI) for patients with rheumatoid arthritis; latent tuberculosis infection (LTBI) screening for new biologic users with RA; and reproductive health counseling among women receiving potentially teratogenic medications. We measured performance for each using standardized metrics, defined as the proportion of eligible patients receiving recommended care.

RESULTS

There were 1205 patients seen in the clinic between 2015 and 2017. Regarding demographics, 71% were women, 88% identified as racial/ethnic minorities, and 45% were eligible for at least 1 of the quality measures. Shewart charts for the PCV13 and CDAI measures showed evidence of improved healthcare delivery over time. Benchmarks were achieved for the CDAI and LTBI measures with 93% and 91% performance, respectively. Performance for the PCV13 and reproductive health counseling measures was 78% and 46%, respectively, but did not meet prespecified improvement targets.

CONCLUSION

Through an interprofessional approach, we were able to achieve durable improvements in key rheumatology quality measures largely by enhancing workflow, engaging nonphysician providers, and managing practice variation.

Development of Monitoring System for Assessing Rheumatoid Arthritis within 5 Minutes Using a Drop of Bio-Fluids

Rheumatoid arthritis (RA) disease activity fluctuates over time. The disease activity score 28 (DAS28_ESR) is a widely used and validated scoring system for assessing RA activity; however, it requires time and expertise. This study aimed to develop a new molecular assay capable of rapidly and objectively assessing RA activity. We used a rapid immuno-assay system (FREND™) to measure soluble CD14 (sCD14) levels, which reflect the DAS28_ESR. SCD14 concentrations in urine and serum of RA patients were measured, and RA activity and responses to anti-rheumatic drugs were examined at baseline and after 6 months. FREND™ quantified sCD14 levels in a drop of serum and urine accurately and within 5 min. Serum sCD14 concentrations and its changes correlated well with disease activity and treatment responses, and the results were comparable to C-reactive protein. The new composite indices, including the DAS28_CD14 and simplified DAS_CD14, better detected RA activity than a single sCD14 value and correlated strongly with the DAS28_ESR. These indices exhibited excellent diagnostic performance for discriminating a good response 6 months after treatment. We developed a new system for assessing RA activity and therapeutic outcome within 5 min. CD14-based composite indices may have utility for accurate and frequent monitoring of RA status.

Patient and Rheumatologist Perspectives Regarding Challenges to Achieving Optimal Disease Control in Rheumatoid Arthritis

OBJECTIVE

To identify and prioritize patient- and rheumatologist-perceived barriers to achieving disease control.

METHODS

Patients with rheumatoid arthritis (RA) and rheumatologists from the Corrona registry were invited by e-mail to participate in nominal groups. Two separate lists of barriers were created, 1 from RA patient-only nominal groups and the other from rheumatologist-only nominal groups, and barriers were sorted into themes. Next, using an online survey, a random sample of RA patients from the Corrona registry were asked to rank their top 3 barriers to achieving disease control.

RESULTS

Four nominal groups totaling 37 RA patients identified patient barriers to achieving control of RA activity that were classified into 17 themes. Three nominal groups totaling 25 rheumatologists identified barriers that were classified into 11 themes. The financial aspects of RA care ranked first for both types of nominal groups, while medication risk aversion ranked second among the perceived barriers of the physician nominal group and third among those of the RA patient nominal group. Among the 450 RA patients surveyed, 77% considered RA a top health priority, and 51% reported being aware of the treat-to-target strategy for RA care; the 3 most important patient-perceived challenges to achieving disease control were RA prognosis uncertainty, medication risk aversion, and the financial/administrative burden associated with RA care.

CONCLUSION

There are common, potentially modifiable, patient- and rheumatologist-reported barriers to achieving RA disease control, including perceived medication risk aversion, suboptimal treatment adherence, and suboptimal patient-physician communication regarding the benefits of tight control of disease activity in RA. Addressing these obstacles may improve adherence to goal-directed RA care.

Unlocking the Value of Anti-TNF Biosimilars: Reducing Disease Burden and Improving Outcomes in Chronic Immune-Mediated Inflammatory Diseases: A Narrative Review

Immune-mediated inflammatory diseases (IMIDs) are chronic conditions that create a significant disease burden on millions of patients while adding a major financial burden to societies and healthcare systems.

The introduction of biologic medicines has contributed majorly to improving the clinical outcomes of IMIDs and as such these modalities have gained first- or second-line positions in a wide range of treatment guidelines from different international clinical societies. However, the high cost of these biologics traditionally limited their accessibility and delayed their initiation, leaving millions of patients with unmet medical needs for a more affordable and sustainable solution.

The introduction of cost-efficient biosimilar anti-TNFs within Europe since 2013 has allowed more patients with IMIDs to access biologic therapies earlier and for longer, potentially altering the course of the disease into a milder phenotype and reducing the long-term disease burden. This review provides the latest evidence for the impact of biosimilars on patient outcomes and demonstrates their clinical value beyond a reduction in price.

Time to initiation of biologic disease-modifying antirheumatic drugs in the French cohort ESPOIR

OBJECTIVE

To assess the time to initiation of biologic disease-modifying anti-rheumatic drugs (bDMARDs) in ESPOIR, the French cohort of patients with rheumatoid arthritis (RA), and factors associated with the timing of bDMARD initiation.

METHODS

In total, 658 patients with early RA satisfying the 2010 ACR/EULAR criteria were included between 2003 and 2005 and followed annually for 10 years (end of follow up: 2013-2015). The timing of bDMARD introduction and predictors of use were analysed by the Kaplan-Meier method based on Cox proportional-hazard models.

RESULTS

Overall, 178 patients (31.0%, 95% confidence interval [27.0-34.7]) initiated a bDMARD during the 10-year follow-up, with a mean delay of 43.6 months. The penetration rate was higher during the first 2 years of follow-up (6% between the first and second year, approximately 3.3% each year between the second and seventh year, and<2.0% after the eighth year). The first-used bDMARD was etanercept for 72 patients and adalimumab for 71. On multivariate analysis, Disease Activity Score in 28 joints, radiologic progression and positivity for anti-citrullinated protein antibodies were significantly associated with rapid initiation of a bDMARD (P<0.0001), whereas older age at first joint pain was inversely associated (P<0.0001).

CONCLUSIONS

Although access to bDMARDs is widespread in France, less than one third of patients with early RA in the ESPOIR cohort initiated a bDMARD over the 10-year follow-up. Poor prognostic factors for RA were associated with more rapid initiation, as expected.

JAK-Inhibitors for the Treatment of Rheumatoid Arthritis: A Focus on the Present and an Outlook on the Future

Janus kinase inhibitors (JAKi) belong to a new class of oral targeted disease-modifying drugs which have recently revolutionized the therapeutic panorama of rheumatoid arthritis (RA) and other immune-mediated diseases, placing alongside or even replacing conventional and biological drugs. JAKi are characterized by a novel mechanism of action, consisting of the intracellular interruption of the JAK-STAT pathway crucially involved in the immune response. The aim of this narrative review is to globally report the most relevant pharmacological features and clinical outcomes of the developed and incoming JAKi for RA, based on the available preclinical and clinical evidence. A total of 219 papers, including narrative and systematic reviews, randomized controlled trials (RCTs), observational studies, case reports, guidelines, and drug factsheets, were selected. The efficacy and safety profile of both the first generation JAKi (baricitinib and tofacitinib) and the second generation JAKi (upadacitinib, filgotinib, peficitinib, decernotinib and itacitinib) were compared and discussed. Results from RCTs and real-life data are encouraging and outline a rapid onset of the pharmacologic effects, which are maintained during the time. Their efficacy and safety profile are comparable or superior to those of biologic agents and JAKi proved to be efficacious when given as monotherapy. Finally, the manufacturing of JAKi is relatively easier and cheaper than that of biologics, thus increasing the number of compounds being formulated and tested for clinical use.

Treat-to-target in rheumatoid arthritis - are we there yet?

Treat-to-target has been established as a guiding principle for the treatment of rheumatoid arthritis (RA) and encompasses several distinct elements: choosing a target and a method for measuring it; assessing the target at a pre-specified time point; a commitment to change the therapy if the target is not achieved; and shared decision-making. A treat-to-target approach yields superior outcomes to standard care in RA, and the ACR, EULAR and other professional organizations have endorsed treat-to-target as a fundamental therapeutic strategy for RA. Nevertheless, data on the degree to which treat-to-target is employed in the clinic are scarce; it seems that although some elements of treat-to-target are widely used, full implementation remains uncommon. Outstanding knowledge gaps to be addressed include how to select the right target for each patient, how often to assess whether the target has been achieved and the selection of each subsequent therapy in an evidence-based manner.

Association among anti-citrullinated protein antibody status, erosive disease and healthcare resource utilization in patients with rheumatoid arthritis

Objective: To characterize the rate of healthcare resource utilization (HCRU) between anti-cyclic citrullinated peptide (CCP; a surrogate for anti-citrullinated protein antibodies [ACPAs]) positive (+) patients with rheumatoid arthritis (RA), either with or without erosions, who initiated biologic disease-modifying antirheumatic drug (bDMARD) treatment.Methods: Data from the Corrona RA registry, a prospective registry of adult patients with RA from 177 sites across 42 states in the US, were analyzed. Annual rates of HCRU (measured based on rates of all-cause hospitalization, joint surgery, imaging procedures and use of assistive devices) were estimated in anti-CCP + patients with and without erosions following bDMARD initiation using a Poisson regression model.Results: Among the 3333 patients with known anti-CCP and erosion status and 12-month post-bDMARD follow-up information in the Corrona registry, 2047 were anti-CCP + and included in this analysis; 868 with and 1179 without erosions. Baseline characteristics were generally well balanced between patients with and without erosions; however, those with erosions had a longer mean RA duration and a higher prior DMARD use. Over 12 months, among anti-CCP + patients, those with erosions had significantly higher rates of all HCRU, except joint surgery, than those without erosions. Age-adjusted risk ratios (95% confidence interval) were as follows: all-cause hospitalization, 1.47 (1.14, 1.90); all-cause imaging, 1.25 (1.03, 1.53); and assistive device use 1.12 (1.00, 1.25). The rate of joint surgery visits was also numerically higher in patients with versus without erosion.Conclusions: ACPA seropositivity with erosive disease was associated with higher rates of HCRU compared with seropositivity without erosions. These findings suggest that providers may want to manage anti-CCP + patients aggressively to achieve better disease control to prevent the development of erosions and the associated increase in HCRU.

Disease activity-based management of rheumatoid arthritis in Dutch daily clinical practice has improved over the past decade

To re-evaluate the adherence to clinical practice guidelines recommended disease activity-based management of rheumatoid arthritis (RA) in daily clinical practice, among Dutch rheumatologists in the past decade. In 2007, disease activity was measured in only 16% of outpatient visits. All rheumatologists that participated in the 2007 study were invited to re-enter our study in 2016/2017. If necessary, data were supplemented with data from other rheumatologists. For all 26 rheumatologists who agreed to participate in our study, data were collected from 30 consecutive patients that visited the outpatient clinic. Per patient, data from four consecutive rheumatologist outpatient visits were collected. Since 2007, disease activity was measured more frequently in Dutch daily clinical practice, increasing from 16 to 79% of visits (2440/3081 visits). In addition, intensification of medication based on disease activity scores increased from 33 to 50% of visits (260/525 visits). DAS/DAS28 was the most frequently used disease activity measure (1596/2440 visits). There was a wide variation among rheumatologists in measuring disease activity and intensification of medication, 20-100% and 0-75% respectively. Over the past years, there has been a large improvement in disease activity assessment in daily clinical practice. Disease activity-based medication intensifications, also called tight control or treat to target, increased to a lesser extent. Large variation between different rheumatologists and clinics indicates that there is still room for improvement. Key Points • Following guideline dissemination disease activity is assessed more frequently (79%). • There is large variation between rheumatologists, indicating room for improvement. • Finding factors that explain variation is necessary to improve tight control in daily practice.

Barriers to treatment optimization and achievement of patients' goals: perspectives from people living with rheumatoid arthritis enrolled in the ArthritisPower registry

BACKGROUND

Few studies have investigated patients' own treatment goals in rheumatoid arthritis (RA). The objective of this real-world, cross-sectional study of US patients with RA was to identify factors that patients believed influenced their physician's treatment decisions. Secondary objectives included reasons patients tolerated sub-optimal disease control and their perceived barriers to treatment optimization.

METHODS

Eligible participants were enrolled in the ArthritisPower registry, ≥ 19 years, had physician-diagnosed RA, unchanged treatment within 3 months of baseline, prior/current disease-modifying antirheumatic drug treatment (DMARDs), and computer/smartphone access. In December 2017, participants completed Patient-Reported Outcomes Measurement Information System-Computerized Adaptive Tests (PROMIS-CAT) for pain interference, fatigue, sleep disturbance, and physical function. Routine Assessment of Patient Index Data 3 (RAPID3) provided disease activity scores (0-30). Participants completed an online survey on barriers to treatment optimization, including self-perception of disease compared to RAPID3/PROMIS scores.

RESULTS

A total of 249 participants met inclusion criteria and completed the survey. Mean age (SD) was 52 (11) years, and the majority were female (92%) with high RAPID3 disease activity (175/249 [70%]; median score 18). The main reason participants did not change treatment was their physician's recommendation (66%; n = 32). Of participants with high RAPID3 disease activity, 66 (38%) were offered a treatment change; 19 (29%) of whom declined the change. Most participants who intensified treatment did so because their symptoms had remained severe or worsened (51%; n = 65); only 16 (25%) participants intensified because they had not reached a specified treatment goal. Among participants who self-reported their disease activity as "none/low" or "medium" (n = 202; 81% of cohort), most still had RAPID3 high disease activity (137/202 [68%]; score > 12). Most PROMIS scores showed moderate agreement with participants' self-assessment of health status, in contrast to RAPID3 (weighted kappa: 0.05 [95% CI - 0.01, 0.11]).

CONCLUSIONS

Most participants trusted their rheumatologist's treatment decisions and prioritized their physician's treatment goals over their own. Patients should be encouraged to share their treatment goals/expectations with their rheumatologist, in line with the treat-to-target approach. RAPID3 may be inappropriate for setting patient-centric treatment goals given the poor agreement with self-reported disease activity; most PROMIS scores showed better alignment with patients' own assessments.

Challenges in Implementing Treat-to-Target Strategies in Rheumatology

Despite evidence that treat-to-target (TTT) approaches lead to better disease outcomes in RA, TTT is not widely implemented in rheumatology clinics in North America. This article discusses the barriers (including access to care, patient and physician factors, and systems issues) to implementing TTT in the clinic, and proposes possible solutions and future research directions.

Assessing disease severity in bio-naïve patients with RA on treatment with csDMARDs: insights from the Corrona Registry

Introduction

This study aimed to characterize disease burden among patients with rheumatoid arthritis (RA) with moderate-to-high disease activity who had received conventional synthetic disease-modifying anti-rheumatic drug (csDMARD) monotherapy for ≥ 6 months but had not advanced to a biologic therapy.

Methods

Patients enrolled in the US Corrona RA Registry between June 1, 2014, and January 30, 2018, with 6 months of continuous csDMARD monotherapy, with moderate-to-high disease activity, who remained biologic naive, and who had ≥ 1 follow-up visit were identified. Disease activity was assessed among patients with a 6-month follow-up visit (± 3 months). Descriptive statistics were used to compare demographics and disease characteristics between patients with or without treatment advancement.

Results

The study included 409 patients with a disease activity assessment at 6 months (mean (SD) age 65.9 (12.6) years; mean duration of csDMARD therapy 407 (221) days). Of those patients, more than half (54%, n = 219) remained in moderate-to-high disease activity. Patients remaining in moderate-to-high vs. remission-to-low disease activity had higher baseline swollen (6.1) and tender joint counts (6.8). Over the 6-month period, treatment advancement occurred in 29% of patients. Those who advanced treatment (n = 118) vs. did not advance treatment (n = 291) were younger, had a shorter duration of RA, had higher disease activity, and reported higher levels of pain and fatigue.

Conclusions

The substantial number of patients with persistent moderate-to-high disease on csDMARDs over a 6-month period and who did not advance treatment indicates that there is considerable need for a treat-to-target approach to care for patients with RA. Key Points•For patients with RA and an inadequate response to treatment with initial csDMARD monotherapy, guidelines recommend treatment advancement; however, this may not be occurring in real-world clinical settings.•In the current study, a substantial proportion of patients (54%) on csDMARDs had persistent moderate-to-severe disease activity at the 6-month (± 3 months) follow-up visit; however, only 29% of patients had their medication treatment advanced, indicating that there is considerable need for a treat-to-target approach to care for patients with RA.•Patients with younger age, shorter RA duration, and higher disease activity were more likely to have their medication treatment advanced, which suggests that potentially more aggressive treatment of disease activity is needed across the whole RA population.

Demographic and Clinical Patterns of Rheumatoid Arthritis in an Emirati Cohort from United Arab Emirates

This retrospective cohort study aimed to assess the demographic and clinical characteristics of rheumatoid arthritis (RA) in Emirati patients attending Cleveland Clinic Abu Dhabi, a large tertiary center in the Middle East. In this study, 414 Emirati patients with RA were evaluated over a 3-year period from April 2015 to April 2018. All patients fulfilled the 2010 RA ACR/EULAR criteria and were assessed for demographic and clinical characteristics. The estimated RA prevalence rate in our population cohort was 2.72%. Females showed predominance (80%) with a higher body mass index (31.4 ± 6.61, P = 0.0001) compared to males (28.8 ± 6.03, P = 0.0001). The most frequent comorbidity observed was dyslipidemia (43.5%) followed by hypertension (37.9%), diabetes mellitus (34.5%), and gastroesophageal reflux disease (33.1%). Xerophthalmia was the most frequent extra-articular manifestation. Rheumatoid factor and anti-citrullinated peptide were detected in 63.3% and 41.5% patients, respectively, while both were present in 33.3% of patients. Methotrexate, adalimumab, and rituximab were the most frequently prescribed disease modifying agents. In this study, we describe disease features that are unique to United Arab Emirates (UAE) patients and demonstrate that RA has a significant disease burden. Our findings highlight the need for a RA national registry to improve the quality of care of these patients in UAE.

Physician Adherence to Treat-to-Target and Practice Guidelines in Rheumatoid Arthritis

Principles of treat-to-target (T2T) have been widely adopted in both multinational and regional guidelines for rheumatoid arthritis (RA). Several questionnaire studies among physicians and real-world data have suggested that an evidence-practice gap exists in RA management. Investigating physician adherence to T2T, which requires a process measure, is difficult. Different practice patterns among physicians are observed, while adherence to protocolized treatment declines over time. Rheumatologist awareness, agreement, and claims of adherence to T2T guidelines are not always consistent with medical records. Comorbidities, a difficult disease course, communication barriers, and individual preferences may hinder an intensive, proactive treatment stance. Interpreting deviations from protocolized treatment/T2T guidelines requires sufficient clinical context, though higher adherence seems to improve clinical outcomes. Nonmedical constraints in routine care may consist of barriers in healthcare structure and socioeconomic factors. Therefore, strategies to improve the institution of T2T should be tailored to local healthcare. Educational interventions to improve T2T adherence among physicians may show a moderate, although beneficial effect. Meanwhile, a proportion of patients with inadequately controlled RA exists, while management decisions may not be in accordance with T2T. Physicians tend to be aware of current guidelines, but their institution in routine practice seems challenging, which warrants attention and further study.

Benefits and Sustainability of a Learning Collaborative for Implementation of Treat-to-Target in Rheumatoid Arthritis: Results of a Cluster-Randomized Controlled Phase II Clinical Trial

OBJECTIVE

We conducted a 2-phase randomized controlled trial of a learning collaborative to facilitate implementation of treat-to-target (T2T) to manage rheumatoid arthritis (RA). We found substantial improvement in implementation of T2T in phase I. Here, we report on a second 9 months (phase II), where we examined the maintenance of response in phase I and predictors of greater improvement in T2T adherence.

METHODS

We recruited patients from 11 rheumatology sites and randomized them to either receive the learning collaborative during phase I or to a wait-list control group that received the learning collaborative intervention during phase II. The outcome was change in T2T implementation score (0-100, where 100 = best) from pre- to postintervention. The T2T implementation score was defined as a percent of components documented in visit notes. Analyses examined the extent to which the phase-I intervention teams sustained improvement in T2T, as well as predictors of T2T improvement.

RESULTS

The analysis included 636 RA patients. At baseline, the mean T2T implementation score was 11% in phase I intervention sites and 13% in phase II sites. After the intervention, T2T implementation score improved to 57% in the phase I intervention sites and to 58% in the phase II sites. Intervention sites from phase I sustained the improvement during the phase II (52%). Predictors of greater T2T improvement included having only rheumatologist providers at the site, academic affiliation of the site, having fewer providers per site, and the rheumatologist provider being a trainee.

CONCLUSION

Improvement in T2T remained relatively stable over a postintervention period.

Barriers to treatment adjustment within a treat to target strategy in rheumatoid arthritis: a secondary analysis of the TRACTION trial

Objectives

Adherence to a treat to target (TTT) strategy is a recommended paradigm for RA; however, research shows there are many barriers to implementation. We conducted a trial to improve TTT implementation, and herein examine barriers to treatment adjustment within TTT among patient visits not in agreement with the TTT paradigm.

Methods

Chart review assessed TTT implementation based on documentation of four items: designation of a treatment target, recording a disease activity measure, shared-decision making when applicable and adjusting treatment when disease activity was not at target. A treatment decision not in agreement with the TTT paradigm was defined as lack of treatment adjustment when disease activity was not at the pre-determined treatment target. Providers were encouraged to report the barriers to treatment change; these were categorized and analysed by study staff. Multiple barriers were possible for one visit.

Results

Eighty-three visits not in agreement with the TTT strategy were observed in 74 patients, during which 90 reported barriers to treatment adjustment were noted. Common barriers to adjusting treatment included patient preference in 37.1% of visits and elevated disease activity measure despite no objective evidence of active RA in 38.6% of visits.

Conclusion

An elevated disease activity measure not reflective of RA disease activity and patient preference are the two leading barriers to treatment adjustment to TTT in RA. Understanding barriers to adherence should guide interventions aimed at using better markers of disease activity and improving alignment with patient preference, with the overarching goal of enhancing TTT adherence.

Uptake and Clinical Utility of Multibiomarker Disease Activity Testing in the United States

OBJECTIVE

The clinical utility of the multibiomarker disease activity (MBDA) test for rheumatoid arthritis (RA) management in routine care in the United States has not been thoroughly studied.

METHODS

Using 2011-2015 Medicare data, we linked each patient with RA to their MBDA test result. Initiation of a biologic or Janus kinase (JAK) inhibitor in the 6 months following MBDA testing was described. Multivariable adjustment evaluated the likelihood of adding or switching biologic/JAK inhibitor, controlling for potential confounders. For patients with high MBDA scores who added a new RA therapy and were subsequently retested, lack of improvement in the MBDA score was evaluated as a predictor of future RA medication failure, defined by the necessity to change RA medications again.

RESULTS

Among 60,596 RA patients with MBDA testing, the proportion adding or switching biologics/JAK inhibitor among those not already taking a biologic/JAK inhibitor was 9.0% (low MBDA), 11.8% (moderate MBDA), and 19.7% (high MBDA, p < 0.0001). Similarly, among those already taking biologics/JAK inhibitor, the proportions were 5.2%, 8.3%, and 13.5% (p < 0.0001). After multivariable adjustment, referent to those with low disease MBDA scores, the likelihood of switching was 1.51-fold greater (95% CI 1.35-1.69) for patients with moderate MBDA scores, and 2.62 (2.26-3.05) for patients with high MBDA scores. Among those with high MBDA scores who subsequently added a biologic/JAK inhibitor and were retested, lack of improvement in the MBDA score category was associated with likelihood of future RA treatment failure (OR 1.61, 95% CI 1.27-2.03).

CONCLUSION

The MBDA score was associated with both biologic and JAK inhibitor medication addition/switching and subsequent treatment outcomes.

The use of information and communication technologies by arthritis health professionals to disseminate a self-management program to patients: a pilot randomized controlled trial protocol

Design and objective: This paper describes the protocol for a three-arm, single-blind, parallel design randomized controlled trial (RCT) to investigate the perceived usability of Facebook to share information from an evidence-based arthritis self-management program with patients compared with email or an educational website after two weeks.

Delayed Treatment Acceleration in Patients with Rheumatoid Arthritis Who Have Inadequate Response to Initial Tumor Necrosis Factor Inhibitors: Data from the Corrona Registry

BACKGROUND

The implementation of treat-to-target principles in rheumatoid arthritis (RA) has not been fully investigated in patients with inadequate response to tumor necrosis factor (TNF) inhibitor treatment.

OBJECTIVES

To evaluate the prevalence of an inadequate response to initial TNF inhibitor treatment at 6 and 12 months among patients with RA in a real-world patient registry, as well as the delay in therapy adjustment and its impact on disease activity and patient-reported outcome (PRO) measures.

METHODS

This analysis is based on data of patients with moderate or severe disease activity (Clinical Disease Activity Index [CDAI] score >10) who were included in the Consortium of Rheumatology Researchers of North America (Corrona) RA registry, a prospective, observational database. The patients had never received treatment with a biologic disease-modifying antirheumatic drug (DMARD) and had initiated treatment with a TNF inhibitor (adalimumab, certolizumab pegol, etanercept, golimumab, or infliximab) between October 2001 and December 2014. We evaluated treatment response (CDAI score ≤10), select PRO measures, and treatment changes at 6 months. Patients who had an inadequate response to TNF inhibitor therapy at 6 months and continued to use their initial TNF inhibitor were evaluated again at 12 months.

RESULTS

This retrospective analysis included 2282 patients. At 6 months, 1732 (75.9%) of the patients continued to use their initial TNF inhibitor; of these, 803 (46.4%) patients had an inadequate response to treatment. Of the 803 patients who had an inadequate response at 6 months, 488 (60.8%) continued their initial treatment at 12 months. Of these 488 patients, 315 (64.5%) had an inadequate response at 12 months, and 173 (35.5%) had a response. Numerically greater improvements in all PRO measures were observed for patients who responded to therapy compared with patients with an inadequate response.

CONCLUSIONS

In this real-world analysis of data from the Corrona RA registry, a considerable proportion of patients with RA had an inadequate response to the initial TNF inhibitor therapy at 6 and 12 months. Many patients continued to have moderate or high disease activity, without accelerating treatment (eg, addition or increase in the dose of concurrent conventional synthetic DMARDs or a TNF inhibitor), contrary to treat-to-target principles, thus remaining at risk for accumulating joint damage and disability.

Timing and Impact of Decisions to Adjust Disease-Modifying Antirheumatic Drug Therapy for Rheumatoid Arthritis Patients With Active Disease

OBJECTIVE

Guidelines recommend that rheumatoid arthritis (RA) patients with moderate-to-high disease activity (MHDAS) adjust disease-modifying antirheumatic drug (DMARD) therapy at least every 3 months until reaching low disease activity or remission (LDAS). We examined how quickly RA patients with MHDAS adjust DMARD therapy in clinical practice, and whether those who adjust DMARDs within 90 days in response to MHDAS reach LDAS sooner.

METHODS

We identified RA patients with MHDAS in the University of Pittsburgh Rheumatoid Arthritis Comparative Effectiveness Research registry, and conducted a competing risks regression on time to DMARD therapy adjustment and a Cox regression on time to LDAS.

RESULTS

We identified 538 eligible subjects with 943.5 patient-years of followup. Sixty percent of patients with persistent MHDAS adjusted DMARDs within 90 days. Among all subjects, median times to DMARD adjustment and LDAS were 154 (interquartile range [IQR] 1-706) days and 301 (IQR 140-706) days, respectively. Being elderly (subdistribution hazard ratio [SHR] 0.61, P = 0.02), lower baseline disease activity (SHR 0.72, P < 0.01), longer duration of RA (SHR 0.98, P < 0.01), and biologic use (SHR 0.71, P < 0.01) were significantly associated with longer times to therapy adjustment. African American race (hazard ratio [HR] 0.63, P = 0.01), higher baseline disease activity (HR 0.75, P < 0.01), and not adjusting DMARD therapy within 90 days (HR 0.76, P = 0.01) were associated with longer times to LDAS.

CONCLUSION

Adjusting DMARDs within 90 days was associated with shorter times to LDAS, but many patients with persistent MHDAS waited >90 days to adjust DMARDs. Interventions are needed to address the timeliness of DMARD adjustments for RA patients with MHDAS.

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

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.

Rheumatoid Arthritis Patients' Motivations for Accepting or Resisting Disease-Modifying Antirheumatic Drug Treatment Regimens

OBJECTIVE

Patient refusal of and nonadherence to treatment with disease-modifying antirheumatic drugs (DMARDs) can adversely affect disease outcomes in rheumatoid arthritis (RA). This qualitative study describes how RA patients' feelings in response to experiences and information affected their decisions to accept (agree to adopt, initiate, and implement) or resist (refuse, avoid, and discontinue) DMARD treatment regimens.

METHODS

A total of 48 RA patients were interviewed about their experiences making decisions about DMARDs. The interviews were transcribed, coded, and analyzed for themes related to their internal motivations for accepting or resisting treatment regimens, using a narrative analysis approach.

RESULTS

In addition to feelings about the necessity and dangers of medications, patients' feelings towards their identity as an ill person, the act of taking medication, and the decision process itself were important drivers of patient's decisions. For patients' motivations to accept treatment regimens, 2 themes emerged: a desire to return to a normal life, and fear of future disability due to RA. For motivations to resist treatment regimens, 5 themes emerged: fear of medications, maintaining control over health, denial of sick identity, disappointment with treatment, and feeling overwhelmed by the cognitive burden of deciding.

CONCLUSION

Feelings in response to experiences and information played a major role in how patients weighed the benefits and costs of treatment options, suggesting that addressing patients' feelings may be important when rheumatologists counsel about therapeutic options. Further research is needed to learn how best to address patients' feelings throughout the treatment decision-making process.

A Retrospective Analysis of Corticosteroid Utilization Before Initiation of Biologic DMARDs Among Patients with Rheumatoid Arthritis in the United States

INTRODUCTION

Understanding the effects of corticosteroid utilization prior to initiation of biologic disease-modifying antirheumatic drugs (DMARDs) can inform decision-makers on the appropriate use of these medications. This study examined treatment patterns and associated burden of corticosteroid utilization before initiation of biologic DMARDs among rheumatoid arthritis (RA) patients.

METHODS

A retrospective analysis was conducted of adult RA patients in the US MarketScan Database (2011-2015). The following patterns of corticosteroid utilization were analyzed: whether corticosteroids were used; duration of use (short/long duration defined as < or ≥ 3 months); and dosage (low as < 2.5, medium as 2.5 to < 7.5 and high as ≥ 7.5 mg/day). Effects of corticosteroid use on time to biologic DMARD initiation were examined using Cox proportional hazards models. Likelihood and number of adverse events were examined using logistic and negative binomial regression models. Generalized linear models were used to examine healthcare costs. Independent variables in all models included patient demographics and health characteristics.

RESULTS

A total of 25,542 patients were included (40.84% used corticosteroids). Lower hazard of biologic DMARD initiation was associated with corticosteroid use (hazard ratio = 0.89, 95% confidence interval = 0.83-0.96), long duration and lower dose. Corticosteroid users compared to non-users had higher incidence rates of various adverse events including cardiovascular events (P < 0.05). Higher likelihood of adverse events was associated with corticosteroid use and long duration of use, as was increased number of adverse events. Corticosteroid users had a greater annualized mean number of physician visits, hospitalizations, and emergency department (ED) visits than non-users in adjusted analysis. Corticosteroid users compared to non-users had higher mean costs for total healthcare, physician visits, hospitalizations, and ED visits.

CONCLUSIONS

Among patients with RA, corticosteroid utilization is associated with delayed initiation of biologic DMARDS and higher burden of adverse events and healthcare utilization/costs before the initiation of biologic DMARDs.

FUNDING

AbbVie Inc.

Factors associated with use of disease modifying agents for rheumatoid arthritis in the National Hospital and Ambulatory Medical Care Survey

OBJECTIVE

We examined the treatment patterns among adults with rheumatoid arthritis (RA) and identified factors influencing access to traditional and biological disease modifying antirheumatic drugs (DMARDs).

METHODS

We analyzed visits recorded in the National Ambulatory Medical Care Survey from 2005 to 2014 with a RA diagnosis. The primary outcome was DMARD use (traditional and/or biological). We included prescriptions of all RA-related treatments such as traditional and biological DMARDs, glucocorticoids, gold preparations, immunosuppressants, and non-steroidal anti-inflammatory drugs. Covariates in the logistic regression models included age, gender, race/ethnicity, type of health care coverage, provider type, geographic region, and number of comorbidities.

RESULTS

Among 1405 visits with a RA diagnosis, 60.4% (n = 807) were prescribed DMARDs and 23.8% (n = 334) biological DMARDs. In fully adjusted models, females have 1.57 times higher odds of any DMARD use (95% confidence interval (CI): 1.02-2.46). Also, Medicare beneficiaries as compared to privately insured have 2.31 times higher odds of receiving any DMARDs (95% CI: 1.40-3.82), while visits with specialist vs. general physician are 2.38 times more associated with any DMARD use (95% CI: 1.37-4.14). For biological DMARDs, Medicare beneficiaries were at 2.58 times higher odds (95% CI: 1.42-4.70) than privately insured, while visits with specialist are at 3.37 times higher odds than general physician (95% CI: 1.40-8.23).

CONCLUSION

Visits with a specialist and Medicare beneficiaries were significantly associated with any DMARD or biological DMARD use. Additionally, contrary to prior evidence, race/ethnicity was not associated with any DMARD or biological DMARD use, which may indicate reduction in disparity of treatment access.

Implementation of Treat-to-Target in Rheumatoid Arthritis Through a Learning Collaborative: Results of a Randomized Controlled Trial

OBJECTIVE

Treat-to-target (TTT) is an accepted paradigm for the management of rheumatoid arthritis (RA), but some evidence suggests poor adherence. The purpose of this study was to test the effects of a group-based multisite improvement learning collaborative on adherence to TTT.

METHODS

We conducted a cluster-randomized quality-improvement trial with waitlist control across 11 rheumatology sites in the US. The intervention entailed a 9-month group-based learning collaborative that incorporated rapid-cycle improvement methods. A composite TTT implementation score was calculated as the percentage of 4 required items documented in the visit notes for each patient at 2 time points, as evaluated by trained staff. The mean change in the implementation score for TTT across all patients for the intervention sites was compared with that for the control sites after accounting for intracluster correlation using linear mixed models.

RESULTS

Five sites with a total of 23 participating rheumatology providers were randomized to intervention and 6 sites with 23 participating rheumatology providers were randomized to the waitlist control. The intervention included 320 patients, and the control included 321 patients. At baseline, the mean TTT implementation score was 11% in both arms; after the 9-month intervention, the mean TTT implementation score was 57% in the intervention group and 25% in the control group (change in score of 46% for intervention and 14% for control; P = 0.004). We did not observe excessive use of resources or excessive occurrence of adverse events in the intervention arm.

CONCLUSION

A learning collaborative resulted in substantial improvements in adherence to TTT for the management of RA. This study supports the use of an educational collaborative to improve quality.

Clinical and demographic factors associated with change and maintenance of disease severity in a large registry of patients with rheumatoid arthritis

Background

We examined models to predict disease activity transitions from moderate to low or severe and associated factors in patients with rheumatoid arthritis (RA).

Methods

Data from RA patients enrolled in the Corrona registry (October 2001 to August 2014) were analyzed. Clinical Disease Activity Index (CDAI) definitions were used for low (≤10), moderate (>10 and ≤22), and severe (>22) disease activity states. A Markov model for repeated measures allowing for covariate dependence was used to model transitions between three (low, moderate, severe) states and estimate population transition probabilities. Mean sojourn times were calculated to compare length of time in particular states. Logistic regression models were used to examine impacts of covariates (time between visits, chronological year, disease duration, age) on disease states.

Results

Data from 29,853 patients (251,375 visits) and a sub-cohort of 9812 patients (46,534 visits) with regular visits (every 3–9 months) were analyzed. The probability of moving from moderate to low or severe disease by next visit was 47% and 18%, respectively. Patients stayed in moderate disease for mean 4.25 months (95% confidence interval: 4.18–4.32). Transition probabilities showed 20% of patients with low disease activity moved to moderate or severe disease within 6 months; >35% of patients with moderate disease remained in moderate disease after 6 months. Results were similar for the regular-visit sub-cohort. Significant interactions with prior disease state were seen with chronological year and disease duration.

Conclusion

A substantial proportion of patients remain in moderate disease, emphasizing the need for treat-to-target strategies for RA patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-017-1289-x) contains supplementary material, which is available to authorized users.

bDMARD Dose Reduction in Rheumatoid Arthritis: A Narrative Review with Systematic Literature Search

Introduction

Although bDMARDs are effective in the treatment of RA, they are associated with dose-dependent side effects, patient burden, and high costs. Recently, many studies have investigated the possibility of discontinuing or tapering bDMARDs when patients have reached their treatment goal. The aim of this review is to provide a narrative overview of the existing evidence on bDMARD dose reduction and to provide answers to specific dose-reduction-related questions that are of interest to clinicians.

Methods

We systematically searched for relevant studies in four scientific databases. Furthermore, we screened the references of reviews and relevant studies.

Results

Our searches resulted in 45 original studies of bDMARD dose reduction in RA patients (15 RCTs and 30 observational studies). Current evidence shows that bDMARD dose reduction can be considered in all RA patients who achieve stable (e.g., ≥6 months) low disease activity or remission. The best strategies seem to be disease-activity-guided dose optimization and fixed dose reduction, since direct bDMARD discontinuation (without restarting) results in a high flare rate, worse physical functioning, and more joint damage. When tapering the bDMARD treatment of a patient, disease activity should be monitored closely, and if a flare occurs, the dose should be increased to the lowest effective dose. Current evidence shows that restarting bDMARD treatment is effective and safe. Unfortunately, no clear predictors of successful dose reduction have been identified so far.

Conclusion

The current evidence and rising healthcare costs urge that dose reduction should be considered for eligible patients. However, the decision to start dose reduction should be made in shared decision-making. Future research should focus not only on a better understanding of the effects of dose reduction on clinical outcomes but also on the perspectives of patients and physicians as well as the implementation of this new treatment principle.

Electronic supplementary material

The online version of this article (doi:10.1007/s40744-017-0055-5) contains supplementary material, which is available to authorized users.

Geographic Variation in the Quality and Cost of Care for Patients with Rheumatoid Arthritis

BACKGROUND

There is considerable push to improve value in health care by simultaneously increasing quality while lowering or containing costs. However, for diseases that are best treated with comparatively expensive treatments, such as rheumatoid arthritis (RA), there could be tension between these aims. In this study, we measured geographic variation in quality, access, and cost for patients with RA, a disease with effective but costly specialty treatments.

OBJECTIVE

To assess the geographic differences in the quality, access, and cost of care for patients with RA.

METHODS

Using large claims databases covering the period between 2008 and 2014, we measured quality of care metrics by metropolitan statistical areas (MSAs) for patients with RA. Quality measures included use of disease-modifying antirheumatic drugs (DMARDs) and tuberculosis (TB) screening before initiating biologic DMARD therapy. Access to care measures included measured detection and the share of patients with RA who visited a rheumatologist. Regression models were used to control for differences in patient demographics and health status across MSAs.

RESULTS

For the 501,376 patients diagnosed with RA, in the average MSA 64.1% of RA patients received a DMARD, and 29.6% of RA patients initiating a biologic DMARD appropriately received a TB screening. Only 17% (73/430) of MSAs comprised the top 2 Medicare Advantage star ratings for DMARD use. Measured detection was 0.59% (IQR = 0.47%-0.71%; CV = 0.355) on average, and 57.6% (IQR = 48%-69%; CV = 0.341) of RA patients visited a rheumatologist. MSAs with the highest DMARD use spent $26,724 (in 2015 U.S. dollars) annually treating patients with RA, $5,428 more (P < 0.001) than low DMARD-use MSAs, largely because of higher pharmacy cost ($5,090 vs. $7,610, P < 0.001). However, MSAs with higher DMARD use had lower RA-related inpatient cost ($1,890 vs. $2,342, P = 0.024).

CONCLUSIONS

There were significant geographic variations in the quality of care received by patients with RA, although quality was poor in most areas. Fewer than 1 in 5 MSAs could be considered high quality based on patient DMARD use. Access to specialist care may be an issue, since just over half of patients with RA visited a rheumatologist annually. Efforts to incentivize better quality of care holds promise in terms of unlocking value for patients, but for some diseases, this approach may result in higher costs.

DISCLOSURES

The research reported in this manuscript was supported by AbbVie through consulting fees paid to Precision Health Economics (PHE). AbbVie and PHE collaborated to develop the study design and protocol. AbbVie and PHE participated in the interpretation of data, review, and approval of the manuscript. Shafrin and Shim are employed by PHE. Ganguli and Sanchez Gonzalez are employed by AbbVie. Seabury reports consulting fees from PHE. The results from this study were presented in poster form at the Academy of Managed Care Pharmacy's 2015 Annual Meeting and Expo; April 7-10, 2015; San Diego, California, and at the Academy of Managed Care Pharmacy's 2016 Annual Meeting and Expo; April 19-22, 2016; San Francisco, California. Study concept and design were contributed primarily by Shafrin, along with Ganguli and Seabury. Shafrin and Shim took the lead in data collection, and data interpretation was performed by Ganguli, Sanchez Gonzalez, Seabury, and Shafrin. The manuscript was written primarily by Shafrin, along with Shim and Seabury, and revised primarily by Ganguli, along with Sanchez Gonzalez and Seabury.

Choosing wisely in daily practice: a mixed methods study on determinants of antinuclear antibody testing by rheumatologists

OBJECTIVES

To explore the relationship between antinuclear antibody (ANA) overuse and rheumatologist-related factors before and after an intervention aimed at reducing ANA overuse.

METHOD

In this mixed methods study we performed surveys among rheumatologists (n = 20) before and after the ANA intervention (education and feedback). We identified clinician-related determinants of ANA overuse (demographic characteristics, cognitive bias, numeracy, personality, thinking styles, and knowledge) by multivariate analysis. Two focus group meetings with rheumatologists were held 6 months after the intervention to explore self-reported determinants.

RESULTS

Questionnaires were completed by all rheumatologists and eight participated in the focus groups. Rheumatologists with more work experience and a less extravert personality ordered more ANA tests before the intervention [β = 0.01, 95% confidence interval (CI) 0.003 to 0.02, p = 0.01 and β = -0.11, 95% CI -0.21 to -0.01, p = 0.04, respectively; R² = 47%]. After the intervention, female rheumatologists changed less than their male colleagues with regard to the number of ANA tests ordered (β = 0.15, 95% CI 0.03-0.26, p = 0.02; R^{2 =} 25%). During the focus groups, seven themes were identified that influenced improvement in ANA overuse: determinants related to the intervention and the study, individual health professionals, patients, professional interactions, incentives and resources, capacity for organizational change, and social, political, and legal factors.

CONCLUSIONS

We identified several determinants that together explained a sizable part of the variance observed in the ANA outcomes at baseline and in the change in ANA outcomes afterwards. Furthermore, the focus groups yielded additional factors suggesting a complex interplay of determinants influencing rheumatologists' ANA ordering behaviour.

Practice what you preach? An exploratory multilevel study on rheumatoid arthritis guideline adherence by rheumatologists

Objectives

To assess variation in and determinants of rheumatologist guideline adherence in patients with rheumatoid arthritis (RA), in daily practice.

Methods

In this retrospective observational study, guideline adherence in the first year of treatment was assessed for 7 predefined parameters on diagnostics, treatment and follow-up in all adult patients with RA with a first outpatient clinic visit at the study centre, from September 2009 to March 2011. Variation in guideline adherence was assessed on parameter and rheumatologist level. Determinants for guideline adherence were assessed in patients (demographic characteristics, rheumatoid factor (RF) and/or anti-cyclic citrullinated peptide antibody (aCCP) positivity, erythrocyte sedimentation rate, erosive disease, comorbidity and the number of available disease modifying anti-rheumatic drug (DMARD) treatment options) and rheumatologists (demographic and practice characteristics, guideline knowledge and agreement, outcome expectancy, cognitive bias, thinking style, numeracy and personality).

Results

A total of 994 visits in 137 patients with RA were reviewed. Variation in guideline adherence among parameters was present (adherence between 21% and 72%), with referral to the physician assistant as lowest scoring and referral to a specialised nurse as highest scoring parameter. Variation in guideline adherence among rheumatologists was also present (adherence between 22% and 100%). Patient sex, the number of DMARD options, presence of erosions, comorbidity, RF/aCCP positivity, type of patient and the rheumatologists' scientific education status were associated with adherence to 1 or more guideline parameters.

Conclusions

Guideline adherence varied considerably among the guideline parameters and rheumatologists, showing that there is room for improvement. Guideline adherence in our sample was related to several patient and rheumatologist determinants.

Incentives in Rheumatology: the Potential Contribution of Physician Responses to Financial Incentives, Public Reporting, and Treatment Guidelines to Health Care Sustainability

Concerns about the sustainability of current health care expenditure are focusing attention on the cost, quality and value of health care provision. Financial incentives, for example pay-for-performance (P4P), seek to reward quality and value in health care provision. There has long been an expectation that P4P schemes are coming to rheumatology. We review the available evidence about the use of incentives in this setting and provide two emerging examples of P4P schemes which may shape the future of service provision in rheumatology. Currently, there is limited and equivocal evidence in rheumatology about the impact of incentive schemes. However, reporting variation in the quality and provision of rheumatology services has highlighted examples of inefficiencies in the delivery of care. If financial incentives can improve the delivery of timely and appropriate care for rheumatology patients, then they may have an important role to play in the sustainability of health care provision.

Patients' Perspectives and Experiences Living with Systemic Sclerosis: A Systematic Review and Thematic Synthesis of Qualitative Studies

OBJECTIVE

Systemic sclerosis (SSc) is a chronic, progressive autoimmune disease with major end-organ involvement. Much attention has been focused on the management of physical and clinical manifestations; however, the effect of the disease and treatment on the patient's identity, relationships, functioning, and mental well-being are less known. We aimed to describe the patients' perspectives and experiences of living with SSc.

METHODS

Electronic databases were searched to October 2014. Thematic synthesis was used to analyze the findings.

RESULTS

We included 26 studies involving 463 patients. Six key themes were identified: distressing appearance transformation (disturbing facial changes, stigmatizing sickness, unrecognizable self), palpable physical limitations (bodily restrictions, frustrating mind-body disconnect, pervasive fatigue, disabling pain), social impairment (breaking intimacy, struggling to fulfill family responsibilities, maintaining work, losing independence), navigating uncertainty (diagnostic ambiguity, medically fending for oneself, unpredictable course of illness), alone and misunderstood (fearful avoidance of fellow patients, invisible suffering), and gradual acceptance and relative optimism (adapting to change and accepting limitations, taking a positive spin, cautious hoping, empowering relationships, valuing medical support).

CONCLUSION

SSc is a rare and unpredictable illness that undermines patients' sense of certainty and control and impairs their self-image, identity, and daily functioning. Patient-centered care that encompasses strategies to promote self-esteem, resilience, and self-efficacy may help to improve treatment satisfaction and health and quality of life outcomes for patients with SSc.

Identifying factors associated with concordance with the American College of Rheumatology rheumatoid arthritis treatment recommendations

BACKGROUND

Factors associated with care concordant with the American College of Rheumatology (ACR) recommendations for the use of disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (RA) are unknown.

METHODS

We identified a national cohort of biologic-naive patients with RA with visits between December 2008 and February 2013. Treatment acceleration (initiation or dose escalation of biologic and nonbiologic DMARDs) in response to moderate to high disease activity (using the Clinical Disease Activity Index) was assessed. The population was divided into two subcohorts: (1) methotrexate (MTX)-only users and (2) multiple nonbiologic DMARD users. In both subcohorts, we compared the characteristics of patients who received care consistent with the ACR recommendations (e.g., prescriptions for treatment acceleration) and their providers with the characteristics of those who did not at the conclusion of one visit and over two visits, using logistic regression and adjusting for clustering of patients by rheumatologist.

RESULTS

Our study included 741 MTX monotherapy and 995 multiple nonbiologic DMARD users cared for by 139 providers. Only 36.2 % of MTX monotherapy users and 39.6 % of multiple nonbiologic DMARD users received care consistent with the recommendations after one visit, which increased over two visits to 78.3 % and 76.2 %, respectively (25-30 % achieved low disease activity by the second visit without DMARD acceleration). Increasing time since the ACR publication on RA treatment recommendations was not associated with improved adherence.

CONCLUSIONS

Allowing two encounters for treatment acceleration was associated with an increase in care concordant with the recommendations; however, time since publication was not.

Economic Burden and Treatment Patterns of Cycling between Conventional Synthetic Disease-modifying Antirheumatic Drugs Among Biologic-treated Patients with Rheumatoid Arthritis

PURPOSE

To assess the economic outcomes and treatment patterns among patients with rheumatoid arthritis (RA) who used 1, 2, or 3 or more conventional synthetic disease-modifying antirheumatic drugs (DMARDs) before receiving a biologic therapy.

METHODS

Adult patients with ≥2 RA diagnoses (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 714.xx) on different dates, ≥1 claim for a conventional synthetic DMARD, and ≥1 claim for a biologic DMARD were identified from a large commercial claims database. The initiation date of the first biologic DMARD was defined as the index date. Based on the number of distinct conventional synthetic DMARDs initiated between the first RA diagnosis and the index date, patients were classified into 3 cohorts: those who used 1, 2, or 3 or more conventional synthetic DMARDs. Baseline characteristics were measured 6 months preindex date and compared between the 3 cohorts. All-cause health care costs (in 2014 US$) were compared during the follow-up period (12 months postbiologic initiation) using multivariable gamma models adjusting for baseline characteristics. Time to discontinuation of the index biologic DMARD and time to switching to a new DMARD were compared using multivariable Cox proportional hazards models.

FINDINGS

The 1, 2, and 3 or more conventional synthetic DMARD cohorts included 6215; 3227; and 976 patients, respectively. At baseline, patients in the 3 or more conventional synthetic DMARD cohort had the least severe RA, as indicated by the lowest claims-based index for RA severity score (1 vs 2 vs 3 or more = 6.1 vs 5.9 vs 5.8). During the study period, there was a significant association between number of conventional synthetic DMARDs and higher all-cause total health care costs (adjusted mean difference, 1 vs 2: $772; P < 0.001; 2 vs 3 or more: $2390; P < 0.001). The all-cause medical and pharmacy costs were also significantly higher with the increasing number of conventional synthetic DMARDs. Patients who cycled more conventional synthetic DMARDs were also more likely to switch treatment after biologic initiation (1 vs 2: adjusted hazard ratio = 0.89; P = 0.005; 2 vs 3 or more: adjusted hazard ratio = 0.89; P = 0.087). There were no differences in index biologic discontinuation between the 3 cohorts.

IMPLICATIONS

Patients with RA who cycled more conventional synthetic DMARDs had increased economic burden in the 12 months following biologic initiation and were more likely to switch therapy. These results highlight the importance of timely switching to biologic DMARDs for the treatment of RA.

Implementation of treat-to-target in rheumatoid arthritis through a Learning Collaborative: Rationale and design of the TRACTION trial

BACKGROUND/PURPOSE

Treat-to-target (TTT) is a recommended strategy in the management of rheumatoid arthritis (RA), but various data sources suggest that its uptake in routine care in the US is suboptimal. Herein, we describe the design of a randomized controlled trial of a Learning Collaborative to facilitate implementation of TTT.

METHODS

We recruited 11 rheumatology sites from across the US and randomized them into the following two groups: one received the Learning Collaborative intervention in Phase 1 (month 1-9) and the second formed a wait-list control group to receive the intervention in Phase 2 (months 10-18). The Learning Collaborative intervention was designed using the Model for Improvement, consisting of a Change Package with corresponding principles and action phases. Phase 1 intervention practices had nine learning sessions, collaborated using a web-based tool, and shared results of plan-do-study-act cycles and monthly improvement metrics collected at each practice. The wait-list control group sites had no intervention during Phase 1. The primary trial outcome is the implementation of TTT as measured by chart review, comparing the differences from baseline to end of Phase 1, between intervention and control sites.

RESULTS

All intervention sites remained engaged in the Learning Collaborative throughout Phase 1, with a total of 38 providers participating. The primary trial outcome measures are currently being collected by the study team through medical record review.

CONCLUSIONS

If the Learning Collaborative is an effective means for improving implementation of TTT, this strategy could serve as a way of implementing disseminating TTT more widely.

Efficacy and Safety of Baricitinib in Japanese Patients with Active Rheumatoid Arthritis Receiving Background Methotrexate Therapy: A 12-week, Double-blind, Randomized Placebo-controlled Study

OBJECTIVE

To evaluate efficacy and safety, baricitinib [Janus kinase (JAK) 1/JAK2 inhibitor] was compared with placebo in Japanese patients with active rheumatoid arthritis (RA) despite background treatment with methotrexate (MTX).

METHODS

This was a phase IIB, double-blind, randomized, placebo-controlled study (clinicaltrials.gov: NCT01469013). Patients had moderate to severe active adult-onset RA despite stable treatment with MTX. Patients (n = 145) were randomized in a 2:1:1:1:1 ratio to placebo or 1 mg, 2 mg, 4 mg, or 8 mg oral baricitinib daily for 12 weeks. The primary analysis compared the combined 4/8-mg dose groups with placebo for the American College of Rheumatology (ACR) 20 response rate at 12 weeks. Other outcomes included additional measures of disease activity, physical function, laboratory abnormalities, and adverse events.

RESULTS

A significantly higher proportion of patients in the combined 4/8-mg baricitinib group (37/48, 77%) compared with the placebo group (15/49, 31%) had at least an ACR20 response after 12 weeks of treatment (p < 0.001). Significant improvements in disease activity, remission, and physical function were observed as early as Week 2 of treatment with baricitinib, particularly with daily doses of ≥ 4 mg. Only 1 patient receiving baricitinib discontinued because of an adverse event. Adverse event rates with baricitinib doses ≤ 4 mg daily were similar to placebo, but there was a higher incidence of adverse events and laboratory abnormalities in the 8-mg group.

CONCLUSION

In this phase II study, baricitinib was well tolerated and rapidly improved the signs, symptoms, and physical function of Japanese patients with active RA, supporting continued development of baricitinib (clinicaltrials.gov NCT01469013).

Quality in rheumatoid arthritis care

While most rheumatology practices are characterized by strong commitment to quality of care and continuous improvement to limit disability and optimize quality of life for patients and their families, the actual step toward improvement is often difficult. This is because there are still barriers to be addressed and facilitators to be captured before a satisfying and cost-effective practice management is installed. Therefore, this review aims to assist practicing rheumatologists with quality improvement of their daily practice, focusing on care for rheumatoid arthritis (RA) patients. First we define quality of care as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge". Often quality is determined by the interplay between structure, processes, and outcomes of care, which is also reflected in the corresponding indicators to measure quality of care. Next, a brief overview is given of the current treatment strategies used in RA, focusing on the tight control strategy, since this strategy forms the basis of international treatment guidelines. Adherence to tight control strategies leads, also in daily practice, to better outcomes in patients with regard to disease control, functional status, and work productivity. Despite evidence in favor of tight control strategies, adherence in daily practice is often challenging. Therefore, the next part of the review focuses on possible barriers and facilitators of adherence, and potential interventions to improve quality of care. Many different barriers and facilitators are known and targeting these can be effective in changing care, but these effects are rather small to moderate. With regard to RA, few studies have tried to improve care, such as a study aiming to increase the number of disease activity measures done by a combination of education and feedback. Two out of the three studies showed markedly positive effects of their interventions, suggesting that change is possible. Finally, a simple step-by-step plan is described, which could be used by rheumatologists in daily practice wanting to improve their RA patient care.

Relationship of multi-biomarker disease activity score and other risk factors with radiographic progression in an observational study of patients with rheumatoid arthritis

Objectives. To evaluate the multi-biomarker disease activity (MBDA) score as a predictor of radiographic progression and compare it with other risk factors among patients with established RA receiving non-biologic DMARDs.

Methods. For 163 patients with RA, we assessed 271 visits for MBDA score (scale of 1−100), clinical data and subsequent 1-year radiographic progression (change in Sharp−van der Heijde score [SHS]). Scatter plot and non-parametric quantile regression curves evaluated the relationship between the MBDA score and change in SHS. Changes in joint space narrowing and erosions were compared among MBDA categories with Wilcoxon rank-sum tests. The ability of the MBDA score to independently predict progression was determined by multivariate models and cross-classification of MBDA score with other risk factors. Generalized estimating equation methodology was used in model estimations to adjust for same-patient visits, always ≥1 year apart.

Results. Patient characteristics included 67% female, 66%/67% RF⁺/anti-CCP⁺; mean age 55 years, MBDA score 43 (moderate = 30−44); median disease duration 4.6 years, SHS 23. Radiographic progression was infrequent for low MBDA scores. Relative risk for progression increased continuously as the MBDA score increased, reaching 17.4 for change in SHS >5 with MBDA scores ≥60. Joint space narrowing and erosion progression were associated with MBDA score. MBDA score was associated with radiographic progression after adjustments for other risk factors. MBDA score significantly differentiated risk for progression when swollen joint count, CRP or DAS28–CRP was low, and among seropositive patients.

Conclusion. MBDA score enhanced the ability of conventional risk factors to predict radiographic progression in patients with established RA receiving non-biologic DMARDs.