Evaluating Adherence to a Treat‐to‐Target Protocol in Recent‐Onset Rheumatoid Arthritis: Reasons for Compliance and Hesitation

Abstract

Objective. To evaluate rheumatologists' adherence to a low Disease Activity Score (DAS)-steered treat-to-target (T2T) strategy in treatment of patients with rheumatoid arthritis (RA) and to assess associated conditions. Methods. Data of the BeSt study were used, a multicenter T2T strategy trial with 10-year followup. During 3 monthly visits, the physician answered questions about satisfaction with level of RA suppression, agreement with the study protocol, and agreement with the DAS. Associations between the answers and nonadherence were evaluated. Results. Protocol adherence decreased over time from 100% to 60% per visit, with an average over time of 79%. Rheumatologists mostly agreed with the DAS (80-90% of visits over time) and were satisfied with the treatment steps (75-90%) and with the level of RA suppression (85-90%). The odds for protocol violation were higher when the rheumatologist disagreed with the DAS (odds ratio [OR] 2.3, 95% confidence interval [95% CI] 2.0-2.7 when they thought the DAS overestimated actual disease activity; OR 2.5, 95% CI 2.0-3.1 when they thought the DAS underestimated actual disease activity) or with the next required treatment step (OR 3.0, 95% CI 2.5-3.5), and when the physician was dissatisfied with disease suppression (OR 1.3, 95% CI 1.1-1.6). Conclusion. Rheumatologists generally agreed with and followed a 10-year followup DAS-steered T2T strategy. Disagreement with the DAS or the required treatment and dissatisfaction with the level of disease suppression were risk factors for nonadherence. These results indicate the feasibility of continued protocol-driven T2T therapy. For daily practice, adherence to T2T therapy might be improved by adopting the structure components of a clinical trial.

Treat-to-target as an approach in inflammatory arthritis

“…On the contrary, nonadherence by physicians in strategic clinical trials was partly because of the discrepancy between physician's opinion on a patient's disease activity and the score results. This situation may indeed occur with DAS28 [58], as DAS28 frequently underestimates and sometimes overestimates disease activity, given the high weight of acute phase reactants and tender joint counts in the formula [59]. Thus, the selection of appropriate endpoints and instruments and the adherence to the strategy are key elements of an optimal therapeutic success.…”

Treating rheumatoid arthritis to target: physician and patient adherence issues in contemporary rheumatoid arthritis therapy

“…The rate of protocol adherence in BeSt study declined over time, from 100% during the first visit up to around 60% of the visits in the final 2 years. The average adherence during 10‐year follow‐up was 79% . In the new Finnish RA Combination Therapy (NEO‐RACo) trial (n = 93), good, intermediate, and low physician adherence were observed in 33.3%, 34.4%, and 32.3% of patients, respectively.…”

“…Physician resistance to change their practice toward some aspects of T2T recommendations (especially frequency of disease monitoring and the use of composite disease activity measures to guide treatment decisions) remains an issue . Busy clinical practice, lack of confidence in composite outcome measures, inadequate understanding of the T2T recommendations, and poor physician‐patient communication were also noted as reasons for physician unwillingness to adopt some T2T recommendations . Practical challenges after implementations of the strategy : The reasons for physician nonadherence to T2T strategies are varied, but can be broadly characterized as patient related (eg, resistance to modify therapy when indicated), physician/disease (eg, persistent disease, relying on clinical scenario rather on composite disease activity measures), therapy related (eg, side effects of medicines), and/or as a result of comorbid conditions . In addition, health care system related factors such as awaiting laboratory results or delays to the approval for use of biological DMARDs or other logistic reasons may also play a role .…”

“…The reasons for physician nonadherence to T2T strategies are varied, but can be broadly characterized as patient related (eg, resistance to modify therapy when indicated), physician/disease (eg, persistent disease, relying on clinical scenario rather on composite disease activity measures), therapy related (eg, side effects of medicines), and/or as a result of comorbid conditions [18,38,40]. In addition, health care system related factors such as awaiting laboratory results or delays to the approval for use of biological DMARDs or other logistic reasons may also play a role [18].…”

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

“…Previous studies evaluating implementation of the T2T approach in trials and in clinical practice have reported the prevalence of therapy adjustment in response to MHDAS, but not the timing . Observational studies in the US have reported rates of therapy adjustment for patients with MHDAS ranging from 43–85% .…”