Implementing Target to Treat Strategy in Rheumatoid Arthritis
Implementing Target to Treat Strategy in Rheumatoid Arthritis is a collaborative effort led by Dr. Daniel H. Solomon. This strategy aims to enhance the evaluation of RA disease activity and optimize treatment outcomes. The work involves various healthcare professionals from different institutions, contributing to the advancement of managing RA effectively.
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Implementing Target to Treat Strategy in Rheumatoid Arthritis Dylan Lee MD-PGY 5 Banner Medical Center, Tucson, AZ
Acknowledgement -The work and results of this trial was done as a learning collaborative lead by the efforts of Daniel H. Solomon, MD, MPH from Brigham and Women s Hospital, Department of Rheumatology -Dr. Solomon gave an oral abstract talk as well as a poster session at ACR -There will likely be further post-hoc analysis using the data collect DH Solomon1, Nancy Shadick1, Theodore Pincus2, Josef Smolen3, Jack Ellrodt1, Jacklyn Stratton1, Leah Santacroce1, Jeffrey Katz1, Prem Chatpar4, Mary Stocks4, Breanna Mundell4, Christina Downey5, Karina Torralba6, Douglas White7, Meggan Baudek7, Steven Szlembarski7, Sharon Barnhart7, Jawad Bilal8, Albert Redford8, Dylan Lee8, Julia Buchfuhrer9, Helene Kramer8, C. Kent Kwoh10, Michel Villatoro- Villar8, Asha Patnaik11, Edgardo Guzman11, Rebecca Trachtman12, John Tesser13, Dijana Music14, Lexi Mickey15, Mona Amin16, Jeffrey Potter17, Joshua Sundhar18, Jessica Sheingold19, Juan Schmukler20, Diane Horowitz21, Hannah Gulko21, Robert Quinet22, Swathi Dhulipala23, Ronak Patel24, Chandana Keshavamurthy25, Guiset Carvajal Bedoya26, Rhonda Dunn27, Bharat Kumar27, Aleksander Lenert27, Hanna Zembrzuska27Matthew Gebre28, Petar Lenert29, Allen Anandarjah30, Annie Yang30, Linda Grinnell-Merrick30, Shadefai Goldsmith30, Jonna Zelie30, Leanna Wise31, Nicole Zagelbaum Ward32and Jeffrey Kaine33 1Brigham and Women's Hospital, Boston, MA, 2Rush University Medical Center, Chicago, IL, 3University of Vienna, Vienna, Austria, 4Dr. Chatpar and Associates, LLC, Plainview, NY, 5Loma Linda University Medical Center, Redlands, CA, 6Division of Rheumatology, Department of Medicine, Loma Linda University Healthcare, Loma Linda, CA, 7Gundersen Health, La Crosse, WI, 8University of Arizona, Phoenix, AZ, 9University of Arizona, Pheonix, AZ, 10University of Arizona College of Medicine, Tuscon, AZ, 11Stony Brook School of Medicine, Stony Brook, NY, 12Icahn School of Medicine at Mount Sinai, New York, NY, 13Arizona Arthritis & Rheumatology Associates, P.C., Phoenix, AZ, 14Arizona Arthritis and Rheumatology Associates, Glendale, AZ, 15Arthritis and Rheumatology Associates- Glendale, Glendale, AZ, 16Arthritis and Rheumatology Associates- Phoenix, Phoenix, AZ, 17Arthritis & Rheumatism Associates, Wheaton, MD, 18Arthritis Rheum & Back Disease Assoc., Voorhees, NJ, 19MedStar Georgetown University Hospital, Washington, DC, 20Mount Sinai- Chicago, Chicago, IL, 21Northwell Health, Great Neck, NY, 22Ochsner Health, River Ridge, LA, 23Ochsner Clinic Foundation, River Ridge, LA, 24Ochsner Health, Jefferson, LA, 25Ochsner, New Orleans, LA, 26University of Colorado, aurora, CO, 27University of Iowa, Iowa City, IA, 28Loma Linda University Medical Center, Loma Linda, CA, 29University of Iowa Medical School, Iowa City, IA, 30University of Rochester, Rochester, NY, 31LAC+USC/Keck Medicine of USC, Pasadena, CA, 32LAC+USC Medical Center, Los Angeles, CA, 33Cullowhee, NC
Disclosures -Dr. Solomon receives royalties from UpToDate on chapters related to NSAIDs and selective COX-2 inhibitors. -NIH: NIAMS, NIA -Research grants: Abbvie, Amgen, Genentech, CorEvitas, Moderna -No personal financial relationship with any pharmaceutical company -Member, FDA Arthritis Advisory Committee -Editor in Chief, A&R
Personal Disclosures None
Objectives -Describe/tell the history of evaluating RA disease activity -Appreciate the usefulness of Learning Collaboratives in clinical practice -Review the process/results of a widespread virtual learning collaborative targeting implementing target to treat strategy in rheumatoid arthritis
Background 1990s -Emerging drug therapies -Lack of consensus on evaluating drug therapy -No guidance on who should receive which treatment
Background June,1993
Background 1990-2000 -Evidence to support those DAMs lead to worse disease Does treatment targeting those DAMs prevent progression of disease? -2000s, Yes support for Treat to Target (TTT) Late 2000s -Workgroups started to recommend TTT in RA
Background Ability to adapt new guidelines?
Background How to increase compliance with recommendations for TTT? -Learning Collaboratives -Diabetes -Hypertension -HIV -Childhood Asthma
Learning Collaboratives Stems from ideas by Lev Vygotsky in the 1930s -People (students) can achieve beyond their individual limits with guidance from someone else
Learning Collaboratives -Modern Model
Treat-to-target in RA: Collaboration To Improve Adoption and Adherence Trial (TRACTION; 2017) Arthritis Rheumatol. 2017 Solomon Et. al Cluster-Randomized (Wait-List Controlled) Quality Improvement Study Two groups of sites: *Sites were randomized, not patients Sites in study arm: participated in Learning Collaboration Sites in control arm: continue usual care September 2014-December 2015 11 Sites 641 Patients
TRACTION (2017)-Methods Primary outcome: -Percentage of clinic visit that TTT was implemented TTT: 1) Specifying a disease activity target 2) Recording RA disease activity, using one of four recommended measures (e.g., DAS28, SDAI, CDAI, or RAPID3) 3) When a decision was being made regarding change in treatment, was shared-decision making documented 4) Was treatment decisions inling with target and disease activity or was there documentation on why TTT was not adhered to
TRACTION (2017)-Discussions/Limitations/Future Works -The TRACTION study suggested adherence to TTT increases with use of a learning collaborative -Did not directly evaluate clinical outcomes -Could a learning collaborative be feasible for wider dissemination
Implementing Treat to Target for Rheumatoid Arthritis Through a Virtual Learning Collaborative-2020 May 2020 Single arm demonstration study October 2020 18 Sites in 10 States Primary outcomes: To determine feasibility and effectiveness of a virtual LC for improving adherence to TTT for RA. Secondary/Post-Hoc outcomes: To compare TTT adherence between virtual and in person visit
Learning Collaborative (2020)- Conclusions -TTT strategy is not being universally used -Adherence to TTT improved during a virtual learning collaborative -Adherence to TTT during virtual appointment becomes similar to in person visits during a learning collaborative
Learning Collaborative (2020)-Discussion -What else can Learning Collaborative be use for? -Does the increase to adherence to TTT improve outcomes in RA? -Should ACR/EULAR organize Learning Collaboratives, particularly for TTT in RA?
Sources -Solomon DH, Losina E, Lu B, Zak A, Corrigan C, Lee SB, Agosti J, Bitton A, Harrold LR, Pincus T, Radner H, Yu Z, Smolen JS, Fraenkel L, Katz JN. Implementation of Treat-to-Target in Rheumatoid Arthritis Through a Learning Collaborative: Results of a Randomized Controlled Trial. Arthritis Rheumatol. 2017 Jul;69(7):1374-1380. doi: 10.1002/art.40111. Epub 2017 May 31. PMID: 28512998; PMCID: PMC5489379. -van der Heijde DM, van 't Hof MA, van Riel PL, Theunisse LA, Lubberts EW, van Leeuwen MA, van Rijswijk MH, van de Putte LB. Judging disease activity in clinical practice in rheumatoid arthritis: first step in the development of a disease activity score. Ann Rheum Dis. 1990 Nov;49(11):916-20. doi: 10.1136/ard.49.11.916. PMID: 2256738; PMCID: PMC1004262. -Harrold LR, Harrington JT, Curtis JR, Furst DE, Bentley MJ, Shan Y, et al. Prescribing practices in a US cohort of rheumatoid arthritis patients before and after publication of the American College of Rheumatology treatment recommendations. Arthritis Rheum. 2012; 64(3):630 8. [PubMed: 21953645] -Schoels M, Knevel R, Aletaha D, Bijlsma JW, Breedveld FC, Boumpas DT, et al. Evidence for treating rheumatoid arthritis to target: results of a systematic literature search. Ann Rheum Dis. 2010; 69(4):638 43. [PubMed: 20237123] -Smolen JS, Aletaha D, Bijlsma JW, Breedveld FC, Boumpas D, Burmester G, et al. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis. 2010; 69(4):631 7. [PubMed: 20215140] -Felson DT, Anderson JJ, Boers M, Bombardier C, Chernoff M, Fried B, et al. The American College of Rheumatology preliminary core set of disease activity measures for rheumatoid arthritis clinical trials. Arthritis Rheum 1993;36:729 40.
