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Treat-to-target (TTT) has become a goal in rheumatoid arthritis (RA) therapeutics, but its implementation in daily practice is varied and viewed to be difficult by most. Solomon and coworkers have shown that TTT education through group-based quality improvement sessions can result in wider use of TTT in practice.
They set out to study the adherence to TTT in practice using a randomized quality improvement intervention with wait-list control across 11 rheumatology sites in the US.
The intervention utilized was a "learning collaborative" effort to establish best practices. These group-based learning collaboratives used rapid cycle testing for change along with frequent assessment of quality care improvements.
For 9-months the LC group incorporated rapid-cycle improvement methods. A composite TTT implementation score was a percentage of four required items documented in the chart. These included: 1) a disease activity target; 2) recording RA disease activity,numerically or by category (i.e., remission, low disease activity, etc.) using either the DAS28, SDAI, CDAI, or RAPID3; 3) documenting shared-decision making; and 4) documenting treatment decisions based on target and disease activity measure.
Five sites (23 providers) were randomized to intervention and managed 320 patients, while six sites (23 provider) were randomized to the wait-list control, managing 321 patients.
At study start a minority utilized TTT with mean TTT implementation score of 11%. After 9 months, the TTT implementation score was higher with the LC intervention (57% vs 25% in control).
Substantial improvement in TTT utilization was seen with this learning collaborative intervention.
While nearly half of all rheumatologists utilize some disease measure in practice, there is little evidence that they utilize this information in daily patient management. These findings suggest that knowing and using the measure in the clinic may not be enough and that a substantial committment to quality care and specific educational interventions are needed to demonstrate treatment decisions based on disease activity measures in RA.