Treat-to-Target a Bust with Rheumatologists Save
Treat-to-target (T2T) strategy is widely advocated as an important means of optimizing treatment responses in patients with rheumatoid arthritis (RA). Even though T2T is encouraged by most guidelines, a current report shows that US Rheumatologists fail to implement T2T in their daily practice.
Rheumatology researchers from the Brigham and Women's Hospital have published the results of the TRACTION trial, which was a randomized controlled study of 641 RA patients recruited from 46 providers practicing at 11 US sites. They collected data on implementation of T2T, patient covariates, provider characteristics, site variables and also calculated a “T2T implementation score” as the percentage of features recorded.
Specifically they were seeking to identify four components of T2T from the medical records. These included:
- A disease activity target “treatment target”
- A RA disease activity measure, recommended by the ACR (CDAI, SDAI, DAS28, PAS, PASII, RAPID3)
- Documented shared-decision making
- Treatment decisions based on target and disease activity measures
Overall T2T Implementation was sub-optimal: nearly two-thirds (64%) of RA patients visits having none of the T2T components recorded, 33.1% had one component, 2.3% had two components, and 0.3% had all components.
T2T implementation differed significantly across providers and sites (P-values < 0.0001).
Older rheumatolgoists with longer experience had higher implementation score; while younger rheumatologists (fellows) had lower T2T scores.
These findings are sobering. Curtis et al have recently shown that over half of rheumatologists collect some measure, but theres little evidence that it affects decision making or therapeutics (J Rheum, In press). Hence, while most rheumatologists believe they practice T2T (largely because they measure something), there is little proof that they manage and treat using well defined T2T strategies.
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Treat to target is Tunnel Vision and there are many other things to consider in the care of a patient. It is a guide but we need more to make a clinical decision.
John, I think your views are those of most rheumatologists. But this study showed that most rheumatologists pay lip service to T2T- we do a measure but dont do T2T. The stark raving truth is that T2T (if practiced) leads to 4 fold higher DAS remissions and ACR70 rates even when using modest DMARDs like HCQ and MTX. IT removes the art of medicine (Ill know it when I see it thinking) and replaces it with a bankable sure-fire use of metrics. Rheums need to go NOT with what works for me or what we think works best, but instead go with an easier mathematical approach to the highly difficult problem of RA management. This article could be viewed as the title states - "T2T is a Bust!" or it could be viewed that Rheums getting a failing grade on what they should easily and routinely do. When and if the day comes that T2T will be required to approve the use of new drugs, we may change our tune - after at least 6 mos of griping, crying and cursing. What do you think? JC
If we going to debate this issue I suggest better armaments. The article based on this report had 64.3 % of the “providers” not including any of the Treat To Target (TTT) criteria. That means they did not even record Disease Activity Measures (DAM) or have shared decision making. The latter is in every office visit and activity measurements are the core to TTT. I do them all the time on every visit using a homunculus tool called Jointman. I question how the data was collected and quantified in this study. Not all who were measured were physicians but the data did not quantitate who did what to this level. They based their data on 4 measures: 1. Choose a target 2. Choose a disease activity measure 3. Shared decision making 4. Decision is either based on target and DAM or why TTT was not adhered to. According to their data 64.3 % had none, 33.1 % had one component, 2.3 % had two components and 0.3 % had all components out of 641 patients, 46 providers at 11 USA sites. The data was collected off of EHR data. How was that reliable? This depends on the interpretation of the record. WHAT! Providers with longer experience are said to have implemented more components of TTT.
Providers with longer experience are said to have implemented more components of TTT. I suspect they used the ‘evil physician gestalt”. This article has lots of holes. My problem with TTT is we have lousy measurement tools. The DAM are helpful but have a lot of variability with wide coefficients of variation in the non-laboratory components. We do not have a hemoglobin A-1-C for RA. Our measurement are not that good. We have Biomarkers like MBDA (or VECTRDA) which is a chemical thermometer and is helpful also but even MBDA is not as pinpoint as Hgb A-1- C, but I like it and use it. All of these DAM make me think about the whole patient but they alone are not enough and thus TTT is tunnel vision. We need more data, synovitis, osteitis, cardiovascular, other comorbidities etc. to make our decision tree. We need physician gestalt. Remember even when TTT indicates a change in therapy is needed how do we choose the therapy? – WE USE PHYSICIAN GESTALT! None of these measurements include one of the most important impediments to patient care the “Insurance, Pharmacy Benefit Manager Complex”. This like the military Industrial complex rules the my response was cut off:
"The Rest of the Story: None of these measurements include one of the most important impediments to patient care the “Insurance, Pharmacy Benefit Manager Complex”. This like the military Industrial complex rules the roost. If we are going to write articles on the therapy of our patients look at the obstruction delivered by the “Insurance, Pharmacy Benefits Manager complex” and as well by Electronic Health records (Actually Electronic Health Regulations) which interfere with our choice of therapy by adding ridiculous time consuming data entry input by us and may have confounded the outcome of the study reported. We should not be satisfied by the present TTT concept and need to build on it. We use it on every visit in our own way. The idea is good but the target is not reliable at present.
I strongly believe that T2T is a royal waste of time. Not only do I lack the time to document the data required but even if I had more time my opinion would not change. People who come up with these exercises obviously never actually spend nine hours a day seeing a full schedule of patients. Performing a thorough history and exam combined with appropriate lab and imaging studies provides much better data than spending wasted minutes filled in data.
I think its ok to differ on this issue, but if you read my comments above - I think this is NOT a waste or a charade. I too see patients all day long, 4 days a week and Do metrics on every patient. Ted Pincus studied the time committment. If you do the HAQ or RAPID3 it costs you nothing and takes no time. if you do a 28 joint exam and metric (I do the GAS, its like the CDAI) it takes an additional 90 seconds max. We spend more time reacting to useless labs and plotting LFT trends than we do on a metric. IF the metric = time; and I can attest to the 90 second effort, the real issue is reacting to and using a metric to guide therapy. This is what Rheums are unwilling to do. Largely because they believe they know better and dont need the metric (BTW...no proof that Gestalt ever beats Metrics and T2T) and they are not required to. But you are right - most rheums believe this is a royal waste and thus they do not do it! thanks JC
I was glad to see the article published online 5/23/2017 in Arthritis Care and Research , showing that "usual care" was as good as T2T in CDAI scores over 1 year . If one is careful, actually listens to patients ,examines them ,and does appropriate tests, it works just as well. It is unfortunate that this got zero coverage by the powers that be who tout T2T. I realize we would all love a real concrete way of achieving controlled remission or LDA. We just aren't there yet for most of us. The fact that this has been force fed to Rheums for years now with almost zero acceptance should tell us about the T2T approaches currently used . The thousands of Rheums in the US are not change averse to anything that advances the specialty . We accept new things that work well, all the time . We would all love something that makes our loves simpler . T2T , the ways it is currently constructed , just doesn't .
In my experience (sorry!), the RAPID 3 correlates weil with my Gestalt assessment. The problem with T2T involvmes co-morbidities (FMS, OA, depression, systemic illnesses) that "muddy" the waters. I always look at the "report card" with the patients who grow to accept it. Patient assessments aren't practical for some patients, but straight forward RA patients are good candidates.
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