Friday, 18 Jan 2019

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Treat-to-Target a Bust with Rheumatologists

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:

  1. A disease activity target “treatment target”
  2. A RA disease activity measure, recommended by the ACR (CDAI, SDAI, DAS28, PAS, PASII, RAPID3)
  3. Documented shared-decision making
  4. 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,  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. 

The author has no conflicts of interest to disclose related to this subject

Rheumatologists' Comments

We were told that T2T came about because of distain of physician gestalt. The first principle was shared decision making with the patient and the physician. Except we have been doing that for centuries. T2T has some important aspects but there is a lot more to take into consideration for patient care. Our Disease Activity measures are inept and made worse by ACR indicating the DAS28ESR and DAS28CRP results are supposed to be identical. My physician gestalt does not accept that. Physician gestalt is physician judgment. Remember you are supposed to use T2T to decide to change your medication and treatment program. Well if you how do you choose? Oh yes, you use "physician gestalt!"

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