Tight control in RA resulted in significantly better clinical outcomes than usual care. It is suggested but not proved that tight control with protocolized treatment adjustments is more beneficial than if no such protocol is used.

Objective Anti-rheumatic drugs are frequently not appropriately modified, according to ACR Guidelines, in patients with active rheumatoid arthritis (RA) as defined by a DAS28 score greater than 3.2. The objective was to determine which factors most strongly influence patients’ and rheumatologists’ decisions to escalate care. Methods We administered a Maximum Difference Scaling survey to 106 rheumatologists and 213 RA patients. The survey included 58 factors related to the decision to escalate care in RA. Participants answered 24 choice tasks. In each task, participants were asked to choose the most important factor from a set of five. We used Hierarchical Bayes modeling to generate the mean relative importance score (RIS) for each factor. Results For rheumatologists, the five most influential factors were: number of swollen joints (RIS: 5.2; sd: 0.4), DAS28 score (RIS 5.2; sd 0.5), physician global assessment of disease activity (RIS 5.2. sd 0.6), worsening erosions over the last year (RIS: 5.2; sd: 0.6) and RA disease activity now compared to three months ago (RIS 5.1; sd: 0.6). For patients, the 5 most important factors were: current level of physical functioning (RIS: 4.3; sd: 1.1), motivation to get better (RIS: 3.5; sd: 1.4), trust in their rheumatologist (RIS: 3.5; sd: 1.6), satisfaction with current DMARDs (RIS: 3.4; sd: 1.4) and current number of painful joints (RIS 3.4; sd: 1.4). Conclusions Factors influencing the decision to escalate care differ between rheumatologists and patients. Better communication between patients and their physicians may improve treatment planning in RA patients with active disease.

Objectives. To determine whether DAS28 measurements by a specialized nurse, before the rheumatologist visit, in combination with the advice to rheumatologists to reach a DAS28 4 3.2, had beneficial effects on disease activity and medication prescription in patients with RA and to explore possible predictors for variation in medication changes and reasons for non-adherence to the advice to reach a DAS28 4 3.2.Methods. In this pilot study, rheumatologists were randomized to 'usual care' (n = 3) or DAS28 measurement by a nurse prior the rheumatologist visit (n = 4). In the usual care group, the DAS28 was measured but not provided to rheumatologists. Mixed model analyses were used for analysing between-group differences and for the prediction model. Rheumatologists in the intervention group were asked to provide reasons in cases of non-adherence to the advice.Results. After 18 months, DAS28 was reduced by À 0.69 and À 0.66 (P = 0.70) in, respectively, the intervention (144 patients) and the usual care (104 patients) groups. In the intervention group, medication was changed by rheumatologists in 35% of the visits with a DAS28 > 3.2; in the usual care group this was 33% (P = 0.99). Baseline DAS28 (OR 1.6; P40.0001) and HAQ (OR 1.3; P = 0.03) were positively related to a medication change. The most frequently mentioned reason not to change medication was patient refusal (26%).Conclusions. DAS28 measurement by a nurse was as effective as usual care; however, this intervention without protocolized treatment adjustments is not sufficient to lead to a considerable reduction in disease activity compared with trials with protocolized treatment adjustments.

This quality indicator set can be used to assess the quality of disease course monitoring of rheumatologists in daily clinical practice, and to determine for which aspects of disease course monitoring rheumatologists perform well, or where there is room for improvement. This information can be used to improve the quality of disease course monitoring.