How to improve DAS28 use in daily clinical practice?--a pilot study of a nurse-led intervention

Abstract

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.

The clinical effectiveness and cost-effectiveness of treat-to-target strategies in rheumatoid arthritis: a systematic review and cost-effectiveness analysis

“…BehandelStrategieën in Reumatoïde Artritis (BeSt), 26- 55 the TreaTing to Twin Targets (T-4) study, 56,57 the Treatment of Early Aggressive Rheumatoid arthritis (TEAR) trial [58][59][60] and the early rheumatoid arthritis treated with tocilizumab, methotrexate or their combination (U-Act-Early) trial 62 ], three trials 9,50,52,53 examined an established RA population [i.e. British Rheumatoid Outcome Study Group (BROSG) trial, 9 Fransen et al 50 and the Optimisation of Adalimumab study 52,53 ] and two trials 61,63 examined populations that include both patients with early RA and those with established RA [i.e. the TIght COntrol for RA (TICORA) trial 61 examined patients with a disease duration of < 5 years and van Hulst et al 63 reported including both newly diagnosed patients and those with established disease (and did not report on the findings for these patients separately at all)].…”

“…British Rheumatoid Outcome Study Group (BROSG) trial, 9 Fransen et al 50 and the Optimisation of Adalimumab study 52,53 ] and two trials 61,63 examined populations that include both patients with early RA and those with established RA [i.e. the TIght COntrol for RA (TICORA) trial 61 examined patients with a disease duration of < 5 years and van Hulst et al 63 reported including both newly diagnosed patients and those with established disease (and did not report on the findings for these patients separately at all)]. Six studies 50 52,53 the T-4 study 56,57 and the TEAR trial [58][59][60] ) and six studies 26- 54 and the TEAR trial [58][59][60] ).…”

“…Most studies specified a RA diagnosis based on ACR 1987 or 2010 criteria; however, the STREAM trial 55 required patients to have 2-5 swollen joints (and did not require an ACR diagnosis), the TICORA trial 61 required a DAS44 of > 2.4 and RA diagnosis was not reported in the Optimisation of Adalimumab study, 52,53 Saunders et al 54 or van Hulst et al 63 Sample sizes ranged from 82 to 755 participants and study durations (randomised phase) ranged from 24 weeks to 3 years. Six trials took place in the Netherlands, 26- …”

“…Two of the included cluster RCTs were rated as being at low risk of bias for random sequence generation 50,52 and one 63 was rated as being at unclear risk for this domain. All three cluster RCTs were rated as being at unclear risk of bias for allocation concealment.…”

“…50,52,63 All three cluster RCTs were rated as being at high risk of bias for blinding of participants and personnel. 50,52,63 One cluster RCT was rated as being at high risk of bias for blinded outcome assessment, 63 whereas the other two cluster RCTs were rated as being at unclear risk for this domain. 50,52 All three cluster RCTs were rated as being at high risk of attrition bias (> 10% participants withdrawing).…”