Physician Adherence to Treat-to-Target and Practice Guidelines in Rheumatoid Arthritis

Abstract

Principles of treat-to-target (T2T) have been widely adopted in both multinational and regional guidelines for rheumatoid arthritis (RA). Several questionnaire studies among physicians and real-world data have suggested that an evidence–practice gap exists in RA management. Investigating physician adherence to T2T, which requires a process measure, is difficult. Different practice patterns among physicians are observed, while adherence to protocolized treatment declines over time. Rheumatologist awareness, agreement, and claims of adherence to T2T guidelines are not always consistent with medical records. Comorbidities, a difficult disease course, communication barriers, and individual preferences may hinder an intensive, proactive treatment stance. Interpreting deviations from protocolized treatment/T2T guidelines requires sufficient clinical context, though higher adherence seems to improve clinical outcomes. Nonmedical constraints in routine care may consist of barriers in healthcare structure and socioeconomic factors. Therefore, strategies to improve the institution of T2T should be tailored to local healthcare. Educational interventions to improve T2T adherence among physicians may show a moderate, although beneficial effect. Meanwhile, a proportion of patients with inadequately controlled RA exists, while management decisions may not be in accordance with T2T. Physicians tend to be aware of current guidelines, but their institution in routine practice seems challenging, which warrants attention and further study.

Treatment Satisfaction, Patient Preferences, and the Impact of Suboptimal Disease Control in a Large International Rheumatoid Arthritis Cohort: SENSE Study

“…Barriers to implementing T2T principles are numerous, including treating physicians’ clinical inertia, patients’ concerns related to treatment intensification, and reimbursement of effective medications. 2 …”

Unlocking the Value of Anti-TNF Biosimilars: Reducing Disease Burden and Improving Outcomes in Chronic Immune-Mediated Inflammatory Diseases: A Narrative Review

“…The value of such an approach is better patient outcomes in both the short and long term, which in addition to remission includes reductions in comorbidities and cardiovascular risk, as well as improvements in quality of life and productivity [81,[85][86][87][88][89][90]. However, several studies have shown that the practices outlined in guidelines do not translate well into the clinic with low rates of adherence to recommendations [70,[91][92][93][94]. Reasons for nonadherence include lack of awareness of guidelines, individual physician beliefs and financial and cost issues [91][92][93], including access to the relevant treatments as outlined earlier in the review.…”

“…In addition, the majority of international guidelines restrict the use of biologics to the second line, following a ‘top-up’ approach, starting with a conventional DMARD before moving onto a bDMARD once disease progresses or does not respond to therapy [ 19 – 21 , 24 , 26 , 28 – 30 , 69 ]. A further complication is that guidelines are often not followed in clinical practice [ 70 – 72 ]. Furthermore, the health economic data that reimbursement criteria are based upon may not be up to date, leading to misalignment between policy and practice [ 73 , 74 ].…”

“…The principle of treat-to-target (T2T) has been successful in different therapeutic areas including hypertension [ 79 ] and diabetes [ 80 ], and is aimed at achieving a prompt and effective control of the disease process that is then maintained over time [ 70 , 81 ]. Current guidelines and recommendations for IMIDs also recommend a treat-to-target approach [ 69 , 82 – 84 ].…”

A patient‐centered knowledge translation tool for treat‐to‐target strategy in rheumatoid arthritis: Patient and rheumatologist perspectives

“…Treat‐to‐target (T2T) regimens in RA reduce disease burden, joint damage, disability 2‐4 and mortality 5 . While an RA‐T2T approach clearly improves outcomes, implementation in clinical practice is challenging and an evidence‐practice gap has likely emerged 6,7 …”