Real-world monitoring of rheumatoid arthritis-associated ILD ‘suboptimal’
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SAN DIEGO — Monitoring of rheumatoid arthritis-associated interstitial lung disease remains highly variable and “suboptimal” in the real world, according to a speaker at ACR Convergence 2023.
“Patients with RA-associated ILD are typically being cared for by rheumatologists and pulmonologists,” Bryant England, MD, PhD, of the University of Nebraska Medical Center, told Healio. “Some of the most frequent tests we use to monitor these patients are pulmonary function tests (PFT) and chest CT. These approaches have been around for a long time but it is not really clear how they are being used to monitor patients. We still do not know the best way to monitor these patients.”
A complicating factor is that there are currently no clinical practice guidelines for monitoring RA-ILD, according to England.
“We wanted to see what is actually happening out in the real world with these monitoring approaches,” he said.
In the current study, the researchers used national Veterans Administration data to identify patients with RA-ILD. England noted that the VA is the largest integrated health care system in the United States.
“We followed them over time to see how frequently they are getting PFT and chest CT, along with how often they are seeing a pulmonologist and rheumatologist,” he said.
Patients were followed for up to 7 years after the index date. The researchers assessed completion of PFTs, chest CT imaging of any type, and outpatient visit frequency to rheumatologists and pulmonologists.
The analysis included 6,232 patients with RA-ILD. The cohort was 92.6% men and had a mean age of 69.1 years.
According to the researchers, follow-up data demonstrated that RA-ILD patients underwent PFT every 1.4 years, with a median 0.5 tests (IQR, 0.2-1) per year. Meanwhile, patients underwent chest CT imaging every 1.1 years, for a median of 0.7 (IQR, 0.3-1.2) tests per year.
“Monitoring is highly variable out in the real world,” England said. “The regularity with which patients are being monitored with PFT and chest CT was not as frequent as you might think.”
Moreover, use of these interventions decreased over time, according to England. Fewer than 50% of patients with RA-ILD underwent PFT or chest CT each year after the first year of follow-up.
“When we looked at patients initially, it seemed they were getting tested frequently,” England said. “But, over time, it really went down.”
For patients who did receive annual monitoring, it was commonly once a year. Patients visited a rheumatologist a median of 1.8 times (IQR, 0.6-2.9) per year, compared with 1.3 (IQR, 0.5-24) times per year for pulmonology visits.
Although patients “stick with their rheumatologists” over time, and pulmonology visits were less frequent, the rheumatology providers were assessing RA-ILD using these interventions less frequently, according to England. A stronger correlation was reported for pulmonology visits and both PFT (r = 0.51; P < .001) and chest CT (r = 0.35; P < .001) than for rheumatology visits (PFT r = 0.2; P < .001; chest CT r = 0.09; P < .001).
“It was a much weaker correlation for rheumatology visits,” England said.
Further data demonstrated a negative correlation between baseline forced vital capacity and both PFT (r = -0.13; P < .001) and CT (r = -0.04; P = .01) testing rates.
“RA-ILD monitoring is highly variable and appears to be suboptimal in the real world,” England said. “More visits with the care team are likely to lead to more tests.”
He added that clinicians should be testing patients, as the question of whether they have a progressive phenotype “increasingly influences” how they are treated. Depending on the results, patients may receive an immunomodulatory or an antifibrotic agent.
Ultimately, clinical practice guidelines for monitoring RA-ILD could solve some of these issues. In the meantime, England highlighted one important conclusion to be drawn from this data set.
“There is definitely room for improvement,” he said.
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England B. Abstract 808. Presented at: ACR Convergence 2023; Nov. 10-15, 2023; San Diego (hybrid meeting).
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