Telehealth, training may improve to treat-to-target rheumatoid arthritis management
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Key takeaways:
- RA treat-to-target strategies are often implemented suboptimally and not adhered to.
- Potential improvement strategies include telehealth education for patients and electronic disease assessment.
The implementation of treat-to-target approaches for rheumatoid arthritis remains largely suboptimal, but could be improved with telehealth and other measures, according to data published in Arthritis Care & Research.
“One or more treat-to-target components, including recording a disease target and activity measure, and [shared decision-making (SDM)], are not performed in more than 50% of routine visits,” Laure Gossec, MD, a professor of rheumatology at Pitié-Salpêtrière University Hospital and Sorbonne University, in Paris, and colleagues wrote. “Patients with high disease activity are not always offered a change of treatment or may decline the offer. Moreover, many [health care providers(HCPs)] believe incorrectly that they are fully adherent to treat-to-target guidelines.
“Previous reports and narrative reviews have outlined some of the barriers to treat-to-target implementation in RA, including the willingness of HCPs and/or patients to adhere to treat-to-target, time and resource limitations, comorbidities, and communication challenges between HCPs and patients,” they added. “However, previous reviews have not examined barriers in detail, or, importantly, identified and evaluated implementation strategies.”
To determine possible strategies for improving treat-to-target adherence in RA, Gossec and colleagues conducted a systematic literature review of articles assessing evidence on its barriers and facilitators. The researchers ultimately included 146 published articles relating to treat-to-target implementation in RA, and assessed the quality of each using Critical Appraisal Skills Program checklists. They later blended their findings into a narrative review.
The studies’ statements related to treat-to-target barriers and facilitators were categorized into 18 “target areas,” including shared decision-making and accounting for patient comorbidities. The effectiveness of each intervention was assessed through recorded improvement in treat-to-target components, including recording a disease target, recording disease activity measure, engaging in shared decision-making and changing treatment if a disease target has not been reached.
According to the researchers, the barriers and facilitators to treat-to-target implementation in RA were “generally consistent” with those found in previous reviews, and included physician adherence, patient cooperation, comorbidities, communication between patients and providers, and factors related to the health care systems. The researchers also identified “many parallels” between physician and patient barriers, and emphasized the importance of interpersonal relationships and communication between patients and providers.
Across 70 studies, the review identified 56 interventions to improve treat-to-target implementation. Most of the interventions (54%) targeted assessment of disease activity or patient-reported outcomes. In all, 36 (64%) were reportedly effective.
“These included disease assessment tools or processes (including [quality improvement (Qi)] initiatives) that improved documentation of composite disease activity measures and HCP training and/or feedback, which led to more global improvements in treat-to-target application, including SDM,” Gossec and colleagues wrote.
“Although interventions such as patient educational materials, patient decision aids and discussion of ultrasound assessment results did not directly improve treat-to-target implementation or patient outcomes, they improved patient knowledge and treatment adherence and/or reduced decisional conflict,” they added.
Based on their narrative review, the researchers proposed potentially “impactful and feasible” strategies for improved treat-to-target implementation. They focused on telehealth education for patients, electronic disease assessment, decision aids to help with shared decision-making during visits, and training and performance feedback for health care providers.
“We suggest supporting treat-to-target application during e-health consultations by providing guidance to HCPs and patients on how to prepare for these visits, including training on online or self-directed joint assessments,” Gossec and colleagues wrote. “Indeed, high-quality patient education and HCP training are integral to treat-to-target implementation, especially to support SDM, but should ideally be individually tailored and needs-based.
“Structured HCP training delivered as a group-based learning collaborative program integrating QI principles and improvement feedback has also been successful in improving both HCP skills and treat-to-target implementation,” they added. “We therefore propose that these are incorporated into existing medical education and scientific meetings to encourage self-directed improvement.”
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