background aim methods results conclusion

Practice what you preach? Suboptimal guideline adherence by
rheumatologists in patients with rheumatoid arthritis.
Nienke Lesuisa, Ronald van Vollenhovenb, Marlies Hulscherc, Alfons den Broedera
aDepartments
of Rheumatology and Pharmacy; Sint Maartenskliniek, the Netherlands. bDepartment of Rheumatology; Karolinska Institute, Sweden. cIQ Healthcare; Radboud University Medical Centre, the Netherlands.
BACKGROUND
Tight control based treatment principles of
rheumatoid arthritis (RA) are superior to usual care
and therefore recommended in many (inter)national
guidelines.1-3 Unfortunately guideline adherence to
these guidelines has often been shown to be
suboptimal in clinical practice.4,5 So far this is mainly
described in clinical trials and pre-defined cohorts.
AIM
To assess RA guideline adherence in daily practice
and explore potential determinants of guideline
adherence.
METHODS
In this retrospective, single-center observational
study, all adult RA patients with a first outpatient
clinic visit at the Sint Maartenskliniek (SMK) between
September 2009 and March 2011 were included,
either new RA patients or second opinions. Data from
all visits in the first year of treatment were collected
by manual chart revision. Afterwards, for every
single visit guideline adherence to 7 indicators was
assessed. The indicators were based on evidencebased national and local RA guideline
recommendations (issued in 2009) and concerned
diagnostic, therapeutic and follow-up decisions.
To assess potential determinants of guideline
adherence, all rheumatologists working at the SMK in
March 2011 received a set of questionnaires about
personality traits, propensity towards cognitive bias,
thinking styles and knowledge about guideline
content. Furthermore, demographic and disease
characteristics of the patients were collected during
the chart revision.
References: 1van Riel et al. Van Zuiden Communications 2009. 2Singh et al.
Arthritis Care Res 2012. 3Peters et al. Ann Rheum Dis 2010. 4van Hulst et al.
Rheumatology 2010. 5Vermeer et al. Arthritis Res Ther 2012.
Disclosures: none
RESULTS
A total of 994 patient visits for 137 RA patients were reviewed (mean age 59 years ± 14.1; 67% female; disease
duration 4.9 years ± 8.5 year; 85% rheumatoid factor and/or anti-CCP positive). Guideline adherence varied
between 21 and 72%, with referral to the physician assistant as worst scoring indicator and referral to a
specialized nurse as best scoring one (see table 1). Both are routine measures implemented at our centre in
order to facilitate frequent systematic follow-up. Patients and physician characteristics were analysed for
relations with guideline adherence, preliminary analyses found two associations. In patients never seen by a
rheumatologist before intervals between visits were more often correct and X-rays were more frequently made if
more treatment options were available.
Table 1: Guideline adherence percentages
Indicator
1)
2)
3)
4)
5)
6)
7)
Diagnostics
X-rays of hands, feet and thorax within the first three visits
Treatment
Therapy change in case of moderate to high disease activity*
Prescription of conventional and biological DMARDs in agreement with the local
preferential sequence
Follow-up and shared care
Referral to a specialized nurse within the first three visits
Referral to a physician assistant (PA) or nurse practitioner (NP) within the first
year of treatment
Regular outpatient clinic visits combined with a visit to the clinimetric center*
Correct intervals between regular outpatient clinic visits
Adherence percentages [lowest –
highest score rheumatologists]
54.7
[29.0 – 100.0]
65.6
23
[46.7 – 84.4]
[0 – 50.0]
71.5
21.2
[43.0 – 100.0]
[0 – 50.0]
35.5
21.3
[9.3 – 70.5]
[11.1 – 44.3]
* Therapy change include starting or increasing dosage of a conventional DMARD or oral prednisone, starting a biological DMARD and intramuscular or -articular
injections with corticosteroids.
CONCLUSION
Guideline adherence to the seven recommendations varied between 21 and 72%, indicating that there is still
room for improvement. Guideline adherence seems only marginally related to factors on patient- or clinician
level. Therefore, adherence is more likely to be guided by a complex interplay of facilitators and barriers.
Contact
Nienke Lesuis, afdeling reumatologie
Hengstdal 3, 6500 GM, Nijmegen
[email protected]
www.maartenskliniek.nl

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