Background/Purpose: More effective teamwork can improve patient care. We studied the effect of a Rheumatologist-Pharmacist Co-management program on the quality of care of rheumatology patients starting DMARDs.

Methods: The Rheumatologist-Pharmacist Co-management team used ACR guideline-driven protocols to manage rheumatic patients starting methotrexate (MTX).Interventions included Rheumatologist-Pharmacist visits, laboratory monitoring, medication tolerability assessment, treat-to-target (T2T) dose titration and disease monitoring. Electronic health record (EHR) data was compared for 3 groups -Rheumatologists at baseline, Rheumatologists at intervention and Co-management at intervention. Patient demographics, adherence with monthly visits and laboratories for the first 3 months after MTX initiation, MTX dose escalation, cumulative prednisone use within 6 months and biologic initiation within 12 months of MTX initiation were analyzed using appropriate statistical measures. Disease activity among the 3 groups was compared by descriptive analysis.

Results: Demographic evaluation showed that the Co-management group was more likely to be RF+ (80.6% vs 63.2% vs 72.4%) and had higher disease activity by CDAI (93.8% vs. 71.1% vs 75.6%) compared to the baseline and intervention period rheumatologist groups (Table 1). For the first 3 months post MTX intervention, the Co-management group was more adherent to all visits and all laboratories versus the baseline rheumatologist group (15% vs 2.2%, p=0.002; 70% vs 31.5%, p< 0.001) and the intervention rheumatologist group (15% vs 1.2%, p=0.001; 70% vs 24.8%, p< 0.001) (Table 2).When compared to the baseline and the intervention period rheumatologist groups, the Co-management group had a higher number of patients who escalated MTX dose to target (77.8% vs 36.6%, p< 0.001; 77.8% vs 34%, p< 0.001) and maximized MTX dose by 6 months (median 20mg vs 15 mg, p=0.01; 20 mg vs 15 mg, p=0.02).Additionally, the Co-management group had lower cumulative prednisone exposure (mean 144.6mg vs 493mg, p< 0.0001; 144.6mg vs 268.5mg, p< 0.58) and fewer patients starting biologics by 12 months of MTX initiation (5% vs 17.6%, p=0.04) when compared to the baseline rheumatologist group. CDAI evaluation post intervention suggested a trend toward more patients with CDAI improvement (90% vs 64.6% vs 73.1%) and low disease activity (CDAI ≤ 10) (70% vs 58.3% vs 38.5%) achieved in the Co-management group vs rheumatologist managed groups respectively, however this analysis is underpowered due to the small Co-management population (Table 3).

Conclusion: Adherence to guideline-driven care is directly correlated with improved patient outcomes. In our study, despite having increased disease severity (higher RF+ and higher CDAI scores pre-intervention), the Co-management group had greater adherence with visits, laboratories and T2T disease management compared to the rheumatologist only groups. Additionally, they used less cumulative steroids within a 6-month period and had better control of their rheumatoid arthritis disease activity. Our Co-management care model shows improved care delivery when compared to usual care and is a model that can be easily replicated.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/optimizing-the-care-of-the-rheumatic-patient-with-rheumatologist-pharmacist-co-management/