Background/Purpose: 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 As this is mainly described in clinical trials and pre-defined cohorts, we aim to assess RA guideline adherence in daily practice. In addition, we will also 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 evidence-based 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.

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; 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

Conclusion: Guideline adherence to the seven recommendations varied between 21 and 72%. This indicates that there is still room for improvement with regard to guideline adherence. 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.

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.