Benefits and Sustainability of a Learning Collaborative for Implementation of Treat to Target in Rheumatoid Arthritis: Results of Phase II of a Cluster Randomized Controlled Trial

Daniel H. Solomon¹, Liana Fraenkel², Zhi Yu³, Bing Lu⁴, Asaf Bitton⁵, Agnes Zak⁶, Cassandra Corrigan⁷, Jen Agosti⁸, Leslie R Harrold⁹, Josef S. Smolen¹⁰, Jeffrey N. Katz¹¹ and Elena Losina¹², ¹Brigham and Women's Hospital and Harvard Medical School, Boston, MA, ²Rheumatology, Rheumatology, Yale University School of Medicine, New Haven, CT, New Haven, CT, ³Rheumatology Immunology & Allergy, Brigham and Women's Hospital, Boston, MA, ⁴Rheumatology, Immunology and Allergy, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, ⁵Medicine, Brigham and Women's Hospital, Boston, MA, ⁶Brigham and Women's Hospital, Boston, MA, ⁷Rheumatology, Brigham and Women's Hospital, Boston, MA, ⁸JRA Consulting, Andover, MA, ⁹University of Massachusetts Medical School, Worcester, MA, ¹⁰Medical University Vienna, Division of Rheumatology, Department of Internal Medicine III, Vienna, Austria, ¹¹Rheumatology, Immunology, and Allergy, Brigham & Women's Hospital, Boston, MA, ¹²Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham & Women's Hospital, Boston, MA

Meeting: 2017 ACR/ARHP Annual Meeting

Date of first publication: September 18, 2017

Keywords: quality improvement, randomized trials and rheumatoid arthritis (RA)

Session Information

Date: Monday, November 6, 2017

Title: Measures and Measurement of Healthcare Quality

Session Type: ACR Concurrent Abstract Session

Session Time: 2:30PM-4:00PM

Background/Purpose: Treat to target (TTT) is a recommended strategy in the management of rheumatoid arthritis (RA), but its uptake in routine rheumatologic care in the US is sub-optimal. We carried out an RCT of a Learning Collaborative (LC) to facilitate implementation of TTT. In the first phase, TTT implementation increased 46% in the intervention group. Herein, we report on the second phase in which the Phase I intervention sites were observed without intervention and additional sites received intervention.

Methods: We recruited 11 rheumatology sites (49 providers) from the US and randomized them into 2 groups: 5 sites received the LC intervention over the first 9 months (Phase I) and the other 6 sites received the intervention over the subsequent 9 months (Phase II). The LC included a face-to-face meeting, 8 learning sessions via webinar, use of a web-based tool for sharing results of plan-do-study-act cycles, and monthly collection of improvement measures. The primary outcome was the change in TTT implementation over 9 months, measured using a chart review before the intervention and then again after. TTT implementation included 4 items: shared-decision making, choice of a target, use of a disease activity measure (DAM), and changing treatments based on the target and DAM. It was scored on a 0-100% scale based on the presence/absence of these items. Phase II analyses allowed us to examine: 1) the sustainability of improvement in TTT among the Phase I intervention teams, and 2) predictors of TTT improvement across the 11 teams. Analyses accounted for clustering within site using Generalized Estimating Equations.

Results: The chart review included 636 RA patients seen by teams during the Phase I or II intervention periods. These patients had mean age 61, 81% were female, and 79% seropositive. At baseline, mean TTT implementation score was 11% in the Phase I intervention arm and 13% in the Phase II intervention arm (see Table 1). After the intervention, TTT implementation improved in the Phase I intervention arm to 57% and to 58% in the Phase II intervention arm (both P-values < 0.001). TTT implementation among the five Phase I intervention teams decreased slightly from 57% to 52% (P = 0.1). Predictors of greater improvement in TTT included not having NP/PA at site, the RA provider being a trainee, and academic affiliation of the site (see Table 2).

Conclusion: Improvement in TTT remained relatively stable over a 9-month post-intervention period. Several predictors of improvement in TTT implementation were identified at the site and provider level that might be used to guide interventions.

Table 1: Absolute Change in Implementation of Treat to Target and Components at Patient Visits in TRACTION Trial
		Phase I Intervention					Phase II Intervention
	Month 0		Month 9	Month 18	Change (0→9)	Month 0		Month 9	Month 18	Change (9→18)
Primary Outcome
Implementation score	11.1%		57.1%	52.4%	46.0%	11.0%		13.3%	58.0%	44.7%
Visits with components present
Treatment target	0.6%		45.6%	51.0%	45.0%	0%		1.0%	52.1%	51.1%
Disease activity measure	20.0%		89.1%	70.7%	69.1%	30.2%		34.2%	85.1%	50.9%
Shared decision-making†	51.3%		85.9%	43.4%	34.6%	24.5%		29.8%	67.0%	37.2%
Treatment decision‡	0.6%		27.8%	36.7%	27.2%	0%		1.0%	36.5%	35.5%
The number of visits included differed by Phase and by month of assessment. For Phase I, there were 320 visits at month 0 and at month 9, and 300 visits at month 18. For Phase II, there were 321 visits at month 0, and 316 visits at month 9 and 18.† The shared decision-making criteria did not apply to all visits when no decisions were being made about changing targets or changing treatments. The number of visits when shared decision-making applied for the Phase I intervention group: 115 at month 0, 184 at month 9, and 99 at month 18. For the Phase II intervention group: 102 at month 0, 94 at month 9, and 112 at month 18. ‡ Treatment decision based on target and disease activity measure.

Table 2: Adjusted Mean Improvement in TTT Implementation Score over 9 months by Site Level and Provider Level Factors
	Univariate*	P-value	Multivariable	P-value
Site level factors
Intervention
Phase I	42.0 (33.8, 50.3)	0.71	—
Phase II	44.6 (34.1, 55.1)		—
Academic affiliation
Yes	47.2 (39.6, 54.8)	0.12	52.9 (45.3, 60.5)	0.02
No	35.7 (23.3, 48.1)		37.9 (24.5, 51.4)
Fellows at site
Yes	47.3 (38.9, 55.6)	0.20	—
No	38.5 (27.8, 49.2)		—
NP/PA at site
Yes	33.9 (25.8, 42.0)	0.002	37.0 (25.2, 48.8)	0.006
No	53.1 (43.7, 62.4)		53.9 (44.6, 63.1)
Provider level factors
Disease activity measure
CDAI	42.1 (32.8, 51.3)	0.47	—
Rapid 3	47.4 (36.3, 58.5)		—
None	33.0 (25.8, 40.1)	0.03	—
Male sex of provider
Yes	39.5 (29.1, 49.8)	0.31	—
No	46.5 (37.8, 55.3)		—
Provider type
Physician	44.3 (37.4, 51.3)	0.46	—
Non-physician	34.7 (10.2, 59.3)		—
Trainee
Yes	58.1 (42.1, 74.0)	0.05	52.3 (37.2, 67.4)	0.09
No	40.3 (33.3, 47.3)		38.5 (31.6, 45.5)
*Adjusted least square means generated using Generalized Estimating Equation, accounting for clustering of patients within providers. Multivariable analyses include the three variables with P values < 0.2 on univariate screen and account for clustering.

Disclosure: D. H. Solomon, None; L. Fraenkel, None; Z. Yu, None; B. Lu, None; A. Bitton, None; A. Zak, None; C. Corrigan, None; J. Agosti, None; L. R. Harrold, Corrona, 1,Pfizer Inc, 2,Roche Pharmaceuticals, 5,Corrona, 3; J. S. Smolen, AbbVie, Eli Lilly, Janssen, MSD, Pfizer Inc, Roche, 2,AbbVie, Amgen, AstraZeneca, Astro, Celgene, Celtrion, Eli Lilly, GSK, ILTOO, Janssen, MedImmune, MSD, Novartis-Sandoz, Pfizer Inc, Roche, Samsung, Sanofi, UCB, 5,AbbVie, Amgen, AstraZeneca, Astro, Celgene, Celtrion, Eli Lilly, GSK, ILTOO, Janssen, MedImmune, MSD, Novartis-Sandoz, Pfizer Inc, Roche, Samsung, Sanofi, UCB, 8; J. N. Katz, None; E. Losina, None.

To cite this abstract in AMA style:

Solomon DH, Fraenkel L, Yu Z, Lu B, Bitton A, Zak A, Corrigan C, Agosti J, Harrold LR, Smolen JS, Katz JN, Losina E. Benefits and Sustainability of a Learning Collaborative for Implementation of Treat to Target in Rheumatoid Arthritis: Results of Phase II of a Cluster Randomized Controlled Trial [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10). https://acrabstracts.org/abstract/benefits-and-sustainability-of-a-learning-collaborative-for-implementation-of-treat-to-target-in-rheumatoid-arthritis-results-of-phase-ii-of-a-cluster-randomized-controlled-trial/. Accessed .

« Back to 2017 ACR/ARHP Annual Meeting

ACR Meeting Abstracts - https://acrabstracts.org/abstract/benefits-and-sustainability-of-a-learning-collaborative-for-implementation-of-treat-to-target-in-rheumatoid-arthritis-results-of-phase-ii-of-a-cluster-randomized-controlled-trial/