Title: 

Comprehensive provider judgment outweighs disease activity measures in the decision to not escalate therapy in patients with moderate to severe rheumatoid arthritis. 

Authors:  

Stever, Sauer, Teng, Accortt, Collier, Cannon.

Background/Purpose:

We evaluated US Veterans with RA in the Veterans Affairs Rheumatoid Arthritis (VARA) registry with moderate/severe disease activity (DAS28>3.2) and noted that of 941 patients with DAS>3.2, 559 (59%) did not have a change in RA therapy.  We reviewed medical chart notes to determine provider reasoning for not modifying therapy despite documented moderate/severe RA disease activity.  

Methods:

US Veterans included in VARA had 1) moderate/severe disease activity (DAS28³3.2) on the index date, 2) 18 months of VA data prior to the index date and 3) no major change to their medical therapy within 7 days before to 90 days after the index date.  A major change was 1) initiation or escalation of DMARDs and/or prednisone and/or 2) 2 joint injections.  There were 220 patients from 9 VARA registry sites randomly selected for chart review and the reasons documented in the patient record for continuing on therapy were recorded.  In all patients, a Òcomprehensive provider judgmentÓ (CPJ) was made by the chart reviewer (JS) for each patient and categorized as mild or moderate/severe disease on the basis of text notes by the provider using these terms or similar comments on disease state. The CPJ was based on text notes and not physician global assessment by visual analog scale (VAS).

Results:

The reasons for continuing current therapy despite DAS28>3.2 are listed in Table 1.   A CPJ reported as mild was the predominant reason for no major change in therapy in 149 (68%) patients.  CPJ mild patients had lower tender joint counts, swollen joint count, and physician global assessment. This CPJ of mild disease activity was not associated with other parameters evaluated including patient global assessment, ESR, CRP, and Heath Assessment Questionnaire (HAQ) (Table 2).

Conclusion:

The most common reason that RA patients remain on current therapy despite a documented DAS28>3.2 is a comprehensive provider judgment of acceptable disease activity.  Many cases involved patients with a low numbers of tender and swollen joints.  This observation suggests that a value of DAS28>3.2 may frequently occur in patients that most providers do not accept as having moderate/severe disease with sufficient confidence to direct therapy.  These data emphasize the need for a better understanding of factors in addition to disease activity measures directing therapy in clinical practice.