Background/Purpose: Compared to routine care, the Treat to Target (TTT) strategy for
rheumatoid arthritis (RA) has been validated to improve functional and
radiographic outcomes via use of disease activity
measures (DAMs) to quantify and track RA activity over time. Several
DAMs have been validated for clinical use by the American College of
Rheumatology (ACR), but routine use of DAMs during RA patient visits is
not standard practice at the University of Texas at Houston (UT Houston)
Rheumatology clinic. 

Via participation
in a learning collaborative (TRACTION [Treat-to-target in Rheumatoid Arthritis: Collaboration To Improve
adoptiOn and adhereNce]) we
sought to increase adherence to TTT strategy in RA and to increase DAM
documentation to a minimum of 80% of RA visits. Our institution adopted use of the Clinical
Disease Activity Index (CDAI), which consists of a 28 tender and swollen joint
count (TJC/SJC), patient global assessment of disease activity, and provider
global assessment of disease activity.

Methods:   The initial intervention
was altering the electronic chart note template to include a dedicated line for
CDAI value.  Simultaneously, printed
CDAI forms from the ACR website were placed in all clinic exam rooms.  Electronic CDAI calculators from the ACR
website were also downloaded onto clinic computers. For TRACTION, percentage of
faculty visits with documented DAM is calculated by reviewing 5 charts per
provider over a 2 week time period on a monthly basis.

After TRACTION faculty reached goal CDAI documentation, interventions targeted
our 5 fellows. To teach proper technique for performing a 28 TJC/SJC, fellows
underwent a learning session wherein they viewed a TJC/SJC instructional video
and practiced TJC/SJC with simultaneous use of musculoskeletal ultrasound to
verify location of the palpated joint space. Individual CDAI
documentation rates based on all RA visits was provided to each fellow
at baseline and then bimonthly.

Results: At baseline, faculty documented a DAM for 6/25 (24%) of RA visits. Over
subsequent months, faculty documented a DAM in 20/20 (100%), 19/20 (95%), 23/25
(92%), and 19/20 (95%) of RA patient visits. At baseline, fellows documented a
DAM in 0% of RA visits.  Over the 8
weeks post-learning session, CDAI documentation increased to 22/29 (76%), 21/17
(78%), 14/23 (60%), and 14/15 (93%) RA visits. (See Figure 1.)

Conclusion: TTT improves outcomes in RA. Validated DAMs can
assess and track RA disease activity at each visit.  Use of DAM without lab value input,
improved access to DAM calculating tools, and use of a template-based
electronic note led to increased CDAI use and documentation among faculty.  A TJC/SJC learning session for fellows with
bimonthly feedback about documentation improved fellow CDAI documentation from 0%
to 93% of RA visits.  More time is
required to assess whether our efforts will lead to a sustainable change in
practice patterns.