Background/Purpose:

Current treatment guidelines for rheumatoid arthritis (RA) recommend using tight control strategies.¹ Despite evidence for the benefits of this strategy,  physician adherence is suboptimal.^2,3 Here we investigated two strategies to improve RA care by increasing physician guideline adherence using a multimodal intervention strategy.

Methods:

A single centre, combined before/after and randomized controlled pilot study was performed to assess effectiveness of two interventions. The first intervention combined education with feedback, whereas the second intervention comprised decision support incorporated in the Electronic Medical Record (EMR).

All clinicians (rheumatologists, residents and physician assistants; n = 20) working at the study centre during the full study period could participate. All participants received intervention 1, while intervention 2 was allocated in a 1:1 intervention vs. control randomization. .

Intervention effects were measured at the patient level using a set of 13 different dichotomous indicators for RA diagnostics, treatment and follow-up. All adult RA patients with a visit to a participating clinician in the study period were eligible for inclusion. The standardized sum score (SSS) of the indicators (indicator sum score divided by number of indicators) served as the primary outcome. The effect of intervention 1 was assessed using a before/after design; whereas the extra effect of intervention 2 was assessed using a randomized controlled design. The total study duration was 10 months (pre-intervention: 6 months; post-intervention: 4 months).

Results:

All 20 clinicians participated in this study.  A total of 1050 patients was included of which 527 in the pre-intervention period and 523 in the post-intervention period.

Three out of 13 indicators improved significantly after the interventions (regular disease activity- and functional status measurements, shared care with the physician assistant) with odds ratios between the 1.8 and 3.1. Intervention 1 resulted in a significant increase in the SSS, from 0.57 before the intervention to 0.63 afterwards (difference 0.06; 95% confidence interval (95%-CI) 0.02 to 0.10; p <0.01). In contrast, the second intervention did not result in an extra effect above intervention 1 alone (difference 0.01; 95%-CI -0.04 to 0.07; p = 0.65).

Table 1  Baseline characteristics of included clinicians

Conclusion:

An intervention consisting of education and feedback, but not electronic decision support, resulted in a significant increase in guideline adherence, reflected by an increase in the indicator sum score and improvement in three out of 13 indicators.

¹Smolen et al. Ann Rheum Dis 2014. ²Schipper et al. Rheumatology 2012. ³Harrold et al. Arthritis Rheum 2012.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/effects-of-two-interventions-on-rheumatologists-adherence-to-optimal-care-recommendations-in-rheumatoid-arthritis-a-combined-beforeafter-and-randomized-controlled-trial/