Background/Purpose: Flares in rheumatoid arthritis (RA) are common. The shortage of readily available specialized care may hinder early detection and timely management of RA flares. Engaging non-physician rheumatology providers in care of RA flares may be beneficial. We aimed to evaluate the effect of a flare management intervention guided by non-physician providers versus usual care between rheumatology visits on flare occurrence and RA disease activity.

Methods: Patients with established RA (2010 ACR/EULAR criteria) were randomized to the intervention arm versus usual care. The Flare Assessment in Rheumatoid Arthritis (FLARE-RA) questionnaire was administered monthly during the 24-month follow-up to all patients in the intervention arm to assess flare status [1]. Telephone nurse-led counseling or an expedited visit with a rheumatology provider was offered to patients in the intervention arm who indicated they were in flare. Patients in the usual care arm were followed by their rheumatology providers according to standards of care. OMERACT9 definition of flare was used to compare flare occurrence between the study arms [2]. All patients completed satisfaction surveys at baseline and at the end of the follow-up.

Results: 150 patients with RA were randomized to intervention (n=75) versus usual care (n=75). At baseline, the majority of patients in the intervention arm (51%) and in the usual care arm (60%, p=0.32) expressed interest in expedited appointments with their rheumatology provider if in RA flare. Patients in the intervention arm completed a median of 8.5 (range 1-24) questionnaires. RA flare was reported on 122 (19%) of these questionnaires; average FLARE-RA score: 2.57 on 0 (no flare) to 10 (maximum flare) scale. Patients agreed to have an expedited clinic visit with a rheumatology provider during 39 (32%) of flares. The majority of patients preferred to self-manage their flare (76, 62%) or receive nursing advice on flare management over the phone 7 (6%). There were no differences in DAS28-CRP, CDAI, SDAI, probability of anti-rheumatic treatment change by rheumatology provider, RA flare by OMERACT9 definition, or remission by CDAI between the study arms over 24-months of follow-up. At the end of the study, a higher proportion of patients in the intervention arm (44%) versus the usual care arm (21%, p=0.04) reported positive effect of participation in the study on the management of RA flares.

Conclusion: The flare management intervention guided by non-physician providers did not have any major effect on RA disease activity metrics over the 24-month follow-up. However, patients in the intervention arm reported a positive effect of the intervention. More studies are needed to further understand patient preferences for optimal RA flare management and to design interventions to meaningfully address these preferences.

References

1) Fautrel B, et al. Validation of FLARE-RA, a Self-Administered Tool to Detect Recent or Current Rheumatoid Arthritis Flare. Arthritis Rheumatol 2017, 69(2):309-319.

2) Bingham CO, et al. Developing a standardized definition for disease “flare” in rheumatoid arthritis (OMERACT 9 Special Interest Group). J Rheumatol 2009, 36:2335-2341.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/optimizing-the-management-of-flares-in-patients-with-rheumatoid-arthritis-with-the-help-of-non-physician-providers-results-of-a-randomized-controlled-trial/