Slow on the uptake
Despite the data and the dictum, however, TTT remains an outlier in the United States. The most recent studies suggest that most U.S. rheumatologists do not employ it.
Dr. Curtis is the primary author on one of the newest studies, which employed a 26-question survey about the use of a quantitative measurement in RA patients and attitudes about using it (J Rheumatol. 2018 Jan;45[1]:40-4). The survey went out to almost 2,000 rheumatologists; 439 returned it.
Overall, just 44% said they “always practice in a treat-to-target manner, regularly using a scoring metric.” Younger physicians, those in group practices, and those who made regular use of TNF inhibitors were more likely to practice this way. A total of 35% said they never used a quantitative metric for their RA patients.
“The No. 1 reason given about not using them is that it’s too time-consuming and not easy enough,” Dr. Curtis said in an interview. “Logistics is a key barrier.” Busy clinicians don’t want to spend time entering data into an electronic medical record, and there aren’t easy ways to merge a specific DAM with a practice’s chosen EHR. “There’s a hassle factor, for sure.”
The age gap was interesting but not unexpected, he said. “Older rheumatologists say they like to go by their gut, by a clinical gestalt,” Dr. Curtis said, while younger physicians without decades of experience are more comfortable with such clinical tools. For some, age contributes to a kind of clinical inertia. “Doctors trained in an earlier era might be more tolerant of patients not doing as well. I’m a younger physician, and I have never known the era of not having biologics. They lived and practiced in that era, so their spectrum of what’s ‘normal’ and acceptable for patient progress may be wider.”
Dr. Daniel H. Solomon
He and his colleagues investigated whether a 9-month group-based learning collaborative could improve TTT numbers among 46 rheumatologists at 11 practices. The endpoint was a combination of four TTT principles: recording a disease target, recording a disease activity measure, engaging in shared decision-making, and changing treatment if disease target hasn’t been reached.
At baseline, 64% of visits to these rheumatologists had none of the TTT components present, 33% had one component, and 2.3% had two components; just 3% of the visits included all of the components (Arthritis Care Res. 2017 Aug 22. doi: 10.1002/acr.23343).
The project consisted of nine sessions, most conducted by webinar. The entire practice team took part, learning the principles and practices of TTT, identifying their unique barriers to implementing it, and coming up with their unique way of integrating TTT into their practice. It was fairly successful, Dr. Solomon said in an interview. After the intervention, 57% of the exposed practices had incorporated TTT.
In January, Dr. Solomon published a follow-up study of the stability of those changes (Arthritis Care Res. 2018 Jan 5. doi: 10.1002/acr.23508). He was impressed with the results. Most sites from the first cohort had sustained the improvement during the second training period (52%).
“We found that people could implement it effectively when we gave them the tools to do it,” he said. “It’s definitely achievable, but it takes some commitment and guidance, and the realization that everyone can contribute to success in a collaborative manner.”
Technology, or the lack of it
Many rheumatologists view TTT and the consistent measuring it involves as just one more headache-inducing time suck, said John Cush, MD.
Dr. John J. Cush
But at the same time, he freely admits that the time spent ticking boxes on a paper form or a computer, and being forced to report those to a federal agency, could be the camel-breaking straw for many.
“It’s going down the path of what makes medicine sucky,” he said in an interview. “Bean counters telling me how to practice medicine, who think they can use this TTT to manage what I do. I don’t need more people trying to regulate my life.”
Dr. Cush has conducted surveys on physician burnout and depression. “Administrative tasks and electronic records are a large part why 24% of people are burning out in medicine.”
Right now, there’s no easy way for many rheumatologists to incorporate regular DAM measures into their EHR system. The extra steps needed to get them there impede physician compliance with the strategy, he and Dr. Curtis agreed. But, Dr. Curtis said, there’s an app for that.
He is the developer of the Rheumatic Disease Activity (READY) measure. The iPad/iPhone app, which is free to download in the app store, is an electronic measurement tool that efficiently captures patient-reported outcomes in RA and other rheumatic conditions.
“This tool really makes it much easier to collect DAM from patients,” Dr. Curtis said. “It is designed for the doc who says, ‘I would take data from patients, just make it easy for me to do that.’ It takes 5-10 minutes to complete, and you get information about pain, fatigue, anxiety, and social interactions and, he said, can be easily integrated into work flow.
On a practice-provided device, the patient answers questions validated on the National Institutes of Health Patient-Reported Outcomes Measurement Information System. It includes a number of electronically scored and validated DAMs and provides trend charts to visualize longitudinal score data and track patient health status over multiple encounters. There are also places to record data about current and past medications.
“The docs input no data, which is the usual deal-killer. All they have to do is figure out how to integrate it into the work flow.”
Dr. Kaleb Michaud
“ACR has been communicating with the major EMR providers out there to make this easier. We are seeing some tools for iPads and smartphones, as well as paper tools.”
The ACR RISE Registry is another option, said Evan Leibowitz, MD, a rheumatologist in Midland Park, N.J.
“RISE is open to all rheumatologists in this country, and ACR has tried to make it as easy as possible. It can interface with most EMRs. All the physician does is collect the data, and it gets transferred to a HIPAA-protected database where it’s analyzed and presented back to the doctors so they can look at all their metrics. It’s currently the least painful way to get involved in a registry, I think.”
But just as techies are rolling out ways to interface DAMs and EHRs, medicine is marching forward. A new blood test called VECTRA DA measures 12 inflammatory biomarkers and may provide all the information needed to make treatment escalation decisions, Dr. Leibowitz said.
“The least painful option will probably be the VECTRA DA score. It’s a single blood test, which we can do easily since we already draw blood. Rather than filling out a RAPID3 [Routine Assessment of Patient Index Data 3] or a CDAI [Clinical Disease Activity Index], we draw the blood, send it to the company, [and] they return us a score that indicates low, moderate, or high disease activity.”
Studies have found that not only is the VECTRA DA score a good clinical management tool, predicting responses, it can also predict impending relapse.