Implementation of the Treat-to-Target Concept in Evaluation of Psoriatic Arthritis Patients.

Tal Gazitt,Devy Zisman,Amir Haddad,Muna Elias,Muhanad Abu Elhija,Idit Lavi

doi:10.3390/jcm10235659

Abstract

Background: The treat-to-target approach was recently adopted for psoriatic arthritis (PsA) management. Objective: To assess the implementation of the “treat-to-target” (T2T) concept in daily management of PsA by use of composite scores of disease activity versus clinical judgement alone. Methods: A total of 117 PsA patients from a longitudinal PsA cohort were enrolled consecutively in the study during each patient’s first clinic visit during 2016–2017. Clinic notes from the treating rheumatologist were reviewed by an independent rheumatologist, noting clinical impression of disease activity, treatment changes based on clinical judgement, and rationale. Treatment changes were then compared to the use of formal disease activity parameters in Minimal Disease Activity (MDA) and Disease Activity Index for Psoriatic Arthritis (DAPSA) composite measures. All associations were assessed using the chi-square test or the Mann–Whitney test, as appropriate. Results: The 117 PsA patient cohort consisted of 65.5% women, mean age 58.4 ± 13.6 years. Clinical judgement of treating rheumatologist concorded with MDA and DAPSA in 76 (65.5%) and 74 (64.9%) patients, respectively. Agreement between clinical judgement and composite measure criteria did not correlate with patient age, sex, alcohol/tobacco use, or treatment regimens chosen. Disagreement between physician assessment and MDA occurred in 40 (34.5%) cases: in 30 cases, the MDA status was overestimated due to disregard of patient reported outcomes (PRO), while underestimation of MDA status occurred in 25% of cases with treatment changes made in patients with a single active joint or enthesis. Underestimation of disease activity using DAPSA occurred in 22 cases and could be attributed to disregarding tender joint count, patient pain visual analogue scale and C-reactive protein level. Conclusion: In our cohort, agreement between clinical impression and formal composite measure utilization for implementation of T2T strategy occurred in 65% of patients. Discordance resulted from physicians’ overlooking PRO and emphasizing objective findings when using clinical judgement alone.

Highlights

Maintaining sustained minimal disease activity is of importance in psoriatic arthritis (PsA), as it is associated with low progression of radiologic joint damage over time [9]
The study by van Mens et al incorporated an independent rheumatologist to evaluate whether the T2T approach was being implemented by providers, and was able to show that only about 35.0% (88/250) of PsA patients considered by the treating rheumatologist to have “acceptable disease state” fulfilled Minimal Disease Activity (MDA) status
Our study showed that the tendency to overemphasize “objective” clinical findings, such as the involvement of a single joint or enthesis, by treating physicians relative to patient reported outcomes (PRO) categories led to the underappreciation of MDA status when it was met in actuality

Summary

Introduction

In many areas of medicine, it has been shown that following a predefined treatment goal, termed the treat-to-target (T2T) approach, is more helpful in reducing complications and organ damage than treatment based on clinical judgement alone [1,2]. This approach was adopted in the management of rheumatic diseases [3,4,5,6]. Maintaining sustained minimal disease activity is of importance in PsA, as it is associated with low progression of radiologic joint damage over time [9]. Objective: To assess the implementation of the “treat-to-target” (T2T) concept in daily management of PsA by use of composite scores of disease activity versus clinical judgement alone

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Methods

Results

Discussion

Conclusion