Arthritis & Rheumatism, Volume 62,
November 2010 Abstract Supplement

Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Atlanta, Georgia November 6-11, 2010.


A Randomized Controlled Trial of Rheumatologist Education Impacting on Systematic Measurements and Treatment Decisions in Rheumatoid Arthritis (RA): Results of the Metrix Study.

Pope3,  Janet E., Thorne2,  J. Carter, Cividino1,  Alfred A., Lucas,  Kurt

McMaster University, Hamilton, ON, Canada
Southlake Regional Health Care, Newmarket, ON, Canada
St Joseph Health Care London, London, ON, Canada

Objective:

The Metrix study was an investigator initiated pilot study where consenting rheumatologists in Ontario were randomized either to an IRB approved, accredited educational intervention over 6 months or no intervention and involved 2000 RA patient-encounters to determine if an intervention could result in behavioral change.

Methods:

Twenty rheumatologists participated (all of whom who did a prospective chart audit of 50 consecutive RA patients at the beginning and again 50 consecutive RA patients at end of 6 months) and 10 rheumatologists were randomized to intervention. Only the intervention group was aware of the results of their practice audit including the frequency of measurements they were performing and outcomes of their patients compared to the others in both the intervention and control groups (comparative data of their practice to others). Interventions were monthly web-based conferences on the value of systematic assessments in RA and barriers to care with recent evidence based information, journal club, surveys and improvements on forms used in daily practice to collect data.

Results:

1000 serial RA charts were audited at 0 and another at 6 months with no between groups differences in patient characteristics (mean disease of 10 years and 77% women, 74% RF positive and mean DAS 3.7); 68% on current Mtx, 14% on steroids and 27% on biologics. At 6 months, there were significantly different within and between groups changes in how often many variables were measured and changes in treatment. The intervention group collected more patient global assessments (53% pre vs 66% post intervention and MD globals 51% vs 60%; p<0.05) and HAQs collected went from 37% to 42%; whereas control group had no change in outcomes collected. For the intervention group there was a 32% increase in calculable composite scores (such as DAS, CDAI, SDAI) (p<0.05) and no change in the control group. There was more targeting to a low disease state. For those with SDAI between 3.3 and 11, the % receiving a change in Rx (injection, or change in DMARD) was 66% in intervention and 36% in control group (p<0.05); similarly in DAS between 2.4 and 3.6; 57% of intervention and 38% of control group made changes to treatment (p<0.05). Table shows within and between groups differences.

Table. Between and Within Groups Differences for Intervention and Control Groups: Changes in Practice (Performing Measurements and Making Treatment Changes)

 InterventionControl
Swollen Joint CountPre 96%Pre 94%
 Post 98%Post 93%
Tender Joint CountPre 80%Pre 93%
 Post 79%Post 92%
CRPPre 69%Pre 69%
 Post 74%Post 73%
HAQPre 37%Pre 42%
 Post 42%Post 44%
Patient global frequencyPre 53% p < 0.05Pre 66% p < 0.05
 Post 62% (within group)Post 59% (within group)(frequency decreased)
MD global frequencyPre 50% p < 0.01Pre 71% p = 0.17
 Post 60% (within group)Post 66% (within group)
CDAI > 2.8 but <10 receiving joint injection or DMARD change44%33% p = 0.44*
SDAI > 3.3 but <11 receiving joint injection or DMARD change56%26% p < 0.01*
DAS28 > 2.4 but <3.6 receiving joint injection or DMARD change57%38% p < 0.01*
*Between groups differences

Conclusions:

Despite a good baseline systematic assessment and many patients in a low disease state, there was improvement in the intervention group that surpassed the control group in both the frequency of performing assessments and the number of treatment changes when patients were not in remission. This is the first RCT of RA rheumatologist education where a result of a change in behavior has been linked directly to an intervention (comparative practice and education) as the control group did not change behavior. Small group learning with feedback from practice audits is an inexpensive way to improve outcomes in RA.

To cite this abstract, please use the following information:
Pope, Janet E., Thorne, J. Carter, Cividino, Alfred A., Lucas, Kurt; A Randomized Controlled Trial of Rheumatologist Education Impacting on Systematic Measurements and Treatment Decisions in Rheumatoid Arthritis (RA): Results of the Metrix Study. [abstract]. Arthritis Rheum 2010;62 Suppl 10 :1735
DOI: 10.1002/art.29500

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