Time for treatment targets in rheumatoid arthritisBMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4170 (Published 04 August 2010) Cite this as: BMJ 2010;341:c4170
All rapid responses
In his letter of 7 August 2010 Professor Emery makes a strong case
for the adoption of a 'treat-to-target' approach to the management of
rheumatoid arthritis (RA). This presents considerable challenges to the
general rheumatologist practicing in a district hospital with financial
constraints, pressure to reduce new to follow-up ratios and return
patients to primary care.
At Poole Hospital NHS Trust, with 800 beds and a catchment area of
about 350,000 we have been moving towards a strategy of 'tight control'
 using systematic monitoring  and target disease activity scores for
the last few years. Our activity scores for RA patients both on biologics
and standard therapy are below the National average (using British Society
for Rheumatology Biologics Register data) and our use of biologics per
capita is the lowest in the Wessex region. While there may be demographic
reasons for these differences we are encouraged that the treatment
strategy results in better outcomes for our patients and the most
effective use of expensive therapies.
But how can these changes be made in a cash strapped NHS? We
conducted a multi-disciplinary away-day last year (including patients,
general practitioners (GPs), rheumatology practitioners and service
managers) to study the local RA patient pathway. We identified a number of
hurdles to best practice including delays in presentation to GPs, delays
in referral to secondary care, and our inability to see patients quickly
and follow up monthly for the first two years. We have been able to
redesign the service to overcome these problems without increasing costs.
We estimate that, by optimising treatment early in the disease with an
aggressive protocol, we will achieve the goal of remission more often
allowing much less frequent follow-up thereafter and this will balance the
early intensive follow-up.
Evaluation of this service presents more challenges as we move
towards measuring patient related outcomes outside a research agenda.
Audit against the EULAR 'treat-to-target' recommendations is an important
start and we are keen to participate in Professor Emery's project but in
the longer term we need nationally agreed outcome measures embedded in our
service. Involvement of the NHS Institute for Innovation and Improvement
may help drive this forward across the Country.
1. Grigor C, Capell H, Stirling A, McMahon AD, Lock P, Vallance R,
Kincaid W, Porter D.Effect of a treatment strategy of tight control for
rheumatoid arthritis (the TICORA study): a single-blind randomised
controlled trial. Lancet, 2004;364:263-9.
2. Fransen J, Moens HB, Speyer I, van Riel PL. Effectiveness of
systematic monitoring of rheumatoid arthritis disease activity in daily
practice: a multicentre, cluster randomised controlled trial. Ann Rheum
Competing interests: No competing interests