A survey of United States rheumatologists concerning effectiveness of disease-modifying antirheumatic drugs and prednisone in the treatment of rheumatoid arthritis

First-year radiographic progression as a predictor of further progression in early arthritis: results of a large national French cohort

OBJECTIVE

A major goal in the treatment of recent arthritis is the prevention of joint destruction. The value of radiographic progression in the first year for predicting further radiographic progression has not been evaluated comparatively with conventional predictive factors.

METHODS

Patients with arthritis of <6 months' duration were included in the prospective French ESPOIR cohort. Radiographs were obtained and modified Sharp scores were determined by a blinded reader. The rate of progression was determined over the first year, then over the second and third years. Rapid progression was defined as a >5-point annual increase in the total Sharp score.

RESULTS

In total, 500 patients had complete data available after 3 years and were included. The total Sharp score indicated rapid progression in 123 patients (25%) in year 1 and 92 patients (18%) in years 2/3. By logistic regression, the variables independently associated with rapid progression in years 2/3 were year 1 rapid progression of the erosion and total Sharp scores, baseline erosion Sharp score, the serologic American College of Rheumatology/European League Against Rheumatism criterion, and interleukin-6 level. When these variables were combined, year 1 rapid progression made the largest contribution to predicting years 2/3 rapid progression.

CONCLUSION

First-year radiologic progression is the best independent predictor of further rapid progression in early arthritis.

First-line DMARD choice in early rheumatoid arthritis--do prognostic factors play a role?

OBJECTIVE

To examine if prognostic factors predict the choice of first DMARD for patients with RA.

METHODS

Details of 616 patients with early RA were collected from 16 centres in the UK Early Rheumatoid Arthritis Network (ERAN). Logistic regression was used to identify whether HAQ score, swollen joint count (SJC), nodules, RF, ESR, CRP and erosions on radiographs were associated with the choice of first DMARD treatment.

RESULTS

Of 616 patients, 547 (88%) were started on a DMARD, 253 (46%) on MTX, 230 (42%) on SSZ, 47 (9%) on other DMARD monotherapies and 17 (3%) on combination DMARD therapy (CoT). SSZ was started less frequently in patients with positive RF (P = 0.018; OR 0.59; 95% CI 0.38, 0.91) and high SJC (P = 0.02; OR 0.95; 95% CI 0.91, 0.99). MTX was favoured in patients with high SJC (P = 0.002; OR 1.07; 95% CI 1.02, 1.11). Non-prescription of DMARDs was associated with old age (P = 0.02; OR 0.98; 95% CI 0.96, 0.99) and low HAQ score (P = 0.009; OR 0.80; 95% CI 0.68, 0.95). None of the variables predicted CoT. All other variables and the hospital where the patient was treated were not independently associated with the choice of DMARD.

CONCLUSIONS

When choosing DMARD monotherapy in early RA, rheumatologists in ERAN seem to preferentially prescribe MTX for patients with a poor prognosis and SSZ for patients with good prognosis. No DMARDs were used in older patients or in those with a low HAQ.

What factors relate to job satisfaction among rheumatologists?

BACKGROUND

A severe shortage of practicing rheumatologists in the workforce is predicted over the next 2 decades. Identification of factors impacting job satisfaction will be needed to design interventional strategies for physician retention.

OBJECTIVE

To examine predictors of job satisfaction among rheumatologists.

METHODS

A cross-sectional survey was conducted among rheumatologists from the American College of Rheumatology directory with a portion of this designed to examine their job satisfaction. Questions regarding demographics, practice setting and job satisfaction, emotional exhaustion, and personal accomplishment based from the Maslach Burnout Inventory were included. Also included was a rank item to prioritize perceived changes that would improve job satisfaction. The response rate was 30% (N = 285) and 236 were analyzed. Data were primarily analyzed by the independent samples chi2 test.

RESULTS

Physician demographics: mean age: 51 years, 76% were male, 27% were full time academicians, and 24% in solo practice. Significant differences (P < 0.04) between the "high" satisfaction versus "very good" and "low" satisfaction groups includes increased age and solo practice, which were associated with "high" satisfaction. Lower job satisfaction rating correlated with items rating emotional exhaustion (r(s) = -0.43) and better satisfaction with personal accomplishment (r(s) = 0.41, P < 0.001 for both). Priority ranking revealed that "better reimbursement for patient care" and "less administrative/business effort" were the most frequently reported items cited to improve job satisfaction.

CONCLUSIONS

Measures to improve job satisfaction may promote physician retention as a means of addressing the predicted workforce shortage.

Factors that impact decision making among rheumatologists in the initiation of treatment for hypertension in rheumatoid arthritis

BACKGROUND

Increased risks of morbidity and mortality from cardiovascular (CV) events are reported in patients with rheumatoid arthritis (RA). Recent reviews recommend aggressive treatment of modifiable CV risk factors, including systemic hypertension (HTN).

OBJECTIVES

We examined possible contributory factors influencing HTN treatment among RA patients by rheumatologists.

METHODS

We conducted a cross-sectional 36-item survey of randomly chosen rheumatologists from the American College of Rheumatology directory collecting the rheumatologists' demographics, practice, and perceptions regarding HTN treatment in their RA patients. Our response variable was initiation of HTN treatment. Independent variables were derived from responses to the survey, and data were analyzed using bivariate analysis and logistic regression.

RESULTS

Of 938 rheumatologists surveyed, 285 (30%) responded, 236 were subsequently analyzed. Respondents' mean age was 52.8 years; 75% were male and most were white (83%). Respondents reported routinely screening for HTN (92.8%), and initiating treatment for HTN (31%) in RA patients. Rheumatologists who believed that their RA patients did not have adequate visits with their primary care providers (PCP) were 2.2 times as likely to initiate treatment for HTN (41.1% vs. 24.3%; P = 0.006). Conversely, 33% of rheumatologists who did not routinely initiate treatment for HTN in their RA patients also did not believe patient access to PCP care was adequate. No associations were observed between initiation of HTN treatment and physician demographic or practice items.

CONCLUSION

The need for more effective minimization of CV risks in RA patients should prompt rheumatologists to consider a revision of routine practice standards to include treatment of uncontrolled HTN or promotion of improved communication with their PCPs.

Use of tumor necrosis factor inhibitors in rheumatoid arthritis: a national survey of practicing United States rheumatologists

OBJECTIVES

To determine the prescribing practices, laboratory monitoring protocols, and perceived barriers of United States rheumatologists in prescribing tumor necrosis factor (TNF) inhibitors in rheumatoid arthritis (RA).

METHODS

A survey questionnaire was mailed to 1970 rheumatologists who were randomly selected from a national sample of 3008 rheumatologists. A one-page non-response questionnaire was mailed to approximately 200 randomly selected non-responding rheumatologists to assess non-response bias.

RESULTS

Two mailings yielded a response rate of 22.3% (428 completed, usable surveys out of 1922 deliverable surveys). Rheumatologists reported using all three agents in patients with moderate RA (82-87%), severe RA (94-96%), and in newly diagnosed and mild RA patients (10-18%). In patients with severe RA who inadequately responded to methotrexate, 91% of rheumatologists reported using a TNF inhibitor with one other disease modifying anti-rheumatic drug. Over 94% of rheumatologists reported switching patients from one TNF inhibitor to a different TNF inhibitor due to inadequate response or side effects. Most rheumatologists (96%) ordered the purified protein derivative test for tuberculosis, with almost 82% conducting this test at baseline. Costs to patients and insurance coverage were perceived as major barriers to prescribing these agents although the perception was slightly lower with infliximab than with adalimumab or etanercept.

CONCLUSIONS

The use of TNF inhibitors is not restricted to patients with moderate and severe RA. Rheumatologists are fairly similar in their utilization of the three TNF inhibitors although some variation exists in terms of laboratory practices and perceived barriers regarding the use of these agents.

Alternative Decision Analysis Modeling in the Economic Evaluation of Tumor Necrosis Factor Inhibitors for Rheumatoid Arthritis

OBJECTIVES

To provide a review of the studies that use decision models in the economic evaluation of tumor necrosis factor (TNF) inhibitors in rheumatoid arthritis (RA) and to address some important issues surrounding the choice of such modeling techniques in these economic evaluations.

METHODS

A systematic literature search was conducted by 1 author from the literature published from January 1996 to March 2005 through Medline, Embase, and Cochrane library databases.

RESULTS

The review yielded 29 studies that used decision models. Only 10 studies used a decision model in the economic analysis of the TNF inhibitors and were included in the final review. Decision model types included the following in the review articles: decision tree (2), Markov model (7), and discrete event simulation (1). These models vary in complexity and their choice depends on the course of disease, the impact of treatment, and the available data.

CONCLUSIONS

Based on the results derived from alternative modeling techniques, it is safe to say that all methods can provide useful information with regard to economic evaluations of TNF inhibitors. Even though different modeling techniques provide an appropriate representation of available data, their results should be interpreted contingent on the input data, assumptions, sensitivity analyses, and other alternative scenario analyses.

RELEVANCE

The transparency in the models will encourage end users such as policymakers and prescribers to make informed judgments regarding the appropriateness of the methods and the validity of the results.

Are rheumatologists' treatment decisions influenced by patients' age?

OBJECTIVES

The objective of this study was to determine whether physicians' treatment preferences are influenced by patients' age.

METHODS

We mailed a survey to a random sample of rheumatologists practicing in the US. The survey included a scenario describing a hypothetical patient with rheumatoid arthritis (RA) on hydroxychloroquine, sulfasalazine and low-dose prednisolone, who presents with active disease during a follow-up appointment. The scenario was formulated in two versions that were identical except for the age of the patient. After reading the scenario, respondents were asked to rate (on a 10 cm numerical rating scale) their recommendations for each of the three options: (i) increasing the dose of prednisolone, (ii) adding a new disease-modifying anti-rheumatic drug (DMARD) and (iii) switching DMARDs. Rheumatologists who rated either adding a new DMARD or switching DMARDs higher than increasing the dose of prednisolone were classified as 'preferring aggressive treatment with DMARDs', while the others were classified as 'NOT preferring aggressive treatment with DMARDs'.

RESULTS

A total of 480 rheumatologists were mailed a questionnaire; 204 responded, giving a response rate of 42.5%. Overall 163 (80%) respondents were classified as preferring aggressive treatment with DMARDs. Rheumatologists responding to this survey were more likely to prefer aggressive DMARD treatment for the young RA patient vs the older RA patient (87 vs 71%, P= 0.007).

CONCLUSIONS

Our findings suggest that rheumatologists' treatment recommendations may be influenced by age. Future educational efforts should increase physician awareness of this possible bias in order to ensure equal service delivery across ages.

Physician treatment preferences in rheumatoid arthritis of differing disease severity and activity: the impact of cost on first-line therapy

OBJECTIVE

To conduct a pilot study to identify rheumatologists' treatment preferences for first-line rheumatoid arthritis (RA) therapy and determine whether pharmacoeconomic variables modify physician choice(s).

METHODS

A questionnaire describing 3 different RA scenarios was mailed to American College of Rheumatology members within 4 geographic regions of the US. Physicians were asked to identify their choice(s) of first-line therapy for each of the cases, first taking cost into consideration, second without considering the influence of cost, and third identifying the therapy that would be chosen for either themselves or a family member.

RESULTS

Three hundred seventy-five questionnaires out of a total of 994 (37.7%) were returned between 3/12/00 and 4/25/00. Hydroxychloroquine was the most commonly cited medication for a mild disease activity/severity presentation, and methotrexate for a moderate-to-severe disease activity/severity presentation. For the severe disease activity/severity presentation, when cost was not considered, 217 (65%) rheumatologists included new disease-modifying antirheumatic drugs (leflunomide, etanercept, and infliximab) in their choice of first-line agents; this number decreased to 47 (14%) when cost was a consideration.

CONCLUSION

Pharmacoeconomics appear to play a dominant role in rheumatologists' choice of treatment regimens, at times contrary to the physician's perception of the effectiveness of a drug. Future studies should address physician preferences in more depth with respect to cost and its various components.