Patient perspectives on achieving treat-to-target goals: a critical examination of patient-reported outcomes.

Abstract

Treat-to-target (T2T) recommendations suggest that rheumatoid arthritis (RA) patients should strive for remission or low disease activity (LDA). However, it is unclear whether patients experiencing a good response to biologic agents might experience further improvement in patient-reported outcomes (PROs) if they subsequently achieve a lower disease activity state, particularly the T2T goals of LDA or remission. Using the Consortium of Rheumatology Researchers of North America database, we identified RA patients initiating biologic agents. We restricted the analysis to patients with improvement (Clinical Disease Activity Index [CDAI] improvement of ≥10 units) at 3-6 months (baseline visit; n = 1,368) with a followup visit approximately 9 months later (n = 984). Patients in CDAI remission or with a worsened disease activity category were excluded, leaving 562 eligible patients. PROs (global assessment, pain, and fatigue by 0-10 visual analog scales and disability by the modified Health Assessment Questionnaire [M-HAQ]) were examined at these 2 visits. Mean change in PROs compared achievement of a lower disease activity category versus staying in the same disease activity category, adjusting for potential confounders. Patients who achieved a lower disease activity category (40% of the eligible cohort, 86% of these achieving LDA or remission) had significantly better improvement in patient pain (-14.9; 95% confidence interval [95% CI] -18.4, -11.6), patient global (-17.5; 95% CI -20.8, -14.3), fatigue (-8.5; 95% CI -15.8, -1.3), and M-HAQ score (-0.13; 95% CI -0.18, -0.08) compared to patients who stayed in the same disease activity category. However, even for patients improving, fewer than half exceeded the minimum clinically important difference for each PRO. Achievement of a lower disease activity disease state, especially T2T goals, was associated with further improvement in PROs, albeit modest in magnitude.