title: Prescribing practices in a US cohort of rheumatoid arthritis patients before and after publication of the American College of Rheumatology treatment recommendations.
abstract: OBJECTIVE
  To examine prescribing practices in the use of biologic and nonbiologic disease-modifying antirheumatic drugs (DMARDs) to treat patients with rheumatoid arthritis (RA), before and after publication of the American College of Rheumatology (ACR) treatment recommendations.
  
  
  METHODS
  Biologics-naive RA patients under the care of a rheumatologist in the US were identified from the Consortium of Rheumatology Researchers of North America registry. Patients were included if their visits occurred prior to and/or at least 6 months after publication of the ACR treatment recommendations (time periods of February 2002-June 2008 versus December 2008-December 2009). The population was divided into 2 mutually exclusive cohorts: 1) methotrexate (MTX) monotherapy users, and 2) multiple nonbiologic DMARD users. Initiation or dose escalation of biologic and nonbiologic DMARDs in response to active disease was assessed cross-sectionally and longitudinally in comparison to the ACR recommendations. The impact of the publication of the ACR recommendations on treatment practices was assessed using logistic regression, stratified by disease activity and adjusted for clustering of physicians and geographic region.
  
  
  RESULTS
  After 1 visit, 24-37% of patients receiving MTX monotherapy who had moderate disease activity and a poor prognosis or high disease activity received care consistent with the ACR recommendations; after 2 visits, 34-56% of the MTX monotherapy group received care consistent with the recommendations. In the patients receiving multiple nonbiologic DMARDs, 31-47% of those with moderate or high disease activity received care consistent with the recommendations after 1 visit, and 43-51% received such care after 2 visits. Publication of the recommendations did not significantly change treatment patterns for those with active disease.
  
  
  CONCLUSIONS
  Substantial numbers of RA patients with active disease did not receive care consistent with the current ACR treatment recommendations. Innovative approaches to improve care are necessary.
authors.affiliation: University of Massachusetts Medical School, Worcester, Massachusetts 01605, USA. Leslie.Harrold@umassmed.edu
authors.forename: Leslie R
authors.initials: LR
authors.lastname: Harrold
authors.forename: J Timothy
authors.initials: JT
authors.lastname: Harrington
authors.forename: Jeffrey R
authors.initials: JR
authors.lastname: Curtis
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Furst
authors.forename: Mary Jane
authors.initials: MJ
authors.lastname: Bentley
authors.forename: Ying
authors.initials: Y
authors.lastname: Shan
authors.forename: George
authors.initials: G
authors.lastname: Reed
authors.forename: Joel
authors.initials: J
authors.lastname: Kremer
authors.forename: Jeffrey D
authors.initials: JD
authors.lastname: Greenberg
mesh_terms: D000368:Aged; D000911:Antibodies, Monoclonal / Q000627:therapeutic use*; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology; D015331:Cohort Studies; D004305:Dose-Response Relationship, Drug; D005260:Female; D017408:Guidelines as Topic; D006304:Health Status; D006801:Humans; D007596:Joints / Q000473:pathology / Q000503:physiopathology; D008297:Male; D008727:Methotrexate / Q000627:therapeutic use*; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011379:Prognosis; D011446:Prospective Studies; D011787:Quality of Health Care; D012042:Registries; D012720:Severity of Illness Index; D011795:Surveys and Questionnaires
chemical_list: D000911:Antibodies, Monoclonal; D018501:Antirheumatic Agents; D008727:Methotrexate