Comparison between Rheumatologists’ Practice and Clinical Guidelines. How Far They Are? Results from the ESPOIR Cohort

Two clinical guidelines have been produced for the management of Early Rheumatoid Arthritis (RA): 1/ EULAR * recommends an early start for Disease Modifying Anti-Rheumatic Drug (DMARD), with methotrexate as the anchor drug; 2/ STPR (Stratégies Thérapeutiques dans la Polyarthrite Rhumatoïde) ^# produced a decision tree for the choice of the first DMARD for very early RA based on
disease activity, joint damage and Rheumatoid Factor (RF).
PURPOSE: To compare the usual care based on ESPOIR’cohort data, and these 2 guidelines (published after the end of ESPOIR’inclusions) for the first DMARD in early RA.
METHODS: ESPOIR is a French multicentric observational cohort which included 813 early arthritis patients from 2002 to 2005.
Patients with definite and probable RA based on ACR criteria fulfillment, usual rheumatologist’ preferred diagnosis and RA’diagnosis certainty on a 0-10 VAS were included in this study. The analysis included 2 steps:
1/ Adequacy defined as the proportion of patients treated within the first 6 months as recommended in the 2 guidelines. Factors associated with adequacy were determined by a multivariate logistic regression.
2/ A survey was mailed to rheumatologists whose patients have a non-adequacy to STPR’guidelines.
RESULTS: 670 patients with definite or probable RA were analyzed (F 76.4%; mean age 48 years; mean HAQ 1.0; mean DAS28 5.3; RF+ 49%; joint damage 16%; ACR criteria + 81%; mean symptom duration at inclusion 15 weeks).
A DMARD was initiated in 528 patients (79%) with a mean delay of 4.4 months, methotrexate in 65%. Adequacy to STPR guidelines is found in 353 / 619 patients (57%) (65% for definite RA, and 45% for probable RA). Adequacy to EULAR guidelines is found in 354 / 670 patients (53%) (60% for definite RA, and 42% for probable RA).
Determinants of STPR adequacy after multivariate analysis are:

	OR	95%CI	p
Female	0.66	0.44-0.99	0.04
Post-secondary education	0.54	0.34-0.86	0.009
Positive Anti-CCP and/or RF	1.80	1.25-2.59	0.002
RA’diagnosis certainty on a 0-10 VAS	1.26	1.14-1.39	<0,001

Similar results were observed for adequacy to EULAR guidelines. Step 2 is currently on progress.
CONCLUSIONS: There are substantial discrepancies between guidelines and usual practice. Potential explanations for the observed differences will be available thanks to the survey.
Funding: Société Française de Rhumatologie
*Combe B. et al., ARD2007;66;34-45.
^#Le Loet X et al., ARD 2006;65;45-50.

 M. Benhamou, None.