Rheumatoid arthritis (RA) is a chronic systemic disease that causes pain and progressive deterioration of the functional capacity of the patients if not properly treated. In recent years, in addition to new therapies for the treatment of this disease, it has been shown that early diagnosis, together with close follow-up of the patients, achieves higher rates of remission or low disease activity.1–3

The treat-to-target, or T2T, strategy, which could be defined as aiming for treatment goals, is an ambitious initiative promoted, after reaching a consensus, by the rheumatology community on an international level.4 It is based on treating RA patients to reach a specific therapeutic goal, which ideally is considered to be clinical remission or, failing that, maintenance of the disease at the lowest possible activity level. Moreover, it recommends seeing patients frequently to reach the goal, using activity scores and quantifying the functional capacity and structural damage. Since the publication of the T2T recommendations in 2010,4 there has been little information on how they are being implemented in rheumatology departments,5,6 and some professionals maintain that their implantation is not simple.7,8 However, knowing that it is a strategy with confirmed results,2,3,9,10 our goal as a community would be to apply it fully. Knowing how RA patients are being followed in real-world practice should serve as an audit to aid in detecting the shortcomings and as a basis for the discussion of how to apply T2T efficiently in rheumatology. The ultimate goal would be to be able to offer close monitoring of the disease to all the patients in order to improve their quality of life and prevent disability over the long term.

The aim of our study was to analyze the application of T2T in a multicenter study in the Canary Islands, and describe compliance according to the characteristics of the patients, for example, whether their disease was of recent onset or whether they had been treated with biological agents.

The ToARCan study was a cross-sectional observational study carried out in 5 hospitals in the Canary Islands between March 2013 and March 2014.

In all, 343 patients were included (77% women), with a mean age of 57 years and a mean duration of RA of 10 years. Table 2 shows the characteristics of the patients included.

Table 1 shows the overall results for the indicators based on the T2T recommendations. The percentages of remission and of low disease activity were very high, and there were no statistically significant differences between hospitals. The recommendable times between visits were appropriate for patients with high activity in general, but there were differences between hospitals in terms of the percentage of patients with no activity seen before 6 months had elapsed, which ranged between 34.8% and 77.8%. The frequency of determining activity scores was also very high, although there were differences between centers; nevertheless, the lowest rate of implementation of a scoring system of some type for any center was 78.4% of all the patients. Less common was the performance of some measure of the patients’ function, with the rates for the 5 hospitals ranging from 0% to 37.8% (P<.001). The majority of the patients had a radiograph of feet or hands from the preceding 5 years, although only 14.6% from the preceding year (P=.008 between hospitals) and the patients had been properly informed by their doctors about the treatment goals (range: 77%–100%; P<.001).

The median of visits over the preceding year, including the current visit, was 3 (interquartile range [IQR]: 2–4). The average time elapsed between the previous visit and the current visit was 5.5±2.3 months (mean±standard deviation [SD]), and was shorter among the patients with a history of RA of 3 years or less (4.9±2.5). Table 3 shows the adaptation broken down by duration of the disease and treatment with biological agents at the present time.

The DAS28 had been calculated during the previous visit in 218 patients (63.6%), 25 (49.0%) of whom had a history of RA of 3 years or less and 68 (67.3%) were receiving biological therapy. The multivariate analysis of the factors that determined the calculation of the DAS28 during the previous visit showed a lack of association with patient-related factors and a clear relationship to the center (in one center, the odds ratio versus the hospital used as a reference for the measurement of the DAS28 was 2.15 and in another, 0.4 [P<.05 in both cases]).

We evaluated compliance with the recommendations of the T2T strategy in the Canary Islands. In general, we can say that there is a high rate of compliance, even with moderate variability among centers.

Our audit illustrates, in a sample that is clearly representative of RA patients from 5 hospitals, the nature of clinical practice in our region: patients visit the rheumatology departments an average of 3 times a year and, although joint counts are carried out in more than 80% of the patients, the patient scores and the DAS28 are documented in the medical records in less than half. In cases of active RA, two thirds of the patients had their next visit scheduled within the recommended period of 1–3 months.

The T2T philosophy states that the important thing is the strategy, more than the specific agent employed, showing that, with a combination of nonbiologic DMARD, it is possible to achieve the same low activity or remission as with biological therapies in many patients.3 The analysis of compliance with the T2T recommendations with its valuable feedback should contribute to achieving better control of the disease activity and comorbidities on the part of rheumatologists. Treatment-to-target does not necessarily mean the application of more costly therapy; in fact, it has been reported that close follow-up can be associated with a reduction in the use of biological therapy achieved with a sensible utilization of conventional therapies.11

The T2T studies have been shown to offer clear advantages in recent-onset arthritis.12 Patients with strict control improve more and sooner than those treated with conventional approaches, and the average difference can be up to 1 point in the DAS28. Nevertheless, there is a need for studies to determine whether the strategy has clear advantages in established RA.13 There is also a lack of cost studies comparing the intensive strategy with the standard approach.12 In this respect, the lack of support for T2T strategies in established RS is reflected in our study in the variability observed among hospitals when all the patients are taken into account, which is reduced when only the RA patients with the most recent onset of the disease are considered.

Kaneko et al. published a survey of 300 Japanese rheumatologists concerning the obstacles to the implementation of T2T, that showed that, in Japan, the degree of agreement with T2T in general is very high, although there are certain barriers to its application. Among them, it can be seen that only 45% of the professionals employs composite scores, only 44% monitor their patients with radiological techniques and only 14% with the HAQ. In addition, Japanese rheumatologists only discuss the treatment with the patients in 56% of the cases, and half of those who do not hold this discussion justify it by explaining that the patients are not fit or cannot make decisions. In Italy, Caporali et al. surveyed 100 rheumatologists to measure the degree of acceptance and applicability of the T2T criteria.14 They observed that agreement with the recommendations is high; however, it is difficult to maintain the treatment target throughout patient follow-up or the course of the disease. Haraoui et al. carried out a similar survey in Canada and revealed that the level of agreement was not high (6.92 of 10) concerning the frequency with which activity scores should be calculated (recommendation 5) or in the use of composite scores. However, the level of agreement for the rest of the recommendations is high.15 In our study, based on patient data, the actions of the rheumatologists show that, in general, acceptance is high, except, perhaps, with respect to the frequency of visits and measurements, despite the fact that an increase in the latter has been shown to improve the outcome and change therapeutic decisions.16 However, reluctance still exists, especially because of the belief that they prolong the consultation time.

A number of published studies have dealt with the barriers to patient access to T2T. Patients with moderate disease activity may not want intensive treatment because they are satisfied, despite the fact that two thirds of the satisfied patients had moderate or high activity.17 This shows that the degree of disease activity in RA is sometimes assessed in different ways by physicians and patients, a circumstance that is demonstrated, at least with regard to pain and joint counts.18 Patients may assume that the improvement they have experienced is relevant and not be convinced that a change could result in greater benefits, in addition to the inconvenience of frequent visits and the fear of adverse drug effects. The paradox is that, if the patient is informed of the goal, as the guidelines clearly recommend, the target values of the T2T strategy may not fare too well. De Wit et al.19 have published a version of these recommendations that patients can understand, so that, when appropriate, it can be used during visits reduce the discrepancies.

Other barriers to the application of 100% of the T2T strategy can arise from other patient characteristics. For example, there is a proportion of RA patients who do not received DMARD, in our case, nearly 10%. There are several causes for this, such as mild disease, comorbidity or toxicity. In other cases, there may not be access to a rheumatologist or access may be difficult, a circumstance that could also have an impact on the number of visits that can be scheduled. It is necessary to understand that the frequent visits and evaluations in the T2T approach require an infrastructure that sometimes is out of reach for overcrowded care settings. It is obvious that each department or service should adapt the T2T recommendations in order to be able to implement them, including a rheumatology nurse, informative T2T material adapted for patients and a protocol for RA follow-up, among other options. On the other hand, in some settings, access to all the available pharmaceuticals in a sudden T2T escalation is limited by the administrations or through some form of copayment.

In conclusion, RA patients in the Canary Islands have high rates of remission and low disease activity, and the T2T recommendation are followed in a generalized, but variable, manner. The recommendations that are followed the least are those referring to the use of the scoring systems and the frequency of visits. It is important that we make an effort to adapt clinical practice to the knowledge and to the circumstance, following criteria based on equity.

The ToARCan study was promoted by Antonio Naranjo, supported by the Canary Rheumatology Society and sponsored by a grant from AbbVie (ACA-SPAI-12-17). AbbVie did not participate in the writing of the article or in the decision to submit it.