Optimizing guideline adherence of rheumatologists

If not well treated rheumatoid arthritis (RA) can lead to severe joint damage and subsequently functional impairment. Current treatment strategies aim at quickly lowering disease activity in order to prevent later damage. RA treatment recommendations are well described in different (inter)national guidelines. But in general there is a discrepancy between available evidence regarding state-of-the-art practice and actual behaviour in daily routine. Although this is not often studied in RA it is presumed that physician adherence to RA treatment strategies is suboptimal; for example therapy is often not changed despite active disease.
With this in mind, we aim to improve RA care by increasing RA guideline adherence of the clinicians working in a specialized rheumatology clinic in the Netherlands. Therefore we developed a multimodal intervention strategy which will be tested in a randomized, controlled study.

Objectives
Primary objective:
1. To assess the effects of several targeted intervention(s) on adherence to different components of optimal RA care by clinicians
Secondary objectives
1. To assess which factors can modify successful guideline implementation
2. To assess user satisfaction with the newly implemented innovations
3. To assess if individual differences in adherence between clinicians exist
4. To assess if differences in adherence to the single indicators exist, and if yes a pattern can be seen

Methods
This study will be a single centre, combined before/after and randomized controlled pilot study assessing the effect of a stepwise implementation strategy on adherence to optimal care recommendations for RA. The study is performed in a specialized clinic for orthopaedics, rehabilitation medicine and rheumatology in the eastern part of the Netherlands (Sint Maartenskliniek). The interventions will be aimed at clinicians involved in the medical treatment of RA patients (rheumatologist, rheumatology trainee, physician assistant) working at the rheumatology department of the study centre. Informed consent will be asked from the clinicians, but not from the patients as the recommendations for optimal care are already usual care.
Based on the expected barriers targeted interventions will be developed, using a structured implementation model [7]. The focus of these interventions will be in the first step to 1/improve knowledge and 2/improve attitude about the recommendations and the RA guideline in general (educational session and feedback) and in the second step to 3/remove practical barriers (including changes in ordering system in the electronic patient information system). The interventions will take place in a stepwise manner, as to assess the impact on guideline adherence of the separate interventions.
At the start of the study all included clinicians who have signed informed consent receive the first intervention step (knowledge and attitude). Directly afterwards the group is randomized in an intervention and control group, with the intervention group receiving intervention step two (practical barriers). In this way the effect of intervention one can be tested in an before/after controlled design and whereas intervention two is tested in a randomized controlled design.
The primary outcomes of this study includes diagnostic and therapeutic behaviour of the clinicians, together forming optimal RA care (proper ordering of diagnostic tests, prescription of medication, planning of follow-up, referral to other clinicians and documentation). Adherence to the recommendations will be measured in the six months before the intervention and the four months thereafter, in order to facilitate both designs. User satisfaction with the interventions is also measured after intervention one and two, and will be taken into account when evaluating both interventions.

Outcome measures & results
To measure adherence to optimal RA care a set of indicators will be developed defining what optimal care is. These indicators have a dichotomous outcome (yes or no) which makes it possible to calculate a sum score per patient of all indicators scored with ¡®yes¡¯. This sum score serves as the primary outcome measure and mean sum scores will be used to judge effectiveness of the interventions.
To assess modifying factors in successful implementation data from an earlier study on guideline adherence will be used. Personality, thinking styles, cognitive bias and knowledge about the (RA) guideline were measured. After every intervention it will be analysed if any of these factors modifies adherence.
User satisfaction will be measured using a short questionnaire, developed specially for this study. Clinicians are encouraged to give feedback on the new system(s) as to make further improvements possible after this study.

If not well treated rheumatoid arthritis (RA) can lead to severe joint damage and subsequently functional impairment. Current treatment strategies aim at quickly lowering disease activity in order to prevent later damage. RA treatment recommendations are well described in different (inter)national guidelines. But in general there is a discrepancy between available evidence regarding state-of-the-art practice and actual behaviour in daily routine. Although this is not often studied in RA it is presumed that physician adherence to RA treatment strategies is suboptimal; for example therapy is often not changed despite active disease.
With this in mind, we aim to improve RA care by increasing RA guideline adherence of the clinicians working in a specialized rheumatology clinic in the Netherlands.
Primary objective:
1. To assess the effects of several targeted intervention(s) on adherence to different components of optimal RA care by clinicians
Secondary objectives
1. To assess which factors can modify successful guideline implementation
2. To assess user satisfaction with the newly implemented innovations
3. To assess if individual differences in adherence between clinicians exist
4. To assess if differences in adherence to the single indicators exist, and if yes a pattern can be seen

Primary outcome:
All data needed to calculate the indicators are collected for both time periods: 6 months before the intervention (july-december 2013; retrospective) and after the intervention (january- may 2014). For every included clinician 30 patients are randomly selected. Of those patients the first visit in the measurement period was selected for data collection.

Secondary outcomes:
All questionnaires were used in a previous study and are therefore already completed (april 2012).

Intervention 1: education and feedback
- information on RA treatment strategies including general background information and feedback on current guideline adherence
(all clinicians)

Intervention 2: IT support
Development of a new electronic ordering and signalling system within the current electronic hospital system.
(intervention group only)