Decision support in the management of rheumatoid arthritis

Rheumatoid Arthritis (RA) is a systemic disease that is mainly characterised by symmetric erosive synovitis. Most patients exhibit a chronic fluctuating course of disease that, if left untreated, results in progressive joint destruction, deformity, disability and premature death. RA cannot be cured, but the disease activity is suppressed with a variety of potentially toxic drugs. In a lot of patients, this suppression is incomplete or lasts only temporarily, and often drug therapy must be changed. Valid assessments of RA disease activity have become available for daily clinical practice. Using regular monitoring of disease activity, the physician can optimise drug dosing guided by the level of disease activity reached. If optimal suppression of disease activity is not reached, drug therapy can be changed. Especially the combination of systematic monitoring with clinical guidelines could be a valuable decision support in RA management. Therefore, a computerised system was devised to monitor the course of RA in daily clinical practice, and positive experiences were made. A trial was carried out to study whether decision support was effective. It appeared that use of decision support was associated with a reduction of disease activity and less progress of disability and joint damage. In another clinical trial, it appeared that physician adherence to guidelines for MTX dosing was associated with higher drug dose and greater reduction of disease activity. A proposal was made to assess the efficacy of decision support for RA using a cluster RCT. It is important to realise that monitoring of RA is not an intervention that causes health effects, but drug therapy may. Physician performance is the important link between monitoring and health effects through drug therapy. As long as RA cannot be cured or RA disease activity cannot be successfully suppressed in the majority of patients, there is a need to tailor drug therap