Factors determining a DMARD initiation in early inflammatory arthritis patients. The ESPOIR cohort study

Immuno-Rhumatologie, Hôpital Lapeyronie, Montpellier, France.
Clinical and experimental rheumatology (Impact Factor: 2.72). 01/2009; 27(1):84-91.
Source: PubMed


To describe the rate and timing of DMARD start in patients with early inflammatory arthritis in France, and to determine the factors leading to this treatment start.
The ESPOIR cohort study collects data on patients presenting with early arthritis. Baseline characteristics were assessed, and Cox regression analysis was performed to estimate the likelihood of starting DMARD treatment over time, adjusting for patient-, disease- and physician characteristics.
Of the 775 analysed patients, 598 (77.2%) received at least 1 DMARD during the follow-up period, after a median time of 4.0 months. In general, a higher tender joint count, involvement of the hands, involvement of more than 3 joint groups, presence of abnormal CRP-levels or CCP-antibodies significantly increased the likelihood of being treated (p<0.01 for all determinants), as well as a positive result on the bilateral foot-squeeze test (p<0.04). In addition, a significant hetero-geneity in therapeutic strategy across the 14 tested French regions was found: adjusted hazard ratios for DMARD start ranged from 1 to 2.15 (p<0.01), depending on the region where a patient was followed. For anti-CCP test and swollen joint count we demonstrated a statistically significant interaction with geographic region, implying that these tests are interpreted differently across regions. The same factors that increased the likelihood to start a DMARD were related to an earlier start.
Rate and timing of treatment start with DMARDs in patients with early inflammatory arthritis in France is determined by well known clinical and biochemical variables. Apart from these variables, however, unknown and intangible factors that seem to cluster geographically are responsible for important variations in practice performance.

Download full-text


Available from: Robert Landewé,
49 Reads
  • Source
    • "Across the 14 participating French regions, the adjusted hazard ratios for DMARD start ranged from 1 to 2.15 (P < 0.01), depending on the region where a patient was living. When exploring the time until initiation of DMARDs further, a significant interaction was found between both anti-CCP and swollen joint count with geographic region, implying that these tests are interpreted differently across regions [91] [92]. These variations in practice performance according to region might reflect variations in availability (number of rheumatologists and waiting times) as well as in the acceptability dimensions of access. "
    [Show abstract] [Hide abstract]
    ABSTRACT: In this chapter, we discuss challenges in collecting data on outcomes of patients who receive usual rheumatology care. We present results of the multinational Quantitative Monitoring of Patients with Rheumatoid Arthritis (QUEST RA) study which is a successful example of quantitative clinical measuring of RA as part of routine clinical care in a large number of centres across more than 30 countries. We further elaborate on what we can learn from these data about inequalities and inequities, both within and between countries. Frameworks to understand socioeconomic determinants of health are presented and, in addition to the QUEST RA data, the literature is summarised to provide further evidence on how socioeconomic determinants can contribute to health disparities of patients within and between countries.
    Best practice & research. Clinical rheumatology 10/2012; 26(5):705-20. DOI:10.1016/j.berh.2012.07.011 · 2.60 Impact Factor
  • Source
    • "The larger difference between the expected progression and observed progression in the DAS-driven group suggests that the suppression of joint damage progression was better in this group than in routine care patients, albeit not to a level of significance (p=0.126).10 The lack of difference in our study could be explained by the fact that the investigators of the ESPOIR cohort were aware of early RA.11 Therefore, in the ESPOIR cohort, baseline tender joint count (>9), abnormal CRP levels and anti-CCP antibodies were closely related to DMARD treatment11 In addition, it is likely that the publication of the preliminary results from the TICORA study in 2003, by underlining the interest of tight control, had influenced the therapeutic care of patients of the ESPOIR cohort.12 "
    [Show abstract] [Hide abstract]
    ABSTRACT: To compare the efficacy of disease activity score in 28 joints (DAS28ESR)-driven therapy with anti-tumour necrosis factor (patients from the GUEPARD trial) and routine care in patients with recent-onset rheumatoid arthritis (patients of the ESPOIR cohort). After matching GUEPARD and ESPOIR patients on the basis of a propensity score and a 1:2 ratio, at baseline all patients had comparable demographic characteristics, rheumatoid factor, anticyclic citrullinated peptide antibody positivity and clinical disease activity parameters: erythrocyte sedimentation rate, C-reactive protein, mean DAS (6.26±0.87), Sharp/van der Heijde radiographic score (SHS), health assessment questionnaire (HAQ). Disease duration was longer in GUEPARD patients (5.6±4.6 vs 3.5±2.0 months, p<0.001). After 1 year, the percentage of patients in remission with an HAQ (<0.5) and an absence of radiological progression was higher in the tight control group (32.3% vs 10.2%, p=0.011) as well as the percentage of patients in low DAS with an HAQ (<0.5) and an absence of radiological progression (36.1% vs 18.9%, p=0.045). However, there was no difference in the decrease in DAS, nor in the percentage of EULAR (good and moderate), ACR20, ACR50 and ACR70 responses. More patients in the tight control group had an HAQ below 0.5 (70.2% vs 45.2%, p=0.005). Overall, pain, patient and physician assessment and fatigue decreased more in the tight control group. The mean SHS progression was similar in the two groups as was the percentage of patients without progression. In patients with recent onset active rheumatoid arthritis, a tight control of disease activity allows more patients to achieve remission without disability and radiographic progression.
    Annals of the rheumatic diseases 03/2011; 70(4):611-5. DOI:10.1136/ard.2010.137695 · 10.38 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To assess the time to access a rheumatologist (TTAR) by early arthritis (EA) patients participating in a nationwide incidental cohort (ESPOIR) and compare it with European League Against Rheumatism (EULAR) recommendations, which recommends rapid referral, ideally within 6 weeks, to a rheumatologist for patients presenting with EA. Eight hundred and thirteen patients with EA were included in the cohort between 2002 and 2005. The inclusion criteria were 18-70 years old, two or more swollen joints, symptom duration from 6 weeks to 6 months and possible RA diagnosis. TTAR was defined as the time between the first synovitis and first visit to a rheumatologist. TTAR and satisfaction of the EULAR guidelines were investigated by multiple linear and logistic regressions. Mean TTAR was 76 days; only 46.2% of patients were seen by a rheumatologist within the EULAR-recommended time frame. Patients' patterns of accessing medical care substantially affected access to specialized care: mean TTAR was 58 days for patients who directly scheduled an appointment with the rheumatologist and 78 days for those referred by their general practitioner (P < 0.0007). Only 57.2 and 44.5%, respectively, were able to consult a rheumatologist within 6 weeks. Multivariate analysis confirmed the significant impact of indirect access on TTAR, after adjustment for EA characteristics and medical density in the region. Significant disparities were identified in the care of EA patients in terms of early access to a rheumatologist. More effort is needed to optimize the physicians' knowledge about EA and to improve the efficiency of medical networks.
    Rheumatology (Oxford, England) 11/2009; 49(1):147-55. DOI:10.1093/rheumatology/kep340 · 4.48 Impact Factor
Show more