AN EVALUATION OF THE POTENTIAL EFFECTS OF A NATIONAL CONSENSUS STATEMENT ON OPTIMAL TREATMENT OF EARLY RHEUMATOID ARTHRITIS IN ONTARIO

Background: Previous research has demonstrated that many Canadians are not provided with optimal Rheumatoid Arthritis (RA) therapy, especially in seniors. An evidence-based Consensus Statement disseminated by the Canadian Rheumatology Association (CRA) in 2004 endorsed early, aggressive therapy, particularly with methotrexate (MTX), in all individuals with symptomatic RA, regardless of age. As Canada's largest province, Ontario provides a special advantage for post-marketing surveillance through the ability to combine administrative and clinical data. Ontario is home to 12 million citizens and 60% of Canadian rheumatologists. The Ontario Biologics Research Initiative (OBRI) represents a collaboration of (rheumatologists, patients and researchers aiming to improve RA management through clincial data collection with administrative database linkages. Objectives: We used provincial administrative data to determine whether drug therapy for seniors with RA has improved since the CRA consensus statement was established. Methods: We assembled an incident RA cohort aged ≥65 years, using the administrative medical databases for April 1998 to March 2007. In Ontario, coverage for health services is universal. The physician billing database maintains information for physician services provided to all provincial beneficiaries, including physician diagnosis codes, provided as International Classification of Diseases (ICD) codes. Medication exposures were determined by the pharmacy claims database, which is limited to provincial residents aged 65 years or older. We relied on a standard algorithm to identify RA patients within the billing data, based on ≥2 billing code diagnoses of RA, ≥60 days apart but within 5 years. We further required the subjects to have had ≥1 prescription for an oral glucocorticoid, DMARD or biologic drug, in an effort to optimize our case definition specificity. The cohort was stratified into sub-cohorts, according to calendar year of RA diagnosis: two cohorts prior to the 2004 consensus guidelines 1997-2000, 2001-2003; and one after 2004-2006. We followed subjects for one year, and assessed whether a subject had been exposed to MTX (defined as ≥1 prescription). We then compared the percent of seniors with early RA (ERA) exposed to MTX over 2001-2003, versus 2004-2006. To assess prescription trends that may have been unrelated to the consensus statement, we also looked for changes between 1997-2000 versus 2001-2003. Results: The results suggested a significant increase in MTX use over 2004-2006, versus 2001-2003.The percent of early RA patients exposed to MTX in 2001-2003 was 16.8% (95% Confidence Interval (CI) 15.4, 18.3) compared to 28.4% (26.5, 30.3) in 2004-2006. This substantial increase was statistically significant (11.5%, 95% CI 9.2%, 13.9%). However, even before implementation of the CRA consensus statement the percent of early RA patients exposed to MTX in 1997-2000 was 9.9% (95% CI 9.1, 10.9), versus 2001-2003 6.8%, (95% CI 5.2%, 8.5%). Conclusion: Our results suggest that a national consensus statement may have led to some improvements in RA care. Given the slight increase in MTX use evident even prior, other factors might explain some of results. Most Canadian seniors with ERA still do not receive optimal care. The CRA is currently developing strategies to improve the uptake of optimal RA treatment guidelines. Disclosure of Interest: Ontario Biologics Research Initiative - Grant Research SupportCitation: Annals of the Rheumatic Diseases, volume 68, supplement 3, year 2009, page 549Session: Rheumatoid arthritis Prognosis, predictorsand outcome (Poster Presentations )