Article Text


Treating rheumatoid arthritis to target: the patient version of the international recommendations
  1. M P T de Wit1,
  2. J S Smolen2,3,
  3. L Gossec4,
  4. D M F M van der Heijde5
  1. 1Department of Medical Humanities, VU Medical Centre, Amsterdam, The Netherlands
  2. 2Department of Internal Medicine 3, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
  3. 32nd Department of Medicine, Hietzing Hospital, Vienna, Austria
  4. 4Rheumatology B Department, Paris Descartes University, Cochin Hospital, Paris, France
  5. 5Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
  1. Correspondence to M P T de Wit, Department Medical Humanities, VU Medical Centre, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands; mp.dewit{at}


To transcribe the treat-to-target (T2T) recommendations into a version that can be easily understood by patients. A core group of physicians and patients involved in the elaboration of the T2T recommendations produced a draft version of the T2T recommendations in lay language. This version was discussed, changed and reworded during a 1-day meeting with nine patients with rheumatoid arthritis (RA) from nine different European countries. Finally, the level of agreement with the translation and with the content of the recommendations was assessed by the patient participants. The project resulted in a patient version of the T2T recommendations. The level of agreement with the translation and the content was high. The group discussion revealed a number of potential barriers for the implementation of the recommendations in clinical practice, such as inequalities in arthritis healthcare provision across Europe. An accurate version of the T2T recommendations that can be easily understood by patients is available and can improve the shared decision process in the management of RA.

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In 2008, an international Steering Group of rheumatologists and patients took the initiative to develop a set of recommendations for the tight control of rheumatoid arthritis (RA) patients (“treat-to-target,” T2T).1 Clinical trial results over the last decade have demonstrated that strategies for tight control lead to better outcomes. These recommendations were developed in line with the European League Against Rheumatism (EULAR) standardised operational procedures,2 including a comprehensive systematic literature review,3 followed by a thorough data driven consensus process. The recommendations were extensively discussed during a 2-day meeting gathering more than 60 experts from different continents, including six patient representatives. They agreed on a set of four overarching principles and 10 recommendations. Important components of these recommendations are target setting for drug treatment, regular monitoring of disease activity—using composite measures, including joint counts—and adjustment of treatment if the desired target is not achieved.

In October 2009, the implications of the recommendations for clinical practice were discussed during a global T2T meeting. More than 25 physicians from 22 countries and two patient delegates expressed the need for developing a patient version of the recommendations as a logical consequence of the first overarching principle that emphasises the importance of a shared decision-making process between the physician and the patient. The last recommendation states that this can only be achieved if the patient is well informed about the different treatment options. As a follow-up on these statements, the Steering Group appointed a small working group with the objective to develop a patient version of the T2T recommendations as an important tool for patient education.

A patient version is important for several reasons. RA patients need to be appropriately informed about the potential benefits and harms of new pharmacological treatments.4,,6 The technical nature of the medical language of recommendations is a barrier for patients to understand their potential value.7 8 Because drugs give the best outcomes when used according to a predefined regime, a proper understanding, acceptance and adherence are of utmost importance,9 especially since some patients believe that the potential benefits do not outweigh the potential harms or personal preferences.10,,12 Patient information that is understandable and written in lay language may enable them to make informed decisions about their treatment. It heightens patients' satisfaction5 and increases adherence to their treatment.13

If patients are aware of the recommendations for the treatment of RA, and they know precisely how the treatment and monitoring should be organised according to these recommendations, they are able to start the dialogue with their rheumatologist.

Furthermore, a patient version might support physicians to engage the patient in the decision-making process on an equal level. Finally, physicians who are still reluctant to follow the T2T principles for their RA patients might be helped with a patient version to start this dialogue about the risks and benefits of tight control. The objective of the present study was to develop a patient version of the T2T recommendations.


The core group, consisting of four members of the international T2T Steering Group, including one patient representative (MPTdW), produced a draft version of the T2T recommendations in lay language.

This version was discussed, amended and reworded during a 1-day consensus meeting with nine RA patients and moderated by two members of the core group (DMFMvdH, MPTdW). Recruitment and selection of participants was carried out with the help of the EULAR Standing Committee of Patients with Arthritis/Rheumatism in Europe and took place through purposive sampling accounting for geographical variation, gender and age. Participants should speak and read English. The core group made the final selection. The group consisted of eight women and one man, from nine countries representing all regions of Europe: Cyprus, Czech Republic, Denmark, Ireland, Norway, Portugal, The Netherlands, Romania and the UK. Age varied between 31 and 66 years. Five participants were already involved in the T2T consensus meeting.

At the start of the meeting, the original recommendations were introduced and explained. Then, the draft patient version, developed by the core group, was shared with the participants. It was emphasised that the group was not allowed to make any changes in the content or meaning of the recommendations when developing the patient version.

Formulating a patient version in lay language was carried out by constantly comparing the original statements and the draft patient version. The consensus meeting was recorded. At the end of the meeting, the level of agreement with the translations as well as with the content was assessed by all patient participants, including the patient moderator, anonymously on a numerical rating scale ranging from 0 (no agreement) to 10 (full agreement). The group finally gave suggestions for implementation.



The patient version of the recommendations is presented in table 1. The group tried to stay as close as possible to the original meaning. Sometimes, simplification was achieved by cutting long sentences in multiple short sentences. At other moments, the group looked for common synonyms or clarification in lay language. Long discussions took place concerning the translation and the value of the words “significant” and “validated.” Finally, the group decided on different solutions, and this kept the word significant and proposed that each country should explore synonyms or translations in their own language. For the word validated, many synonyms were brought forward, but in no cases did this capture the meaning of the word. At the end, the term was not seen as a crucial element to understand the message of the recommendation. The decision was made to delete the word.

Table 1

Original and patient version of the treat-to-target (T2T) recommendations for treating rheumatoid arthritis (RA) to target

Table 2

Glossary of terms in lay language, in alphabetical order

Table 3

Validated composite measures and their cut-off points for different states of disease activity

To avoid long sentences in the patient version, the group identified other words and concepts that should be explained in the accompanying text and suggested words for the glossary (see table 2).

Evaluation of the patient version

The patient group, including the patient moderator, emphasised the importance of the recommendations (mean level of agreement with the content: 9.3; see figure 1). The group was convinced that patients would benefit greatly from a patient version that informs them about the treatment regime that they receive, or empowers people with RA who do not receive treatment according to these recommendations.

Figure 1

Level of agreement with the overarching principles A–D and the recommendations 1–10 according to the patient representatives (n=10). The level of agreement (indicated on the y-axis) was measured on a 10-point numerical rating scale with the highest number (10) representing “full agreement” and the lowest number (1) “no agreement at all.” The black bars represent the level of agreement with the translation in lay language, and the grey bars represent the level of agreement with the content.


The patient group assumed that currently only a few patients are being treated according to these recommendations and that there is a substantial gap between daily practice and the recommended treatment strategy. The recommendations reflect the ideal world; many clinicians are aware of the importance but are confronted with barriers for implementation, and compliance is poor. The patient group also identified differences in healthcare delivery across Europe. Therefore, improvement of healthcare for people with RA requires thoughtful implementation of the recommendations. This patient version has been developed by experienced patient representatives fluent in English. The patient version has not yet been validated in a group of lay patients. Translation into different languages and testing the recommendations in different countries were seen as important subsequent steps in this process.

Dissemination of a patient version, leaflet or booklet could make patients aware of what constitutes good disease management for them: how often should they see their rheumatologist, what should they expect from the consult, what is their involvement in the decision-making process, and what should they expect from the treatment? In this respect, the perception and understanding of the target are important factors that need more consideration. A clear and uniform target in other diseases has been successfully identified and implemented for diabetes, hyperlipidaemia and hypertension.1 A similar uniform value is not available for RA. Rheumatologists use different measurements and a different terminology for disease activity,14 which complicates education of patients and a clear dialogue about the treatment target. As long as a simple and worldwide-accepted indicator for disease activity is lacking, the group felt it necessary to provide a clear overview of definitions used for high, moderate and low disease activity and remission (see table 3).

A recent initiative by American College of Rheumatology and EULAR resulted in two proposals for more stringent criteria for remission in clinical trials15: one is a Boolean-based definition encompassing tender joint count ≤1 AND swollen joint count ≤1 AND C reactive protein (CRP) ≤1 mg/dl AND patient global assessment ≤1 (on a 0–10 scale). The other definition is the index-based Simplified Disease Activity Index ≤3.3 (table 3). For use in clinical practice, both definitions are suggested without CRP.


Development of a patient version of a set of recommendations is currently not a common activity, and in the field of rheumatology two initiatives have been published to incorporate the patient perspective in an international project. For the patient version of the ASAS/EULAR recommendations for the management of ankylosing spondylitis,16 18 patient representatives from 10 countries were invited for a 2-day consensus meeting. They not only translated the original recommendations in lay language,17 but also extensively discussed the content of the recommendations and produced a wish list from a patient's perspective to be discussed when the recommendations are updated.

A similar endeavour was undertaken by the task force for the development of EULAR recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases.18 Using different methods, they explored the perspectives of patients and rheumatologists on glucocorticoid therapy in order to enhance the implementation of the recommendations. Although they did not produce a patient version, patient participants did provide ideas for improving the implementation of the recommendations and a research agenda.19 They conclude that patients' and rheumatologists' perspectives should be included early in the process of formulating recommendations.

The T2T patient group indicated that, according to a holistic approach of arthritis healthcare, drug treatment is an important, but not the only, component that determines clinical outcomes. The participants noticed that the T2T recommendations, like the EULAR/ASAS recommendations, have a strong focus on body functions and structures, while patient-centred care in rheumatology also requires, besides medical expertise and monitoring, non-pharmacological and psychosocial support.20 In this regard, the group emphasised the importance of multidisciplinary teamwork in the management of RA, because in carrying out the scores and in educating and empowering the patient to actually engage in shared decision-making with rheumatologists, they need support from other key professionals. Although nurse practitioners and physician assistants could be ideally positioned to educate RA patients regarding treatment options and to monitor disease activity,21 they are not available in many countries.

The patients reported from their experiences that they cannot absorb all the information provided, specifically at the first visit to a rheumatologist. A meeting with a specialised nurse could be very useful. Because it is crucial to start treatment as soon as possible after the diagnosis is made, patients should receive information about the risks of the disease and the expected outcomes of the treatment. To be effective, the patient should adhere to the drug strategy, and this can only be achieved if the patient is well informed and accepts the consequences of the strategy. A patient version is very useful to support this process.

In contrast to the EULAR/ASAS patient version, the participants did not disagree with the content of any of the recommendations and, in contrast to the glucocorticoid patient group, did not add any topics to the research agenda. This might be because some patient representatives were also actively involved at different levels in the development process of the original recommendations. In the final discussion, however, the group mentioned barriers for implementation. Above all, they referred to the limited access to rheumatology care. It is not in every country that RA patients see their rheumatologist every 3 months or more often, the doctor's time is restricted, and joint assessments are not regularly carried out, properly documented or provided to the patient. In a majority of countries, people do not have access to their own data. There are advanced digital registration systems available that allow for regular reports on disease activity, management, monitoring, patient education and self-management.22 Some are also accessible for patients who can monitor their own disease using the internet from home, but such use is not widespread.

The group thought that there is also a role for patient organisations to use the patient version of the T2T recommendations to approach politicians, regulators and healthcare payers in their country. They could make a claim for better legislation that is in agreement with widely accepted recommendations to guarantee better access to appropriate treatment strategies, good healthcare information and programmes for self-management, finally resulting in better health outcomes for people with RA.


The authors are grateful for the commitment and feedback of the participants in the consensus meeting: L Anderson (Denmark), S Canadelo (Portugal), C Filip (Romania), S Halland (Norway), C Kinneavy (Ireland), M Kouloumos (Cyprus), E Quest (UK), M Scholte (The Netherlands) and E Slamova (Czech Republic).


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  • Competing interests This project was supported by an unrestricted educational grant from Abbott Immunology. Abbott affiliates were not involved in the programme or voting.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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