Digital tools as support for predict-to-treat?

In contrast to other therapeutic areas, it is still difficult to achieve remission in all patients in rheumatology. Two applications can increase the chance of clinical remission through joint decision-making between patients and the medical profession [1-4]. One is the treat-to-target (T2T ) strategy and the other is the predict-to-treat (P2T ) concept, in which digital tools can help predict outcomes or monitor disease progression [5]. On the eve of the SGR Annual Congress from August 31 – September 1, 2023, Prof. Dr. med. Gerd Burmester (Charité Universitätsmedizin, Berlin) and Prof. Dr. Dr. Thomas Hügle (Centre hospitalier universitaire vaudois, Lausanne) spoke about the two concepts in the familiar setting “Room-for-Rheum”. The highlights are summarized for you below.

Targeted treatment according to the T2T strategy has established itself as a guiding principle for the treatment of rheumatoid arthritis (RA) since it was first published in 2010 and comprises several different elements: the definition of a target and a method for measuring it, the assessment of the target at a predetermined point in time, the obligation to change therapy if the target is not achieved, and joint decision-making by patients and the medical profession [1-4]. According to Prof. Burmester, however, young rheumatologists are much less familiar with the development and origins of the T2T concept than experienced colleagues. Global initiatives such as EVEREST (EleVatE care in RhEumatoid arthritiS with Treat-to-target) are intended to help the new generation to recall the T2T concept. The aim of EVEREST is to improve the comprehensive implementation and achievement of the target values agreed in advance [6].

Thomas Hügle: With the establishment of ultrasound in rheumatology, the T2T concept seems to have taken a back seat in everyday life. Is the concept generally used less today?

Gerd Burmester: I wouldn’t say that. At the Charité, we always work according to the T2T concept and I believe that T2T will continue to be pursued in many countries. But you have to bear in mind that the technical aids and access to medication are not the same in all countries. Therefore, the literature deliberately does not mention drugs, laboratory scores or outcome parameters, nor imaging data to be used as part of the T2T strategy. The lack of concrete information is intended to promote the development of country-specific implementation options for the T2T strategy, always with the aim of improving the remission of patients. However, this makes the concrete implementation of this concept more difficult.

Thomas Hügle: An important cornerstone of the T2T concept is the choice of a pre-defined goal and a method for determining whether the therapy goal has been achieved. How is the “remission” goal evaluated at the Charité in Berlin? Are the values measured every 3 or 6 months?

Gerd Burmester: I carry out a full count of the affected joints in all patients every 3 months and calculate both the Disease Activity Score 28, i.e. the DAS28, and the Clinical Disease Activity Index, CDAI. We use the CDAI for the evaluation of remission and the DAS28 for general activity. Consistent surveying is essential in order to work according to T2T, even though we are all under time pressure. The electronic recording of this data in particular is often very time-consuming.

Thomas Hügle: The electronic recording of this data would be of great importance for future models. In certain electronic medical records, automatic parameter calculators are already used to visualize the predefined therapy goal using graphics. Would such automation help to work more in line with T2T?

Gerd Burmester: Such graphics would definitely help to directly see the impact of T2T. DAS28 calculators are already integrated in some electronic medical records. However, many IT departments do not allow external programs for automatic calculation. I personally determine the DAS28 and the CDAI manually and write the values into the electronic medical record.

Thomas Hügle: So you can see that the electronic recording of patient data is time-consuming. This can be expensive, especially if patients are called in every 3 months. Will T2T ultimately save costs or will it be more expensive if we implement the concept for all patients? In other words, how cost-effective is T2T in practice?

Gerd Burmester: I believe that T2T is absolutely cost-efficient. Rheumatologists in Berlin, for example, are paid 40 euros per quarter and per patient. Even if they come by 10 times a quarter, the price remains the same. Those affected can expect good disease control at a lower cost and will no longer become disabled so quickly thanks to T2T treatment and timely diagnosis. In the future, this can also be supported by other concepts such as P2T.

Thomas Hügle: Keyword P2T: As the name predict-to-treat suggests, this concept offers an exciting approach to changing the prediction of disease progression. What role will predictive parameters such as biomarkers play in the future?

Gerd Burmester: There has been a lot of discussion about biomarkers in recent years, but unfortunately these predictive biomarkers for RA do not yet exist. Imagine Mrs. Meier is sitting in my consultation and has not responded to methotrexate (MTX) therapy. Which medication should I give her next? In such cases, predictive markers for or against a drug would be of great benefit. In the future, artificial intelligence will certainly also help us to analyze and evaluate all parameters and variables. But unfortunately we are still a long way off.

Thomas Hügle: It might be more effective to first make predictions using registry data instead of immediately expecting a suitable drug based on a predictive factor. I often give the example of a pneumonia patient who is treated as an inpatient and is better after 5 days, but the CRP value is still lagging behind. Could you make a special note in the lab report that based on registry data you can expect a decrease in CRP in the next two days and then discharge the patient given the trend? How helpful are such predictions in practice?

Gerd Burmester: These processes will soon be implemented in the USA and these predictions will also be increasingly used here in the future. With expensive healthcare systems, the pressure to discharge patients earlier is growing. The development of models and algorithms will promote this trend.

Thomas Hügle: Exactly, such models already exist in the USA. Epic is the market leader in electronic medical records andtheir program Cosmos works with trillions of data and patient contacts to make predictions. To come back to the pneumonia example: If the aforementioned note in the patient file could play a role in pneumonia, why not in arthritis?

Gerd Burmester: Absolutely. We would not simply discharge pneumonia patients home, but would carry out remote monitoring using oxygen and blood pressure measurements so that they could be called back in an emergency. RA patients are rarely emergencies, which means that there is an even larger treatment window. In the future, wearables such as smart watches could also play a role in monitoring.

Thomas Hügle: These wearables are currently very popular and would definitely be a cost-effective option for monitoring. Unfortunately, everyday wearables do not have a function for evaluating clinical values such as DAS28.

Gerd Burmester: Maybe it’s just a question of time. The devices can now measure the number of steps, blood oxygen content, calorie consumption, walking speed, etc. It is possible that the DAS28 correlates with one of these measurements.

Thomas Hügle: However, such measurements are more monitoring than prediction. However, some patients already know during the consultation that they will not get better the next time they see their doctor. We have shown this with the Swiss Quality Management (SCQM) data: there is a deviation of 8% between the estimated and actual DAS28 values at follow-up consultations [7]. In the future, such algorithms could therefore predict the DAS28 in 6 months. Will this knowledge help us?

Gerd Burmester: These algorithms will increasingly come our way in the future and we will have to carry out extensive studies to evaluate the significance of the predictive parameters. However, with the large amounts of American insurance data, such predictions are becoming increasingly likely. However, this data must be critically scrutinized, as incorrect diagnoses or miscoded entries can affect the prediction. However, it is possible that the incorrect entries are thinned out by the large amount of data.

Thomas Hügle: Let me come back to wearables and the potential to support the P2T concept with everyday tools. Patients like the wearables, but can this data be used in the clinical workflow?

Gerd Burmester: I believe in objective measurements in order to determine the therapy and medication in a medical consultation. I now check whether my patients are wearing a wearable and discuss the data with them. With 12,000 steps a day, I know that the suffering is not that great. However, if a patient only manages 2,000 steps a day compared to 5,000 steps previously, this indicates that something is wrong. This puts the discussion with patients on a different footing. We will certainly be dealing with more of this type of data during consultation hours in the future.

The animated discussion between Prof. Hügle and Prof. Burmester showed that the T2T concept has become further established as a therapeutic strategy in the treatment of RA patients since 2010. T2T continues to strive for the goals of “no pain, no functional impairment and a normal life” through the joint treatment decision and objective assessment of the disease [1-4]. Although better and better RA treatment options are becoming available, the predictive parameters for precision medicine are still lacking. The P2T concept, also with the help of everyday tools such as wearables, could play an exciting role here in the future.

This article was produced with the financial support of AbbVie AG, Alte Steinhauserstrasse 14, Cham.

CH-ABBV-230156_12/2023

This article has been released in German.

Literature

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6 Irish Medical Times. Irish rheumatology committee formed as part of global initiative focused on achieving treat-to-target goals. https://www.imt.ie/news/healthcare-news/irish-rheumatology-committee-formed-as-part-of-global-initiative-focused-on-achieving-treat-to-target-goals-10-08-2023/. Last access: 13.12.2023.
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