Table 5 Reasons for discordance between the effectiveness algorithm and the effectiveness gold standard

Presumed reasons for not meeting gold standard, obtained from medical record review

   Biologic change deferred in light of concerns for new/worsened comorbidity

10

-

   Clinically stable or improved and patient/physician satisfied, but DAS and DAS change did not meet gold standard effectiveness criteria

4

-

   Physician recognized inadequate response, but chose to retreat with rituximab only after 1 year

2

   Receiving some medications (for example, glucocorticoids) outside of the VHA system

1

-

   Biologic change deferred in light of surgery or procedure

1

-

   Physician recommended biologic change or dose change, but patient declined

1

-

   Noncompliance with nonbiologic RA medications

1

-

Components of the effectiveness algorithm that were not met despite having met the effectiveness gold standard

   Glucocorticoid dose increase or initiation

-

15

   Added new DMARD(s)

-

6

   Increase in biologic dose and/or frequency

-

2