Evolution

Dutch rheumatologists have been registering since 1979, mostly for epidemiological reasons. After the turn of the century collaborations between rheumatologist emerged aiming at registering outcomes of patients with rheumatic conditions. The Dutch RhEumatoid Arthritis Monitoring (DREAM) collaboration was established in 2003 to improve the quality and efficiency of the care for rheumatic patients and to stimulate scientific research.

In 2003, DREAM started to systematically document the data of patients with rheumatoid arthritis (RA) who were treated with tumor necrosis factor (TNF) inhibitors. From the moment patients start with this expensive biological therapy, clinical and patient-reported data are registered every three months. Analyses of the data so far have shown that the right patients are being treated, that they are treated safely and that treatment outcomes are acceptable from a health-economic standpoint.

In 2006, DREAM additionally started a cohort to register the protocolized treatment of patients with early-onset RA. The aim of this so-called treat-to-target strategy is to achieve remission as soon as possible, using cheaper medications when possible and more expensive medications when necessary. Treatment is tapered or even discontinued when possible. A new cohort was started in 2011, with an adapted treatment protocol. Analyses of both cohorts show that more than 70% of the patients achieve clinical remission within one year, which is a strong improvement over usual treatment. The treat-to-target strategy also proved to be cost-effective. Despite being initially more expensive, costs were saved in the long run.

Today, the DREAM registry facilitates the monitoring of all patients with RA and the registry has evolved into a fully integrated quality management system. The system can be used to show whether treatment guidelines are being followed and quality indicators are produced for rheumatologists for purposes of benchmarking and quality improvements. International benchmarking research has shown that the outcomes of RA treatment in the Netherlands rank among the world’s best.

New DREAM cohorts

Since 2014, the knowledge and experience gained in the DREAM registry are being used to monitor treatment outcomes in other chronic conditions as well. Under the auspices of DREAM, new registries have been developed for ankylosing spondylitis, juvenile idiopathic arthritis, gout and inflammatory bowel disease.