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Feuchtenberger M, Kovacs MS, Nigg A, Schäfer A. Prioritising Appointments by Telephone Interview: Duration from Symptom Onset to Appointment Request Predicts Likelihood of Inflammatory Rheumatic Disease. J Clin Med 2024; 13:4551. [PMID: 39124816 PMCID: PMC11313392 DOI: 10.3390/jcm13154551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 07/30/2024] [Accepted: 08/01/2024] [Indexed: 08/12/2024] Open
Abstract
Background: This study aims to determine the rate of inflammatory rheumatic diseases (IRDs) in a cohort of initial referrals and the efficacy of prioritising appointments to the early arthritis clinic (EAC) based on symptom duration. Methods: In the present study, we used algorithm-based telephone triage to assign routine care appointments according to the time between symptom onset and request for an appointment (cut-off criterion: 6 months). This retrospective, monocentric analysis evaluated the effectiveness of our triage in identifying patients with IRDs as a function of the assigned appointment category (elective, EAC, or emergency appointment). Results: A total of 1407 patients were included in the study (34.7% male; 65.3% female). Of the 1407 patients evaluated, 361 (25.7%) presented with IRD. There were significant differences in the frequency of inflammatory diagnoses between appointment categories (p < 0.001): elective 13.8%, EAC 32.9%, and emergency 45.9%. The sample without the emergency category included a total of 1222 patients. The classification into "inflammatory" or "non-inflammatory" in this subsample was as follows: Sensitivity was 37.7%, and specificity was 92.6%. The positive predictive value (PPV) was 59.8%, and the negative predictive value (NPV) was 83.6%. Overall, 80.2% of patients were correctly assigned using the appointment category and C-reactive protein (CRP). Conclusions: The algorithm-based triage system presented here, which focuses on the time between symptom onset and request for an appointment, allows for the prioritisation of appointments in favour of patients with IRDs and thus earlier initiation of therapy.
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Affiliation(s)
- Martin Feuchtenberger
- MVZ MED BAYERN OST, Rheumatologie, 84489 Burghausen, Germany; (M.S.K.); (A.N.)
- University Hospital Würzburg, Medizinische Klinik und Poliklinik II, 97080 Würzburg, Germany;
| | | | - Axel Nigg
- MVZ MED BAYERN OST, Rheumatologie, 84489 Burghausen, Germany; (M.S.K.); (A.N.)
| | - Arne Schäfer
- University Hospital Würzburg, Medizinische Klinik und Poliklinik II, 97080 Würzburg, Germany;
- Diabetes Zentrum Mergentheim, 97980 Bad Mergentheim, Germany
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Inchingolo F, Inchingolo AM, Fatone MC, Avantario P, Del Vecchio G, Pezzolla C, Mancini A, Galante F, Palermo A, Inchingolo AD, Dipalma G. Management of Rheumatoid Arthritis in Primary Care: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:662. [PMID: 38928909 PMCID: PMC11203333 DOI: 10.3390/ijerph21060662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 06/28/2024]
Abstract
Rheumatoid arthritis (RA) can lead to severe joint impairment and chronic disability. Primary care (PC), provided by general practitioners (GPs), is the first level of contact for the population with the healthcare system. The aim of this scoping review was to analyze the approach to RA in the PC setting. PubMed, Scopus, and Web of Science were searched using the MESH terms "rheumatoid arthritis" and "primary care" from 2013 to 2023. The search strategy followed the PRISMA-ScR guidelines. The 61 articles selected were analyzed qualitatively in a table and discussed in two sections, namely criticisms and strategies for the management of RA in PC. The main critical issues in the management of RA in PC are the following: difficulty and delay in diagnosis, in accessing rheumatological care, and in using DMARDs by GPs; ineffective communication between GPs and specialists; poor patient education; lack of cardiovascular prevention; and increase in healthcare costs. To overcome these criticisms, several management strategies have been identified, namely early diagnosis of RA, quick access to rheumatology care, effective communication between GPs and specialists, active patient involvement, screening for risk factors and comorbidities, clinical audit, interdisciplinary patient management, digital health, and cost analysis. PC appears to be the ideal healthcare setting to reduce the morbidity and mortality of chronic disease, including RA, if a widespread change in GPs' approach to the disease and patients is mandatory.
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Affiliation(s)
- Francesco Inchingolo
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy; (A.M.I.); (P.A.); (G.D.V.); (C.P.); (A.M.); (A.D.I.); (G.D.)
| | - Angelo Michele Inchingolo
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy; (A.M.I.); (P.A.); (G.D.V.); (C.P.); (A.M.); (A.D.I.); (G.D.)
| | | | - Pasquale Avantario
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy; (A.M.I.); (P.A.); (G.D.V.); (C.P.); (A.M.); (A.D.I.); (G.D.)
| | - Gaetano Del Vecchio
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy; (A.M.I.); (P.A.); (G.D.V.); (C.P.); (A.M.); (A.D.I.); (G.D.)
| | - Carmela Pezzolla
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy; (A.M.I.); (P.A.); (G.D.V.); (C.P.); (A.M.); (A.D.I.); (G.D.)
| | - Antonio Mancini
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy; (A.M.I.); (P.A.); (G.D.V.); (C.P.); (A.M.); (A.D.I.); (G.D.)
| | | | - Andrea Palermo
- College of Medicine and Dentistry, Birmingham B4 6BN, UK
| | - Alessio Danilo Inchingolo
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy; (A.M.I.); (P.A.); (G.D.V.); (C.P.); (A.M.); (A.D.I.); (G.D.)
| | - Gianna Dipalma
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy; (A.M.I.); (P.A.); (G.D.V.); (C.P.); (A.M.); (A.D.I.); (G.D.)
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Al-Mehmadi BA, Alelaiwi MMM, Alnumayr HSA, Alghamdi BS, Alomari BA, Alzahrani HS. Knowledge of Common Symptoms of Rheumatic Diseases and Causes of Delayed Diagnosis in Saudi Arabia. Patient Prefer Adherence 2024; 18:635-647. [PMID: 38476592 PMCID: PMC10929651 DOI: 10.2147/ppa.s448999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/17/2024] [Indexed: 03/14/2024] Open
Abstract
Purpose The aim of this study is to determine the general population's knowledge on the different symptoms of rheumatic diseases, the key factors for diagnosis delays from the patient's perspective, the length of delay from the onset of symptoms to the diagnosis, and the effect this holds on the disease activity, response to therapy, and the development of complications and nonreversible deformities in patients diagnosed with rheumatic diseases. Patients and Methods This is a cross-sectional study. Our target study population were the residents of Saudi Arabia. Data were collected via an online questionnaire and analyzed with SPSS. Results The overall prevalence of rheumatic disease in our cohort was 8.7%. Joint pain (75.7%), joint swelling (47.1%) and morning stiffness (32.9%) were the first and most common presenting symptom. Persistence of symptoms (N=32, 45.7%) and symptom worsening (N=21, 30.0%) was the predominant cause to visit rheumatologist. The duration between first symptom and rheumatic disease diagnosis is significantly longer for patients aged <50 years compared to that of those with ≥50 years of age. Results show that 36.4% of patients aged ≥50 years had delayed diagnosis due to late appointment compared with 5.7% of patients aged <50 years. In addition, patients with longer duration of symptoms were likely to have more visits to the rheumatologist. Most of the participants of <50 years significantly agreed that rheumatologists treat autoimmune diseases, only a few approved that they treat muscle problems. Conclusion Most participants in our study have lesser knowledge about their symptoms and they did not know where to consult for the treatment of their disease. This caused unnecessary delays and worsening and aggravation of the symptoms. There is an increased need to organize an awareness campaign in the general population regarding autoimmune and rheumatic diseases.
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Affiliation(s)
- Bader A Al-Mehmadi
- Department of Internal Medicine, College of Medicine, Majmaah University, Al-Majmaah, 11952, Saudi Arabia
| | | | | | | | | | - Hayat Saleh Alzahrani
- Department of Family and Community Medicine, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
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Alhumaid S, Alsuhibani A, Alsabr AA, Alrajeh A, Alhumaidi Y, Al Suwairi W. Referral Patterns to Pediatric Rheumatology From Primary Care Physicians and General Pediatrics at a Single Pediatric Rheumatology Center in Saudi Arabia. Cureus 2023; 15:e43594. [PMID: 37719605 PMCID: PMC10503964 DOI: 10.7759/cureus.43594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2023] [Indexed: 09/19/2023] Open
Abstract
Objective This study aims to investigate referral patterns to pediatric rheumatology and assess the correctness of referrals from primary care physicians and pediatric specialties. Methodology A cross-sectional, retrospective study was conducted on all patients who were referred to the Pediatric Rheumatology Department since 2015 (N = 282) at King Abdullah Specialized Children's Hospital (KASCH), Pediatric Rheumatology Clinic. Age, gender, reason for referral, clinical features, referring department, and final diagnosis were taken as variables. Data were collected through the documents and records of the cases (referrals) in the electronic medical records system of the hospital (BestCare). Then Excel was used for data entry, and JMP statistical software, version 14.0.0 (SAS Institute Inc., Cary, NC, USA) was used for data analysis. Results In a total of 282 patients across the Pediatric Rheumatology Clinic, KASCH, the most common reason for referral to the clinic was joint pain (112, 43%) and the least common reason was rash (6, 2.3%). The most common diagnosis was juvenile idiopathic arthritis (JIA) (24, 26.6%). The majority of patients referred to the rheumatology department did not have a rheumatological disease (169, 65%). The majority of the referrals were from pediatrics subspecialties (168, 65%). The least referred department was primary care ( 21, 8%). Conclusions To our knowledge, this is the first study showing the referral pattern, accuracy, and profile of a pediatric rheumatology clinic population in Saudi Arabia. Expectedly, the most common reason for referral was arthralgia. The most common diagnosis was JIA. According to the results, most of the referrals were inaccurate as they did not end up with a rheumatological diagnosis. Pediatric subspecialties should be more aware of the nature of rheumatological disease to avoid over-referrals. Finding a pattern of referrals to pediatric rheumatology is an excellent modality to accomplish early diagnosis and the best possible prognosis.
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Affiliation(s)
- Sulaiman Alhumaid
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Abdulaziz Alsuhibani
- Collage of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Abdulmajeed A Alsabr
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Abdulmajed Alrajeh
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Yazeed Alhumaidi
- Collage of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Wafaa Al Suwairi
- Pediatric Rheumatology, King Abdullah Specialized Children's Hospital (KASCH) National Guard Health Affairs, Riyadh, SAU
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Aboabat A, Ahmad Z, Steiman A, Johnson SR. Quality Measures in Systemic Sclerosis. Diagnostics (Basel) 2023; 13:diagnostics13040579. [PMID: 36832067 PMCID: PMC9955321 DOI: 10.3390/diagnostics13040579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 02/07/2023] Open
Abstract
Quality improvement is an emerging field, that applies principles of improvement science and utilizes measurement methods with the aim of improving patient care. Systemic sclerosis (SSc) is a systemic autoimmune rheumatic disease associated with increased healthcare burden, cost, morbidity, and mortality. Gaps in delivering care to patients with SSc have been consistently observed. In this article, we introduce the discipline of quality improvement and its use of quality measures. We summarize and comparatively evaluate three sets of quality measures that have been proposed to evaluate the quality of care of patients with SSc. Finally, we highlight the areas of unmet needs and indicate future directions for quality improvement and quality measures in SSc.
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Affiliation(s)
- Aos Aboabat
- Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, University of Toronto, Toronto, ON M5T 1R8, Canada
| | - Zareen Ahmad
- Toronto Scleroderma Program, Division of Rheumatology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON M5T 1R8, Canada
| | - Amanda Steiman
- Division of Rheumatology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON M5T 1R8, Canada
| | - Sindhu R. Johnson
- Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON M5T 1R8, Canada
- Correspondence: ; Tel.: +1-416-603-6417; Fax: +1-416-603-4348
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Seyferth AV, Cichocki MN, Wang CW, Huang YJ, Huang YW, Chen JS, Kuo CF, Chung KC. Factors Associated With Quality Care Among Adults With Rheumatoid Arthritis. JAMA Netw Open 2022; 5:e2246299. [PMID: 36508216 PMCID: PMC9856345 DOI: 10.1001/jamanetworkopen.2022.46299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Although quality care markers exist for patients with rheumatoid arthritis (RA), the predictors of meeting these markers are unclear. OBJECTIVE To explore factors associated with quality care among patients with RA. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study using insurance claims from 2009 to 2017 was conducted, and 6 sequential logistic regression models were built to evaluate quality care markers. Quality care markers were measured at 1 year post-RA diagnosis for each patient. The MarketScan Research Database, which contains commercial and Medicare Advantage administrative claims data from more than 100 million individuals in the US, was used to identify patients aged 18 to 64 years with a diagnosis claim for RA. Patients with conditions presenting similar to RA and missing demographic characteristics were excluded. Data analysis occurred between February 18 and May 5, 2022. EXPOSURES Success or failure to meet selected RA quality care markers within 1 year after RA diagnosis. MAIN OUTCOMES AND MEASURES Prevalence of meeting successive quality care markers for RA. RESULTS Among 581 770 patients, 430 843 (74.1%) were women and the mean (SD) age was 48.9 (11.3) years. Most patients (236 285 [40.6%]) resided in the South and had an income less than or equal to $45 200 (490 366 [84.3%]). Of the total study population, 399 862 individuals (68.7%) met at least 1 quality care marker and 181 908 (31.3%) met 0 markers. Most commonly, patients met annual laboratory testing (299 323 [51.5%]) and referral to a rheumatologist (256 765 [44.1%]) markers. The least met marker was receiving hepatitis B screening prior to initiation of disease-modifying antirheumatic drug (DMARD) therapy (18 548 [3.2%]). Women were most likely to meet all quality care markers except receiving DMARDs with hepatitis B screening (odds ratio, 1.14; 95% CI, 1.12-1.16). Individuals with lower median household income had lower odds of receiving a rheumatologist referral, an annual physical examination, or annual laboratory testing, but greater odds of receiving the other quality care markers. Patients with Medicare and those with comorbidities were generally less likely to meet quality care markers. CONCLUSIONS AND RELEVANCE In this cohort study of patients with RA, findings indicated downstream associations with rheumatologist referral and receiving DMARDs and varied associations between meeting quality care markers and patient characteristics. These findings suggest that prioritizing early care, especially for vulnerable patients, will ensure that quality care continues.
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Affiliation(s)
- Anne V. Seyferth
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Meghan N. Cichocki
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Chien-Wei Wang
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Yun-Ju Huang
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Wei Huang
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Jung-Sheng Chen
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Chang-Fu Kuo
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Kevin C. Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
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Power JD, Perruccio AV, Paterson JM, Canizares M, Veillette C, Coyte PC, Badley EM, Mahomed NN, Rampersaud YR. Healthcare utilization and costs for musculoskeletal disorders in Ontario, Canada. J Rheumatol Suppl 2022; 49:740-747. [PMID: 35365584 DOI: 10.3899/jrheum.210938] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To examine the magnitude and costs of ambulatory primary and specialist physician care and hospital service use for musculoskeletal disorders (MSDs) in Canada's largest province, Ontario. METHODS Administrative health databases were analyzed for fiscal year 2013-2014 for adults 18+ years, including data on physician services, emergency department (ED) visits and hospitalizations. ICD diagnostic codes were used to identify MSD services. A validated algorithm was used to estimate direct medical costs. Person visit rates and numbers of persons and visits were tabulated by care setting, age and sex, and physician specialty. Data were examined for all MSDs combined as well as specific diagnostic groupings. RESULTS Overall, 3.1 million adult Ontarians (28.5%) made 8 million outpatient physician visits associated with MSDs. These included 5.6 million primary care visits. MSDs accounted for 560,000, 12.3%, of all adult ED visits. Total costs for MSD-related care were $1.6 billion, with 12.6% of costs attributed to primary care, 9.2% to specialist care, 8.6% to ED care, 8.5% to day surgery and 61.2% of total costs associated with inpatient hospitalizations. Costs due to arthritis accounted for 40% of total MSD care costs ($639 million). MSD-related imaging costs were $169 million. Including these costs yields a total estimate of $1.8 billion for all MSDs combined. CONCLUSION MSDs place a significant and costly burden on the health care system. Health system planning needs to consider the large and escalating demand for care to reduce both the individual and population burden.
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Affiliation(s)
- J Denise Power
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Orthopaedics, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Support: This study was financially supported by the Toronto General & Western Hospital Foundation through the University Health Network Arthritis Program. The funding source had no involvement in study design or manuscript preparation. Conflict of Interest: There are no potential conflicts of interest relevant to this work. Corresponding Author: J. Denise Power, 399 Bathurst Street MP10-326, Toronto, Ontario, Canada, M5T 2S8.
| | - Anthony V Perruccio
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Orthopaedics, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Support: This study was financially supported by the Toronto General & Western Hospital Foundation through the University Health Network Arthritis Program. The funding source had no involvement in study design or manuscript preparation. Conflict of Interest: There are no potential conflicts of interest relevant to this work. Corresponding Author: J. Denise Power, 399 Bathurst Street MP10-326, Toronto, Ontario, Canada, M5T 2S8.
| | - J Michael Paterson
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Orthopaedics, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Support: This study was financially supported by the Toronto General & Western Hospital Foundation through the University Health Network Arthritis Program. The funding source had no involvement in study design or manuscript preparation. Conflict of Interest: There are no potential conflicts of interest relevant to this work. Corresponding Author: J. Denise Power, 399 Bathurst Street MP10-326, Toronto, Ontario, Canada, M5T 2S8.
| | - Mayilee Canizares
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Orthopaedics, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Support: This study was financially supported by the Toronto General & Western Hospital Foundation through the University Health Network Arthritis Program. The funding source had no involvement in study design or manuscript preparation. Conflict of Interest: There are no potential conflicts of interest relevant to this work. Corresponding Author: J. Denise Power, 399 Bathurst Street MP10-326, Toronto, Ontario, Canada, M5T 2S8.
| | - Christian Veillette
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Orthopaedics, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Support: This study was financially supported by the Toronto General & Western Hospital Foundation through the University Health Network Arthritis Program. The funding source had no involvement in study design or manuscript preparation. Conflict of Interest: There are no potential conflicts of interest relevant to this work. Corresponding Author: J. Denise Power, 399 Bathurst Street MP10-326, Toronto, Ontario, Canada, M5T 2S8.
| | - Peter C Coyte
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Orthopaedics, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Support: This study was financially supported by the Toronto General & Western Hospital Foundation through the University Health Network Arthritis Program. The funding source had no involvement in study design or manuscript preparation. Conflict of Interest: There are no potential conflicts of interest relevant to this work. Corresponding Author: J. Denise Power, 399 Bathurst Street MP10-326, Toronto, Ontario, Canada, M5T 2S8.
| | - Elizabeth M Badley
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Orthopaedics, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Support: This study was financially supported by the Toronto General & Western Hospital Foundation through the University Health Network Arthritis Program. The funding source had no involvement in study design or manuscript preparation. Conflict of Interest: There are no potential conflicts of interest relevant to this work. Corresponding Author: J. Denise Power, 399 Bathurst Street MP10-326, Toronto, Ontario, Canada, M5T 2S8.
| | - Nizar N Mahomed
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Orthopaedics, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Support: This study was financially supported by the Toronto General & Western Hospital Foundation through the University Health Network Arthritis Program. The funding source had no involvement in study design or manuscript preparation. Conflict of Interest: There are no potential conflicts of interest relevant to this work. Corresponding Author: J. Denise Power, 399 Bathurst Street MP10-326, Toronto, Ontario, Canada, M5T 2S8.
| | - Y Raja Rampersaud
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Orthopaedics, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Support: This study was financially supported by the Toronto General & Western Hospital Foundation through the University Health Network Arthritis Program. The funding source had no involvement in study design or manuscript preparation. Conflict of Interest: There are no potential conflicts of interest relevant to this work. Corresponding Author: J. Denise Power, 399 Bathurst Street MP10-326, Toronto, Ontario, Canada, M5T 2S8.
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Hartford W, Backman CL, Li LC, McQuitty S, McKinnon A, Kherani R, Nimmon L. Networks of Care: A Social Network Perspective of Distributed Multidisciplinary Care for People With Inflammatory Arthritis. ACR Open Rheumatol 2022; 4:40-56. [PMID: 34687173 PMCID: PMC8754010 DOI: 10.1002/acr2.11349] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 09/02/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To explore how multidisciplinary inflammatory arthritis (IA) care is accessed from the perspectives of people with IA and their health care network members. METHODS In this phenomenological study, we used purposive sampling to recruit patients with IA for less than 5 years and age of more than 18 years who spoke English and reported two or more health care network members. We conducted one-to-one interviews with patients and their health care network members. Data were analysed using a social network perspective. RESULTS We interviewed 14 patient participants and 19 health care network members comprising health care providers and informal caregivers. An overarching theme of whole person (holistic) IA care was identified, with the following two broad multifaceted subthemes: 1) connected networks and whole person care and 2) network disconnect and disrupted access to care. The first subtheme notes how access to health care providers and social support was fundamental to holistic care and how care was facilitated by communication pathways that promoted care. The second subtheme illustrates impediments to access, including appointment time pressures, inadequacies in communication delivery modes, and family physicians' unfamiliarity with rheumatology care. Inequities in care were also reported. CONCLUSION Participants shared a goal of whole person care. Although health care networks included multiple disciplines, they did not always provide coordinated multidisciplinary care. Communication modes, linkages between network actors, and organizational structures governed the flow of information and resources through networks and influenced access to equitable whole person care. The development of health care system structures to support the flow of information and resource transfer is needed to promote network collaboration and equitable access to resources.
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Affiliation(s)
- Wendy Hartford
- University of British ColumbiaVancouverBritish ColumbiaCanada
| | | | - Linda C. Li
- University of British ColumbiaVancouverBritish ColumbiaCanada
| | | | | | - Raheem Kherani
- University of British ColumbiaVancouverBritish ColumbiaCanada
| | - Laura Nimmon
- University of British ColumbiaVancouverBritish ColumbiaCanada
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Castro-Domínguez F, Vargas-Negrín F, Pérez C, Gutiérrez-Prieto H, Rebollo P. Unmet Needs in the Osteoarthritis Chronic Moderate to Severe Pain Management in Spain: A Real Word Data Study. Rheumatol Ther 2021; 8:1113-1127. [PMID: 34109548 PMCID: PMC8380598 DOI: 10.1007/s40744-021-00327-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/25/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Patients with moderate or severe pain due to osteoarthritis (OAP) usually undergo pharmacological treatment with NSAIDs and/or opioids. Many of them do not get adequate pain relief because of intolerances, contraindications and the ineffectiveness of these treatments. The main objective of the present study was to quantify the group of OAP patients who are inadequately treated for their pain in routine clinical practice in Spain and to describe the prescription flow of these patients. METHODS This was a non-interventional, retrospective cohort study conducted using the IQVIA's electronic medical records database in Spain. Patients with osteoarthritis (OA), aged ≥ 15 years and receiving any pain treatment during 12 out of 24 months between 1 October 2017 and 30 September 2019 were studied. Assumptions were made to identify patients with contraindication or intolerance to NSAIDs or opioids and those who failed NSAID or opioid therapy. RESULTS Out of 136,556 patients with OA, 29,886 had moderate-to-severe pain, which extrapolated to the general population in Spain represents 1,541,286 OAP patients. Mean age (SD) of OAP patients was 75 (12.8) years, and 73.8% were female; 52.8% were treated with NSAIDs and/or weak opioids. There were were 16,748 OAP patients (56.08%) (extrapolated figure 838,620) with one or more conditions associated with being inadequately treated (contraindication, intolerance or failed NSAID and/or opioid therapy). In most OAP patients (91%) pain treatment was initiated by the general practitioner (GP) alone. Considering overall successive therapy lines, after the first prescription, pain drugs were prescribed by a GP in 61% of the cases, by a specialist in 20% and by both in 18%. CONCLUSION More than half of the patients with OA in Spain have unsatisfactory pain control. Pain drugs are mainly prescribed by GPs, and specialists (traumatologists, rheumatologists, physiatrists and pain management specialists) are not very involved in the management of OAP patients.
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Affiliation(s)
- Francisco Castro-Domínguez
- Rheumatology Unit, Teknon Medical Center, Quirónsalud Group, Barcelona, Spain
- Rheumatology Unit, University Hospital "Sagrat Cor", Quirónsalud Group, Barcelona, Spain
- SER Working Group in Osteoarthritis, Spanish Society of Rheumatology, Madrid, Spain
| | | | | | | | - Pablo Rebollo
- IQVIA, C/ Juan Esplandiu 11, 6º, 28007, Madrid, Spain.
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10
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Ahluwalia V, Inrig T, Larsen T, Shupak R, Papneja T, Karasik A, Kennedy C, Lundon K. An Advanced Clinician Practitioner in Arthritis Care (ACPAC) Maintains a Positive Patient Experience While Increasing Capacity in Rheumatology Community Care. J Multidiscip Healthc 2021; 14:1299-1310. [PMID: 34113118 PMCID: PMC8184238 DOI: 10.2147/jmdh.s304206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 04/06/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose This study describes patient care experiences of solo-rheumatologist and co-managed care models utilizing an Advanced Clinician Practitioner in Arthritis Care-trained Extended Role Practitioner (ACPAC-ERP) in three community rheumatology practices. Materials and Methods Patients with inflammatory arthritis (IA) were assigned to care provided by one of three (2 senior, 1 early-career) community-based rheumatologists (usual care), or an ACPAC-ERP (co-managed care) for the 6-months following diagnosis. Patient experiences were surveyed using validated measures of patient satisfaction (Patient Doctor Interaction Scale-PDIS), global ratings of confidence and satisfaction, referral patterns, disease activity (RADAI) and self-perceived disability (HAQ-Disability) as well as demographic information. Practice capacity was evaluated 18-months prior to, and across, the study period. Results Of 55 participants (mean age 56.6 years, 61.8% female), 33 received co-managed care. Most participants were diagnosed with rheumatoid arthritis (65.5%) with a median symptom duration of 1.1 years. At 6-months, patients from both models of care were equally satisfied in terms of the information provided (usual care 4.6 vs co-managed care 4.7/5=greater satisfaction), rapport with health-care provider (4.6 vs 4.6/5) and having needs met (4.7 vs 4.5/5). Overall satisfaction was high (87.2 vs 85.3/100=completely satisfied) as was confidence in the system by which care was received (85.0 vs 82.1/100=completely confident). Usual care patients reported higher perceived disability than co-managed patients (HAQ-Disability 0.5 vs 0.2/3=unable to do). Significant differences in overall RADAI score (p=0.014) were found between the two models. The senior rheumatologist, with a previously saturated practice, attained a 37% capacity increase for new patients utilizing the co-managed care model. Conclusion The ACPAC-ERP model was equivalent to the solo-rheumatologist model with regard to patient experience and satisfaction. A co-management model utilizing a highly trained ACPAC-ERP can increase capacity in community rheumatology clinics for patients newly diagnosed with IA while maintaining confidence and satisfaction with their care.
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Affiliation(s)
- Vandana Ahluwalia
- Division of Rheumatology, Department of Internal Medicine, William Osler Health System, Brampton, ON, Canada
| | - Taucha Inrig
- Musculoskeletal Health and Outcomes Research, St. Michael's Hospital, Toronto, ON, Canada
| | - Tiffany Larsen
- Department of Physiotherapy, Headwaters Healthcare Centre, Orangeville, ON, Canada
| | - Rachel Shupak
- Division of Rheumatology, Department of Internal Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | - Tripti Papneja
- Division of Rheumatology, Department of Internal Medicine, William Osler Health System, Brampton, ON, Canada
| | - Arthur Karasik
- Independent Rheumatology Practice, Etobicoke, ON, Canada
| | - Carol Kennedy
- Musculoskeletal Health and Outcomes Research, St. Michael's Hospital, Toronto, ON, Canada
| | - Katie Lundon
- Continuing Professional Development, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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11
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Barber CEH, Marshall DA, Szefer E, Barnabe C, Shiff NJ, Bykerk V, Homik J, Thorne JC, Ahluwalia V, Benseler S, Mosher D, Twilt M, Lacaille D. A Population-Based Approach to Reporting System-Level Performance Measures for Rheumatoid Arthritis Care. Arthritis Care Res (Hoboken) 2021; 73:640-648. [PMID: 32144843 DOI: 10.1002/acr.24178] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 02/25/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To operationalize and report on nationally endorsed rheumatoid arthritis (RA) performance measures (PMs) using health administrative data for British Columbia (BC), Canada. METHODS All patients with RA in BC ages ≥18 years were identified between January 1, 1997 and December 31, 2009 using health administrative data and followed until December 2014. PMs tested include: the percentage of incident patients with ≥1 rheumatologist visit within 365 days; the percentage of prevalent patients with ≥1 rheumatologist visit per year; the percentage of prevalent patients dispensed disease-modifying antirheumatic drug (DMARD) therapy; and time from RA diagnosis to DMARD therapy. Measures were reported on patients seen by rheumatologists, and in the total population. RESULTS The cohort included 38,673 incident and 57,922 prevalent RA cases. The percentage of patients seen by a rheumatologist within 365 days increased over time (35% in 2000 to 65% in 2009), while the percentage of RA patients under the care of a rheumatologist seen yearly declined (79% in 2001 to 39% in 2014). The decline was due to decreasing visit rates with increasing follow-up time rather than calendar effect. The percentage of RA patients dispensed a DMARD was suboptimal over follow-up (37% in 2014) in the total population but higher (87%) in those under current rheumatologist care. The median time to DMARD in those seen by a rheumatologist improved from 49 days in 2000 to 23 days in 2009, with 34% receiving treatment within the 14-day benchmark. CONCLUSION This study describes the operationalization and reporting of national PMs using administrative data and identifies gaps in care to further examine and address.
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Affiliation(s)
- Claire E H Barber
- University of Calgary, Calgary, Alberta, Canada, and Arthritis Research Canada, Richmond, British Columbia, Canada
| | - Deborah A Marshall
- University of Calgary, Calgary, Alberta, Canada, and Arthritis Research Canada, Richmond, British Columbia, Canada
| | | | - Cheryl Barnabe
- University of Calgary, Calgary, Alberta, Canada, and Arthritis Research Canada, Richmond, British Columbia, Canada
| | | | - Vivian Bykerk
- Hospital for Special Surgery and Cornell University, New York, New York
| | - Joanne Homik
- University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Susanne Benseler
- Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | | | - Marinka Twilt
- Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Diane Lacaille
- Arthritis Research Canada, Richmond, and University of British Columbia, Vancouver, British Columbia, Canada
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12
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Widdifield J, Bernatsky S, Pope JE, Kuriya B, Barber CEH, Eder L, Ahluwalia V, Ling V, Gozdyra P, Hofstetter C, Lyddiatt A, Paterson JM, Thorne C. Evaluation of Rheumatology Workforce Supply Changes in Ontario, Canada, from 2000 to 2030. ACTA ACUST UNITED AC 2021; 16:119-134. [PMID: 33720829 PMCID: PMC7957360 DOI: 10.12927/hcpol.2021.26428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Rheumatology workforces are increasingly challenged by too few physicians in face of the growing burden of rheumatic and musculoskeletal diseases (RMDs). Rheumatology is one of the most frequent non-surgical specialty referrals and has the longest wait times for subspecialists. We used a population-based approach to describe changes in the rheumatology workforce, patient volumes and geographic variation in the supply of and access to rheumatologists, in Ontario, Canada, between 2000 and 2019, and projected changes in supply by 2030. Over time, we observed greater feminization of the workforce and increasing age of workforce members. We identified a large regional variation in rheumatology supply. Fewer new patients are seen annually, which likely contributes to increasing wait times and reduced access to care. Strategies and policies to raise the critical mass and improve regional distribution of supply to effectively provide rheumatology care and support the healthcare delivery of patients with RMDs are needed.
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Affiliation(s)
- Jessica Widdifield
- Scientist, Sunnybrook Research Institute Holland Bone & Joint Program; Assistant Professor, University of Toronto, Institute of Health Policy, Management & Evaluation Toronto, ON; Scientist, ICES Toronto, ON
| | - Sasha Bernatsky
- Rheumatologist and Scientist, Research Institute of the McGill University Health Centre; Associate Professor, Department of Epidemiology, McGill University, Montreal, QC
| | - Janet E Pope
- Rheumatologist, St Joseph's Health Care London; Professor of Medicine Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University London, ON
| | - Bindee Kuriya
- Rheumatologist, Sinai Health System; Assistant Professor, Department of Medicine, University of Toronto, Toronto, ON
| | - Claire E H Barber
- Rheumatologist, Assistant Professor, University of Calgary, Calgary, AB; Research Scientist, Arthritis Research Canada, Richmond, BC
| | - Lihi Eder
- Rheumatologist, Clinician Scientist, Women's College Research Institute, Toronto, ON
| | | | | | | | | | | | - J Michael Paterson
- Scientist, ICES, Toronto, ON; Assistant Professor, Department of Family Medicine, McMaster University, Hamilton, ON; Assistant Professor, University of Toronto, Institute of Health Policy, Management & Evaluation, Toronto, ON
| | - Carter Thorne
- Rheumatologist, Southlake Regional Health Centre, Newmarket, ON; Assistant Professor of Medicine, University of Toronto, Toronto, ON
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13
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Keely E, Rostom K, Smith D, Liddy C. A comparison of faxed referrals and eConsult questions for rheumatology referrals: a descriptive study. CMAJ Open 2021; 9:E38-E43. [PMID: 33436454 PMCID: PMC7843073 DOI: 10.9778/cmajo.20200025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In Canada, wait times for access to specialized rheumatology services have increased, leading to new strategies to improve timely care; electronic consultations (eConsults) enable providers to ask specialists a clinical question using a secure platform, often reducing the need for a face-to-face visit. In this study, we sought to compare the types of referrals received through fax versus eConsult and to determine whether faxed referrals could be addressed using eConsult. METHODS We conducted a descriptive study of consecutive faxed referrals sent to a tertiary care centre between Feb. 1 and Mar. 6, 2017, and a convenience sample of eConsults directed to rheumatology between Feb. 1, 2015, and Sept. 30, 2016, through the Champlain BASE eConsult Service, an Ontario-based service. We reviewed all referrals and categorized them by clinical content and question type. A rheumatologist with experience completing eConsult referrals assessed faxed referrals for their suitability to be answered through eConsults. Descriptive statistics were generated. RESULTS We analyzed 300 consecutive faxed referrals and 300 (of 470) eConsult referrals. Faxed questions more often pertained to rheumatoid arthritis (32/300 [10.7%] v. 17/300 [5.7%]), systemic lupus erythematosus (24/300 [8.0%] v. 10/300 [3.3%]), and polyarthritis (30/300 [10.0%] v. 18/300 [6.0%]). eConsults more often addressed abnormal serology without joint symptoms (27/300 [9.0%] v. 8/300 [2.7%]) and gout (15/300 [5.0%] v. 4/300 [1.3%]). Faxed referrals were more likely to have no specific question (116/300 [38.7%]), and eConsults were more likely to have more than 1 question posed (99/300 [33.0%]) and a drug-related question (67/300 [22.3%]). The rheumatologist identified potential benefit from eConsult in 216/300 (72.0%) faxed referrals and 55/59 (93.2%) declined faxed referrals. INTERPRETATION Despite differences in diagnosis between eConsults and faxed referrals, most faxed referrals showed the potential to be addressed through eConsult. Using eConsult may allow primary care providers to obtain answers to questions without requesting a face-to-face specialist referral, or provide support for patients awaiting face-to-face consultation.
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Affiliation(s)
- Erin Keely
- Department of Medicine (Keely, Smith), University of Ottawa; Department of Medicine (Keely, Smith) and Ontario eConsult Centre of Excellence (Keely, Liddy), The Ottawa Hospital; Department of Medicine (Rostom), Queensway Carleton Hospital; Department of Family Medicine (Liddy), C.T. Lamont Primary Health Care Research Centre, University of Ottawa; Bruyère Research Institute (Liddy), Ottawa, Ont.
| | - Krista Rostom
- Department of Medicine (Keely, Smith), University of Ottawa; Department of Medicine (Keely, Smith) and Ontario eConsult Centre of Excellence (Keely, Liddy), The Ottawa Hospital; Department of Medicine (Rostom), Queensway Carleton Hospital; Department of Family Medicine (Liddy), C.T. Lamont Primary Health Care Research Centre, University of Ottawa; Bruyère Research Institute (Liddy), Ottawa, Ont
| | - Douglas Smith
- Department of Medicine (Keely, Smith), University of Ottawa; Department of Medicine (Keely, Smith) and Ontario eConsult Centre of Excellence (Keely, Liddy), The Ottawa Hospital; Department of Medicine (Rostom), Queensway Carleton Hospital; Department of Family Medicine (Liddy), C.T. Lamont Primary Health Care Research Centre, University of Ottawa; Bruyère Research Institute (Liddy), Ottawa, Ont
| | - Clare Liddy
- Department of Medicine (Keely, Smith), University of Ottawa; Department of Medicine (Keely, Smith) and Ontario eConsult Centre of Excellence (Keely, Liddy), The Ottawa Hospital; Department of Medicine (Rostom), Queensway Carleton Hospital; Department of Family Medicine (Liddy), C.T. Lamont Primary Health Care Research Centre, University of Ottawa; Bruyère Research Institute (Liddy), Ottawa, Ont
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14
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Barber CEH, Mosher D, Dowling S, Bohm V, Solbak NM, MacMullan P, Pan B, Barnabe C, Hazlewood GS, Then KL, Marshall DA, Rankin JA, Li LC, Tsui K, English K, Homik J, Spencer N, Hall M, Lacaille D. Implementation and Evaluation of Audit and Feedback for Monitoring Treat-to-Target (T2T) Strategies in Rheumatoid Arthritis Using Performance Measures. Rheumatol Ther 2020; 7:909-925. [PMID: 33034861 PMCID: PMC7695654 DOI: 10.1007/s40744-020-00237-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/16/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION In collaboration with the Alberta Medical Association's Physician Learning Program we developed individualized physician reports and held a group feedback session on rheumatoid arthritis (RA) performance measures (PM) to facilitate treat-to-target (T2T) strategies and evaluated physician experiences with this process. METHODS 5 PMs addressing T2T concepts from an established Canadian quality framework were operationalized for physician practice reports at 2 university-affiliated rheumatology clinics. Rheum4U, a quality improvement and research platform, was the data source. The audit results were reviewed in a facilitated group feedback session. Rheumatologists provided experiential feedback on the process through survey and/or an interview. Transcripts from interviews were analyzed using a 6-step thematic analysis. RESULTS 11 of 12 eligible rheumatologists consented to receive practice reports and provided feedback through surveys (n = 5) and interviews (n = 6). The practice reports from Rheum4U (n = 448 patients) revealed high rates of yearly follow-up (> 85%, PM1) and 100% performance on documentation of disease activity at ≥ 50% of visits (PM2). Only 34% of patients were seen within 3 months if not in remission (PM3) with 62% (2017) and 69% (2018) of those with active RA achieving a LDA state within 6 months (PM4). Approximately 70% of patients were in remission at any time point (PM5). All survey respondents agreed or strongly agreed comparison to peers was valuable and helped them reflect on their practice. Several strategies for improvement were identified, including but not limited to, leveraging of electronic records for future audit and feedback reports, providing additional granularity of results, additional stratification of results, and using high-performing peers as the comparator rather than the group mean. CONCLUSIONS Audit and feedback was perceived by clinicians as a useful strategy for evaluating T2T efforts in RA. Future work will focus on longitudinal evaluation of the clinical impact of this quality improvement initiative.
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Affiliation(s)
- Claire E H Barber
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Arthritis Research Canada, Richmond, BC, Canada.
| | - Dianne Mosher
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Shawn Dowling
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Victoria Bohm
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Nathan M Solbak
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Paul MacMullan
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bo Pan
- Epidemiology Coordinating and Research Centre (EPICORE), Edmonton, AB, Canada
| | - Cheryl Barnabe
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Arthritis Research Canada, Richmond, BC, Canada
| | - Glen S Hazlewood
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Arthritis Research Canada, Richmond, BC, Canada
| | - Karen L Then
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
| | - Deborah A Marshall
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Arthritis Research Canada, Richmond, BC, Canada
| | - James A Rankin
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
| | - Linda C Li
- Arthritis Research Canada, Richmond, BC, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada
| | - Karen Tsui
- Arthritis Patient Advisory Board, Richmond, BC, Canada
| | - Kelly English
- Arthritis Patient Advisory Board, Richmond, BC, Canada
| | - Joanne Homik
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Nicole Spencer
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Marc Hall
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
| | - Diane Lacaille
- Arthritis Research Canada, Richmond, BC, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
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Zanetti A, Scirè CA, Argnani L, Carrara G, Zambon A. Can the adherence to quality of care indicators for early rheumatoid arthritis in clinical practice reduce risk of hospitalisation? Retrospective cohort study based on the Record Linkage of Rheumatic Disease study of the Italian Society for Rheumatology. BMJ Open 2020; 10:e038295. [PMID: 32994247 PMCID: PMC7526308 DOI: 10.1136/bmjopen-2020-038295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To describe the adherence to quality of care indicators in early rheumatoid arthritis (RA) and to evaluate its impact on the risk of hospitalisation in a real-world setting. DESIGN Retrospective cohort study. SETTING Patients with early-onset RA identified from healthcare regional administrative databases by means of a validated algorithm between 2006 and 2012 in the Lombardy region (Italy). PARTICIPANTS The study cohort included 14 203 early-onset RA (71% female, mean age 60 years). OUTCOME MEASURES For each patient, a summary adherence score was calculated starting from the compliance to six quality indicators: (1-2) methotrexate or sulfasalazine or leflunomide with/without glucocorticoids, (3-4) other disease-modifying antirheumatic drugs (DMARDs) with/without glucocorticoids, (5) early interruption of glucocorticoids, (6) early clinical assessment.The relationship between low, intermediate and high categories of the summary score and the 12-month risk of hospitalisation for all causes and for RA was assessed. RESULTS During a follow-up of 1 year, 2609 hospitalisations occurred, of which 704 were for RA (main or secondary diagnosis) and 252 primarily for RA. In a 7-year period (2006-2012), early DMARDs and timely clinical monitoring treatment increased (from 52% to 62% p trend <0.001 and from 25% to 30% p trend 0.009, respectively).Intermediate and high summary adherence score categories (compared with the low category) were related significantly with a lower risk of hospitalisation (adjusted HR 0.85 (95% CI 0.77 to 0.93), p<0.001 and HR 0.76 (95% CI 0.69 to 0.84), p<0.001, respectively). Among the indicators of the adherence score, early DMARD prescription showed the strongest positive impact, while long-term use of glucocorticoids was the worst negative one. CONCLUSION In early RA, adherence to quality standards of care is associated with a lower risk of hospitalisation. Future interventions to improve the adherence to quality standards of care in this setting should decrease the risk of hospitalisation with a significant impact on individual and population health.
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Affiliation(s)
- Anna Zanetti
- Epidemiology Unit, Italian Society for Rheumatology (SIR), Milan, Italy
- Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Lombardy, Italy
| | | | - Lisa Argnani
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Emilia-Romagna, Italy
| | - Greta Carrara
- Epidemiology Unit, Italian Society for Rheumatology (SIR), Milan, Italy
| | - Antonella Zambon
- Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Lombardy, Italy
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16
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Barber CEH, Lacaille D, Faris P, Mosher D, Katz S, Patel JN, Zhang S, Yee K, Barnabe C, Hazlewood GS, Bykerk V, Shiff NJ, Twilt M, Burt J, Benseler SM, Homik J, Marshall DA. Evaluating Quality of Care for Rheumatoid Arthritis for the Population of Alberta Using System-level Performance Measures. J Rheumatol 2020; 48:482-485. [PMID: 32934120 DOI: 10.3899/jrheum.200420] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE We evaluated 4 national rheumatoid arthritis (RA) system-level performance measures (PM) in Alberta, Canada. METHODS Incident and prevalent RA cases ≥ 16 years of age since 2002 were identified using a validated case definition applied in provincial administrative data. Performance was ascertained through analysis of health data between fiscal years 2012/13-2015/16. Measures evaluated were as follows: proportion of incident RA cases with a rheumatologist visit within 1 year of first RA diagnosis code (PM1); proportion of prevalent RA patients who were dispensed a disease-modifying antirheumatic drug (DMARD) annually (PM2); time from first visit with an RA code to DMARD dispensation and proportion of incident cases where the 14-day benchmark for dispensation was met (PM3); and proportion of patients seen in annual follow-up (PM4). RESULTS There were 31,566 prevalent and 2730 incident RA cases (2012/13). Over the analysis period, the proportion of patients seen by a rheumatologist within 1 year of onset (PM1) increased from 55% to 63%; however, the proportion of RA patients dispensed DMARD annually (PM2) remained low at 43%. While the median time to DMARD from first visit date in people who received DMARD improved over time from 39 days to 28 days, only 38-41% of patients received treatment within the 14-day benchmark (PM3). The percentage of patients seen in yearly follow-up (PM4) varied between 73-80%. CONCLUSION The existing Alberta healthcare system for RA is suboptimal, indicating barriers to accessing specialty care and treatment. Our results inform quality improvement initiatives required within the province to meet national standards of care.
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Affiliation(s)
- Claire E H Barber
- C.E. Barber, MD, FRCPC, PhD, Assistant Professor, C. Barnabe, MD, FRCPC, MSc, Associate Professor, G.S. Hazlewood, MD, FRCPC, PhD, Associate Professor, D.A. Marshall, PhD, Professor, Department of Medicine, Cumming School of Medicine, University of Calgary, and Department of Community Health Sciences, University of Calgary, and Arthritis Research Canada, and McCaig Bone and Joint Health Institute, Calgary, Alberta, Canada;
| | - Diane Lacaille
- D. Lacaille, MD, FRCPC, MHSc, Professor, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada, and Scientific Director, Arthritis Research Canada
| | - Peter Faris
- P. Faris, PhD, Director, Health Services Statistical and Analytic Methods Analytics (DIMER), S. Zhang, MSc, Senior Data Analyst, K. Yee, MSc, MPH, Senior Data Analyst, Alberta Health Services, Calgary, Alberta, Canada
| | - Dianne Mosher
- D. Mosher, MD, FRCPC, Professor, Department of Medicine, Cumming School of Medicine, University of Calgary, and McCaig Bone and Joint Health Institute, Calgary, Alberta, Canada
| | - Steven Katz
- S. Katz, MD, FRCPC, J. Homik, MD, FRCPC, MSc, Professor, Department of Medicine, University of Alberta, Calgary, Alberta, Canada
| | - Jatin N Patel
- J.N. Patel, MBT, Project Manager, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Sharon Zhang
- P. Faris, PhD, Director, Health Services Statistical and Analytic Methods Analytics (DIMER), S. Zhang, MSc, Senior Data Analyst, K. Yee, MSc, MPH, Senior Data Analyst, Alberta Health Services, Calgary, Alberta, Canada
| | - Karen Yee
- P. Faris, PhD, Director, Health Services Statistical and Analytic Methods Analytics (DIMER), S. Zhang, MSc, Senior Data Analyst, K. Yee, MSc, MPH, Senior Data Analyst, Alberta Health Services, Calgary, Alberta, Canada
| | - Cheryl Barnabe
- C.E. Barber, MD, FRCPC, PhD, Assistant Professor, C. Barnabe, MD, FRCPC, MSc, Associate Professor, G.S. Hazlewood, MD, FRCPC, PhD, Associate Professor, D.A. Marshall, PhD, Professor, Department of Medicine, Cumming School of Medicine, University of Calgary, and Department of Community Health Sciences, University of Calgary, and Arthritis Research Canada, and McCaig Bone and Joint Health Institute, Calgary, Alberta, Canada
| | - Glen S Hazlewood
- C.E. Barber, MD, FRCPC, PhD, Assistant Professor, C. Barnabe, MD, FRCPC, MSc, Associate Professor, G.S. Hazlewood, MD, FRCPC, PhD, Associate Professor, D.A. Marshall, PhD, Professor, Department of Medicine, Cumming School of Medicine, University of Calgary, and Department of Community Health Sciences, University of Calgary, and Arthritis Research Canada, and McCaig Bone and Joint Health Institute, Calgary, Alberta, Canada
| | - Vivian Bykerk
- V. Bykerk, MD, FRCPC, Associate Professor, Hospital for Special Services, New York, New York, USA
| | - Natalie J Shiff
- N. J. Shiff, MD, MHSc, Adjunct Professor, Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Marinka Twilt
- M. Twilt, MD, MSCE, PhD, Assistant Professor, S.M. Benseler, MD, PhD, Professor, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer Burt
- J. Burt, PT, ACPAC-trained ERP, St Clare's Mercy Hospital, St. John's, Newfoundland, Canada
| | - Susanne M Benseler
- M. Twilt, MD, MSCE, PhD, Assistant Professor, S.M. Benseler, MD, PhD, Professor, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Joanne Homik
- S. Katz, MD, FRCPC, J. Homik, MD, FRCPC, MSc, Professor, Department of Medicine, University of Alberta, Calgary, Alberta, Canada
| | - Deborah A Marshall
- C.E. Barber, MD, FRCPC, PhD, Assistant Professor, C. Barnabe, MD, FRCPC, MSc, Associate Professor, G.S. Hazlewood, MD, FRCPC, PhD, Associate Professor, D.A. Marshall, PhD, Professor, Department of Medicine, Cumming School of Medicine, University of Calgary, and Department of Community Health Sciences, University of Calgary, and Arthritis Research Canada, and McCaig Bone and Joint Health Institute, Calgary, Alberta, Canada
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A service evaluation of e-triage in the osteoporosis outpatient clinic-an effective tool to improve patient access? Arch Osteoporos 2020; 15:53. [PMID: 32198547 PMCID: PMC7083822 DOI: 10.1007/s11657-020-0703-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/06/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED We introduced an electronic triage system into our osteoporosis service to actively manage referral demand in a busy outpatient service. Our study demonstrated the effectiveness of e-triage in supporting alternative management pathways, through use of virtual advice and direct to investigation services, to improve patient access. PURPOSE Osteoporosis referrals are increasing with awareness of the potential for prevention of fragility fracture and with complex decision making around management with long-term bisphosphonate therapy. We examined whether active triage of referrals might improve referral management processes and patient access to osteoporosis services. METHODS We implemented electronic triage (e-triage) of referrals to our osteoporosis service using the Northern Ireland electronic health care record. This included the option of 'advice only', direct to investigation with DXA or face-to-face appointments at the consultant-led complex osteoporosis service. We anticipated that there was scope to manage patient flow direct to investigation, or to provide referring clinicians with clinical advice without the need for a face-to-face assessment, at the consultant-led specialist service. RESULTS We reviewed e-triage outcomes of 809 referrals (692 F; 117 M) to osteoporosis specialist services (mean age 65 ± 16.5 years) over a 12-month period. There was a high degree of agreement for the triage category between the referring clinician and specialist services (741/809). 73.3% attended a face-to-face appointment at the consultant-led clinic, while active triage enabled direct to investigation (18.4%) or discharge (8.3%) in the remainder. The mean time between receipt of an electronic referral and e-triage was 3 days over the 12-month period as compared with 2.1 days (median 1.1 days) when annual leave periods were excluded. CONCLUSION E-triage supports effective referral management in a busy osteoporosis service. Efficiency is limited by reliance on a sole clinician and 5 day working at present. There is scope to further improve systems access through multidisciplinary team working, virtual clinics and future information technology developments.
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Hoffmann T, Oelzner P, Böttcher J, Wolf G, Pfeil A. [Analysis of referral diagnoses to the rheumatology department]. Z Rheumatol 2019; 79:160-167. [PMID: 31388735 DOI: 10.1007/s00393-019-0672-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The initial presentation of patients with symptoms indicative of a rheumatic disease is in most cases not directly to a rheumatologist. This study evaluated the following questions: I. Which medical specialists refer patients to a department of rheumatology? II. Evaluation of the accordance of the presumptive referral diagnosis and the final diagnosis by a rheumatologist. METHODS A total of 947 patients (279 men and 668 women) who initially presented to a university hospital for rheumatological diagnostics were included in the study. The referring medical specialist fields were identified. Furthermore, a kappa analysis was performed to evaluate the accordance of the presumptive referral diagnosis and the final diagnosis generated after a rheumatological evaluation of the patients. RESULTS Of the referrals 73% were initiated by general practitioners or internists functioning as general practitioners. The other referrers were 5% specialists in internal medicine (excluding rheumatology), 4% orthopedic/trauma surgeons, 1% other surgeons and 4% other specialist fields. A rheumatological diagnosis was made in 58% of the patients and rheumatological inflammatory joint diseases (26%), collagenosis (14%) and vasculitides (5%) were the most frequently diagnoses. The accordance of the presumptive diagnosis of the general practitioners and the final diagnosis after rheumatological evaluation was a kappa coefficient of κ = 0.304. Lower kappa values were evaluated for orthopedic surgeons (κ = 0.277) and other specialists (κ = 0.200). CONCLUSION The referrals to a rheumatology institution were frequently initiated by general practitioners and internists functioning as general practitioners. In this context the presumptive diagnosis of general practitioners showed a low accordance with the final rheumatological diagnosis. In contrast, a detailed presumptive diagnosis is desirable for optimal use of the limited resources for rheumatological care.
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Affiliation(s)
- T Hoffmann
- Klinik für Innere Medizin III, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| | - P Oelzner
- Klinik für Innere Medizin III, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| | - J Böttcher
- Institut für Diagnostische und Interventionelle Radiologie, SRH Wald-Klinikum Gera, Gera, Deutschland
| | - G Wolf
- Klinik für Innere Medizin III, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| | - A Pfeil
- Klinik für Innere Medizin III, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland.
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Adelowo OO, Akpabio AA, Oderinlo O, Okonkwo ON, Raphael J. Case Series and Literature Review of Ophthalmologic Disorders Seen in a Specialist Rheumatology Clinic in Lagos, Nigeria. Ocul Immunol Inflamm 2019; 27:905-911. [PMID: 31314623 DOI: 10.1080/09273948.2019.1611873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose: To highlight the pattern and treatment outcomes of ophthalmologic disorders referred to a private specialist rheumatology clinic. Methods: Retrospective review (January 2015-December 2016) of referrals from Eye Foundation Hospital, Lagos to Arthrimed Specialist Clinic, Lagos. Case records were retrieved and relevant information extracted. Ethical standards were observed. Results: Twenty-two referrals (35 eyes) were received out of 643 patients (3.4%) seen during the study period. The majority were female (63.6%) with mean age 48.9 ± 19.3 years and bilateral disease (59%). Diagnoses included uveitis (45.5%), optic neuritis (36.4%), non-specific autoimmune eye disease (9.1%), keratoconjunctivitis sicca (4.5%), and giant cell arteritis (4.5%). Treatment was with steroids and immunosuppressive agents. Fourteen patients improved (63.6%), five remained unchanged (22.7%), while three worsened (13.6%). Conclusions: Our patients were mostly fourth-decade females with bilateral disease. Uveitis was the commonest presentation, and two-thirds of the treated patients improved after treatment. Early specialist referral and co-management of severe autoimmune eye diseases are desirable.
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Affiliation(s)
- Olufemi O Adelowo
- Internal Medicine Department, Lagos State University Teaching Hospital , Ikeja , Lagos , Nigeria.,Arthrimed Specialist Clinic , Ikeja , Lagos , Nigeria
| | - Akpabio A Akpabio
- Internal Medicine Department, University of Uyo Teaching Hospital , Uyo , Akwa Ibom State , Nigeria
| | | | | | - John Raphael
- Internal Medicine Department, Delta State University Teaching Hospital , Oghara , Delta State , Nigeria
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20
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Widdifield J. Preventing Rheumatoid Arthritis: A Global Challenge. Clin Ther 2019; 41:1355-1365. [DOI: 10.1016/j.clinthera.2019.04.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/08/2019] [Accepted: 04/10/2019] [Indexed: 02/06/2023]
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Widdifield J, Bernatsky S, Pope JE, Ahluwalia V, Barber CEH, Eder L, Kuriya B, Ling V, Paterson JM, Thorne JC. Encounters with Rheumatologists in a Publicly Funded Canadian Healthcare System: A Population-based Study. J Rheumatol 2019; 47:468-476. [PMID: 31203224 DOI: 10.3899/jrheum.190034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To quantify population-level and practice-level encounters with rheumatologists over time. METHODS We conducted a population-based study from 2000 to 2015 in Ontario, Canada, where all residents are covered by a single-payer healthcare system. Annual total number of unique patients seen by rheumatologists, the number of new patients seen, and total number of encounters with rheumatologists were identified. RESULTS From 2000 to 2015, the percentage of the population seen by rheumatologists was constant over time (2.7%). During this time, Ontario had a stable supply of rheumatologists (0.8 full-time equivalents/75,000). From 2000 to 2015, the number of annual rheumatology encounters increased from 561,452 to 786,061, but the adjusted encounter rates remained stable over time (at 62 encounters per 1000 population). New patient assessment rates declined over time from 10 new outpatient assessments per 1000 in 2000 to 6 per 1000 in 2015. The crude volume of new patients seen annually decreased and an increasing proportion of rheumatology encounters were with established patients. We observed a shift in patient case mix over time, with more assessments for systemic inflammatory conditions. Rheumatologists' practice volumes, practice sizes, and the annual number of days providing clinical care decreased over time. CONCLUSION Over a 15-year period, the annual percentage of the population seen by a rheumatologist remained constant and the volume of new patients decreased, while followup patient encounters increased. Patient encounters per rheumatologist decreased over time. Our findings provide novel information for rheumatology workforce planning. Factors affecting clinical activity warrant further research.
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Affiliation(s)
- Jessica Widdifield
- From Sunnybrook Research Institute, Holland Bone and Joint Program; University of Toronto, Institute of Health Policy, Management and Evaluation; ICES; Arthritis Research Canada; Women's College Research Institute; Sinai Health System, University of Toronto, Toronto, Ontario; McGill University, Department of Epidemiology; Research Institute of the McGill University Health Centre, Montreal, Quebec; William Osler Health System, Brampton, Ontario; The Cumming School of Medicine, University of Calgary, Calgary, Alberta; McMaster University, Department of Family Medicine, Hamilton; Western University, Schulich School of Medicine & Dentistry; St. Joseph's Health Care London, London, Ontario; Southlake Regional Health Centre, Newmarket, Ontario, Canada. .,J. Widdifield, PhD, Sunnybrook Research Institute, Holland Bone and Joint Program, and University of Toronto, Institute of Health Policy, Management and Evaluation, and ICES; S. Bernatsky, MD, FRCPC, PhD, McGill University, Department of Epidemiology, and Research Institute of the McGill University Health Centre; J.E. Pope, MD, FRCPC, MPH, Western University, Schulich School of Medicine & Dentistry, and St. Joseph's Health Care London; V. Ahluwalia, MD, FRCPC, William Osler Health System; C.E. Barber, MD, FRCPC, PhD, The Cumming School of Medicine, University of Calgary, and Arthritis Research Canada; L. Eder, MD, PhD, University of Toronto, Institute of Health Policy, Management and Evaluation, and Women's College Research Institute; B. Kuriya, MD, FRCPC, SM, Sinai Health System, University of Toronto; V. Ling, MSc, ICES; J.M. Paterson, MSc, University of Toronto, Institute of Health Policy, Management and Evaluation, and ICES, and McMaster University, Department of Family Medicine; J.C. Thorne, MD, FRCPC, Southlake Regional Health Centre.
| | - Sasha Bernatsky
- From Sunnybrook Research Institute, Holland Bone and Joint Program; University of Toronto, Institute of Health Policy, Management and Evaluation; ICES; Arthritis Research Canada; Women's College Research Institute; Sinai Health System, University of Toronto, Toronto, Ontario; McGill University, Department of Epidemiology; Research Institute of the McGill University Health Centre, Montreal, Quebec; William Osler Health System, Brampton, Ontario; The Cumming School of Medicine, University of Calgary, Calgary, Alberta; McMaster University, Department of Family Medicine, Hamilton; Western University, Schulich School of Medicine & Dentistry; St. Joseph's Health Care London, London, Ontario; Southlake Regional Health Centre, Newmarket, Ontario, Canada.,J. Widdifield, PhD, Sunnybrook Research Institute, Holland Bone and Joint Program, and University of Toronto, Institute of Health Policy, Management and Evaluation, and ICES; S. Bernatsky, MD, FRCPC, PhD, McGill University, Department of Epidemiology, and Research Institute of the McGill University Health Centre; J.E. Pope, MD, FRCPC, MPH, Western University, Schulich School of Medicine & Dentistry, and St. Joseph's Health Care London; V. Ahluwalia, MD, FRCPC, William Osler Health System; C.E. Barber, MD, FRCPC, PhD, The Cumming School of Medicine, University of Calgary, and Arthritis Research Canada; L. Eder, MD, PhD, University of Toronto, Institute of Health Policy, Management and Evaluation, and Women's College Research Institute; B. Kuriya, MD, FRCPC, SM, Sinai Health System, University of Toronto; V. Ling, MSc, ICES; J.M. Paterson, MSc, University of Toronto, Institute of Health Policy, Management and Evaluation, and ICES, and McMaster University, Department of Family Medicine; J.C. Thorne, MD, FRCPC, Southlake Regional Health Centre
| | - Janet E Pope
- From Sunnybrook Research Institute, Holland Bone and Joint Program; University of Toronto, Institute of Health Policy, Management and Evaluation; ICES; Arthritis Research Canada; Women's College Research Institute; Sinai Health System, University of Toronto, Toronto, Ontario; McGill University, Department of Epidemiology; Research Institute of the McGill University Health Centre, Montreal, Quebec; William Osler Health System, Brampton, Ontario; The Cumming School of Medicine, University of Calgary, Calgary, Alberta; McMaster University, Department of Family Medicine, Hamilton; Western University, Schulich School of Medicine & Dentistry; St. Joseph's Health Care London, London, Ontario; Southlake Regional Health Centre, Newmarket, Ontario, Canada.,J. Widdifield, PhD, Sunnybrook Research Institute, Holland Bone and Joint Program, and University of Toronto, Institute of Health Policy, Management and Evaluation, and ICES; S. Bernatsky, MD, FRCPC, PhD, McGill University, Department of Epidemiology, and Research Institute of the McGill University Health Centre; J.E. Pope, MD, FRCPC, MPH, Western University, Schulich School of Medicine & Dentistry, and St. Joseph's Health Care London; V. Ahluwalia, MD, FRCPC, William Osler Health System; C.E. Barber, MD, FRCPC, PhD, The Cumming School of Medicine, University of Calgary, and Arthritis Research Canada; L. Eder, MD, PhD, University of Toronto, Institute of Health Policy, Management and Evaluation, and Women's College Research Institute; B. Kuriya, MD, FRCPC, SM, Sinai Health System, University of Toronto; V. Ling, MSc, ICES; J.M. Paterson, MSc, University of Toronto, Institute of Health Policy, Management and Evaluation, and ICES, and McMaster University, Department of Family Medicine; J.C. Thorne, MD, FRCPC, Southlake Regional Health Centre
| | - Vandana Ahluwalia
- From Sunnybrook Research Institute, Holland Bone and Joint Program; University of Toronto, Institute of Health Policy, Management and Evaluation; ICES; Arthritis Research Canada; Women's College Research Institute; Sinai Health System, University of Toronto, Toronto, Ontario; McGill University, Department of Epidemiology; Research Institute of the McGill University Health Centre, Montreal, Quebec; William Osler Health System, Brampton, Ontario; The Cumming School of Medicine, University of Calgary, Calgary, Alberta; McMaster University, Department of Family Medicine, Hamilton; Western University, Schulich School of Medicine & Dentistry; St. Joseph's Health Care London, London, Ontario; Southlake Regional Health Centre, Newmarket, Ontario, Canada.,J. Widdifield, PhD, Sunnybrook Research Institute, Holland Bone and Joint Program, and University of Toronto, Institute of Health Policy, Management and Evaluation, and ICES; S. Bernatsky, MD, FRCPC, PhD, McGill University, Department of Epidemiology, and Research Institute of the McGill University Health Centre; J.E. Pope, MD, FRCPC, MPH, Western University, Schulich School of Medicine & Dentistry, and St. Joseph's Health Care London; V. Ahluwalia, MD, FRCPC, William Osler Health System; C.E. Barber, MD, FRCPC, PhD, The Cumming School of Medicine, University of Calgary, and Arthritis Research Canada; L. Eder, MD, PhD, University of Toronto, Institute of Health Policy, Management and Evaluation, and Women's College Research Institute; B. Kuriya, MD, FRCPC, SM, Sinai Health System, University of Toronto; V. Ling, MSc, ICES; J.M. Paterson, MSc, University of Toronto, Institute of Health Policy, Management and Evaluation, and ICES, and McMaster University, Department of Family Medicine; J.C. Thorne, MD, FRCPC, Southlake Regional Health Centre
| | - Claire E H Barber
- From Sunnybrook Research Institute, Holland Bone and Joint Program; University of Toronto, Institute of Health Policy, Management and Evaluation; ICES; Arthritis Research Canada; Women's College Research Institute; Sinai Health System, University of Toronto, Toronto, Ontario; McGill University, Department of Epidemiology; Research Institute of the McGill University Health Centre, Montreal, Quebec; William Osler Health System, Brampton, Ontario; The Cumming School of Medicine, University of Calgary, Calgary, Alberta; McMaster University, Department of Family Medicine, Hamilton; Western University, Schulich School of Medicine & Dentistry; St. Joseph's Health Care London, London, Ontario; Southlake Regional Health Centre, Newmarket, Ontario, Canada.,J. Widdifield, PhD, Sunnybrook Research Institute, Holland Bone and Joint Program, and University of Toronto, Institute of Health Policy, Management and Evaluation, and ICES; S. Bernatsky, MD, FRCPC, PhD, McGill University, Department of Epidemiology, and Research Institute of the McGill University Health Centre; J.E. Pope, MD, FRCPC, MPH, Western University, Schulich School of Medicine & Dentistry, and St. Joseph's Health Care London; V. Ahluwalia, MD, FRCPC, William Osler Health System; C.E. Barber, MD, FRCPC, PhD, The Cumming School of Medicine, University of Calgary, and Arthritis Research Canada; L. Eder, MD, PhD, University of Toronto, Institute of Health Policy, Management and Evaluation, and Women's College Research Institute; B. Kuriya, MD, FRCPC, SM, Sinai Health System, University of Toronto; V. Ling, MSc, ICES; J.M. Paterson, MSc, University of Toronto, Institute of Health Policy, Management and Evaluation, and ICES, and McMaster University, Department of Family Medicine; J.C. Thorne, MD, FRCPC, Southlake Regional Health Centre
| | - Lihi Eder
- From Sunnybrook Research Institute, Holland Bone and Joint Program; University of Toronto, Institute of Health Policy, Management and Evaluation; ICES; Arthritis Research Canada; Women's College Research Institute; Sinai Health System, University of Toronto, Toronto, Ontario; McGill University, Department of Epidemiology; Research Institute of the McGill University Health Centre, Montreal, Quebec; William Osler Health System, Brampton, Ontario; The Cumming School of Medicine, University of Calgary, Calgary, Alberta; McMaster University, Department of Family Medicine, Hamilton; Western University, Schulich School of Medicine & Dentistry; St. Joseph's Health Care London, London, Ontario; Southlake Regional Health Centre, Newmarket, Ontario, Canada.,J. Widdifield, PhD, Sunnybrook Research Institute, Holland Bone and Joint Program, and University of Toronto, Institute of Health Policy, Management and Evaluation, and ICES; S. Bernatsky, MD, FRCPC, PhD, McGill University, Department of Epidemiology, and Research Institute of the McGill University Health Centre; J.E. Pope, MD, FRCPC, MPH, Western University, Schulich School of Medicine & Dentistry, and St. Joseph's Health Care London; V. Ahluwalia, MD, FRCPC, William Osler Health System; C.E. Barber, MD, FRCPC, PhD, The Cumming School of Medicine, University of Calgary, and Arthritis Research Canada; L. Eder, MD, PhD, University of Toronto, Institute of Health Policy, Management and Evaluation, and Women's College Research Institute; B. Kuriya, MD, FRCPC, SM, Sinai Health System, University of Toronto; V. Ling, MSc, ICES; J.M. Paterson, MSc, University of Toronto, Institute of Health Policy, Management and Evaluation, and ICES, and McMaster University, Department of Family Medicine; J.C. Thorne, MD, FRCPC, Southlake Regional Health Centre
| | - Bindee Kuriya
- From Sunnybrook Research Institute, Holland Bone and Joint Program; University of Toronto, Institute of Health Policy, Management and Evaluation; ICES; Arthritis Research Canada; Women's College Research Institute; Sinai Health System, University of Toronto, Toronto, Ontario; McGill University, Department of Epidemiology; Research Institute of the McGill University Health Centre, Montreal, Quebec; William Osler Health System, Brampton, Ontario; The Cumming School of Medicine, University of Calgary, Calgary, Alberta; McMaster University, Department of Family Medicine, Hamilton; Western University, Schulich School of Medicine & Dentistry; St. Joseph's Health Care London, London, Ontario; Southlake Regional Health Centre, Newmarket, Ontario, Canada.,J. Widdifield, PhD, Sunnybrook Research Institute, Holland Bone and Joint Program, and University of Toronto, Institute of Health Policy, Management and Evaluation, and ICES; S. Bernatsky, MD, FRCPC, PhD, McGill University, Department of Epidemiology, and Research Institute of the McGill University Health Centre; J.E. Pope, MD, FRCPC, MPH, Western University, Schulich School of Medicine & Dentistry, and St. Joseph's Health Care London; V. Ahluwalia, MD, FRCPC, William Osler Health System; C.E. Barber, MD, FRCPC, PhD, The Cumming School of Medicine, University of Calgary, and Arthritis Research Canada; L. Eder, MD, PhD, University of Toronto, Institute of Health Policy, Management and Evaluation, and Women's College Research Institute; B. Kuriya, MD, FRCPC, SM, Sinai Health System, University of Toronto; V. Ling, MSc, ICES; J.M. Paterson, MSc, University of Toronto, Institute of Health Policy, Management and Evaluation, and ICES, and McMaster University, Department of Family Medicine; J.C. Thorne, MD, FRCPC, Southlake Regional Health Centre
| | - Vicki Ling
- From Sunnybrook Research Institute, Holland Bone and Joint Program; University of Toronto, Institute of Health Policy, Management and Evaluation; ICES; Arthritis Research Canada; Women's College Research Institute; Sinai Health System, University of Toronto, Toronto, Ontario; McGill University, Department of Epidemiology; Research Institute of the McGill University Health Centre, Montreal, Quebec; William Osler Health System, Brampton, Ontario; The Cumming School of Medicine, University of Calgary, Calgary, Alberta; McMaster University, Department of Family Medicine, Hamilton; Western University, Schulich School of Medicine & Dentistry; St. Joseph's Health Care London, London, Ontario; Southlake Regional Health Centre, Newmarket, Ontario, Canada.,J. Widdifield, PhD, Sunnybrook Research Institute, Holland Bone and Joint Program, and University of Toronto, Institute of Health Policy, Management and Evaluation, and ICES; S. Bernatsky, MD, FRCPC, PhD, McGill University, Department of Epidemiology, and Research Institute of the McGill University Health Centre; J.E. Pope, MD, FRCPC, MPH, Western University, Schulich School of Medicine & Dentistry, and St. Joseph's Health Care London; V. Ahluwalia, MD, FRCPC, William Osler Health System; C.E. Barber, MD, FRCPC, PhD, The Cumming School of Medicine, University of Calgary, and Arthritis Research Canada; L. Eder, MD, PhD, University of Toronto, Institute of Health Policy, Management and Evaluation, and Women's College Research Institute; B. Kuriya, MD, FRCPC, SM, Sinai Health System, University of Toronto; V. Ling, MSc, ICES; J.M. Paterson, MSc, University of Toronto, Institute of Health Policy, Management and Evaluation, and ICES, and McMaster University, Department of Family Medicine; J.C. Thorne, MD, FRCPC, Southlake Regional Health Centre
| | - J Michael Paterson
- From Sunnybrook Research Institute, Holland Bone and Joint Program; University of Toronto, Institute of Health Policy, Management and Evaluation; ICES; Arthritis Research Canada; Women's College Research Institute; Sinai Health System, University of Toronto, Toronto, Ontario; McGill University, Department of Epidemiology; Research Institute of the McGill University Health Centre, Montreal, Quebec; William Osler Health System, Brampton, Ontario; The Cumming School of Medicine, University of Calgary, Calgary, Alberta; McMaster University, Department of Family Medicine, Hamilton; Western University, Schulich School of Medicine & Dentistry; St. Joseph's Health Care London, London, Ontario; Southlake Regional Health Centre, Newmarket, Ontario, Canada.,J. Widdifield, PhD, Sunnybrook Research Institute, Holland Bone and Joint Program, and University of Toronto, Institute of Health Policy, Management and Evaluation, and ICES; S. Bernatsky, MD, FRCPC, PhD, McGill University, Department of Epidemiology, and Research Institute of the McGill University Health Centre; J.E. Pope, MD, FRCPC, MPH, Western University, Schulich School of Medicine & Dentistry, and St. Joseph's Health Care London; V. Ahluwalia, MD, FRCPC, William Osler Health System; C.E. Barber, MD, FRCPC, PhD, The Cumming School of Medicine, University of Calgary, and Arthritis Research Canada; L. Eder, MD, PhD, University of Toronto, Institute of Health Policy, Management and Evaluation, and Women's College Research Institute; B. Kuriya, MD, FRCPC, SM, Sinai Health System, University of Toronto; V. Ling, MSc, ICES; J.M. Paterson, MSc, University of Toronto, Institute of Health Policy, Management and Evaluation, and ICES, and McMaster University, Department of Family Medicine; J.C. Thorne, MD, FRCPC, Southlake Regional Health Centre
| | - J Carter Thorne
- From Sunnybrook Research Institute, Holland Bone and Joint Program; University of Toronto, Institute of Health Policy, Management and Evaluation; ICES; Arthritis Research Canada; Women's College Research Institute; Sinai Health System, University of Toronto, Toronto, Ontario; McGill University, Department of Epidemiology; Research Institute of the McGill University Health Centre, Montreal, Quebec; William Osler Health System, Brampton, Ontario; The Cumming School of Medicine, University of Calgary, Calgary, Alberta; McMaster University, Department of Family Medicine, Hamilton; Western University, Schulich School of Medicine & Dentistry; St. Joseph's Health Care London, London, Ontario; Southlake Regional Health Centre, Newmarket, Ontario, Canada.,J. Widdifield, PhD, Sunnybrook Research Institute, Holland Bone and Joint Program, and University of Toronto, Institute of Health Policy, Management and Evaluation, and ICES; S. Bernatsky, MD, FRCPC, PhD, McGill University, Department of Epidemiology, and Research Institute of the McGill University Health Centre; J.E. Pope, MD, FRCPC, MPH, Western University, Schulich School of Medicine & Dentistry, and St. Joseph's Health Care London; V. Ahluwalia, MD, FRCPC, William Osler Health System; C.E. Barber, MD, FRCPC, PhD, The Cumming School of Medicine, University of Calgary, and Arthritis Research Canada; L. Eder, MD, PhD, University of Toronto, Institute of Health Policy, Management and Evaluation, and Women's College Research Institute; B. Kuriya, MD, FRCPC, SM, Sinai Health System, University of Toronto; V. Ling, MSc, ICES; J.M. Paterson, MSc, University of Toronto, Institute of Health Policy, Management and Evaluation, and ICES, and McMaster University, Department of Family Medicine; J.C. Thorne, MD, FRCPC, Southlake Regional Health Centre
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Ahluwalia V, Lineker S, Sweezie R, Bell MJ, Kendzerska T, Widdifield J, Bombardier C. The Effect of Triage Assessments on Identifying Inflammatory Arthritis and Reducing Rheumatology Wait Times in Ontario. J Rheumatol 2019; 47:461-467. [PMID: 31154411 DOI: 10.3899/jrheum.180734] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We evaluated the influence of triage assessments by extended role practitioners (ERP) on improving timeliness of rheumatology consultations for patients with suspected inflammatory arthritis (IA) or systemic autoimmune rheumatic diseases (SARD). METHODS Rheumatologists reviewed primary care providers' referrals and identified patients with inadequate referral information, so that a decision about priority could not be made. Patients were assessed by an ERP to identify those with IA/SARD requiring an expedited rheumatologist consult. The time from referral to the first consultation was determined comparing patients who were expedited to those who were not, and to similar patients in a usual care control group identified through retrospective chart review. RESULTS Seven rheumatologists from 5 communities participated in the study. Among 177 patients who received an ERP triage assessment, 75 patients were expedited and 102 were not. Expedited patients had a significantly shorter median (interquartile range) wait time to rheumatologist consult: 37.0 (24.5-55.5) days compared to non-expedited patients [105 (71.0-135.0) days] and controls [58.0 (24.0-104.0) days]. Accuracy comparing the ERP identification of IA/SARD to that of the rheumatologists was fair (κ 0.39, 95% CI 0.25-0.53). CONCLUSION Patients triaged and expedited by ERP experienced shorter wait times compared to usual care; however, some patients with IA/SARD were missed and waited longer. Our findings suggest that ERP working in a triage role can improve access to care for those patients correctly identified with IA/SARD. Further research needs to identify an ongoing ERP educational process to ensure the success of the model.
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Affiliation(s)
- Vandana Ahluwalia
- From the Ontario (Canada) Rheumatology Association, Ontario Best Practices Research Initiative, and the Arthritis Society. .,V. Ahluwalia, MD, FRCPC, William Osler Health System; S. Lineker, PhD, Arthritis Society; R. Sweezie, PhD, Arthritis Society; M.J. Bell, MD, FRCPC, Sunnybrook Health Sciences Centre; T. Kendzerska, MD, PhD, The Ottawa Hospital Research Institute, University of Ottawa; J. Widdifield, PhD, Sunnybrook Research Institute, Institute for Clinical Evaluative Sciences, Institute of Health Policy, Management and Evaluation, University of Toronto; C. Bombardier, MD, FRCPC, University of Toronto.
| | - Sydney Lineker
- From the Ontario (Canada) Rheumatology Association, Ontario Best Practices Research Initiative, and the Arthritis Society.,V. Ahluwalia, MD, FRCPC, William Osler Health System; S. Lineker, PhD, Arthritis Society; R. Sweezie, PhD, Arthritis Society; M.J. Bell, MD, FRCPC, Sunnybrook Health Sciences Centre; T. Kendzerska, MD, PhD, The Ottawa Hospital Research Institute, University of Ottawa; J. Widdifield, PhD, Sunnybrook Research Institute, Institute for Clinical Evaluative Sciences, Institute of Health Policy, Management and Evaluation, University of Toronto; C. Bombardier, MD, FRCPC, University of Toronto
| | - Raquel Sweezie
- From the Ontario (Canada) Rheumatology Association, Ontario Best Practices Research Initiative, and the Arthritis Society.,V. Ahluwalia, MD, FRCPC, William Osler Health System; S. Lineker, PhD, Arthritis Society; R. Sweezie, PhD, Arthritis Society; M.J. Bell, MD, FRCPC, Sunnybrook Health Sciences Centre; T. Kendzerska, MD, PhD, The Ottawa Hospital Research Institute, University of Ottawa; J. Widdifield, PhD, Sunnybrook Research Institute, Institute for Clinical Evaluative Sciences, Institute of Health Policy, Management and Evaluation, University of Toronto; C. Bombardier, MD, FRCPC, University of Toronto
| | - Mary J Bell
- From the Ontario (Canada) Rheumatology Association, Ontario Best Practices Research Initiative, and the Arthritis Society.,V. Ahluwalia, MD, FRCPC, William Osler Health System; S. Lineker, PhD, Arthritis Society; R. Sweezie, PhD, Arthritis Society; M.J. Bell, MD, FRCPC, Sunnybrook Health Sciences Centre; T. Kendzerska, MD, PhD, The Ottawa Hospital Research Institute, University of Ottawa; J. Widdifield, PhD, Sunnybrook Research Institute, Institute for Clinical Evaluative Sciences, Institute of Health Policy, Management and Evaluation, University of Toronto; C. Bombardier, MD, FRCPC, University of Toronto
| | - Tetyana Kendzerska
- From the Ontario (Canada) Rheumatology Association, Ontario Best Practices Research Initiative, and the Arthritis Society.,V. Ahluwalia, MD, FRCPC, William Osler Health System; S. Lineker, PhD, Arthritis Society; R. Sweezie, PhD, Arthritis Society; M.J. Bell, MD, FRCPC, Sunnybrook Health Sciences Centre; T. Kendzerska, MD, PhD, The Ottawa Hospital Research Institute, University of Ottawa; J. Widdifield, PhD, Sunnybrook Research Institute, Institute for Clinical Evaluative Sciences, Institute of Health Policy, Management and Evaluation, University of Toronto; C. Bombardier, MD, FRCPC, University of Toronto
| | - Jessica Widdifield
- From the Ontario (Canada) Rheumatology Association, Ontario Best Practices Research Initiative, and the Arthritis Society.,V. Ahluwalia, MD, FRCPC, William Osler Health System; S. Lineker, PhD, Arthritis Society; R. Sweezie, PhD, Arthritis Society; M.J. Bell, MD, FRCPC, Sunnybrook Health Sciences Centre; T. Kendzerska, MD, PhD, The Ottawa Hospital Research Institute, University of Ottawa; J. Widdifield, PhD, Sunnybrook Research Institute, Institute for Clinical Evaluative Sciences, Institute of Health Policy, Management and Evaluation, University of Toronto; C. Bombardier, MD, FRCPC, University of Toronto
| | - Claire Bombardier
- From the Ontario (Canada) Rheumatology Association, Ontario Best Practices Research Initiative, and the Arthritis Society.,V. Ahluwalia, MD, FRCPC, William Osler Health System; S. Lineker, PhD, Arthritis Society; R. Sweezie, PhD, Arthritis Society; M.J. Bell, MD, FRCPC, Sunnybrook Health Sciences Centre; T. Kendzerska, MD, PhD, The Ottawa Hospital Research Institute, University of Ottawa; J. Widdifield, PhD, Sunnybrook Research Institute, Institute for Clinical Evaluative Sciences, Institute of Health Policy, Management and Evaluation, University of Toronto; C. Bombardier, MD, FRCPC, University of Toronto
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23
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Wong J, Tu K, Bernatsky S, Jaakkimainen L, Thorne JC, Ahluwalia V, Paterson JM, Widdifield J. Quality and continuity of information between primary care physicians and rheumatologists. BMC Rheumatol 2019; 3:1. [PMID: 31149655 PMCID: PMC6533707 DOI: 10.1186/s41927-019-0067-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 04/25/2019] [Indexed: 12/12/2022] Open
Abstract
Background Good communication is central to a high-quality consultation process. We assessed the quality of referral information from primary care physicians (PCPs) to rheumatologists and the quality and timeliness of consultation letters from rheumatologists back to PCPs. Methods We sampled referral letters between 2000 and 2013 from 168 PCPs and performed a retrospective chart review of 2430 patients referred to 146 rheumatologists. We assessed the completeness and timeliness of referral and consultation letters. Results Osteoarthritis (n = 787, 32%) and systemic inflammatory rheumatic diseases (n = 745, 31%) comprised the top reasons for referral. Only 55% of referral letters summarized the patients’ medical history. Referral letters provided some details of diagnostic tests (51% labs, 34% imaging) but there was underreporting of this information on referral letters. Almost all referral letters (92%) contained details of at least one patient symptom, with the most common complaint being joint pain (54%). Only half of all referral letters provided symptom duration. The PCP only stressed an urgent consultation among 211 patients (9%). Overall, 69% of consultation letters were returned to PCPs within 30 days of consultation visit. Conclusion We found that basic items necessary for appropriate triage, including a description of symptoms or other relevant history and results of investigations were often lacking in referral letters. The delay of receipt of consultation letters may further represent a lost opportunity for coordination and continuity of care, and may affect the quality of care patients receive.
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Affiliation(s)
- Jenna Wong
- 1Sunnybrook Research Institute, Holland Bone and Joint Research Program, Toronto, Ontario Canada
| | - Karen Tu
- 2Department of Family and Community Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario Canada
| | - Sasha Bernatsky
- 3McGill University, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Liisa Jaakkimainen
- 4Department of Family and Community Medicine, Institute of Health Policy, Management and Evaluation, ICES, University of Toronto, Toronto, Ontario Canada
| | - J Carter Thorne
- 5Southlake Regional Health Centre, Newmarket, Ontario Canada
| | - Vandana Ahluwalia
- 6William Olser Health System, Brampton Civic Hospital, Brampton, Ontario Canada
| | - J Michael Paterson
- 7Department of Family Medicine, McMaster University, Hamilton, Ontario Canada.,8Chronic Disease & Pharmacotherapy Program, ICES, Toronto, Ontario Canada.,9University of Toronto Institute of Health Policy, Management and Evaluation, MG 352 - 2075 Bayview Avenue, Toronto, Ontario M4N 3M5 Canada
| | - Jessica Widdifield
- 1Sunnybrook Research Institute, Holland Bone and Joint Research Program, Toronto, Ontario Canada.,8Chronic Disease & Pharmacotherapy Program, ICES, Toronto, Ontario Canada.,9University of Toronto Institute of Health Policy, Management and Evaluation, MG 352 - 2075 Bayview Avenue, Toronto, Ontario M4N 3M5 Canada
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24
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Ahluwalia V, Larsen TLH, Kennedy CA, Inrig T, Lundon K. An advanced clinician practitioner in arthritis care can improve access to rheumatology care in community-based practice. J Multidiscip Healthc 2019; 12:63-71. [PMID: 30662267 PMCID: PMC6327890 DOI: 10.2147/jmdh.s183397] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To facilitate access and improve wait times to a rheumatologist's consultation, this study aimed to 1) determine the ability of an advanced clinician practitioner in arthritis care (ACPAC)-trained extended role practitioner (ERP) to triage patients with suspected inflammatory arthritis (IA) for priority assessment by a rheumatologist and 2) determine the impact of an ERP on access-to-care as measured by time-to-rheumatologist-assessment and time-to-treatment-decision. MATERIALS AND METHODS A community-based ACPAC-trained ERP triaged new referrals for suspected IA. Patients with suspected IA were booked to see the rheumatologist on a priority basis. Diagnostic accuracy of the ERP to correctly identify priority patients; the level of agreement between ERP and rheumatologist (Kappa coefficient and percent agreement); and the time-to-treatment-decision for confirmed cases of IA were investigated. Retrospective chart review then compared time-to-rheumatologist-assessment and time-to-treatment-decision in the solo-rheumatologist versus the ERP-triage model. RESULTS One hundred twenty-one patients were triaged. The ERP designated 54 patients for priority assessment. The rheumatologist confirmed IA in 49/54 (90.7% positive predictive value [PPV]). Of the 121 patients, 67 patients were designated as nonpriority by the ERP, and none were determined to have IA by the rheumatologist (100% negative predictive value [NPV]). Excellent agreement was found between the ERP and the rheumatologist (Kappa coefficient 0.92, 95% CI: 0.84-0.99). In the ERP-triage model, time-from-referral-to-treatment-decision for patients with IA was 73.7 days (SD 40.4, range 12-183) compared with 124.6 days (SD 61.7, range 26-359) in the solo-rheumatologist model (40% reduction in time-to-treatment-decision). CONCLUSION A well-trained and experienced ERP can shorten the time-to-Rheumatologist-assessment and time-to-treatment-decision for patients with suspected IA.
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Affiliation(s)
- Vandana Ahluwalia
- Division of Rheumatology, Department of Internal Medicine, William Osler Health System, Brampton, ON, Canada,
| | - Tiffany L H Larsen
- Department of Physiotherapy, Headwaters Health Care Center, Orangeville, ON, Canada
| | - Carol A Kennedy
- Musculoskeletal Health and Outcomes Research, St. Michael's Hospital, Toronto, ON, Canada
| | - Taucha Inrig
- Musculoskeletal Health and Outcomes Research, St. Michael's Hospital, Toronto, ON, Canada
| | - Katie Lundon
- Office of Continuing Professional Development and the Department of Medicine, Faculty of Medicine, University of Toronto, ON, Canada
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25
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Barber CEH, Mosher DP, Ahluwalia V, Zummer M, Marshall DA, Choquette D, Lacaille D, Bombardier C, Lyddiatt A, Chandran V, Khodyakov D, Dao E, Barnabe C. Development of a Canadian Core Clinical Dataset to Support High-quality Care for Canadian Patients with Rheumatoid Arthritis. J Rheumatol 2017; 44:1813-1822. [PMID: 28966205 DOI: 10.3899/jrheum.170421] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To develop a Canadian Rheumatoid Arthritis Core Clinical Dataset (CAN-RACCD) to standardize documentation encouraging high-quality care. METHODS A set of candidate elements was drafted through meetings with 27 rheumatologists, researchers, and patients, and supplemented with focused literature reviews. A 3-round online-modified Delphi consensus process was held with rheumatologists (n = 26), allied health professionals (n = 7), and patients (n = 4); for the remainder there was no demographic information. Participants rated both the importance and feasibility of documenting candidate elements on a Likert scale of 1-9, contributed to an online moderated discussion, and re-rated the elements for inclusion in the CAN-RACCD. Elements were included in the final set if importance and feasibility ratings had a median score of ≥ 6.5 and there was no disagreement among participants. RESULTS Fifty-five individual elements in 10 subgroups were proposed to the Delphi participants: measures of RA disease activity; dates to calculate waiting times, disease duration, and disease-modifying antirheumatic drug start; comorbidities; smoking status; patient-reported pain and fatigue; physical function; laboratory and radiographic investigations; medications; clinical characteristics; and vaccines. All groups were included in the final set, with the exception of vaccination status. Additionally, 3 individual elements from the smoking subgroup were eliminated with a recommendation to record smoking status as never/ever/current, and 2 elements relating to coping and effect of fatigue were eliminated due to low feasibility and importance ratings. CONCLUSION The CAN-RACCD stands as a national recommendation on which data elements should be routinely collected in clinical practice to monitor and support high-quality RA care.
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Affiliation(s)
- Claire E H Barber
- From the Division of Rheumatology, Department of Medicine, and the Department of Community Health Sciences of the Cumming School of Medicine, and the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta; Arthritis Research Canada, Richmond; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, and the Department of Medicine and Laboratory Medicine and Pathobiology, and the Institute of Medical Science, and the Krembil Research Institute, University of Toronto, Toronto; Arthritis Alliance of Canada (AAC) Inflammatory Arthritis Models of Care, Toronto; William Osler Health System, Brampton; Canadian Institute of Health Research (CIHR) National Steering Committee, Ottawa; Outcome Measures in Rheumatology (OMERACT), Ottawa, Ontario; Hôpital Maisonneuve-Rosemont, and the Institut de Recherche en Rhumatologie de Montréal, Université de Montréal, Montreal, Quebec, Canada; RAND Corp., Santa Monica, California, USA. .,C.E. Barber, MD, FRCPC, PhD, Assistant Professor, Division of Rheumatology, departments of Medicine and Community Health Sciences, University of Calgary, Cumming School of Medicine, McCaig Institute for Bone and Joint Health, Research Scientist, Arthritis Research Canada; D.P. Mosher, MD, FRCPC, Professor, Chief, Division of Rheumatology, Department of Medicine, University of Calgary; V. Ahluwalia, MD, FRCPC, Consultant Rheumatologist, William Osler Health System; M. Zummer, MD, FRCPC, Chief, Rheumatology, Hôpital Maisonneuve-Rosemont, Associate Professor, Université de Montréal; D.A. Marshall, PhD, Professor, Department of Community Health Sciences, Cumming School of Medicine, Canada Research Chair (Health Services and Systems Research), Arthur J.E. Child Chair in Rheumatology Research, Department of Medicine, University of Calgary, McCaig Institute for Bone and Joint Health, and Arthritis Research Canada; D. Choquette, MD, FRCPC, Institut de Recherche en Rhumatologie de Montréal, Scientific Director, Rhumadata, Université de Montréal; D. Lacaille, MD, FRCPC, MHSc, Professor, Division of Rheumatology, Department of Medicine, University of British Columbia, Senior Scientist, Arthritis Research Canada; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology, University of Toronto; A. Lyddiatt, member, CIHR National Steering Committee, OMERACT patient research partner, AAC Inflammatory Arthritis Models of Care Executive Member; V. Chandran, MBBS, MD, DM, PhD, Assistant Professor, Department of Medicine and Laboratory Medicine and Pathobiology, Institute of Medical Science, Krembil Research Institute; D. Khodyakov, PhD, MA, BA, Senior Behavioral/Social Scientist, RAND Corp.; E. Dao, BS, RAND Corp.; C. Barnabe, MD, MSc, FRCPC, Associate Professor, departments of Medicine and Community Health Sciences, University of Calgary.
| | - Dianne P Mosher
- From the Division of Rheumatology, Department of Medicine, and the Department of Community Health Sciences of the Cumming School of Medicine, and the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta; Arthritis Research Canada, Richmond; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, and the Department of Medicine and Laboratory Medicine and Pathobiology, and the Institute of Medical Science, and the Krembil Research Institute, University of Toronto, Toronto; Arthritis Alliance of Canada (AAC) Inflammatory Arthritis Models of Care, Toronto; William Osler Health System, Brampton; Canadian Institute of Health Research (CIHR) National Steering Committee, Ottawa; Outcome Measures in Rheumatology (OMERACT), Ottawa, Ontario; Hôpital Maisonneuve-Rosemont, and the Institut de Recherche en Rhumatologie de Montréal, Université de Montréal, Montreal, Quebec, Canada; RAND Corp., Santa Monica, California, USA.,C.E. Barber, MD, FRCPC, PhD, Assistant Professor, Division of Rheumatology, departments of Medicine and Community Health Sciences, University of Calgary, Cumming School of Medicine, McCaig Institute for Bone and Joint Health, Research Scientist, Arthritis Research Canada; D.P. Mosher, MD, FRCPC, Professor, Chief, Division of Rheumatology, Department of Medicine, University of Calgary; V. Ahluwalia, MD, FRCPC, Consultant Rheumatologist, William Osler Health System; M. Zummer, MD, FRCPC, Chief, Rheumatology, Hôpital Maisonneuve-Rosemont, Associate Professor, Université de Montréal; D.A. Marshall, PhD, Professor, Department of Community Health Sciences, Cumming School of Medicine, Canada Research Chair (Health Services and Systems Research), Arthur J.E. Child Chair in Rheumatology Research, Department of Medicine, University of Calgary, McCaig Institute for Bone and Joint Health, and Arthritis Research Canada; D. Choquette, MD, FRCPC, Institut de Recherche en Rhumatologie de Montréal, Scientific Director, Rhumadata, Université de Montréal; D. Lacaille, MD, FRCPC, MHSc, Professor, Division of Rheumatology, Department of Medicine, University of British Columbia, Senior Scientist, Arthritis Research Canada; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology, University of Toronto; A. Lyddiatt, member, CIHR National Steering Committee, OMERACT patient research partner, AAC Inflammatory Arthritis Models of Care Executive Member; V. Chandran, MBBS, MD, DM, PhD, Assistant Professor, Department of Medicine and Laboratory Medicine and Pathobiology, Institute of Medical Science, Krembil Research Institute; D. Khodyakov, PhD, MA, BA, Senior Behavioral/Social Scientist, RAND Corp.; E. Dao, BS, RAND Corp.; C. Barnabe, MD, MSc, FRCPC, Associate Professor, departments of Medicine and Community Health Sciences, University of Calgary
| | - Vandana Ahluwalia
- From the Division of Rheumatology, Department of Medicine, and the Department of Community Health Sciences of the Cumming School of Medicine, and the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta; Arthritis Research Canada, Richmond; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, and the Department of Medicine and Laboratory Medicine and Pathobiology, and the Institute of Medical Science, and the Krembil Research Institute, University of Toronto, Toronto; Arthritis Alliance of Canada (AAC) Inflammatory Arthritis Models of Care, Toronto; William Osler Health System, Brampton; Canadian Institute of Health Research (CIHR) National Steering Committee, Ottawa; Outcome Measures in Rheumatology (OMERACT), Ottawa, Ontario; Hôpital Maisonneuve-Rosemont, and the Institut de Recherche en Rhumatologie de Montréal, Université de Montréal, Montreal, Quebec, Canada; RAND Corp., Santa Monica, California, USA.,C.E. Barber, MD, FRCPC, PhD, Assistant Professor, Division of Rheumatology, departments of Medicine and Community Health Sciences, University of Calgary, Cumming School of Medicine, McCaig Institute for Bone and Joint Health, Research Scientist, Arthritis Research Canada; D.P. Mosher, MD, FRCPC, Professor, Chief, Division of Rheumatology, Department of Medicine, University of Calgary; V. Ahluwalia, MD, FRCPC, Consultant Rheumatologist, William Osler Health System; M. Zummer, MD, FRCPC, Chief, Rheumatology, Hôpital Maisonneuve-Rosemont, Associate Professor, Université de Montréal; D.A. Marshall, PhD, Professor, Department of Community Health Sciences, Cumming School of Medicine, Canada Research Chair (Health Services and Systems Research), Arthur J.E. Child Chair in Rheumatology Research, Department of Medicine, University of Calgary, McCaig Institute for Bone and Joint Health, and Arthritis Research Canada; D. Choquette, MD, FRCPC, Institut de Recherche en Rhumatologie de Montréal, Scientific Director, Rhumadata, Université de Montréal; D. Lacaille, MD, FRCPC, MHSc, Professor, Division of Rheumatology, Department of Medicine, University of British Columbia, Senior Scientist, Arthritis Research Canada; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology, University of Toronto; A. Lyddiatt, member, CIHR National Steering Committee, OMERACT patient research partner, AAC Inflammatory Arthritis Models of Care Executive Member; V. Chandran, MBBS, MD, DM, PhD, Assistant Professor, Department of Medicine and Laboratory Medicine and Pathobiology, Institute of Medical Science, Krembil Research Institute; D. Khodyakov, PhD, MA, BA, Senior Behavioral/Social Scientist, RAND Corp.; E. Dao, BS, RAND Corp.; C. Barnabe, MD, MSc, FRCPC, Associate Professor, departments of Medicine and Community Health Sciences, University of Calgary
| | - Michel Zummer
- From the Division of Rheumatology, Department of Medicine, and the Department of Community Health Sciences of the Cumming School of Medicine, and the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta; Arthritis Research Canada, Richmond; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, and the Department of Medicine and Laboratory Medicine and Pathobiology, and the Institute of Medical Science, and the Krembil Research Institute, University of Toronto, Toronto; Arthritis Alliance of Canada (AAC) Inflammatory Arthritis Models of Care, Toronto; William Osler Health System, Brampton; Canadian Institute of Health Research (CIHR) National Steering Committee, Ottawa; Outcome Measures in Rheumatology (OMERACT), Ottawa, Ontario; Hôpital Maisonneuve-Rosemont, and the Institut de Recherche en Rhumatologie de Montréal, Université de Montréal, Montreal, Quebec, Canada; RAND Corp., Santa Monica, California, USA.,C.E. Barber, MD, FRCPC, PhD, Assistant Professor, Division of Rheumatology, departments of Medicine and Community Health Sciences, University of Calgary, Cumming School of Medicine, McCaig Institute for Bone and Joint Health, Research Scientist, Arthritis Research Canada; D.P. Mosher, MD, FRCPC, Professor, Chief, Division of Rheumatology, Department of Medicine, University of Calgary; V. Ahluwalia, MD, FRCPC, Consultant Rheumatologist, William Osler Health System; M. Zummer, MD, FRCPC, Chief, Rheumatology, Hôpital Maisonneuve-Rosemont, Associate Professor, Université de Montréal; D.A. Marshall, PhD, Professor, Department of Community Health Sciences, Cumming School of Medicine, Canada Research Chair (Health Services and Systems Research), Arthur J.E. Child Chair in Rheumatology Research, Department of Medicine, University of Calgary, McCaig Institute for Bone and Joint Health, and Arthritis Research Canada; D. Choquette, MD, FRCPC, Institut de Recherche en Rhumatologie de Montréal, Scientific Director, Rhumadata, Université de Montréal; D. Lacaille, MD, FRCPC, MHSc, Professor, Division of Rheumatology, Department of Medicine, University of British Columbia, Senior Scientist, Arthritis Research Canada; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology, University of Toronto; A. Lyddiatt, member, CIHR National Steering Committee, OMERACT patient research partner, AAC Inflammatory Arthritis Models of Care Executive Member; V. Chandran, MBBS, MD, DM, PhD, Assistant Professor, Department of Medicine and Laboratory Medicine and Pathobiology, Institute of Medical Science, Krembil Research Institute; D. Khodyakov, PhD, MA, BA, Senior Behavioral/Social Scientist, RAND Corp.; E. Dao, BS, RAND Corp.; C. Barnabe, MD, MSc, FRCPC, Associate Professor, departments of Medicine and Community Health Sciences, University of Calgary
| | - Deborah A Marshall
- From the Division of Rheumatology, Department of Medicine, and the Department of Community Health Sciences of the Cumming School of Medicine, and the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta; Arthritis Research Canada, Richmond; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, and the Department of Medicine and Laboratory Medicine and Pathobiology, and the Institute of Medical Science, and the Krembil Research Institute, University of Toronto, Toronto; Arthritis Alliance of Canada (AAC) Inflammatory Arthritis Models of Care, Toronto; William Osler Health System, Brampton; Canadian Institute of Health Research (CIHR) National Steering Committee, Ottawa; Outcome Measures in Rheumatology (OMERACT), Ottawa, Ontario; Hôpital Maisonneuve-Rosemont, and the Institut de Recherche en Rhumatologie de Montréal, Université de Montréal, Montreal, Quebec, Canada; RAND Corp., Santa Monica, California, USA.,C.E. Barber, MD, FRCPC, PhD, Assistant Professor, Division of Rheumatology, departments of Medicine and Community Health Sciences, University of Calgary, Cumming School of Medicine, McCaig Institute for Bone and Joint Health, Research Scientist, Arthritis Research Canada; D.P. Mosher, MD, FRCPC, Professor, Chief, Division of Rheumatology, Department of Medicine, University of Calgary; V. Ahluwalia, MD, FRCPC, Consultant Rheumatologist, William Osler Health System; M. Zummer, MD, FRCPC, Chief, Rheumatology, Hôpital Maisonneuve-Rosemont, Associate Professor, Université de Montréal; D.A. Marshall, PhD, Professor, Department of Community Health Sciences, Cumming School of Medicine, Canada Research Chair (Health Services and Systems Research), Arthur J.E. Child Chair in Rheumatology Research, Department of Medicine, University of Calgary, McCaig Institute for Bone and Joint Health, and Arthritis Research Canada; D. Choquette, MD, FRCPC, Institut de Recherche en Rhumatologie de Montréal, Scientific Director, Rhumadata, Université de Montréal; D. Lacaille, MD, FRCPC, MHSc, Professor, Division of Rheumatology, Department of Medicine, University of British Columbia, Senior Scientist, Arthritis Research Canada; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology, University of Toronto; A. Lyddiatt, member, CIHR National Steering Committee, OMERACT patient research partner, AAC Inflammatory Arthritis Models of Care Executive Member; V. Chandran, MBBS, MD, DM, PhD, Assistant Professor, Department of Medicine and Laboratory Medicine and Pathobiology, Institute of Medical Science, Krembil Research Institute; D. Khodyakov, PhD, MA, BA, Senior Behavioral/Social Scientist, RAND Corp.; E. Dao, BS, RAND Corp.; C. Barnabe, MD, MSc, FRCPC, Associate Professor, departments of Medicine and Community Health Sciences, University of Calgary
| | - Denis Choquette
- From the Division of Rheumatology, Department of Medicine, and the Department of Community Health Sciences of the Cumming School of Medicine, and the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta; Arthritis Research Canada, Richmond; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, and the Department of Medicine and Laboratory Medicine and Pathobiology, and the Institute of Medical Science, and the Krembil Research Institute, University of Toronto, Toronto; Arthritis Alliance of Canada (AAC) Inflammatory Arthritis Models of Care, Toronto; William Osler Health System, Brampton; Canadian Institute of Health Research (CIHR) National Steering Committee, Ottawa; Outcome Measures in Rheumatology (OMERACT), Ottawa, Ontario; Hôpital Maisonneuve-Rosemont, and the Institut de Recherche en Rhumatologie de Montréal, Université de Montréal, Montreal, Quebec, Canada; RAND Corp., Santa Monica, California, USA.,C.E. Barber, MD, FRCPC, PhD, Assistant Professor, Division of Rheumatology, departments of Medicine and Community Health Sciences, University of Calgary, Cumming School of Medicine, McCaig Institute for Bone and Joint Health, Research Scientist, Arthritis Research Canada; D.P. Mosher, MD, FRCPC, Professor, Chief, Division of Rheumatology, Department of Medicine, University of Calgary; V. Ahluwalia, MD, FRCPC, Consultant Rheumatologist, William Osler Health System; M. Zummer, MD, FRCPC, Chief, Rheumatology, Hôpital Maisonneuve-Rosemont, Associate Professor, Université de Montréal; D.A. Marshall, PhD, Professor, Department of Community Health Sciences, Cumming School of Medicine, Canada Research Chair (Health Services and Systems Research), Arthur J.E. Child Chair in Rheumatology Research, Department of Medicine, University of Calgary, McCaig Institute for Bone and Joint Health, and Arthritis Research Canada; D. Choquette, MD, FRCPC, Institut de Recherche en Rhumatologie de Montréal, Scientific Director, Rhumadata, Université de Montréal; D. Lacaille, MD, FRCPC, MHSc, Professor, Division of Rheumatology, Department of Medicine, University of British Columbia, Senior Scientist, Arthritis Research Canada; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology, University of Toronto; A. Lyddiatt, member, CIHR National Steering Committee, OMERACT patient research partner, AAC Inflammatory Arthritis Models of Care Executive Member; V. Chandran, MBBS, MD, DM, PhD, Assistant Professor, Department of Medicine and Laboratory Medicine and Pathobiology, Institute of Medical Science, Krembil Research Institute; D. Khodyakov, PhD, MA, BA, Senior Behavioral/Social Scientist, RAND Corp.; E. Dao, BS, RAND Corp.; C. Barnabe, MD, MSc, FRCPC, Associate Professor, departments of Medicine and Community Health Sciences, University of Calgary
| | - Diane Lacaille
- From the Division of Rheumatology, Department of Medicine, and the Department of Community Health Sciences of the Cumming School of Medicine, and the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta; Arthritis Research Canada, Richmond; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, and the Department of Medicine and Laboratory Medicine and Pathobiology, and the Institute of Medical Science, and the Krembil Research Institute, University of Toronto, Toronto; Arthritis Alliance of Canada (AAC) Inflammatory Arthritis Models of Care, Toronto; William Osler Health System, Brampton; Canadian Institute of Health Research (CIHR) National Steering Committee, Ottawa; Outcome Measures in Rheumatology (OMERACT), Ottawa, Ontario; Hôpital Maisonneuve-Rosemont, and the Institut de Recherche en Rhumatologie de Montréal, Université de Montréal, Montreal, Quebec, Canada; RAND Corp., Santa Monica, California, USA.,C.E. Barber, MD, FRCPC, PhD, Assistant Professor, Division of Rheumatology, departments of Medicine and Community Health Sciences, University of Calgary, Cumming School of Medicine, McCaig Institute for Bone and Joint Health, Research Scientist, Arthritis Research Canada; D.P. Mosher, MD, FRCPC, Professor, Chief, Division of Rheumatology, Department of Medicine, University of Calgary; V. Ahluwalia, MD, FRCPC, Consultant Rheumatologist, William Osler Health System; M. Zummer, MD, FRCPC, Chief, Rheumatology, Hôpital Maisonneuve-Rosemont, Associate Professor, Université de Montréal; D.A. Marshall, PhD, Professor, Department of Community Health Sciences, Cumming School of Medicine, Canada Research Chair (Health Services and Systems Research), Arthur J.E. Child Chair in Rheumatology Research, Department of Medicine, University of Calgary, McCaig Institute for Bone and Joint Health, and Arthritis Research Canada; D. Choquette, MD, FRCPC, Institut de Recherche en Rhumatologie de Montréal, Scientific Director, Rhumadata, Université de Montréal; D. Lacaille, MD, FRCPC, MHSc, Professor, Division of Rheumatology, Department of Medicine, University of British Columbia, Senior Scientist, Arthritis Research Canada; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology, University of Toronto; A. Lyddiatt, member, CIHR National Steering Committee, OMERACT patient research partner, AAC Inflammatory Arthritis Models of Care Executive Member; V. Chandran, MBBS, MD, DM, PhD, Assistant Professor, Department of Medicine and Laboratory Medicine and Pathobiology, Institute of Medical Science, Krembil Research Institute; D. Khodyakov, PhD, MA, BA, Senior Behavioral/Social Scientist, RAND Corp.; E. Dao, BS, RAND Corp.; C. Barnabe, MD, MSc, FRCPC, Associate Professor, departments of Medicine and Community Health Sciences, University of Calgary
| | - Claire Bombardier
- From the Division of Rheumatology, Department of Medicine, and the Department of Community Health Sciences of the Cumming School of Medicine, and the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta; Arthritis Research Canada, Richmond; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, and the Department of Medicine and Laboratory Medicine and Pathobiology, and the Institute of Medical Science, and the Krembil Research Institute, University of Toronto, Toronto; Arthritis Alliance of Canada (AAC) Inflammatory Arthritis Models of Care, Toronto; William Osler Health System, Brampton; Canadian Institute of Health Research (CIHR) National Steering Committee, Ottawa; Outcome Measures in Rheumatology (OMERACT), Ottawa, Ontario; Hôpital Maisonneuve-Rosemont, and the Institut de Recherche en Rhumatologie de Montréal, Université de Montréal, Montreal, Quebec, Canada; RAND Corp., Santa Monica, California, USA.,C.E. Barber, MD, FRCPC, PhD, Assistant Professor, Division of Rheumatology, departments of Medicine and Community Health Sciences, University of Calgary, Cumming School of Medicine, McCaig Institute for Bone and Joint Health, Research Scientist, Arthritis Research Canada; D.P. Mosher, MD, FRCPC, Professor, Chief, Division of Rheumatology, Department of Medicine, University of Calgary; V. Ahluwalia, MD, FRCPC, Consultant Rheumatologist, William Osler Health System; M. Zummer, MD, FRCPC, Chief, Rheumatology, Hôpital Maisonneuve-Rosemont, Associate Professor, Université de Montréal; D.A. Marshall, PhD, Professor, Department of Community Health Sciences, Cumming School of Medicine, Canada Research Chair (Health Services and Systems Research), Arthur J.E. Child Chair in Rheumatology Research, Department of Medicine, University of Calgary, McCaig Institute for Bone and Joint Health, and Arthritis Research Canada; D. Choquette, MD, FRCPC, Institut de Recherche en Rhumatologie de Montréal, Scientific Director, Rhumadata, Université de Montréal; D. Lacaille, MD, FRCPC, MHSc, Professor, Division of Rheumatology, Department of Medicine, University of British Columbia, Senior Scientist, Arthritis Research Canada; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology, University of Toronto; A. Lyddiatt, member, CIHR National Steering Committee, OMERACT patient research partner, AAC Inflammatory Arthritis Models of Care Executive Member; V. Chandran, MBBS, MD, DM, PhD, Assistant Professor, Department of Medicine and Laboratory Medicine and Pathobiology, Institute of Medical Science, Krembil Research Institute; D. Khodyakov, PhD, MA, BA, Senior Behavioral/Social Scientist, RAND Corp.; E. Dao, BS, RAND Corp.; C. Barnabe, MD, MSc, FRCPC, Associate Professor, departments of Medicine and Community Health Sciences, University of Calgary
| | - Anne Lyddiatt
- From the Division of Rheumatology, Department of Medicine, and the Department of Community Health Sciences of the Cumming School of Medicine, and the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta; Arthritis Research Canada, Richmond; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, and the Department of Medicine and Laboratory Medicine and Pathobiology, and the Institute of Medical Science, and the Krembil Research Institute, University of Toronto, Toronto; Arthritis Alliance of Canada (AAC) Inflammatory Arthritis Models of Care, Toronto; William Osler Health System, Brampton; Canadian Institute of Health Research (CIHR) National Steering Committee, Ottawa; Outcome Measures in Rheumatology (OMERACT), Ottawa, Ontario; Hôpital Maisonneuve-Rosemont, and the Institut de Recherche en Rhumatologie de Montréal, Université de Montréal, Montreal, Quebec, Canada; RAND Corp., Santa Monica, California, USA.,C.E. Barber, MD, FRCPC, PhD, Assistant Professor, Division of Rheumatology, departments of Medicine and Community Health Sciences, University of Calgary, Cumming School of Medicine, McCaig Institute for Bone and Joint Health, Research Scientist, Arthritis Research Canada; D.P. Mosher, MD, FRCPC, Professor, Chief, Division of Rheumatology, Department of Medicine, University of Calgary; V. Ahluwalia, MD, FRCPC, Consultant Rheumatologist, William Osler Health System; M. Zummer, MD, FRCPC, Chief, Rheumatology, Hôpital Maisonneuve-Rosemont, Associate Professor, Université de Montréal; D.A. Marshall, PhD, Professor, Department of Community Health Sciences, Cumming School of Medicine, Canada Research Chair (Health Services and Systems Research), Arthur J.E. Child Chair in Rheumatology Research, Department of Medicine, University of Calgary, McCaig Institute for Bone and Joint Health, and Arthritis Research Canada; D. Choquette, MD, FRCPC, Institut de Recherche en Rhumatologie de Montréal, Scientific Director, Rhumadata, Université de Montréal; D. Lacaille, MD, FRCPC, MHSc, Professor, Division of Rheumatology, Department of Medicine, University of British Columbia, Senior Scientist, Arthritis Research Canada; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology, University of Toronto; A. Lyddiatt, member, CIHR National Steering Committee, OMERACT patient research partner, AAC Inflammatory Arthritis Models of Care Executive Member; V. Chandran, MBBS, MD, DM, PhD, Assistant Professor, Department of Medicine and Laboratory Medicine and Pathobiology, Institute of Medical Science, Krembil Research Institute; D. Khodyakov, PhD, MA, BA, Senior Behavioral/Social Scientist, RAND Corp.; E. Dao, BS, RAND Corp.; C. Barnabe, MD, MSc, FRCPC, Associate Professor, departments of Medicine and Community Health Sciences, University of Calgary
| | - Vinod Chandran
- From the Division of Rheumatology, Department of Medicine, and the Department of Community Health Sciences of the Cumming School of Medicine, and the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta; Arthritis Research Canada, Richmond; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, and the Department of Medicine and Laboratory Medicine and Pathobiology, and the Institute of Medical Science, and the Krembil Research Institute, University of Toronto, Toronto; Arthritis Alliance of Canada (AAC) Inflammatory Arthritis Models of Care, Toronto; William Osler Health System, Brampton; Canadian Institute of Health Research (CIHR) National Steering Committee, Ottawa; Outcome Measures in Rheumatology (OMERACT), Ottawa, Ontario; Hôpital Maisonneuve-Rosemont, and the Institut de Recherche en Rhumatologie de Montréal, Université de Montréal, Montreal, Quebec, Canada; RAND Corp., Santa Monica, California, USA.,C.E. Barber, MD, FRCPC, PhD, Assistant Professor, Division of Rheumatology, departments of Medicine and Community Health Sciences, University of Calgary, Cumming School of Medicine, McCaig Institute for Bone and Joint Health, Research Scientist, Arthritis Research Canada; D.P. Mosher, MD, FRCPC, Professor, Chief, Division of Rheumatology, Department of Medicine, University of Calgary; V. Ahluwalia, MD, FRCPC, Consultant Rheumatologist, William Osler Health System; M. Zummer, MD, FRCPC, Chief, Rheumatology, Hôpital Maisonneuve-Rosemont, Associate Professor, Université de Montréal; D.A. Marshall, PhD, Professor, Department of Community Health Sciences, Cumming School of Medicine, Canada Research Chair (Health Services and Systems Research), Arthur J.E. Child Chair in Rheumatology Research, Department of Medicine, University of Calgary, McCaig Institute for Bone and Joint Health, and Arthritis Research Canada; D. Choquette, MD, FRCPC, Institut de Recherche en Rhumatologie de Montréal, Scientific Director, Rhumadata, Université de Montréal; D. Lacaille, MD, FRCPC, MHSc, Professor, Division of Rheumatology, Department of Medicine, University of British Columbia, Senior Scientist, Arthritis Research Canada; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology, University of Toronto; A. Lyddiatt, member, CIHR National Steering Committee, OMERACT patient research partner, AAC Inflammatory Arthritis Models of Care Executive Member; V. Chandran, MBBS, MD, DM, PhD, Assistant Professor, Department of Medicine and Laboratory Medicine and Pathobiology, Institute of Medical Science, Krembil Research Institute; D. Khodyakov, PhD, MA, BA, Senior Behavioral/Social Scientist, RAND Corp.; E. Dao, BS, RAND Corp.; C. Barnabe, MD, MSc, FRCPC, Associate Professor, departments of Medicine and Community Health Sciences, University of Calgary
| | - Dmitry Khodyakov
- From the Division of Rheumatology, Department of Medicine, and the Department of Community Health Sciences of the Cumming School of Medicine, and the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta; Arthritis Research Canada, Richmond; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, and the Department of Medicine and Laboratory Medicine and Pathobiology, and the Institute of Medical Science, and the Krembil Research Institute, University of Toronto, Toronto; Arthritis Alliance of Canada (AAC) Inflammatory Arthritis Models of Care, Toronto; William Osler Health System, Brampton; Canadian Institute of Health Research (CIHR) National Steering Committee, Ottawa; Outcome Measures in Rheumatology (OMERACT), Ottawa, Ontario; Hôpital Maisonneuve-Rosemont, and the Institut de Recherche en Rhumatologie de Montréal, Université de Montréal, Montreal, Quebec, Canada; RAND Corp., Santa Monica, California, USA.,C.E. Barber, MD, FRCPC, PhD, Assistant Professor, Division of Rheumatology, departments of Medicine and Community Health Sciences, University of Calgary, Cumming School of Medicine, McCaig Institute for Bone and Joint Health, Research Scientist, Arthritis Research Canada; D.P. Mosher, MD, FRCPC, Professor, Chief, Division of Rheumatology, Department of Medicine, University of Calgary; V. Ahluwalia, MD, FRCPC, Consultant Rheumatologist, William Osler Health System; M. Zummer, MD, FRCPC, Chief, Rheumatology, Hôpital Maisonneuve-Rosemont, Associate Professor, Université de Montréal; D.A. Marshall, PhD, Professor, Department of Community Health Sciences, Cumming School of Medicine, Canada Research Chair (Health Services and Systems Research), Arthur J.E. Child Chair in Rheumatology Research, Department of Medicine, University of Calgary, McCaig Institute for Bone and Joint Health, and Arthritis Research Canada; D. Choquette, MD, FRCPC, Institut de Recherche en Rhumatologie de Montréal, Scientific Director, Rhumadata, Université de Montréal; D. Lacaille, MD, FRCPC, MHSc, Professor, Division of Rheumatology, Department of Medicine, University of British Columbia, Senior Scientist, Arthritis Research Canada; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology, University of Toronto; A. Lyddiatt, member, CIHR National Steering Committee, OMERACT patient research partner, AAC Inflammatory Arthritis Models of Care Executive Member; V. Chandran, MBBS, MD, DM, PhD, Assistant Professor, Department of Medicine and Laboratory Medicine and Pathobiology, Institute of Medical Science, Krembil Research Institute; D. Khodyakov, PhD, MA, BA, Senior Behavioral/Social Scientist, RAND Corp.; E. Dao, BS, RAND Corp.; C. Barnabe, MD, MSc, FRCPC, Associate Professor, departments of Medicine and Community Health Sciences, University of Calgary
| | - Emily Dao
- From the Division of Rheumatology, Department of Medicine, and the Department of Community Health Sciences of the Cumming School of Medicine, and the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta; Arthritis Research Canada, Richmond; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, and the Department of Medicine and Laboratory Medicine and Pathobiology, and the Institute of Medical Science, and the Krembil Research Institute, University of Toronto, Toronto; Arthritis Alliance of Canada (AAC) Inflammatory Arthritis Models of Care, Toronto; William Osler Health System, Brampton; Canadian Institute of Health Research (CIHR) National Steering Committee, Ottawa; Outcome Measures in Rheumatology (OMERACT), Ottawa, Ontario; Hôpital Maisonneuve-Rosemont, and the Institut de Recherche en Rhumatologie de Montréal, Université de Montréal, Montreal, Quebec, Canada; RAND Corp., Santa Monica, California, USA.,C.E. Barber, MD, FRCPC, PhD, Assistant Professor, Division of Rheumatology, departments of Medicine and Community Health Sciences, University of Calgary, Cumming School of Medicine, McCaig Institute for Bone and Joint Health, Research Scientist, Arthritis Research Canada; D.P. Mosher, MD, FRCPC, Professor, Chief, Division of Rheumatology, Department of Medicine, University of Calgary; V. Ahluwalia, MD, FRCPC, Consultant Rheumatologist, William Osler Health System; M. Zummer, MD, FRCPC, Chief, Rheumatology, Hôpital Maisonneuve-Rosemont, Associate Professor, Université de Montréal; D.A. Marshall, PhD, Professor, Department of Community Health Sciences, Cumming School of Medicine, Canada Research Chair (Health Services and Systems Research), Arthur J.E. Child Chair in Rheumatology Research, Department of Medicine, University of Calgary, McCaig Institute for Bone and Joint Health, and Arthritis Research Canada; D. Choquette, MD, FRCPC, Institut de Recherche en Rhumatologie de Montréal, Scientific Director, Rhumadata, Université de Montréal; D. Lacaille, MD, FRCPC, MHSc, Professor, Division of Rheumatology, Department of Medicine, University of British Columbia, Senior Scientist, Arthritis Research Canada; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology, University of Toronto; A. Lyddiatt, member, CIHR National Steering Committee, OMERACT patient research partner, AAC Inflammatory Arthritis Models of Care Executive Member; V. Chandran, MBBS, MD, DM, PhD, Assistant Professor, Department of Medicine and Laboratory Medicine and Pathobiology, Institute of Medical Science, Krembil Research Institute; D. Khodyakov, PhD, MA, BA, Senior Behavioral/Social Scientist, RAND Corp.; E. Dao, BS, RAND Corp.; C. Barnabe, MD, MSc, FRCPC, Associate Professor, departments of Medicine and Community Health Sciences, University of Calgary
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Eder L, Polachek A, Rosen CF, Chandran V, Cook R, Gladman DD. The Development of Psoriatic Arthritis in Patients With Psoriasis Is Preceded by a Period of Nonspecific Musculoskeletal Symptoms: A Prospective Cohort Study. Arthritis Rheumatol 2017; 69:622-629. [PMID: 27792862 DOI: 10.1002/art.39973] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 10/27/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To assess whether the presence of nonspecific musculoskeletal symptoms, their degree, and change over time predict the development of psoriatic arthritis (PsA) in a prospective cohort of psoriasis patients without arthritis at baseline. METHODS This prospective cohort study involved patients with psoriasis who were assessed at baseline to exclude the presence of clinical PsA. The study participants were reassessed annually to determine if they had developed PsA. The presence of musculoskeletal symptoms and the patients' assessments of pain, fatigue, stiffness, physical function, and psychological distress were recorded at each visit. Cox proportional hazards models were used to assess what symptoms predicted the development of PsA. RESULTS A total of 57 of 410 psoriasis patients developed PsA. At baseline, the presence of arthralgia in women (hazard ratio [HR] 2.59, P = 0.02), heel pain (HR 4.18, P = 0.02), high fatigue score (HR 2.36, P = 0.007), and high stiffness score (HR 2.03, P = 0.045) predicted subsequent development of PsA. In addition, an increase from baseline in fatigue score (HR 1.27, P = 0.001), pain score (HR 1.34, P < 0.001), and stiffness score (HR 1.21, P = 0.03), and a worsening in physical function score (HR 0.96, P = 0.04) predicted the development of PsA. CONCLUSION A preclinical phase exists in patients with PsA prior to the diagnosis of the disease. This phase is characterized by nonspecific musculoskeletal symptoms, including joint pain, fatigue, and stiffness.
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Affiliation(s)
- Lihi Eder
- Women's College Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Ari Polachek
- University Health Network, Toronto, Ontario, Canada
| | - Cheryl F Rosen
- University of Toronto and University Health Network, Toronto, Ontario, Canada
| | - Vinod Chandran
- University of Toronto and University Health Network, Toronto, Ontario, Canada
| | - Richard Cook
- University of Waterloo, Waterloo, Ontario, Canada
| | - Dafna D Gladman
- University of Toronto and University Health Network, Toronto, Ontario, Canada
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27
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Villaseñor-Ovies P, Navarro-Zarza JE, Saavedra MÁ, Hernández-Díaz C, Canoso JJ, Biundo JJ, Kalish RA, de Toro Santos FJ, McGonagle D, Carette S, Alvarez-Nemegyei J. A survey of anatomical items relevant to the practice of rheumatology: upper extremity, head, neck, spine, and general concepts. Clin Rheumatol 2016; 35:3025-3030. [PMID: 27539219 DOI: 10.1007/s10067-016-3378-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 08/06/2016] [Indexed: 11/25/2022]
Abstract
This study aimed to identify the anatomical items of the upper extremity and spine that are potentially relevant to the practice of rheumatology. Ten rheumatologists interested in clinical anatomy who published, taught, and/or participated as active members of Clinical Anatomy Interest groups (six seniors, four juniors), participated in a one-round relevance Delphi exercise. An initial, 560-item list that included 45 (8.0 %) general concepts items; 138 (24.8 %) hand items; 100 (17.8 %) forearm and elbow items; 147 (26.2 %) shoulder items; and 130 (23.2 %) head, neck, and spine items was compiled by 5 of the participants. Each item was graded for importance with a Likert scale from 1 (not important) to 5 (very important). Thus, scores could range from 10 (1 × 10) to 50 (5 × 10). An item score of ≥40 was considered most relevant to competent practice as a rheumatologist. Mean item Likert scores ranged from 2.2 ± 0.5 to 4.6 ± 0.7. A total of 115 (20.5 %) of the 560 initial items reached relevance. Broken down by categories, this final relevant item list was composed by 7 (6.1 %) general concepts items; 32 (27.8 %) hand items; 20 (17.4 %) forearm and elbow items; 33 (28.7 %) shoulder items; and 23 (17.6 %) head, neck, and spine items. In this Delphi exercise, a group of practicing academic rheumatologists with an interest in clinical anatomy compiled a list of anatomical items that were deemed important to the practice of rheumatology. We suggest these items be considered curricular priorities when training rheumatology fellows in clinical anatomy skills and in programs of continuing rheumatology education.
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Affiliation(s)
- Pablo Villaseñor-Ovies
- Hospital Ángeles de Tijuana, Tijuana, BC, Mexico
- Universidad Autónoma de Baja California, Mexicali, Mexico
| | - José Eduardo Navarro-Zarza
- Hospital General de Chilpancingo Raymundo Abarca Alarcón, Chilpancingo, Gro, Mexico
- Universidad Autónoma de Guerrero, Acapulco, Gro, Mexico
| | - Miguel Ángel Saavedra
- Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico.
| | - Cristina Hernández-Díaz
- Laboratorio de Ultrasonido Musculoesquelético y Articular, Instituto Nacional de Rehabilitación, México, DF, Mexico
| | - Juan J Canoso
- Centro Médico ABC, México, DF, Mexico
- Tufts Medical School, Boston, MA, USA
| | | | - Robert A Kalish
- Tufts Medical School, Boston, MA, USA
- Tufts Medical Center, Boston, MA, USA
| | - Francisco Javier de Toro Santos
- Servicio de Reumatología, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complejo Hospitalario Universitario A Coruña (CHUAC), Sergas, Universidad La Coruña (UDC), Coruña, Spain
| | - Dennis McGonagle
- UK National Institute for Health Research Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Simon Carette
- Division of Rheumatology, University Health Network, Mount Sinai Hospital, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - José Alvarez-Nemegyei
- Unidad de Investigación, Hospital Regional de Alta Especialidad de la Península de Yucatán, Mérida, Yucatán, Mexico
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