Joint orthopaedic and rheumatology clinics: evidence to support the guidelines

Identifying barriers to the care of the rheumatoid hand in China: comparing attitudes of rheumatologists and hand surgeons

AIM

In China, hand surgeons treat fewer rheumatoid arthritis (RA) patients compared to other countries. We investigated whether physician and surgeon knowledge, attitudes and practices regarding RA hand deformities reflect current evidence and may contribute to the low utilization of surgery.

METHOD

We surveyed hand surgeons and rheumatologists at three tertiary hospitals in Beijing, China. Questionnaires were developed from literature and expert review to assess their knowledge, attitudes and practice patterns related to rheumatoid hand surgery.

RESULTS

Thirty-five hand surgeons and 59 rheumatologists completed the survey. Roughly one-third felt that the rheumatologists and hand surgeons agree on how to manage RA hand deformities. One-fifth of rheumatologists and 29% of hand surgeons believed that drug therapy can correct hand deformities, which contradicts current evidence. Likewise, 30% and 14%, respectively, recommended surgery for early-stage hand sequelae that do not meet current indications for surgery. Over 80% of surgeons and rheumatologists had no exposure to the other specialty during training and felt their training on the treatment of rheumatoid hand deformities was inadequate.

CONCLUSION

Although we found similar interspeciality disagreement in China as is seen in the United States, there appears to be less interaction through training and consultations. Our results also indicate potential deficits in training and unawareness of evidence and indications for rheumatoid hand surgery. These findings help to explain why surgery for rheumatoid hand deformities is rare in China; doctors have fewer opportunities to collaborate across specialties and may not be able to select appropriate candidates for surgery.

Barriers to Reconstructive Hand Surgery for Rheumatoid Arthritis in China: A Multicenter Survey of Patients and Physicians

BACKGROUND

China has a similar rheumatoid arthritis (RA) disease burden compared with other countries, yet RA patients rarely receive surgical treatment for hand deformities that limit function and impact appearance. We investigated potential barriers to rheumatoid hand surgery in China.

METHODS

Patients with RA, rheumatologists, and hand surgeons at 3 large tertiary hospitals in Beijing completed questionnaires that assess knowledge and attitudes surrounding RA hand surgery. We calculated descriptive statistics and compared responses among groups using chi-square and Fisher exact tests as appropriate.

RESULTS

One hundred RA patients with hand deformities and 94 physicians completed the surveys. No patients had received hand surgery, and just 13% were aware of this treatment option. Patients and physicians most frequently cited uncertain effectiveness of surgery, high cost, and risk of surgical complications as potential barriers to hand reconstruction. Rheumatologists reported low rates of referral to hand surgeons (39% referred <5% of the time and 31% never referred). Most hand surgeons (69%) had not performed metacarpophalangeal arthroplasty, a common procedure for RA hand deformities, within the past year. Some had never performed this operation.

CONCLUSIONS

This survey revealed multiple barriers that support previous observations of infrequent reconstruction of RA hand deformities in China. These obstacles can be addressed through patient education, coordination between specialists, and more robust hand surgeon training in common RA procedures through the application of international plastic surgery collaborations.

Training the next generation of clinical researchers: evaluation of a graduate podiatrist research internship in rheumatology

Background

The aim of this study was to evaluate the effectiveness of the Arthritis Research UK funded graduate internship scheme for podiatrists and to explore the experiences of interns and mentors.

Methods

Nine new graduates completed the internship programme (July 2006–June 2010); six interns and two mentors participated in this study. The study was conducted in three phases. Phase 1: quantitative survey of career and research outcomes for interns. Phase 2 and 3: qualitative asynchronous interviews through email to explore the experiences of interns and mentors. Interpretive phenomenological analysis (IPA) of coded transcripts identified recurring themes.

Results

Research outputs included ten peer reviewed publications with authorial contributions from interns, 23 conference abstract presentations and one subsequent ‘Jewel in the Crown’ award at the British Society for Rheumatology Conference. Career progression includes two National Institute for Health research (NIHR) PhD fellowships, two Arthritis Research UK PhD fellowships, one NIHR Master of Research fellowship and one specialist rheumatology clinical post. Two interns are members of NIHR and professional body committees.

Seven important themes arose from the qualitative phases: perceptions of the internship pre-application; internship values; maximising personal and professional development; psychosocial components of the internship; the role of mentoring and networking; access to research career pathways; perceptions of future developments for the internship programme. The role of mentorship and the peer support network have had benefits that have persisted beyond the formal period of the scheme.

Conclusions

The internship model appears to have been perceived to have been valuable to the interns’ careers and may have contributed significantly to the broader building of capacity in clinical research in foot and ankle rheumatology. We believe the model has potential to be transferable across health disciplines and on national and international scales.

A case series to describe the clinical characteristics of foot ulceration in patients with rheumatoid arthritis

The aim of this study was to describe the clinical characteristics of foot ulceration in patients with rheumatoid arthritis (RA). Adults with RA and current foot ulceration but without diabetes were recruited. Clinical examination included assessment of RA disease activity, foot deformity, peripheral vascular disease, neuropathy and plantar pressures. Location, wound characteristics and time to healing were recorded for each ulcer. Participants completed the Health Assessment Questionnaire and Leeds Foot Impact Scale. Thirty-two cases with 52 current ulcers were recruited. Thirteen patients (41%) experienced more than one current ulcer: 5 (16%) had bilateral ulceration, 15 (47%) had previous ulceration at a current ulcer site. The majority (n = 33) of open ulcers were located over the dorsal aspect of the interphalangeal joints (n = 12), plantar aspect of the metatarsophalangeal joints (MTPJs) (n = 12) and medial aspect of first MTPJs (n = 9). In ulcerated limbs (n = 37), ankle brachial pressure index (ABPI) was <0.8 in 2 (5%); protective sensation was reduced in 25 (68%) and peak plantar pressures were >6 kg/cm(2) in 6 (16%). Mean ulcer size was 4.84 by 3.29 mm. Most ulcers (n = 42, 81%) were superficial; five (9.6%) were infected. Time to healing was available for 41 ulcers: mean duration was 28 weeks. Three ulcers remained open. In conclusion, foot ulceration in RA is recurrent and multiple ulcers are common. Whilst ulcers are small and shallow, time to achieve healing is slow, posing infection risk. Reduced protective sensation is common in affected patients. The prevalence of arterial disease is low but may be under estimated due to high intolerance of ABPI.