Systematic review of rheumatic disease phenotypes and outcomes in the Indigenous populations of Canada, the USA, Australia and New Zealand

Physical pain among Indigenous Peoples in Canada: a scoping review

PURPOSE

Pain is a multifaceted experience shaped by various factors including context of pain, previous life events, and ongoing ethnocultural circumstances. Moreover, the definition of pain is inconsistent across cultures. Western medicine views physical pain (e.g., associated with a bone fracture) and nonphysical mental pain (e.g., depression) as two distinct conditions. Indigenous perspectives are often more wholistic, encompassing mental, spiritual, emotional, and physical hurt. The subjective nature of pain invites ample opportunity for discrimination in both its assessment and management. As such, it is important to consider Indigenous perspectives of pain in research and clinical practice. To investigate which aspects of Indigenous pain knowledge are currently considered by Western research, we conducted a scoping review of the literature on pain in Indigenous Peoples of Canada.

SOURCE

In June 2021, we searched nine databases and downloaded 8,220 papers after removal of duplicates. Two independent reviewers screened abstracts and full-text articles.

PRINCIPLE FINDINGS

Seventy-seven papers were included in the analysis. Using grounded theory, five themes emerged: pain measures/scales (n = 7), interventions (n = 13), pharmaceuticals (n = 17), pain expression/experiences (n = 45), and pain conditions (n = 70).

CONCLUSION

This scoping review shows that there is a paucity of research on pain measurement in Indigenous Peoples of Canada. This finding is concerning in light of numerous studies reporting that Indigenous Peoples experience their pain as ignored, minimized, or disbelieved. Furthermore, a clear disconnect emerged between pain expression in Indigenous Peoples and assessment in medical professionals. We hope that this scoping review will serve to translate current knowledge to other non-Indigenous academics and to initiate meaningful collaboration with Indigenous partners. Future research led by Indigenous academics and community partners is critically needed to better address pain needs in Canada.

Personalized medicine in rheumatoid arthritis: Combining biomarkers and patient preferences to guide therapeutic decisions

The last few decades have seen major therapeutic advancements in rheumatoid arthritis (RA) therapeutics. New disease-modifying antirheumatic drugs (DMARDs) have continued to emerge, creating more choices for people. However, no therapeutic works for all patients. Each has its own inherent benefits, risks, costs, dosing, and monitoring considerations. In parallel, there has been a focus on personalized medicine initiatives that tailor therapeutic decisions to patients based on their unique characteristics or biomarkers. Personalized effect estimates require an understanding of a patient's baseline probability of response to treatment and data on the comparative effectiveness of the available treatments. However, even if accurate risk prediction models are available, trade-offs often still need to be made between treatments. In this paper, we review the history of RA therapeutics and progress that has been made toward personalized risk predictive models for DMARDs, outlining where knowledge gaps still exist. We further review why patient preferences play a key role in a holistic view of personalized medicine and how this links with shared decision-making. We argue that a "preference misdiagnosis" may be equally important as a medical misdiagnosis but is often overlooked.

Prevalence of rheumatoid arthritis in South America: a systematic review and meta-analysis

Rheumatoid arthritis (RA) is among the most prevalent chronic autoimmune and inflammatory diseases worldwide. The aim of this study was to establish a pooled estimate of the RA prevalence in South America by means of a meta-analysis of the available epidemiologic studies. Systematic searches in PubMed, Lilacs, SciELO, Scopus, and Web of Science databases (updated May 2019) were done followed by a systematic grey literature search to identify original research articles and reports, published after 2000, providing data of RA prevalence in any South American country. Proportion meta-analysis of weighted pooled was performed, with between-trial heterogeneity assessed by the inconsistency relative index. Sensitivity analyses and sub-group analyses were also done. A total of 25 articles, representing 27 population-based studies were included. Pooled prevalence of RA resulted in 0.48% with 591,981 cases in a population of 114,537,812 individuals (I2=99%). Brazil and Colombia presented the lowest rates of RA prevalence 0.22%, and 0.24%, respectively. RA prevalence in indigenous population was higher 1.45%, and studies using COPCORD method reported also the highest rates 1.07%.

Informing the GRADE evidence to decision process with health equity considerations: demonstration from the Canadian rheumatoid arthritis care context

OBJECTIVES

Health equity is a priority for clinical and public health practice and promoted in GRADE's Evidence to Decision (EtD) Framework, yet there is still limited integration of specific equity considerations in chronic disease guideline development and implementation. Our objective was to embed equity considerations for upcoming Canadian Rheumatoid Arthritis treatment guidelines.

STUDY DESIGN AND SETTING

In parallel with the Guidelines Committee process, considerations for six population groups (rural and remote residents, Indigenous Peoples, elderly persons with frailty, minority populations of first-generation immigrants and refugees, persons with low socioeconomic status or who are vulnerably housed, and sex and gender populations) based on literature reviews and key informant interviews were identified and contextualized to each step in the GRADE EtD framework.

RESULTS

The EtD Framework domains relevant to rheumatoid arthritis treatment and management were analyzed through patient-centric, social determinant and economic lenses, while considering implementation feasibility. This determined tailored considerations relevant to recommendations for the priority populations to mitigate potential intervention-generated inequities.

CONCLUSION

This approach provides a demonstration of the process of incorporating equity in the evidence to decision process and can be applied in future rheumatic disease guidelines while also informing a research agenda for equity in rheumatology outcomes.

Arthritis liaison: a First Nations community-based patient care facilitator

INTRODUCTION

Arthritis is a leading cause of disability in First Nations communities and is often accompanied by other chronic diseases. Existing care models prioritize accessibility to specialty care for treatment, whereas patient-centred approaches support broader health goals.

METHODS

A patient care facilitator model of care, termed "arthritis liaison," was developed with the community to support culturally relevant patient-centred care plans. Following a one-year-long intervention, we report on the feasibility and acceptability of this care model from the perspectives of patients and health care providers.

RESULTS

The arthritis liaison served as a bridge between the clinicians and patients, and fostered continuity, helping patients receive coordinated care within the community.

Canadian Rheumatology Association Recommendation for the Use of COVID-19 Vaccination for Patients With Autoimmune Rheumatic Diseases

OBJECTIVE

To develop guidance on the use of coronavirus disease 2019 (COVID-19) vaccines in patients with autoimmune rheumatic diseases (ARD).

METHODS

The Canadian Rheumatology Association (CRA) formed a multidisciplinary panel including rheumatologists, researchers, methodologists, vaccine experts, and patients. The panel used the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. Outcomes were prioritized according to their importance for patients and clinicians. Evidence from the COVID-19 clinical trials was summarized. Indirect evidence for non-COVID-19 vaccines in ARD was also considered. The GRADE evidence-to-decision (EtD) framework was used to develop a recommendation for the use of the 4 COVID-19 vaccines approved in Canada as of March 25, 2021 (BNT162b2, mRNA-1273, ChAdOx1, and Ad26.COV2.S), over 4 virtual panel meetings.

RESULTS

The CRA guideline panel suggests using COVID-19 vaccination in persons with ARD. The panel unanimously agreed that for the majority of patients, the potential health benefits of vaccination outweigh the potential harms in people with ARDs. The recommendation was graded as conditional because of low or very low certainty of the evidence on the effects in the population of interest, primarily due to indirectness and imprecise effect estimates. The panel felt strongly that persons with autoimmune rheumatic diseases who meet local eligibility should not be required to take additional steps compared to people without ARDs to obtain their vaccination. Guidance on medications, implementation, monitoring of vaccine uptake, and research priorities are also provided.

CONCLUSION

This recommendation will be updated over time as new evidence emerges, with the latest recommendation, evidence summaries, and EtD available on the CRA website.

Supporting Equity in Rheumatoid Arthritis Outcomes in Canada: Population-specific Factors in Patient-centered Care

OBJECTIVE

Health equity considerations have not been incorporated into prior Canadian Rheumatology Association guidelines. Our objective was to identify the challenges and possible solutions to mitigate threats to health equity in rheumatoid arthritis (RA) care in Canada.

METHODS

A consultation process informed selection of priority populations, determined to be rural and remote, Indigenous, elderly with frailty, first-generation immigrant and refugee, low income and vulnerably housed, and diverse gender and sex populations. Semistructured interviews were completed with patients with lived experience, healthcare providers, and equity-oriented researchers. These interviews probed on population factors, initial and ongoing healthcare access issues, and therapeutic considerations influencing RA care. Known or proposed solutions to mitigate inequities during implementation of service models for the population group were requested. The research team used a phenomenological thematic analysis model and mapped the data into a logic model. Solutions applicable to several population groups were proposed.

RESULTS

Thirty-five interviews were completed to identify realities for each population in accessing RA care. Five themes emerged as primary solutions to population-based inequities, including actively improving the patient-practitioner relationship, increasing accessibility and coordination of care through alternative models of care, upholding autonomy in treatment selection while actively addressing logistical barriers and individualized therapy needs, collaborating with health supports valued by the patient, and being advocates for policy change and health system restructuring to ensure appropriate resource redistribution.

CONCLUSION

The challenges for populations facing inequities in rheumatology care and promising solutions should inform guideline development and implementation, policy change, and health system restructuring.

Addressing surgical inequity for Aboriginal and Torres Strait Islander people in Australia's universal health care system: a call to action

Aboriginal and Torres Strait Islander people continue to experience health inequity within the Australian health care system. Little research has examined how disparities in surgical care access and outcomes contribute to Aboriginal health. In this narrative review and call to action, we discuss five care points along the journey to high-quality surgical care: health care seeking, primary health care services, specialist services, surgery and surgical outcomes. We highlight barriers and disparities that exist along this journey, drawing examples from the field of joint replacement surgery. Finally, we present opportunities for change at the health system, health service and clinician level, calling upon researchers, clinicians and policy makers to confront the surgical disparities experienced by Aboriginal and Torres Strait Islander people.

Participant-reported effect of an Indigenous health continuing professional development initiative for specialists

BACKGROUND

Health outcomes of Indigenous patients are impacted by culturally unsafe specialty care environments. The 'Educating for Equity (E4E)' program is a continuing professional development (CPD) intervention which incorporates skill-based teaching to improve Indigenous patient experiences and outcomes in healthcare interactions.

METHODS

The E4E program was delivered to rheumatologists in two phases, each delivered as experiential learning workshops where participants engaged with and applied course content within an interactive format focusing on real-time feedback. The phase 1 workshop focused on skill development of E4E Framework concepts and principles. Phase 2 concentrated on building capacity for teaching of E4E content. Evaluation of the program's effectiveness was through longitudinal responses to the Social Cultural Confidence in Care Survey (SCCCS), self-reported strategies employed to address social issues and improve therapeutic relationships, engagement with teaching others, and satisfaction with the program.

RESULTS

Two cohorts of participants have participated in the program (n = 24 Phase 1, n = 10 Phase 2). For participants completing both phases of training, statistically significant improvements were observed in exploring social factors with patients, gaining knowledge and skills related to cultural aspects of care, improved communication and relationship building, and reflections on held stereotypes. Strategies to address social issues and build therapeutic relationships remained consistent throughout participation, while the training enhanced exploration and confidence to ask about cultural and traditional practices, and stronger communication strategies for exploring beliefs, expectations, social barriers, and residential school impacts on health. Participants reported feeling prepared to teach Indigenous health concepts to others and subsequently lead teaching with residents, fellows, and allied health professionals. Satisfaction with the delivery and content of the workshops was high, and participants valued interactions with peers in learning.

CONCLUSIONS

This CPD intervention had a beneficial impact on self-reported confidence and enhanced practice strategies to engage with Indigenous patients.

Access to healthcare system of indigenous communities with musculoskeletal disorders and rheumatic disease in Chaco, Argentina: a qualitative study

Introduction/objectives

The objective of this study is to describe the local healthcare system from the perspective of the health professionals, community health workers, and local representatives of the qom community living in the province of Chaco, Argentina.

Methods

A qualitative study, with an ethnographic approach, was carried out using two techniques: non-participant observations and semi-structured interviews. A guide for the interviews was designed and developed by a multidisciplinary group of GLADERPO researchers. The main aspects included were the following: reference into the local healthcare system and accessibility to the system. Andersen’s base conceptual model of health service utilization was applied for the analysis and for structuring the results.

Results

A total of 21 people were interviewed, twelve women and nine men with an age ranging between 25 and 60 years old. The main findings were different barriers (communication and cultural) between the community and the healthcare system; “navigation” within the health system carried out by the qom community; and migration and bureaucratization of the health system.

Conclusions

These findings should be incorporated into educational strategies to improve access to healthcare system and adherence to medical treatment, establishing an interaction between the different levels of the local care system and providing community health workers with an appropriate training with the support of the community representatives.

Key Points • The different barriers between the community and the healthcare system were described. • The “navigation” within the health system carried out by the qom community and the migration were relevant points. • The bureaucratization of the health system and the need to design and implement educational strategies in the future were highlighted.

Understanding the Disproportionate Burden of Rheumatic Diseases in Indigenous North American Populations

Studies have described a high incidence and prevalence of several rheumatic diseases in indigenous North American populations. Conditions studied most frequently with consistently high burden of disease include rheumatoid arthritis, spondyloarthritis, and systemic lupus erythematosus. Crystal-induced arthritis has been reported to have a lower prevalence than expected. Information about genetic and environmental risk factors is available for some of these conditions. An awareness of the epidemiology of rheumatic diseases in indigenous North American populations is important for clinicians involved in caring for patients in these populations as well as for planning health service delivery in these communities.

Opportunities and challenges for physical rehabilitation with indigenous populations

Indigenous peoples in colonised countries internationally experience a disproportionately high burden of disease and disability. The impact of many of these conditions, such as musculoskeletal pain, can be ameliorated by participating in physical rehabilitation. However, access by Indigenous peoples to physical rehabilitation is low. Overcoming barriers for Indigenous peoples to access high-quality, effective, culturally secure physical rehabilitation should be a priority. Physical rehabilitation outcomes for Indigenous peoples can be enhanced by addressing health system, health service, and individual clinician-level considerations. System-level changes include a greater commitment to cultural security, improving the funding of physical rehabilitation to Indigenous communities, building the Indigenous physical rehabilitation workforce, and developing and using Indigenous-identified indicators in quality improvement. At the health service level, physical rehabilitation should be based within Indigenous health services, Indigenous people should be employed as physical rehabilitation professionals or in allied roles, and cultural training and support provided to the existing physical rehabilitation workforce. For clinicians, a focus on cultural development and the quality of communication is needed. Indigenous ill-health is complex and includes societal and social influences. These recommendations offer practical guidance toward fair, reasonable, and equitable physical rehabilitation outcomes for Indigenous peoples.

Tackling the Burden of Osteoarthritis as a Health Care Opportunity in Indigenous Communities-A Call to Action

Osteoarthritis is a highly prevalent and disabling disease, causing a significant individual and socioeconomic burden worldwide. Until now, there has been a dearth of research exploring the impact of osteoarthritis in global Indigenous communities. Osteoarthritis has a similar risk factor profile to many chronic diseases that disproportionately affect Indigenous peoples. In this editorial, we argue that osteoarthritis and associated mobility restrictions play a central role in the chronic disease profile of Indigenous peoples. We present a call to action for clinicians and health care providers, researchers and policymakers to begin to recognise the interrelated nature of osteoarthritis and chronic disease. We have an opportunity to change the way we do business, to improve access to culturally secure osteoarthritis care and the health and wellbeing of Indigenous communities.

Prevalence of musculoskeletal disorders and rheumatic diseases in an Argentinean indigenous Wichi community

OBJECTIVE

To estimate the prevalence of musculoskeletal disorders (MSK) and rheumatic diseases in an indigenous Wichi population in Argentina.

METHODS

This is a cross-sectional, community-based study using the Community-Oriented Program for the Control of Rheumatic Diseases (COPCORD) methodology in ≥ 18-year-old subjects. Validated surveys were conducted by trained interviewers. Subjects with MSK pain (positive cases) were evaluated by internists and rheumatologists for diagnosis and treatment.

RESULTS

A total of 648 interviews were performed (90.4% of the census population). Mean age was 37.5 years (SD 14.8), and 379 (58.5%) were female. The mean years of education was 7.0 (SD 3.7); 552 subjects (85.2%) were covered by the public health care system. A total of 216 (33.3%) subjects had MSK pain in the last 7 days. Rheumatic disease prevalence was as follows: mechanical back pain (19.0%), rheumatic regional pain syndrome (5.2%), osteoarthritis (3.2%), rheumatoid arthritis (RA) (3.2%), inflammatory back pain (1.2%), undifferentiated arthritis (0.3%), Sjögren syndrome (0.15%), and fibromyalgia (0.15%). RA patients included 19 (90.5%) women and 9 (42.9%) with RA family history. One hundred percent were seropositive and 66.7% showed radiologic erosions. The mean of Disease Activity Score [DAS-28 (ESR)] at the time of diagnosis was 5.1 (SD 1.5) and the Health Assessment Questionnaire Disability Index (HAQ-DI) was 0.8 (SD 0.4).

CONCLUSION

RA prevalence was 3.2%, one of the highest reported using the COPCORD methodology in indigenous and non-indigenous peoples in Latin America, with a high percentage of family cases. Pain and functional capacity were the variables allowing patients' early referral to a specialist. Key Points • The RA prevalence was 3.2%, one of the highest reported using COPCORD methodology in indigenous and non-indigenous peoples in Latin America. • The patients with RA had high percentage of familiar history of RA. • The pain and functional capacity were the variables associated with a diagnosis of any rheumatic disease and should be considered for early referral. • The mean of the delay in the diagnosis was 5.8 years. In this community, the lack of the "migration health" phenomenon may be a social determinant that negatively impacts their health.

Comparative United States autoimmune disease rates for 2010-2016 by sex, geographic region, and race

PURPOSE

AIDs may disproportionately impact specific racial groups, but autoimmune (AID) prevalence information by minority racial group is sparse for many AIDs. The objective of this analysis was to supplement previously published AID prevalence rates by providing information on race rate ratios (minority race populations compared to Caucasian populations) in the United States. Preliminary to estimating race rate ratios, contemporary US-specific, health care utilization-based AID prevalence rates and female-to-male ratios were estimated and compared to previously published AID prevalence rates.

METHODS

We used a large national electronic medical record database of 52 million individuals to estimate age-adjusted direct standardized rates for 22 AIDs for 2010 through 2016 by gender, race, and US census division. These were compared to previously published estimates.

RESULTS

Female-to-male ratios were comparable with published studies. Almost all observed Multiracial AID rates were significantly higher than Caucasian rates, as well as 9 of 22 AID rates observed among Native Americans and 8 of 22 AID rates estimated among African-American patients. Regional variation was noted: highest African-American systemic lupus erythematosus rates were observed in the West North Central and South Atlantic divisions, highest African-American multiple sclerosis rates in the South Atlantic and Pacific divisions, and highest Native American rheumatoid arthritis rates in the West North Central, Mountain, and Pacific divisions.

CONCLUSIONS

Substantial AID heterogeneity exists by race and by geographic area. An important research area is further exploring factors related to heterogeneity such as potential interactions between genetic susceptibility and environmental factors.

Acute myopic shift in a patient with systemic lupus erythematosus

Purpose

To describe a rare case of acute, transient myopic shift occurring as a feature of a flare of systemic lupus erythematosus.

Observations

A 22-year-old Indigenous Australian woman with diagnosed systemic lupus erythematosus was admitted with blurry vision and periorbital oedema. She had a refractive error of −7.50 DS in the right eye and −3.50 DS in the left eye and cotton wool spots throughout the posterior poles of the retina of each eye. Treatment with intravenous and oral steroids resulted in rapid resolution of myopia and improvement in visual acuity.

Conclusions and importance

Systemic lupus erythematosus disproportionately affects more indigenous than non-indigenous Australians with greater disease burden and severity. This case describes a rare manifestation of this disease.

A Prospective Study of the Development of Inflammatory Arthritis in the Family Members of Indigenous North American People With Rheumatoid Arthritis

OBJECTIVE

To determine the incidence of inflammatory arthritis and autoantibody prevalence in Indigenous North American people.

METHODS

Unaffected relatives of Indigenous North Americans with rheumatoid arthritis (RA) from central Canada and Alaska were systematically monitored from 2005 to 2017. Rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPAs) were tested at every visit, and a subset was tested for ACPA fine specificity using a custom multiplex assay. Multistate models based on all available study visits were developed to determine the likelihood of transitioning between autoantibody states, or to inflammatory arthritis.

RESULTS

Eighteen of 374 relatives (4.8%) developed inflammatory arthritis during follow-up (after a mean ± SD of 4.7 ± 2.4 years), yielding a transition rate of 9.2 cases/1,000 person-years. Thirty percent of those who developed inflammatory arthritis were seronegative at baseline, but all were seropositive at inflammatory arthritis onset. Although 30% of ACPA/RF double-seropositive individuals developed inflammatory arthritis (after 3.2 ± 2.2 years), the majority of these individuals did not develop inflammatory arthritis. Multistate modeling indicated a 71% and 68% likelihood of ACPA and RF seropositive states, respectively, reverting to a seronegative state after 5 years, and a 39% likelihood of an ACPA/RF double-seropositive state becoming seronegative. Fine specificity testing demonstrated an expansion of the ACPA repertoire prior to the development of inflammatory arthritis.

CONCLUSION

Despite a high incidence of inflammatory arthritis in this cohort of at-risk relatives of Indigenous North Americans with RA, a large proportion of autoantibody-positive individuals do not develop inflammatory arthritis and revert back to an autoantibody-negative state.

Early Rheumatoid Arthritis Presentation, Treatment, and Outcomes in Aboriginal Patients in Canada: A Canadian Early Arthritis Cohort Study Analysis

OBJECTIVE

Health inequities exist in chronic diseases for Aboriginal people. This study compared early rheumatoid arthritis (RA) presentation, treatment, and outcomes between Aboriginal and white patients in a large Canadian cohort study.

METHODS

Longitudinal data from the Canadian Early Arthritis Cohort, a prospective multicenter early RA study, were analyzed for participants who self-identified as Aboriginal or white ethnicity. Disease characteristics at presentation, prognostic factors, frequency of remission, and disease-modifying therapy strategies were contrasted between population groups. Linear mixed models were used to estimate rates of change for disease activity measures over a 5-year period.

RESULTS

At baseline, 2,173 participants (100 Aboriginal and 2,073 white) had similar mean ± SD symptom duration (179 ± 91 days), 28-joint Disease Activity Scores (DAS28; 4.87 ± 1.48), and Health Assessment Questionnaire (0.88 ± 0.68) scores. Factors associated with poor prognosis were more frequently present in Aboriginal participants, but disease-modifying therapy selection and frequency of therapy escalation was similar between the 2 groups. DAS28 remission was achieved less frequently in Aboriginal than in white participants (adjusted odds ratio 0.39 [95% confidence interval 0.25-0.62]). Results were primarily driven by slower improvement in swollen joint counts and nonsignificant improvement in patient global scores in Aboriginal participants. Pain levels remained higher in Aboriginal patients.

CONCLUSION

Aboriginal early RA patients experienced worse disease outcomes than their white counterparts. This may reflect unmeasured biologic differences and/or disparities in prognostic factors informed by inequities in determinants of health. The appropriateness of current treatment strategies applied in different contexts should be considered.

Characterization of indigenous community engagement in arthritis studies conducted in Canada, United States of America, Australia and New Zealand

BACKGROUND

Research adhering to community engagement processes leads to improved outcomes. The level of Indigenous communities' engagement in rheumatology research is unknown.

OBJECTIVE

To characterize the frequency and level of community engagement reporting in arthritis studies conducted in Australia (AUS), Canada (CAN), New Zealand (NZ) and the United States of America (USA).

METHODS

Studies identified through systematic reviews on topics of arthritis epidemiology, disease phenotypes and outcomes, health service utilization and mortality in Indigenous populations of AUS, CAN, NZ and USA, were evaluated for their descriptions of community engagement. The level of community engagement during inception, data collection and results interpretation/dissemination stages of research was evaluated using a custom-made instrument, which ranked studies along the community engagement spectrum (i.e. inform-consult-involve-collaborate-empower). Meaningful community engagement was defined as involving, collaborating or empowering communities. Descriptive analyses for community engagement were performed and secondary non-parametric inferential analyses were conducted to evaluate the possible associations between year of publication, origin of the research idea, publication type and region of study; and meaningful community engagement.

RESULTS

Only 34% (n = 69) of the 205 studies identified reported community engagement at ≥ 1 stage of research. Nearly all studies that engaged communities (99% (n = 68)) did so during data collection, while only 10% (n = 7) did so at the inception of research and 16% (n = 11) described community engagement at the results' interpretation/dissemination stage. Most studies provided community engagement descriptions that were assessed to be at the lower end of the spectrum. At the inception of research stage, 3 studies reported consulting communities, while 42 studies reported community consultation at data collection stage and 4 studies reported informing or consulting communities at the interpretation/dissemination of results stage. Only 4 studies described meaningful community engagement through all stages of the research. Inferential statistics identified that studies with research ideas that originated from the Indigenous communities involved were significantly more associated with achieving meaningful community engagement.

CONCLUSIONS

The reporting of Indigenous community engagement in published arthritis studies is limited in frequency and is most frequently described at the lower end of the community engagement spectrum. Processes that support meaningful community engagement are to be promoted.

Feasibility of Measurement and Adherence to System Performance Measures for Rheumatoid Arthritis in 5 Models of Care

OBJECTIVE

To test the feasibility of reporting on 4 national performance measures for patients with rheumatoid arthritis (RA) in 5 different models of care.

METHODS

The following performance measures were evaluated in 5 models of care: waiting time (WT) to rheumatologist consultation, percentage of patients seen in yearly followup (FU), percentage taking disease-modifying antirheumatic drugs (DMARD), and time to starting DMARD. All models aimed to improve early access and care for patients with RA.

RESULTS

A number of feasibility issues were encountered in performance measure evaluation because of differences in site data collection and/or the duration of the model of care. For example, while 4/5 programs maintained clinical or research databases, chart reviews were still required to report on WT. Median WT for care in 2015 varied by site between 21 and 75 days. Yearly FU rates could only be calculated in 2 sites (combined owing to small numbers) and varied between 83% and 100%. Percentage of patients taking a DMARD and time to DMARD could be calculated in 3 models, and rates of DMARD use were between 90% and 100%, with median time to DMARD of 0 days in each.

CONCLUSION

Our review has shown that even in models of care designed to improve access to care and early treatment, data to document improvements are often lacking. Where data were available for measuring, deficits in WT performance were noted for some centers. Our results highlight a need to improve reporting processes to drive quality improvement.

Effectiveness, Complications, and Costs of Rheumatoid Arthritis Treatment with Biologics in Alberta: Experience of Indigenous and Non-indigenous Patients

OBJECTIVE

To examine clinical effectiveness, treatment complications, and healthcare costs for indigenous and non-indigenous Albertans with rheumatoid arthritis (RA) participating in the Alberta Biologics Pharmacosurveillance program.

METHODS

Patients initiating biologic therapy in Alberta (2004-2012) were characterized for disease severity and treatment response. Provincial hospitalization separations, physician claims, outpatient department data, and emergency department data were used to estimate treatment complication event rates and healthcare costs.

RESULTS

Indigenous patients (n = 90) presented with higher disease activity [mean 28-joint count Disease Activity Score (DAS28) 6.11] than non-indigenous patients (n = 1400, mean DAS28 5.19, p < 0.0001). Improvements in DAS28, function, swollen joint count, CRP, and patient and physician global evaluation scores were comparable to non-indigenous patients, but indigenous patients did not have a significant improvement in erythrocyte sedimentation rate (-0.31 per month, 95% CI -0.79 to 0.16, p = 0.199). At the end of study followup, 13% (12/90) of indigenous and 33% (455/1400) of non-indigenous patients were in DAS28 remission (p < 0.001). Indigenous patients had a 40% increased risk of all-cause hospitalization [adjusted incidence rate ratio (IRR) 1.4, 95% CI 1.1-1.8, p = 0.01] and a 4-fold increase in serious infection rate (adjusted IRR 4.0, 95% CI 2.3-7.0, p < 0.001). Non-indigenous patients incurred higher costs for RA-related hospitalizations (difference $896, 95% CI 520-1273, p < 0.001), and outpatient department visits (difference $128, 95% CI 2-255, p = 0.047).

CONCLUSION

We identified disparities in treatment outcomes, safety profiles, and patient-experienced effects of RA for the indigenous population in Alberta. These disparities are critical to address to facilitate and achieve desired RA outcomes from individual and population perspectives.

Patient-reported Outcomes, Resource Use, and Social Participation of Patients with Rheumatoid Arthritis Treated with Biologics in Alberta: Experience of Indigenous and Non-indigenous Patients

OBJECTIVE

To characterize patient-reported outcomes, resource use, and social participation during the course of biologic therapy for indigenous and non-indigenous patients with rheumatoid arthritis (RA).

METHODS

Patients initiating biologic therapy (2004 to 2012) were characterized longitudinally for patient-reported outcomes including physical function measured by the Health Assessment Questionnaire, EQ-5D, well-being [Medical Outcomes Study Short Form-36 (SF-36)], and visual analog scales for pain, fatigue, sleep, stiffness, and patient's global assessment. Resource use, participation in activities of daily living, and effect of RA on work productivity were also evaluated for change during therapy.

RESULTS

Indigenous patients (n = 90) presented with significantly worse scores for global evaluation, pain, sleep, quality of life, well-being, and physical function compared to non-indigenous patients (n = 1400). All patient-reported outcomes improved significantly during treatment for patients in both groups, but pain, sleep, and SF-36 physical health score changes occurred at slower rates for indigenous patients [difference in slopes 0.09 (p = 0.029), 0.08 (p = 0.043), and -0.35 (p = 0.03), respectively]. Performance of daily activities was affected for 50% of indigenous compared to 37% of non-indigenous patients, with more use of community services and assistance from others. Employed indigenous patients reported twice the number of days being unable to work owing to RA compared to employed non-indigenous patients. Of the unemployed indigenous patients, 82% indicated they had stopped working because of arthritis, versus 48% of non-indigenous patients (p < 0.0001).

CONCLUSIONS

Indigenous patients have greater consequences of RA regarding experienced symptoms, health-related quality of life, disruption of performance of activities of daily living, and reduced employment participation.

Mortality causes and outcomes in Indigenous populations of Canada, the United States, and Australia with rheumatic disease: A systematic review

BACKGROUND

Indigenous populations of Canada, America, Australia, and New Zealand have increased rates and severity of rheumatic disease. Our objective was to summarize mortality outcomes and explore disease and social factors related to mortality.

METHODS

A systematic search was performed in medical (Medline, EMBASE, and CINAHL), Indigenous and conference abstract databases (to June 2015) combining search terms for Indigenous populations and rheumatic diseases. Studies were included if they reported measures of mortality (crude frequency, mortality rate, survival, and potential years of life lost (PYLL)) in Indigenous populations from the four countries.

RESULTS

Of 5269 titles and abstracts identified, 504 underwent full-text review and 12 were included. No studies from New Zealand were found. In five Canadian studies of systemic lupus erythematosus (SLE) patients, First Nations ethnicity was associated with lower survival after adjusting for disease and social factors, and an increased frequency of death from lupus and its complications compared to Caucasians was found. All-cause mortality was higher in Native Americans (n = 2 studies) relative to Whites with SLE after adjusting for disease and social factors, but not in those with lupus nephritis alone. Australian Aborigines with SLE frequently developed infection and lupus complications leading to death (n = 3 studies). Mortality rates were increased in Pima Indians in the United States with rheumatoid arthritis (RA) compared to those without RA. One study in Native Americans with scleroderma found nearly all deaths were related to progressive disease.

CONCLUSIONS

Canadian and American Indigenous populations with SLE have increased mortality rates compared to Caucasian populations. Mortality in Canadian and Australian Indigenous populations with SLE, and in Native American populations with RA and scleroderma, is frequently attributed to disease progression or complications. The proportional attribution of rheumatic disease severity and social factors to mortality and complications leading to death between Indigenous and non-Indigenous populations has not been fully evaluated.