Mary J Bell

Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada

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Publications (13)38.48 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives. To determine the comprehensibility, internal consistency, test-retest reliability and discriminative properties of an early inflammatory arthritis (IA) detection tool.Methods. Four groups were recruited from outpatient clinics at two tertiary care hospitals: early IA, established IA, non-IA musculoskeletal conditions (MSK) and non-MSK. Participants attended a study visit where they completed the 11-item tool with binary yes/no response options. Comprehensibility was assessed for each tool item on a 5-point Likert scale. For test-retest assessment, the tool was mailed to participants following a 2-week recall washout interval. Two items were randomly selected to test internal consistency. Discriminative properties compared tool item responses with blinded rheumatologist clinical assessments. A previously developed rheumatology triage algorithm was externally validated.Results. A total of 170 participants were enrolled in the study. Comprehensibility approached unity for all tool items. The internal consistency Kuder-Richardson Formula 20 was 0.985 (P < 0.0001). The mean test-retest reliability kappa (s.d.) was 0.81 (0.02). The intraclass correlation coefficient (ICC) (95% CI) for summed yes responses between test and retest phases was 0.94 (0.93, 0.95) and for algorithm scores was 0.97 (0.96, 0.98). Patient responses were significantly associated with the corresponding clinical evaluations (P < 0.0001, respectively). The sum of yes responses and rheumatology triage algorithm scores both differentiated early IA from each of the other three groups (P < 0.004, respectively). The scoring algorithm receiver operating characteristic plot area under the curve (s.e.) was 0.829 (0.003).Conclusion. The tool has favourable measurement and discriminative properties. The discriminative properties of the rheumatology triage scoring algorithm were externally validated.
    Rheumatology (Oxford, England) 08/2013; · 4.24 Impact Factor
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    ABSTRACT: OBJECTIVE: The benefits of early intensive treatment of inflammatory arthritis (IA) are dependent on timely and accurate case identification. In our study, a scoring algorithm for a self-administered IA detection tool was developed and validated for the rheumatology triage clinical setting. METHODS: A total of 143 consecutive consenting adults, newly referred to 2 outpatient rheumatology practices, completed the tool. A scoring algorithm was derived from the best-fit logistic regression model using age, sex, and responses to the 12 tool items as candidate predictors of the rheumatologists' blinded classification of IA. Bootstrapping was used to internally validate and refine the model. RESULTS: The 30 IA cases were younger than the 113 non-cases (p < 0.0001) and included clinical diagnoses of early IA (n = 10), rheumatoid arthritis (n = 9), and spondyloarthropathies (n = 11). Non-cases included osteoarthritis (n = 46), pain syndromes (n = 19), systemic lupus erythematosus (n = 5), and miscellaneous, noninflammatory musculoskeletal complaints (n = 43). The best-fit model included younger age, male sex, "trouble making a fist," "morning stiffness," "ever told you have RA," and "psoriasis diagnosis." The overall predictive performance (standard error, SE) of the derivation model was 0.91 (0.03). Internal validation of the derivation model across 200 bootstrap samples resulted in a mean predictive performance (SE) of 0.904 (0.002). The refined tool had a mean predictive performance (SE) of 0.915 (0.002), a sensitivity of 0.855 (0.005), and specificity of 0.873 (0.003). CONCLUSION: A simple, self-administered tool was developed and internally validated for the sensitive and specific detection of IA in a rheumatology waiting list sample. The tool may be used to triage IA from rheumatology referrals.
    The Journal of Rheumatology 02/2013; · 3.26 Impact Factor
  • Journal of clinical rheumatology: practical reports on rheumatic & musculoskeletal diseases 01/2013; 19(1):54. · 1.19 Impact Factor
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    ABSTRACT: To examine the feasibility and potential benefits of early peer support to improve the health and quality of life of individuals with early inflammatory arthritis (EIA). Feasibility study using the 2008 Medical Research Council framework as a theoretical basis. A literature review, environmental scan, and interviews with patients, families and healthcare providers guided the development of peer mentor training sessions and a peer-to-peer mentoring programme. Peer mentors were trained and paired with a mentee to receive (face-to-face or telephone) support over 12 weeks. Two academic teaching hospitals in Toronto, Ontario, Canada. Nine pairs consisting of one peer mentor and one mentee were matched based on factors such as age and work status. Mentee outcomes of disease modifying antirheumatic drugs (DMARDs)/biological treatment use, self-efficacy, self-management, health-related quality of life, anxiety, coping efficacy, social support and disease activity were measured using validated tools. Descriptive statistics and effect sizes were calculated to determine clinically important (>0.3) changes. Peer mentor self-efficacy was assessed using a self-efficacy scale. Interviews conducted with participants examined acceptability and feasibility of procedures and outcome measures, as well as perspectives on the value of peer support for individuals with EIA. Themes were identified through constant comparison. Mentees experienced improvements in the overall arthritis impact on life, coping efficacy and social support (effect size >0.3). Mentees also perceived emotional, informational, appraisal and instrumental support. Mentors also reported benefits and learnt from mentees' fortitude and self-management skills. The training was well received by mentors. Their self-efficacy increased significantly after training completion. Participants' experience of peer support was informed by the unique relationship with their peer. All participants were unequivocal about the need for peer support for individuals with EIA. The intervention was well received. Training, peer support programme and outcome measures were demonstrated to be feasible with modifications. Early peer support may augment current rheumatological care. NCT01054963, NCT01054131.
    BMJ Open 01/2013; 3(3). · 1.58 Impact Factor
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    ABSTRACT: OBJECTIVE: To determine the proportion of patients with rheumatoid arthritis (RA) under rheumatologic care treated with disease-modifying antirheumatic drugs (DMARD) within 6 months from symptom onset and the components of time to treatment and its predictors. METHODS: A historical inception cohort of 339 patients with RA randomly selected from 18 rheumatology practices was audited. The proportion that initiated DMARD treatment within 6 months from symptom onset was estimated using Kaplan-Meier analysis. Time to each component of the care pathway was estimated. Multivariable modeling was used to determine predictors of early treatment using 12 preselected variables available in the clinical charts. Bootstrapping was used to validate the model. RESULTS: Within 6 months from symptom onset, 41% (95% CI 36%-46%) of patients were treated with DMARD. The median time to treatment was 8.4 (interquartile range 3.8-24) months. Events preceding rheumatology referral accounted for 78.1% of the time to treatment. The most prominent predictor of increased time to treatment was a concomitant musculoskeletal condition, such as osteoarthritis or fibromyalgia. The significance of other variables was less consistent across the models investigated. Included variables accounted for 0.69 ± 0.03 of the variability in the model. CONCLUSION: Fewer than 50% of patients with RA are treated with DMARD within 6 months from symptom onset. Time to referral to rheumatology represents the greatest component delay to treatment. Concomitant musculoskeletal condition was the most prominent predictor of delayed initiation of DMARD. Implications of these and other findings warrant further investigation.
    The Journal of Rheumatology 08/2012; · 3.26 Impact Factor
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    ABSTRACT: Despite the high burden of musculoskeletal (MSK) diseases, few generalists are comfortable teaching MSK physical examination (PE) skills. Patient Partners® in Arthritis (PP®IA) is a standardized patient educator program that could potentially supplement current MSK PE teaching. This study aims to determine if differences exist in MSK PE skills between non-MSK specialist physician and PP®IA taught students. Pre-clerkship medical students attended 2-hour small group MSK PE teaching by either non-MSK specialist physician tutors or by PP®IA. All students underwent an MSK OSCE and completed retrospective pre-post questionnaires regarding comfort with MSK PE and interest in MSK. 83 students completed the OSCE (42 PP®IA, 41 physician taught) and 82 completed the questionnaire (42 PP®IA, 40 physician taught). There were no significant differences between groups in OSCE scores. For all questionnaire items, post-session ratings were significantly higher than pre-session ratings for both groups. In exploratory analysis PP®IA students showed significantly greater improvement in 12 of 22 questions including three of five patient-centred learning questions. PP®IA MSK PE teaching is as good as non-MSK specialist physician tutor teaching when measured by a five station OSCE and provide an excellent complementary resource to address current deficits in MSK PE teaching.
    BMC Medical Education 09/2011; 11:65. · 1.41 Impact Factor
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    ABSTRACT: To describe early rheumatologic management for newly diagnosed rheumatoid arthritis (RA) in Canada. A retrospective cohort of 339 randomly selected patients with RA diagnosed from 2001-2003 from 18 rheumatology practices was audited between 2005-2007. The most frequent initial disease-modifying antirheumatic drugs (DMARD) included hydroxychloroquine (55.5%) and methotrexate (40.1%). Initial therapy with multiple DMARD (15.6%) or single DMARD and corticosteroid combinations (30.7%) was infrequent. Formal assessment measures were noted infrequently, including the Health Assessment Questionnaire (34.6%) and Disease Activity Score for 28 joints (8.9%). Initial pharmacotherapy is consistent with guidelines from the period. The infrequent reporting of multiple DMARD combinations and formal assessment measures has implications for current clinical management and warrants contemporary reassessment.
    The Journal of Rheumatology 09/2011; 38(11):2342-5. · 3.26 Impact Factor
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    ABSTRACT: Musculoskeletal (MSK) complaints comprise 12-20% of primary healthcare; however, practicing physicians' MSK physical examination (PE) skills are weak. Further, there is a shortage of specialists able to effectively teach this subject. Previous evaluations of patient educators have yielded mixed results. The aim of this study is to document how teaching by patient educators and physician tutors in MSK PE skills differs. A qualitative researcher observed, video-recorded, and took notes during preclerkship MSK PE teaching sessions given by patient educators or physician tutors. The researcher identified themes which were evaluated by collective case study methods. Two patient educator and four physician groups were evaluated. The patient educators were more consistent regarding content and style than the physicians. There appeared to be a continuum in teaching organization from patient educator to novice physician tutors to experienced physician tutors. The patient educators consistently covered all major joints (physicians did not); physicians were more likely to request verbalization of actions, relate findings to history, receive questions, and use opportunistic teaching moments. Understanding preclerkship MSK teaching by patient educators compared to physician tutors is necessary for appropriate targeting of the existing Patient Partners® in Arthritis patient educator program and to guide the development of future MSK teaching initiatives.
    Medical Teacher 01/2011; 33(5):e227-35. · 1.82 Impact Factor
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    ABSTRACT: Interrater variability limits rheumatologic opinion as a reference standard for early inflammatory arthritis (IA) classification. The study objectives were to determine whether rheumatologic opinion is associated with potential early IA classification methods despite high interrater variability, and to compare the relative strengths of those associations. Eighteen rheumatologists independently classified 30 initial rheumatology presentation summaries as early IA or not and recommended a pharmacotherapy. Case fulfillment of the following classification methods was independently determined: early referral to rheumatology recommendation for rheumatoid arthritis (ERRR), common early IA cohort inclusion criteria (CEAC), and prevalent IA classification criteria (American College of Rheumatology [ACR]/European Spondylarthropathy Study Group [ESSG]). Associations between rheumatologic opinion, disease-modifying antirheumatic drug (DMARD) recommendation, and each classification method were determined. Participating rheumatologists published on early IA and represented 3 continents. The median case was age 43 (interquartile range [IQR] 30-53) years, had 40 (IQR 24-104) weeks of symptoms, 60 (IQR 18-120) minutes of morning stiffness, a swollen joint count of 6 (IQR 1-13), and an erythrocyte sedimentation rate of 25 (IQR 10-51) mm/hour. The mean ± SD multiple-rater kappa for rheumatologic opinion on early IA was 0.16 ± 0.02. The common odds ratios for associations between rheumatologic opinion and ERRR, CEAC, and ACR/ESSG were 10.3 (95% confidence interval [95% CI] 4.6-23.2), 4.4 (95% CI 2.5-7.7), and 0.7 (95% CI 0.4-1.1), respectively. Odds ratios for associations between DMARD recommendation and ERRR, rheumatologic opinion, CEAC, and ACR/ESSG were 18.7 (95% CI 8.1-43.2), 10.6 (95% CI 6.0-18.8), 2.8 (95% CI 1.7-4.6), and 0.5 (95% CI 0.3-0.7), respectively. Classification methods can be used to harmonize rheumatologic opinion of early IA despite high interrater variability. The ERRR is very strongly associated with both rheumatologic opinions of early IA and DMARD treatment recommendations.
    Arthritis care & research. 10/2010; 62(10):1407-14.
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    ABSTRACT: The ability of the Bellamy et al. Low-Intensity Symptom State-attainment (BLISS) Index to differentiate between treatment groups (hylan G-F 20 vs. appropriate care) at low and very low levels of state attainment in patients with knee osteoarthritis was explored using the stiffness, function, and total index (TI) components of the WOMAC. Six different BLISS measures were analyzed using five WOMAC score thresholds: <or=5 normalized units (NUs): <or=10, <or=15, <or=20, and <or=25 (lower=better health). More patients in the hylan G-F 20 group achieved BLISS states in all three WOMAC subscales for all six BLISS analyses. These differences were statistically significant for the BLISS response at any time at all threshold levels except </=5NU. The six BLISS measures and threshold levels of stiffness, function, and TI score were able to statistically discriminate between treatment groups. BLISS-10 is a therapeutically attainable very low symptom state at which clinically important statistically significant between-group differences are detectable in pain, stiffness, function, and TI score and therefore may provide a benchmark against which therapeutic interventions can be assessed. However, the value to patients of these symptom states requires further elaboration.
    Journal of clinical epidemiology 11/2009; 63(5):566-74. · 5.48 Impact Factor
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    ABSTRACT: Musculoskeletal (MSK) complaints have high prevalence in primary care practice (12%-20% of visits), yet many trainees and physicians identify themselves as weak in MSK physical examination (PE) skills. As recruitment to MSK specialties lags behind retirement rates, there is a shortage of physicians able to effectively teach this subject. We investigated current practices of Canadian undergraduate medical programs regarding the nature, amount, and source of preclerkship MSK PE clinical skills teaching; and documented the frequency and extent that Patient Partners in Arthritis (PPIA) are used in this educational setting. A 2-page self-administered electronic questionnaire combining open- and close-ended questions was developed and piloted. It was distributed by e-mail to all Canadian undergraduate associate-deans and to 16/17 undergraduate MSK course organizers. Supervised practice in small groups and the PPIA are the most prevalent teaching methods. Objective structured clinical examinations are the most prevalent evaluation methods. The average number of hours devoted to teaching these skills is very small compared to the prevalence of MSK complaints in the population. Canadian schools' preclerkship MSK PE clinical skills teaching is heavily dependent on the contributions of non-MSK specialists. The weak link in the Canadian MSK PE educational cycle appears to be the amount of time available for students' deliberate practice with expert feedback. There is a need for methods to evaluate and further develop MSK PE teaching by non-MSK specialists. This and increased use of PPIA at the preclerkship level may provide students more time for practice with feedback.
    The Journal of Rheumatology 11/2008; 35(12):2419-26. · 3.26 Impact Factor
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    ABSTRACT: Different pain thresholds were investigated, using the WOMAC Pain Scale (WOMAC-P) to determine if they could differentiate between treatment groups (hylan G-F 20 vs. appropriate care) at low and very low levels of state attainment in patients with knee osteoarthritis (OA). A method, termed the BLISS (Bellamy et al. Low Intensity Symptom State-attainment) Index, for analyzing OA knee clinical trials data, was proposed. Five analyses were performed: time to first BLISS day, BLISS days over 12 months, patients with a BLISS response at month 12, patients with a BLISS response at any time, and number of BLISS periods over 12 months. For each analysis, five levels of WOMAC-P were examined: <or=5 normalized units (NU), <or=10, <or=15, <or=20, and <or=25 (higher=more pain). More patients in the hylan G-F 20 group achieved BLISS states in all five analyses. These differences were statistically significant for all pain threshold levels except <or=5 NU. Five methods of measuring BLISS attainment using four prespecified threshold levels of pain were able to statistically discriminate between treatment groups. This method may potentially provide an approach, to defining which patients not only improve but also achieve a good state of health, at low and very low levels of pain intensity. BLISS-10 is a therapeutically attainable very low symptom state at which clinically important, statistically significant between-group differences are detectable, and therefore may provide a benchmark against which therapeutic interventions can be assessed. However, the value to patients, of this and other low and very low intensity pain states, requires further elaboration.
    Journal of Clinical Epidemiology 03/2007; 60(2):124-32. · 5.48 Impact Factor
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    ABSTRACT: Secondary analyses of a previously conducted 1-year randomized controlled trial were performed to assess the application of responder criteria in patients with knee osteoarthritis (OA) using different sets of responder criteria developed by the Osteoarthritis Research Society International (OARSI) (Propositions A and B) for intra-articular drugs and Outcome Measures in Arthritis Clinical Trials (OMERACT)-OARSI (Proposition D). Two hundred fifty-five patients with knee OA were randomized to "appropriate care with hylan G-F 20" (AC+H) or "appropriate care without hylan G-F 20" (AC). A patient was defined as a responder at month 12 based on change in Western Ontario and McMaster Universities Osteoarthritis Index pain and function (0-100 normalized scale) and patient global assessment of OA in the study knee (at least one-category improvement in very poor, poor, fair, good and very good). All propositions incorporate both minimum relative and absolute changes. Results demonstrated that statistically significant differences in responders between treatment groups, in favor of hylan G-F 20, were detected for Proposition A (AC+H=53.5%, AC=25.2%), Proposition B (AC+H=56.7%, AC=32.3%) and Proposition D (AC+H=66.9%, AC=42.5%). The highest effectiveness in both treatment groups was observed with Proposition D, whereas Proposition A resulted in the lowest effectiveness in both treatment groups. The treatment group differences always exceeded the required 20% minimum clinically important difference between groups established a priori, and were 28.3%, 24.4% and 24.4% for Propositions A, B and D, respectively. This analysis provides evidence for the capacity of OARSI and OMERACT-OARSI responder criteria to detect clinically important statistically detectable differences between treatment groups.
    Osteoarthritis and Cartilage 03/2005; 13(2):104-10. · 4.26 Impact Factor

Publication Stats

59 Citations
38.48 Total Impact Points

Institutions

  • 2013
    • Sunnybrook Health Sciences Centre
      • Division of Rheumatology
      Toronto, Ontario, Canada
  • 2010–2013
    • McMaster University
      Hamilton, Ontario, Canada
  • 2005–2011
    • University of Toronto
      • Sunnybrook Health Sciences Centre
      Toronto, Ontario, Canada