[Show abstract][Hide abstract] ABSTRACT: To develop a list of 5 tests or treatments used in rheumatology that have evidence indicating that they may be unnecessary and thus should be reevaluated by rheumatology healthcare providers and patients.
Using the Delphi method, a committee of 16 rheumatologists from across Canada and an allied health professional generated a list of tests, procedures, or treatments in rheumatology that may be unnecessary, nonspecific, or insensitive. Items with high content agreement and perceived relevance advanced to a survey of Canadian Rheumatology Association (CRA) members. CRA members ranked these top items based on content agreement, effect, and item ranking. A methodology subcommittee discussed the items in light of their relevance to rheumatology, potential effect on patients, and the member survey results. Five candidate items selected were then subjected to a literature review. A group of patient collaborators with rheumatic diseases also reviewed these items.
Sixty-four unique items were proposed and after 3 Delphi rounds, this list was narrowed down to 13 items. In the member-wide survey, 172 rheumatologists responded (36% of those contacted). The respondent characteristics were similar to the membership at large in terms of sex and geographical distribution. Five topics (antinuclear antibodies testing, HLA-B27 testing, bone density testing, bone scans, and bisphosphonate use) with high ratings on agreement and effect were chosen for literature review.
The list of 5 items has identified starting points to promote discussion about practices that should be questioned to assist rheumatology healthcare providers in delivering high-quality care.
The Journal of Rheumatology 02/2015; 42(4). DOI:10.3899/jrheum.141140 · 3.17 Impact Factor
[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.
[Show abstract][Hide abstract] 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.
BMJ Open 03/2013; 3(3). DOI:10.1136/bmjopen-2012-002267 · 2.06 Impact Factor
[Show abstract][Hide abstract] 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; 40(4). DOI:10.3899/jrheum.120096 · 3.17 Impact Factor
[Show abstract][Hide abstract] 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; 39(11). DOI:10.3899/jrheum.120100 · 3.17 Impact Factor
[Show abstract][Hide abstract] 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. DOI:10.1186/1472-6920-11-65 · 1.41 Impact Factor
[Show abstract][Hide abstract] 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. DOI:10.3899/jrheum.110249 · 3.17 Impact Factor
[Show abstract][Hide abstract] 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 05/2011; 33(5):e227-35. DOI:10.3109/0142159X.2011.557412 · 2.05 Impact Factor
[Show abstract][Hide abstract] 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.
[Show abstract][Hide abstract] 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.
[Show abstract][Hide abstract] 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. DOI:10.3899/jrheum.080308 · 3.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine the degree to which documented knee osteoarthritis (OA) care in a teaching rheumatology clinic corresponds to evidence-based treatment guidelines.
The charts of 105 randomly selected patients meeting criteria for knee OA were reviewed. The patients received care from 3 rheumatologists working in a major Canadian teaching center between 2002 and 2005. The chart abstraction tool was based on European League Against Rheumatism, American College of Rheumatology, and The Arthritis Society guidelines for OA treatment. Descriptive statistics were used for patient demographics and the proportion of patients receiving recommended care.
The most frequently recommended nonpharmacologic treatments were any kind of exercise (58.1%), weight loss in those overweight (50.0%), physiotherapy (42.9%), and strengthening exercise (40.0%). Other nonpharmacologic treatments were documented in less than 30% of patient charts. The most frequently prescribed pharmacologic treatments were acetaminophen (68.6%), intraarticular (IA) corticosteroids (65.7%), nonsteroidal antiinflammatory drugs/cyclooxygenase-2-selective inhibitors (COXIB; 50.5%), and IA hyaluronans (43.8%). Topical pharmaceuticals, glucosamine/chondroitin, and opioid analgesics were recommended to less than 20% of the patients. Exploratory analyses suggested the following factors may be associated with increased documentation of recommended care: female sex, younger age, overweight, more clinic visits, decreased symptom length, and the individual rheumatologist.
Nonpharmacologic knee OA treatments currently recommended by practice guidelines were seldom documented in patients' charts in this Canadian rheumatology teaching center. These findings are similar to studies conducted before the practice guidelines became available and to results reported from general practices. This suggests the need for reminder systems or other strategies to promote physician adherence to current guidelines.
The Journal of Rheumatology 11/2007; 34(10):2099-105. · 3.17 Impact Factor
[Show abstract][Hide abstract] 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.
[Show abstract][Hide abstract] ABSTRACT: Hyperbaric oxygen therapy (HBOT) has been used to treat refractory wounds for the last several decades, with the majority of research focusing on wounds secondary to arterial insufficiency. We describe 2 patients with scleroderma with intractable bilateral extremity ulcers. Local ischemia was identified using transcutaneous oximetry. Each patient then underwent 30 treatments of HBOT at a relative depth of 2.4 ATA with resulting wound healing. This is the first reported successful use of HBOT to treat scleroderma ulcers, and may represent an unrecognized treatment option for these notoriously difficult chronic wounds.
The Journal of Rheumatology 09/2006; 33(8):1694-6. · 3.17 Impact Factor
[Show abstract][Hide abstract] 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. DOI:10.1016/j.joca.2004.10.016 · 4.66 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate a community-based educational intervention designed to improve the diagnosis and treatment of arthritis in primary care.
The educational intervention, entitled "Getting a Grip on Arthritis", consisted of a 2-day workshop and followup reinforcement activities for healthcare providers (providers) and was supported by a toolkit of written materials for providers and clients. The content of the intervention was designed around 10 arthritis best practices derived from published arthritis guidelines. Five community health centers (CHC) participated as intervention sites and 2 as control sites. Intervention impact was determined through a mailed survey to clients with arthritis. Primary outcome analysis compared responses to questions about arthritis best practices between intervention and control sites at baseline and followup.
The workshop was attended by 21 multidisciplinary providers from intervention CHC. At baseline, 423 of 624 eligible and consenting clients completed the survey and 376 of 593 completed the followup survey. At followup clients in the intervention group reported significantly higher referrals to The Arthritis Society therapy program, and were more often provided information on type of arthritis, medications and their side effects, disease management strategies, and arthritis community resources.
This demonstration project is one of the first to show changes in the management of arthritis in a primary care setting. This project has recently received funding from Health Canada's Primary Health Care Transition Fund for implementation across Canada and is expected to provide a template for use in other chronic diseases.
The Journal of Rheumatology 02/2005; 32(1):137-42. · 3.17 Impact Factor