Private Rheumatology Practices Research Articles

AB0224 Treating rheumatoid arthritis to target: a singapore survey

BackgroundIn recent years, the treatment paradigm for rheumatoid arthritis (RA) has changed significantly. Treat to Target (T2T) is a global initiative that aims to provide guidance to treat RA to...

THU0248 Patient-Oriented Decision of Early Treatment of Rheumatoid Arthritis with Combination of Triple Conventional Disease Modifying Anti-Rheumatic Drugs or Tumor Necrosis Factor Inhibitors and Methotrexate (Prospective, Open-Label Clinical Trial)

BackgroundEarly optimization of conventional disease modifying anti-rheumatic drugs (cDMARD) treatment is imperative as delay of biologics in certain patients can lead to irreversible functional disability. Bucillamine (BUC) is a unique...

AB0524 Design characteristics of the corrona certain study: A US comparative effectiveness and biomarker study of rheumatoid arthritis biologic agents

BackgroundBiologic agents have revolutionised the treatment of rheumatoid arthritis (RA). Few comparative, long-term data on treatment effectiveness and safety in the real world exist for patients typically seen in clinical...

FRI0170 Effect of alcohol on response to therapy with TNF-a inhibitors for rheumatoid arthritis: Results from corrona registry

BackgroundTNF-α inhibitors (TNFi) have revolutionized the therapy of Rheumatoid Arthritis (RA). However, up to 30% of patients (pts) fail to respond to treatment (tx) with TNFi or respond inadequately. While...

SAT0147 Effect of smoking on response to therapy with TNF-A inhibitors for rheumatoid arthritis: Results from the corrona registry

BackgroundTNF-a inhibitors (TNFi) have revolutionized the therapy of Rheumatoid Arthritis (RA). However, up to 30% of patients fail to respond to treatment (tx) with TNFi or respond inadequately. Factors affecting...

AB0169 Type of rheumatology practice is an important determinant of treatment delay in flanders

BackgroundThe time between symptom onset and treatment initiation is determined by patient-, disease- and physician-related factors but also by differences in healthcare organization and referral pathways across various countries.ObjectivesTo explore...

PMS47 The Health and Economic Consequences of Delay in Starting Disease-Modifying Antirheumatic Drugs (DMARDs) in Rheumatoid Arthritis

THE HEALTH AND ECONOMIC CONSEQUENCES OF DELAY IN STARTING DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDS) IN RHEUMATOID ARTHRITIS Van doornum S1, Roberts L2, Reed MD3, Liew D1 1The University of Melbourne, Parkville, Vic, Australia, 2James Cook University, Douglas, Queensland, Australia, 3Sir Charles Gairdiner Hospital, Nedlands, Western Australi, Australia OBJECTIVES: Several international studies suggest that the time between symptom onset and DMARD initiation in RA patients is longer than is considered optimal. We sought to assess the health economic impact of this delay in an Australian context. METHODS: The delay in DMARD initiation was estimated from a 2005 study of 96 Australian RA patients referred to one public and four private rheumatology practices. RA-associated utilities and costs were sourced from published data. Patients not taking and taking DMARD therapy were assumed to have utilities of 0.443 and 0.543, respectively. The annual direct costs of RA, excluding DMARDs, was AUD $3780, and of DMARD therapy was $2658. It was conservatively assumed that DMARD therapy did not reduce non-DMARD RA costs. RESULTS: In the 2005 study, the mean time from symptom onset to initiation of DMARD therapy was 1.48 years. Over this time a mean of 0.65 QALYs would have been lived per patient and $5579 of direct health care costs incurred. Had DMARDs been commenced at symptom onset, 0.80 QALYs would have been lived per patient, and $9503 of direct health care costs incurred. Hence early initiation of DMARDs would have saved 0.15 QALYs at a cost of $3924 per person, equating to an incremental cost-effectiveness ratio (ICER) of $26,583 per QALY saved. An additional $3400 could be spent per patient to reduce the time to DMARD initiation before the ICER breached the arbitrary cut-off of $50,000 per QALY saved. Our analysis was conservative in it did not consider the long-term health and cost savings associated with avoidance of permanent joint damage. CONCLUSIONS: The considerable delay in the initiation of DMARD therapy among patients with RA leads to significant health loss. Reducing the time to initiation of DMARDs represents a cost-effective means of reducing the burden of RA.

The point prevalence of clinically relevant primary Sjögren's syndrome in two Norwegian counties

Objective: Primary Sjögren's syndrome (PSS) is a chronic autoimmune inflammatory disease characterized by exocrine gland inflammation producing clinical symptoms such as dryness of the mouth and eyes. The reported prevalence of PSS is variable, probably because of different classification criteria used and selection bias. The aim of this study was to determine the prevalence of PSS in a well-defined Norwegian Caucasian population using the revised American–European Consensus Group (AECG) criteria.Methods: Three hospitals and three private rheumatology practices provide all of the rheumatology services to the local population in Hordaland and Rogaland counties, which included 852 342 Caucasian inhabitants as of 1 January 2009. Patients on file fulfilling the new revised AECG criteria for PSS were included, and patients with incomplete data were invited to a screening visit.Results: A total of 424 PSS patients were identified. Their mean age was 61.6 ± 13.2 years; 28 (7%) were men and 396 (93%) were women. The point estimate for the proportion of PSS was 0.050% [95% confidence interval (CI) 0.048–0.052].Conclusion: The prevalence of PSS in this Norwegian population of Caucasians is lower than previously reported when less stringent criteria for identifying PSS were used, but is in line with more recent studies using the same criteria and methods as in this study.

Methotrexate: long‐term safety and efficacy in an Australian consultant rheumatology practice

The aim of this study was to evaluate the rate and cause of methotrexate (MTX) termination in clinical practice, describe the types of toxicities noted, assess the incidence of achieving remission in rheumatoid arthritis (RA) patients and review the appropriateness of current clinical guidelines for monitoring MTX treatment. A retrospective, case review of patients seen in a private rheumatology practice attached to a major Sydney Teaching Hospital was undertaken over an 18-year period. The primary outcome was time to cessation of MTX. Seven hundred and ninety patients satisfied the inclusion criteria. MTX was terminated in 272 patients (34.4%). Toxicity-related discontinuation occurred in 93 patients (11.8%) and due to non-adverse reactions in 179 patients. The median duration of therapy in these two groups was 2.0 and 2.9 years, respectively. There was no difference in the average maximum weekly dose of MTX. Of patients with RA, 47.5% were in remission at last follow up. Cox proportional hazards analyses showed that those of the female sex remained on treatment significantly longer than the male sex (hazard ratio (HR) 0.73, 95% confidence interval (CI) 0.57-0.96; P = 0.014); patients with RA remained on treatment significantly longer than patients with seronegative arthritis (HR 0.56, 95%CI 0.42-0.74; P < 0.001). Being of the male sex aged more than 60 years and having a non-RA diagnosis predisposed to stopping MTX earlier. MTX is a safe and effective medication. Notable remission rates are achievable in patients with RA with current conventional treatment protocols. MTX has a low toxicity profile and this study stresses the need to re-evaluate and revise the current monitoring guidelines.

Belgian rheumatologists' perception on eligibility of RA patients for anti-TNF treatment matches more closely Dutch rather than Belgian reimbursement criteria

To assess discrepancies between perception of Belgian rheumatologists on eligibility of RA patients for anti-TNF treatment and Belgian reimbursement criteria and to compare Belgian with Dutch criteria and UK guidelines. Consecutive MTX-experienced patients with active RA were recruited from 25 private and academic rheumatology practices. Discrepancies between eligibility for anti-TNF treatment according to the rheumatologist and fulfillment of Belgian reimbursement criteria [HAQ > or =25%, tender joint count (TJC) and swollen joint count (SJC) > or =8; > or =1 erosion; failure of > or =2 DMARDs including MTX; no tuberculosis] were recorded. Reasons for failing the Belgian criteria and results of applying Dutch reimbursement criteria and UK guidelines on the dataset were analysed. Of 492 patients, rheumatologists considered 135 (27.4%) as eligible, whereas Belgian criteria were fulfilled for only 34 (6.9%). Positive predictive value (PPV) of rheumatologists' perception on eligibility for fulfillment of Belgian criteria was 22.9%, whereas negative predictive value (NPV) was 99.1%. The 104 patients (21.1%) considered eligible despite criteria not being fulfilled had significantly greater TJCs, SJCs, disease activity score (DAS28) and Rheumatoid Arthritis Disease Activity Index scores than the 385 patients (78.2%) in the no-discrepancy group. Number of swollen joints, HAQ and erosions mainly accounted for discrepancies. Of 492 patients, 263 (53.4%) qualified for Dutch criteria and 41 (8.3%) for UK guidelines. PPV of Belgian rheumatologists' perception was 72.6% for fulfilling Dutch criteria (NPV 49.6%) and 23.4% for UK guidelines (NPV 96.7%). Rheumatologists consider more RA patients eligible for anti-TNF treatment than would be reimbursed according to Belgian criteria. Dutch guidelines, based on DAS28, match more closely eligibility according to Belgian rheumatologists.

Frühdiagnose von Arthritiden und Spondyloarthritiden im Rahmen einer Integrierten Versorgung in Niedersachsen

In September 2005, the Collaborative Arthritis Center in Hannover, the Hannover Medical School, general practitioners, rheumatologists in private practice, the League against Rheumatism in Lower Saxony (Rheuma-Liga Niedersachsen, a regional patient self-help organization), the State Pension Authority (Deutsche Rentenversicherung Braunschweig-Hannover) and a health insurance fund (Kaufmännische Krankenkasse), in collaboration with the Physician's Association of Lower Saxony, entered a contract for integrated health care in rheumatology in Lower Saxony. The agreement aims at patients with early arthritis or spondyloarthritis. Through close collaboration between primary health care physicians and rheumatologists, the diagnosis of arthritis or spondyloarthritis should be made soon after disease manifestation and an adequate therapy initiated. The article describes the background and contents of the contract.

Access to pediatric rheumatology care in the United States

To describe rheumatology providers, depict their availability, and determine the extent to which internist rheumatologists may expand access to care for children with rheumatic diseases. Using data from the American College of Rheumatology and the Bureau of Health Professions Area Resource File, we generated a national map of providers' practice locations and calculated distances between each county and the nearest rheumatologist. We also performed a logit analysis to identify provider and county characteristics that were associated with internist rheumatologists' willingness to treat children. Approximately 50% of the under 18 population in the United States live within 50 miles of a pediatric rheumatologist and nearly 90% live within 50 miles of a pediatric rheumatologist or an internist rheumatologist who treats children. Internist rheumatologists in private practice were 3 times as likely as those in medical schools to treat children (P < 0.001). Likewise, internist rheumatologists who live 200 or more miles from a pediatric rheumatologist were more than twice as likely to treat children as those who lived within 10 miles of a pediatric rheumatologist (P < 0.001). Our analysis suggests that internist rheumatologists are more geographically diffuse than pediatric rheumatologists and act as substitutes for pediatric rheumatologists in those regions that lack such providers. Research is needed to understand the role of internist rheumatologists in caring for children with rheumatic diseases and the quality of the care that they provide to this population.

Poster 5: Predictors of fatigue in patients with rheumatoid arthritis and major depressive disorder

Objectives: To determine the relationship between fatigue and disease activity in persons with concomitant rheumatoid arthritis (RA) and major depressive disorder (MDD) and to replicate a previous study that found fatigue was predicted by higher levels of pain, more depressive symptoms, and female gender in a cohort of persons with RA who did not have MDD. Design: Prospective 15-month study using longitudinal data. Setting: Midwestern veterans’ hospital, university medical center, and private rheumatology practice. Participants: 54 subjects (39 women, 15 men) with diagnoses of RA and MDD. Intervention: All participants received a therapeutic dosage of sertraline for their body mass. Outcome measures were collected at 4 time periods: preintervention, and at 3, 6, and 15 months postintervention. Main Outcome Measures: Measures were as follows: Multidimensional Assessment of Fatigue, Center for Epidemiological Studies-Depression scale, pain visual analog scale, Arthritis Activity Today, erythrocyte sedimentation rate, and average sleep over a 3-month period. Results: A multiple regression with fatigue as the dependent variable and pain, depression, and female gender as independent variables demonstrated a replication of the previous study at baseline ( R 2=.19, P=.015), 3 months ( R 2=.30, P=.002), 6 months ( R 2=.55, P<.0001), and 15 months ( R 2=.52, P<.0001). However, the addition of disease activity and sleep variables in hierarchical fashion found that disease activity and sleep did not make significant contributions above and beyond the replicated model. Conclusions: In this cohort of patients with RA and MDD, higher levels of pain, more depressive symptoms, and female gender were significantly related to fatigue; subjective and objective measures of disease activity, as well as sleep, did not make additive contributions.

Rheumatology online: A survey among the members of the German Rheumatology Society

On behalf of the "Systemic Inflammatory Rheumatic Diseases Network" comprehensive, nationwide horizontal and vertical cross-linking of research and care is to be developed for the first time. The quality of scientific work and patient care is to be increased in the medium term through this improved communication and co-operation. Our objective was to determine what hardware and software are avail- able to the physicians involved, with a view to the Internet being used as a basis for communication and documentation within the network. A survey was carried out among 723 active members of the German Rheumatology Society (DGRh). Data on the hardware and software used and on Internet access were collected using a unilateral questionnaire. The response rate among the addressed rheumatologists was 55.3%, with 64.1% of members in private practice replying. Of those responding 85% have Internet access, with rheumatologists in private practice using the Internet significantly less frequently at work than those working at a hospital (42% vs 80%). The latter accordingly reported a higher proportion of medical Internet usage (69% vs 52%, p<0.001). The survey demonstrated that software for private practices and hospitals shows a very variable picture with a multiplicity of systems being used. Use of the Internet for communication in the "Systemic Inflammatory Rheumatic Diseases Network" is practicable in hospitals but clearly restricted in the private practice sector. The widely varying software used in hospitals and private practices underlines the need for standardized, comprehensive documentation systems to be developed. To ensure acceptance and broadly based application, they need to be integrated into the existing computer infrastructure. In this context, Internetbased applications offer new opportunities through the use of system-independent file formats.

Eligibility of patients in routine care for major clinical trials of anti-tumor necrosis factor alpha agents in rheumatoid arthritis.

To identify the proportion of patients with rheumatoid arthritis (RA) in 2 cohorts from Nashville, Tennessee, who met basic criteria for inclusion in 2 important recent clinical trials of anti-tumor necrosis factor alpha (anti-TNFalpha) agents, the early RA (ERA) trial of etanercept versus methotrexate, and the anti-TNFalpha trial in RA with concomitant therapy (ATTRACT) study of infliximab plus methotrexate versus methotrexate. Two cohorts of patients, all of whom had met the American College of Rheumatology criteria for RA at some time, were studied. Cohort E (early) comprised 232 patients who were under the care of 5 private practice rheumatologists, whose duration of RA was fewer than 3 years, and who were reviewed for basic inclusion criteria for the ERA clinical trial. Cohort L (long-term) comprised 152 consecutive patients who had been under care at a weekly academic rheumatology clinic for a mean of 4.5 years, and were reviewed for basic inclusion criteria for the ATTRACT study. In cohort E, basic inclusion criteria for the ERA trial were met by 11 of 36 patients (31%) who had not taken methotrexate, 8 of 19 patients (42%) who were at their first visit and had not taken methotrexate, and 37 of all 232 patients (16%). In cohort L, 5% of patients met the basic inclusion criteria for the ATTRACT study. Most patients who were seen in routine care in these 2 cohorts did not meet the criteria for inclusion in these 2 important recent clinical trials. The conclusion that anti-TNFalpha therapy has greater efficacy than methotrexate may be valid only in a limited number of patients with the most severe RA. Anti-TNFalpha therapy may be desirable in most patients with RA, but this possibility has not been studied formally. Criteria for inclusion in RA clinical trials might be modified for greater generalizability of results.

Effects of Intercessory Prayer on Patients With Rheumatoid Arthritis

Many individuals pray during times of illness, but the clinical effects of prayer are not well-understood. We prospectively studied a cohort of 40 patients (mean age, 62 years; 100% white; 82% women) at a private rheumatology practice. All had class II or III rheumatoid arthritis and took stable doses of antirheumatic medications. All received a 3-day intervention, including 6 hours of education and 6 hours of direct-contact intercessory prayer. Nineteen randomly selected sample patients had 6 months of daily, supplemental intercessory prayer by individuals located elsewhere. Ten arthritis-specific outcome variables were measured at baseline and at 3-month intervals for 1 year. Patients receiving in-person intercessory prayer showed significant overall improvement during 1-year follow-up. No additional effects from supplemental, distant intercessory prayer were found. In-person intercessory prayer may be a useful adjunct to standard medical care for certain patients with rheumatoid arthritis. Supplemental, distant intercessory prayer offers no additional benefits.

Characteristics of rheumatoid arthritis patients: who participates in long-term research and who drops out?

A 10-year study of rheumatoid arthritis (RA) patients was conducted to identify characteristics associated with continued participation in a long-term research project. Nine hundred eighty-eight RA patients were recruited from 56 private rheumatology practices. Over the course of the study, 45 patients died and were eliminated from the analysis. Patients were interviewed by phone each year for 10 years, and their physicians provided clinical data. Variables measured included demographic characteristics, perceived health status, employment status, family responsibilities, social support, and clinical health status. Forty-six percent of patients remained in the study after 10 years. Survival analysis using Cox regression techniques assessed baseline factors that significantly predicted characteristics of patients who remained in the study. The multivariate analysis found that more educated patients, female patients, those with moderate to high levels of social support, patients having fewer joint groups with flares, and employed patients were more likely to remain in the study. Disease characteristics of stage of disease, level of pain, self-reported level of physical disability, and duration of RA were not significantly associated with continued study participation. The results suggest that psychosocial and socioeconomic factors are more important determinants of continued participation in long-term research studies than are most clinical disease characteristics. Among clinical variables, only the active disease characteristic of joint flares predicted continued study participation. Overall disease characteristics such as disease stage or duration did not predict subject attrition.

Frequency of sepsis after local corticosteroid injection (an inquiry on 1160000 injections in rheumatological private practice in France).

The principal aims of this study were to determine the frequency of sepsis after local corticosteroid injection (SALCSI), to compare the results with those of the literature and to determine the main factors leading to a decrease in the frequency of SALCSI. A retrospective study was conducted among 69 rheumatologists in private practice. Sixteen items were studied and are reported. The mean number of years of private practice in rheumatology was 20.9. The total number of CS injections (CSI) was 1160000 for an average of 809 CSI per year and per therapist. The mean number of CSI performed by one rheumatologist was 16 800. Fifteen SALCSI had occurred, which corresponds to a frequency of 1/77300 CSI. The rate of SALCSI for the older rheumatologists was lower than that of their younger colleagues. The frequency of use of corticosteroid packaged in a sterile syringe (CSPSS) was approximately 85%. Nine out of the 15 cases of sepsis had occurred after the use of CS not packaged in a sterile syringe and six after the use of CSPSS. Thus, the frequency of SALCSI was 1/162000 after the use of CSPSS and 1/21000 after the use of CS not packaged in a sterile syringe. The mean frequency of SALCSI in Paris and the surrounding area was 1/77300 during the last 21 yr, a decrease since the 1960s and 1970s. This decreased incidence is in part due to the greater experience of the rheumatologist, but even more to the use of CSPSS.

Use of Complementary Therapies for Arthritis among Patients of Rheumatologists

Use of complementary and alternative medicine (CAM) is common among persons with chronic conditions. To identify correlates of and describe patients' perspective on use of CAM for rheumatologic conditions. Telephone survey. Three university practices and three private rheumatology practices. 232 of 428 eligible consecutive patients (54%) with scheduled appointments. Patients answered questions on CAM use, functional status, pain, provider satisfaction, and health services utilization. Chart reviews provided demographic information and rheumatologic diagnoses. Bivariate analyses identified correlates of four CAM outcomes (history, magnitude, and frequency of CAM use and communication about CAM use with a physician), and multiple logistic regression identified independent correlates of regular CAM use. Approximately two thirds of the respondents (n = 146) had used CAM. Of these 146 respondents, 82 (56%) currently used CAM and 132 (90%) regularly used CAM or had done so in the past. Fifty-five respondents (24%) had used three or more types of CAM. In multivariate analyses, persons who used CAM regularly were more likely to have osteoarthritis (odds ratio, 5.6 [95% CI, 1.9 to 16.8]), severe pain (odds ratio, 2.5 [CI, 1.4 to 4.8]), and a college degree (odds ratio, 2.6 [CI, 1.3 to 5.4]) than patients who had never used CAM. Nearly half of the respondents discussed CAM use with their physicians. The most common reasons for not disclosing CAM use were that the physician had not asked about it and that the patient forgot to tell the physician; fear of disapproval was rarely cited. Discussions about CAM use between patient and physician occurred more frequently among patients with fibromyalgia and persons who regularly used CAM or used several types of CAM. Patients with rheumatologic conditions frequently use CAM. Severe pain and osteoarthritis predict regular use of CAM but do not predict a greater likelihood of discussing CAM use with physicians. Routine inquiry by physicians will probably detect CAM use.

Medication adherence in rheumatoid arthritis patients: older is wiser.

To create a profile of individuals nonadherent to their medications in an age-stratified sample (ages 34-84) of community-dwelling rheumatoid arthritis patients. The relative contributions of age, cognitive function, disability, emotional state, lifestyle, and beliefs about illness to nonadherence were assessed. A direct observation approach was used in conjunction with structural equation modeling. All participants were administered a preliminary assessment battery. Medications were then transferred to vials with microelectronic caps that recorded medication events for all medications for the next 4 weeks. A volunteer sample of 121 community-dwelling rheumatoid arthritis (RA) patients were recruited from newspaper ads, posters, and via informal physician contact from private rheumatology practices in Atlanta and Athens, Georgia. Written verification of the RA diagnosis and a disease severity rating were obtained from personal physicians before patients were enrolled in the study. Patients were tested in a private physician's office, and their medication adherence was monitored electronically for a month in their every-day work and home settings. Structural equation modeling techniques were used to develop a model of adherence behavior. Cognitive and psychosocial measures were used to construct latent variables to predict adherence errors. The model of medication adherence explained 39% of the variance in adherence errors. The model demonstrated that older adults made the fewest adherence errors, and middle-aged adults made the most. A busy lifestyle, age, and cognitive deficits predicted nonadherence, whereas coping with arthritis-related moods predicted adherence. Illness severity, medication load, and physical function did not predict adherence errors. Omission of medication accounted for nearly all errors. Despite strong evidence for normal, age-related cognitive decline in this sample, older adults had sufficient cognitive function to manage medications. A busy lifestyle and middle age were more determinant of who was at risk of nonadherence than beliefs about medication or illness. Thus, practicing physicians should not assume that older adults have insufficient cognitive resources to manage medications and that they will be the most likely to make adherence errors. Very busy middle-aged adults seem to be at the greatest risk of managing medications improperly.