Rheumatology Care Research Articles

Polypharmacy and Potentially Inappropriate Medication Use in Older Adults With Systemic Lupus Erythematosus.

To assess the prevalence and potential risk factors for polypharmacy and prescribing of the potentially inappropriate medications, opioids and benzodiazepines/Z-drugs, in older adults with systemic lupus erythematosus (SLE). The study population comprised adults age ≥50 years meeting American College of Rheumatology or Systemic Lupus International Collaborating Clinics classification criteria followed at a tertiary care rheumatology clinic. Information on prescriptions filled in the 4 months preceding chart review was obtained from the Manitoba Drug Program Information Network. Clinical data, including age, sex, Charlson Comorbidity Index (CCI) score, Systemic Lupus Erythematosus Disease Activity Index 2000 score, prednisone use, SLE duration, and rural residence were abstracted from electronic medical records. Logistic regression analyses were performed to assess any association between polypharmacy (using 2 definitions: ≥5 and ≥10 medications), potentially inappropriate medication use, and clinical features. A total of 206 patients (mean age 62 years, 91% female, 36% rural) were included: 148 (72%) filled ≥5 medications, 71 (35%) filled ≥10 medications, 63 (31%) used benzodiazepines/Z-drugs, and 50 (24%) used opioids. Among the 77 patients age ≥65 years, 57 (74%) filled ≥5 medications, and 26 (34%) filled ≥10 medications, compared to 30% and 4%, respectively, of Manitobans age ≥65 years (National Prescription Drug Utilization Information System, 2016). The odds of polypharmacy were greater with prednisone use (adjusted odds ratio [OR] 3.70 [95% confidence interval (95% CI) 1.40-9.79] for ≥5 medications), CCI score (adjusted OR 1.62 [95% CI 1.20-2.17]), and rural residence (adjusted OR 2.05 [95% CI 1.01-4.18]). Odds of benzodiazepine/Z-drug use were increased with polypharmacy (adjusted OR 4.35 [95% CI 1.69-11.22]), and odds of opioid use were increased with polypharmacy (adjusted OR 6.75 [95% CI 1.93-23.69]) and CCI score (adjusted OR 1.29 [95% CI 1.08-1.54]). The prevalence of polypharmacy in this SLE cohort was higher than in the general Manitoban population. Polypharmacy is a strong marker for use of prescription benzodiazepines/Z-drugs and opioids.

Changes in Service Delivery and Access to Rheumatologists Before and During the COVID-19 Pandemic in a Canadian Universal Healthcare Setting.

To describe changes in service delivery and access to rheumatologists before and during the coronavirus disease 2019 (COVID-19) pandemic periods. We conducted a population-based study in Ontario, Canada. Patient visits with rheumatologists were ascertained using billing claims data. Contact with rheumatologists was defined separately by the type of patient encounter (including office visits, telemedicine visits, and new patient consultations). Changes in the total weekly volume of encounters and monthly rates after COVID-19 public health measures were imposed were compared to expected baseline rates determined before pandemic onset (March 17, 2020). In the year prior to the pandemic, there were 289,202 patients (of which 96,955 were new consults) seen by 239 rheumatologists. In the 1 year following the pandemic onset, there were 276,686 patients (of which 86,553 were new consults) seen by 247 rheumatologists. In March 2020, there was an immediate 75.9% decrease in outpatient office visits and a rapid rise in telemedicine visits. By September 2021, 49.7% of patient encounters remained telemedicine visits. For new patient consultations, there was an immediate 50% decrease in visits at the pandemic onset, with 54.8% diverted to telemedicine visits in the first year of the pandemic versus 37.4% by September 2021. New rheumatology consultation rates continued decreasing over the study period. Rheumatology care delivery has shifted due to the pandemic, with telemedicine increasing sharply early in the pandemic and persisting over time. The pandemic also negatively affected access to rheumatologists, resulting in fewer new consultations and raising concerns for potential delays to diagnosis.

Transitioning patients with juvenile idiopathic arthritis to adult care: the Nordic experience

BackgroundWith juvenile idiopathic arthritis (JIA), there are several protocols and practices used worldwide for the transition from paediatric to adult care. In this study, we examined the transferral rates and disease activity after transition, as well as the disease- and health-related outcomes. We also introduce the transition practices employed in the Nordic countries.MethodsThe study population comprised 408 participants with a disease onset from 1997 to 2000 who attended an 18-year follow-up visit in this population-based Nordic JIA cohort study. The patients were retrospectively divided into three subgroups: Patients transferred directly from paediatric care to adult rheumatology care, patients referred there later, and patients never transferred during the 18-year follow-up period.ResultsOne hundred and sixty-three (40%) JIA patients had been directly transferred to an adult clinic. The cumulative transition rate was 52%, but there were significant differences between the participating centres. Fifty patients had later been referred to an adult clinic. Among the 195 patients who had never been transferred, 39% were found to have disease activity at the study visit.ConclusionThis study highlights the need to reconsider transition practices to avoid our undesirable finding of patients with disease activity in JIA, but no appropriate health care follow-up.

Capturing critical data elements in Juvenile Idiopathic Arthritis: initiatives to improve data capture

BackgroundDocumentation of critical data elements is a focus of the Pediatric Rheumatology Care and Outcomes Improvement Network to aid in clinical care and research for patients with juvenile idiopathic arthritis. We aimed to increase data capture for critical data elements and hypothesized that quality improvement methodology would improve data capture. We also hypothesized that data capture for all critical data elements would be lower for virtual visits compared to in-person visits.MethodsAll visits for patients with JIA between 9/14/2020 and 12/31/2021 at the University of Minnesota were included. We assessed completeness of critical data element capture. Sixteen interventions with providers were conducted, including email reminders, individual discussions, group meetings, and feedback reports. We used statistical process control charts to evaluate change over time.ResultsBaseline included 355 patient-visits: 221 (62%) in-person and 134 (38%) virtual with critical data elements entry ranging between 50 and 60%. Post-intervention included 1,596 patient-visits: 1,350 (85%) in-person and 246 (15%) virtual, with critical data elements entry reaching 91%. All providers improved data entry during this study. In-person visits had significantly higher data capture rates than virtual visits for all 4 critical data elements.ConclusionWe achieved our aim to increase critical data element documentation by focusing on provider buy-in, frequent reminders, and individualized feedback. We also found that collection of critical data elements occurred significantly less often with virtual visits than with in-person visits. Now that we improved capture of critical data elements, we can shift the focus to efforts aimed at improving outcomes for patients with juvenile arthritis.

Rheumatology centers according to the regulations of the Federal Joint Committee

With the Nursing Staff Strengthening Act (Pflegepersonal-Stärkungs-Gesetz), the legislator delegated the specification of the special tasks of centers and focal points to the Federal Joint Committee (G-BA). Due to extensive preliminary work it was already possible to agree on quality requirements and special tasks for rheumatology centers and centers for pediatric and adolescent rheumatology in the first version of the G‑BA regulations. Since publication in the Federal Gazette (Bundesanzeiger) on 12 March 2020, rheumatology centers have been able to negotiate surcharges for their special tasks if they have been designated accordingly by the state authorities responsible for hospital planning. So far, 14rheumatological centers have been designated. Many patients continue to be treated in healthcare structures that are not specialized in acute inpatient rheumatological care. In addition to the additional remuneration, the designation as arheumatology center can also contribute to patients becoming even more aware of the healthcare structures that are specialized for them. Acute inpatient rheumatology has several specializations. Some clinics have specialized in the multimodal treatment of chronic rheumatism patients and have gained ahigh level of expertise in this field. Many of these highly specialized clinics have so far been denied recognition as acenter because the regulations of the G‑BA require the provision of further specialist departments at the same location. While for alarge number of medical specializations the establishment at amaximum care hospital is likely to make sense, the specialist clinics focusing on the multimodal treatment of chronic rheumatism patients offer the possibility of strengthening rural areas.

P53 An audit comparing current clinical practice against the British Society for Paediatric and Adolescent Rheumatology/the Arthritis and Musculoskeletal Alliance Standards of Care for children and young people with juvenile idiopathic arthritis in Grimsby since 2015

P53 An audit comparing current clinical practice against the British Society for Paediatric and Adolescent Rheumatology/the Arthritis and Musculoskeletal Alliance Standards of Care for children and young people with juvenile idiopathic arthritis in Grimsby since 2015

P59 Growing up in rheumatology: An Evaluation of a Young Adult Rheumatology Service

P59 Growing up in rheumatology: An Evaluation of a Young Adult Rheumatology Service

A consensus-based approach on the management of patients with both psoriasis and psoriatic arthritis in the dermatological and rheumatological settings in Italy: The ADOI PSO-Amore Project.

Psoriasis is a complex disease often needing a multidisciplinary approach. In particular, the collaboration between dermatologist and rheumatologist is crucial for the management of patients suffering from both psoriasis (PSO) and psoriatic arthritis (PsA). Here we report a series of recommendations from a group of experts, as a result of a Consensus Conference, defining the circumstances in which it is preferable or even mandatory, depending on the available settings, to rely on the opinion of the two specialists, jointly or in a deferred manner. Indications are given on how to organize a 3rd level joint Dermatology- Rheumatology care unit, in connection with 1st and 2nd level clinicians of both specialties, GPs, and other specialists involved in the management of psoriasis. A potential patient journey is suggested, that can be used as a basis for future design and validation of national and/or local diagnostic therapeutic and assistance pathways.

P71 What are parents’ and patients’ perceptions of paediatric rheumatology shared-care in a London district general hospital? An evaluation to drive service improvement

P71 What are parents’ and patients’ perceptions of paediatric rheumatology shared-care in a London district general hospital? An evaluation to drive service improvement

The outlook of rheumatological care in Africa: Current state, challenges, and recommendation.

There is a gross lack of access to rheumatological access in Africa. For example, the most populous country in the continent, Nigeria, has just 30 rheumatologists serving a population of about 200 million. In Ghana, there are just 2 rheumatologists serving a population of about 28 million people. Unfortunately, the prevalence of rheumatologic and musculoskeletal diseases is on the rise in Africa. The main issues facing rheumatologic care in Africa are inadequate health professionals, inadequate research, and a weak health system. These factors have hindered the progress of rheumatologic care and treatment in the region. Prompt action must be taken in tackling these effects and to achieve better care for rheumatologic patients in Africa. This paper analyzes carefully the current state of rheumatologic care in Africa, identifying the needs for rheumatologic care, determinants of quality of rheumatologic care delivery, and the challenges currently facing rheumatology care in Africa. Also, this review gives some recommendations on ways by which the existing system of rheumatologic care in Africa can be improved.

Understanding sex-related differences in healthcare utilisation among patients with inflammatory arthritis: a population-based study

ObjectivesOur aim was to compare patterns of musculoskeletal-related healthcare utilisation between male and female patients before and after the diagnosis of inflammatory arthritis (IA).MethodsWe used Ontario administrative health data to...

Patient-Reported Outcomes Among Transition-Age Young Adults With Juvenile Idiopathic Arthritis in the Childhood Arthritis and Rheumatology Research Alliance Registry.

To evaluate patient-reported care utilization and outcomes among young adults with juvenile idiopathic arthritis (JIA), including factors associated with complete transfer to adult rheumatology. We included young adults with JIA enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from 2015 to 2019 with age ≥ 18 years at their last clinical site visit. We used data from the CARRA Registry Long-term Follow-up program, which follows inactive CARRA Registry patients and collects patient-reported information through phone surveys. We compared the characteristics of respondents with complete and incomplete transfer to adult rheumatology care at their first Long-term Follow-up phone survey. We identified 540 young adults with JIA; 187 (35%) responded to the Long-term Follow-up phone survey. The 54% of respondents with complete transfer to adult rheumatology were slightly older and reported more self-assessed disease activity, morning stiffness, and pain compared to those with incomplete transfer. Biologic use was high at both timepoints and did not differ by transfer status. Patients who completed the transfer were more likely to have private insurance and be actively pursuing postsecondary education compared to those with an incomplete transfer. Across the cohort, 65% reported problems with pain or discomfort and 45% with anxiety or depression. Young adult respondents with JIA in the CARRA Registry commonly report persistent medication use, but still report more problems with pain as compared to population norms. Additional work is needed to understand how best to address comorbid pain around the period of transition to adult care.

"You can't touch, you can't bond": Exploring COVID-19 pandemic impacts on rheumatoid arthritis patient goals and communication with clinicians.

"You can't touch, you can't bond": Exploring COVID-19 pandemic impacts on rheumatoid arthritis patient goals and communication with clinicians.

Sex-related differences in health-care use in adult patients with inflammatory arthritis in Ontario, Canada: a population-based cohort study

<h2>Abstract</h2><h3>Background</h3> Timely access and appropriate use of health-care resources is crucial for the management of people with inflammatory arthritis. Sex (biological) and gender (sociocultural) are important health determinants that influence different aspects of care, such as referral to specialists, performance of diagnostic tests, continuity of care, and prescription patterns, which ultimately affect disease outcomes. We aimed to compare health-care use between males and females with inflammatory arthritis. <h3>Methods</h3> This population-based study was conducted using health administrative data of Ontario, Canada. We included Ontario residents aged 20 years or older with valid health insurance and diagnosed with rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis using Ontario health administrative data (the Ontario Health Insurance Plan Claims Database). Sex (the primary predictor of this study) was coded as male or female in the database. Health-care use (the study outcome) was assessed at least once per year for 3 years before and after an inflammatory arthritis diagnosis and compared between males and females using regression models, after adjusting for demographics and comorbidities. Prescription dispensation was assessed at least once per year for 3 years after the diagnosis in individuals aged 66 years or older at the time of diagnosis. Results were expressed as female to male adjusted odds ratio (OR) with 95% CIs. <h3>Findings</h3> Between April 1, 2010, and March 31, 2017, 41 277 people with rheumatoid arthritis (28 575 [69%] females), 8150 with ankylosing spondylitis (4160 [51%] females), and 6446 with psoriatic arthritis (3483 [54%] females) were analysed. Males were significantly older (mean 60·4 years [SD 14·2]) than females (mean 57·1 years [15·2]) in the rheumatoid arthritis cohort. Across the cohorts, multimorbidity was more common in females (75–81% <i>vs</i> 58–66% in males) as was depression (8% <i>vs</i> 4%) and osteoporosis (4–5% <i>vs</i> 1%), whereas cardiovascular disease was more common in males (7–15% <i>vs</i> 4–7% in females). Females were more likely to visit family physicians (adjusted OR ranging from 1·10 [95% CI 1·05–1·15]; p<0·001 to 1·15 [1·04–1·28]; p<0·01) and rheumatologists (adjusted OR from 1·32 [1·22–1·43] to 2·28 [1·92–2·70]; p<0·001). Females also had higher odds for receiving imaging before a diagnosis in all 3 cohorts (adjusted OR from 1·15 [1·10–1·20] to 1·18 [1·12–1·23]; p<0·001 for x-rays and adjusted OR from 1·27 [1·09–1·48] to 1·44 [1·15–1·80]; p<0·01 for ultrasound examinations). Similarly, laboratory tests were more likely to be ordered for female patients before diagnosis than for males (adjusted OR from 1·10 [1·05–1·15] to 2·17 [1·89–2·50]; p<0·001) across all cohorts. These sex differences were most notable among people with rheumatoid arthritis and ankylosing spondylitis, and in the prediagnostic period. Males were more likely to visit the emergency department immediately before an inflammatory arthritis diagnosis (adjusted OR from 0·76 [95% CI 0·72–0·81]; p<0·001 to 0·87 [0·80–0·95]; p<0·01). After diagnosis, females were more likely to remain in rheumatology care (adjusted OR from 1·12 [1·01–1·25]; p=0·04 to 1·24 [1·19–1·30]; p<0·001). Prescription dispensation of non-steroidal anti-inflammatory drugs (adjusted OR 1·14 [1·04–1·25]; p<0·01) and opioids (adjusted OR 1·46 [1·27–1·68]; p<0·001) was higher in older females (aged 66 years or older) with rheumatoid arthritis and conventional disease-modifying antirheumatic drug use was higher in older females with ankylosing spondylitis (adjusted OR 1·66 [1·24–2·22]; p<0·001). <h3>Interpretation</h3> Females with inflammatory arthritis are more likely to use health care than males, which might indicate sex-related biological differences in disease course or gender-related sociocultural differences in health-care access, health-care seeking behaviour or patient–provider interactions. <h3>Funding</h3> Enid Walker Graduate Student Award for Research in Women's Health (partial).

Discovery of Psoriatic Arthritis in Psoriasis Patients for Early Rheumatological Referral (DAPPER) Study: A Prospective Observational Cohort.

Patients with psoriasis are at risk of developing psoriatic arthritis, which can lead to irreversible joint damage. However, a proportion of patients with psoriasis and concomitant psoriatic arthritis remain undiscovered in practice. The aims of this study were: to prospectively determine prevalence, characteristics, and disease burden of psoriatic arthritis in a psoriasis population; and to determine the prevalence and characteristics of patients with active psoriatic arthritis, who were not under rheumatological care. Patients with psoriasis were screened by a rheumatologist at the dermatology outpatient clinic for psoriatic arthritis. Patients with suspected active psoriatic arthritis who were not seeing a rheumatologist were referred to a rheumatologist for confirmation. The total prevalence of psoriatic arthritis in this observational, prospective cohort (n = 303) was 24%. Patients with psoriasis with concomitant psoriatic arthritis had longer duration of skin disease and more often a treatment history with systemic therapies. In this academic, specialized, setting, 2.3% of patients (n = 7), were not receiving rheumatological care despite having active psoriatic arthritis. These patients were characterized by a combination of low (perceived) disease burden and low yield of screening questionnaires, making it difficult for dermatologists to discover psoriatic arthritis in these patients. Thus, screening for more subtle active arthritis in patients with psoriasis in a dermatology setting could be improved.

Consistency evaluation between patient-completed and physician-completed Caprini scores

Objective: To evaluate the consistency of patient-completed and physician-completed Caprini scores. Methods: This study was a diagnostic study. We prospectively recruited 200 inpatients (including respiratory and critical care medicine, rheumatology and immunology, obstetrics and gynecology, and orthopedics). Clinical data of the recruited patients were collected. The Wechat applet was developed based on the Chinese version of the patient-completed Caprini score. Patient could enter the Wechat applet by scanning the QR code, and enter the height, weight and other contents to the Wechat applet. The applet could automatically calculate the score and make the risk stratification according to total score. At the same time, physicians would calculate the traditional Caprini score for the same patient and make risk stratification to evaluate the consistency of scores derived from the two methods. Results: The average age of these 200 patients was (59.6±13.9) years, 112(56.0%) of them were female and 184(92.0%) with high school education or above. There was no significant difference between the patient-completed and physician-completed scores (4.8±2.5 vs. 4.7±2.5,P=0.336). The time of physician-completed score was shorter than that of patient-completed score ((2.0±1.0) minutes vs.(2.4±1.2) minutes, P<0.000 1). There was no significant difference on the number of high-highest venous thromboembolism risk patients assessed by the patient-completed and the physician-completed scores: 84.5% (169/200) vs. 83.0%(166/200)(χ2=0.165, P=0.684).There was strong positive correlations between patient-completed and physician-completed scores (r=0.98, P<0.000 1). Cohen's ĸ evaluation showed that the patient-completed Caprini score was in excellent consistency with physician-completed Caprini score(κ=0.97,P<0.000 1). The result of Bland Altman method showed that only 3.0% (6/200) of the scores biased greatly, which was not within the 95% confidence interval, the result proved that the bias belonged to a small probability event. It was inferred that the scores of patient-completed were consistent with those of the physician-completed. Conclusions: The patient-completed Caprini score is in good agreement with the physician-completed Caprini score in this patient cohort.

Cardiology co-management of rheumatoid arthritis patients with coronary artery disease as an intervention reduces hospitalization rates and adverse event occurrence.

IntroductionRheumatoid arthritis (RA) is a systemic autoimmune disease with important cardiovascular (CV) implications. CV disease represents over half of RA patient deaths and causes significant morbidity. CV manifestations in RA can be complex, raising concerns for adequate patient management and provider-dependent roles.MethodsThis is a retrospective study of patients diagnosed with RA and coronary artery disease (CAD). Patients were identified and filtered via EPIC Database search engine. Parameters were set from January 1, 2014, to December 31, 2020. Inclusion criteria consisted of patients who met diagnostic criteria for both RA and CAD. A total of 399 patients met criteria.ResultsOf the 399 identified patients, 272 were female (68.2%) and 127 were male (31.8%) with a median age of 73 (range 26–98). The population was further divided into two groups: those with established cardiology care versus those without. Patients without cardiology follow-up experienced significantly more hospitalizations (RR 1.63 95% CI 1.12, 2.38), higher rates of adverse events including myocardial infarction (MI) (RR 4.82 95% CI 1.94, 11.98), heart failure (HF) (OR 15.81 95% CI 3.54, 70.52), and stroke (RR 2.55 95% CI 1.29, 5.03). Patients not followed by cardiology also had numerical increases in CV death (4 deaths compared to none in those with cardiology follow) and all-cause mortality (HR 1.03 95% CI 0.63, 1.67).ConclusionPatients with regular cardiology follow-up demonstrated fewer cardiac-related adverse events. This suggests that co-management may have a role in adverse cardiac event risk reduction and should therefore be an early consideration. Key Points• Rheumatoid arthritis patients demonstrate higher rates of coronary disease compared to the general population. Traditional cardiac risk factors may not be entirely responsible for this phenomenon• Hospitalization rates and adverse event occurrence are significantly higher in patients with single-provider care (rheumatology only) compared to dual provider care (rheumatology and cardiology)• Cardiology co-management should be an early consideration in the management of RA patients• Early screening, risk stratification of coronary disease, and utilization of appropriate treatment algorithms are important to decrease morbidity and mortalitySupplementary InformationThe online version contains supplementary material available at 10.1007/s10067-022-06335-4.

Real-life vaccination coverage in Slovak children with rheumatic diseases.

BackgroundEvidence-based recommendations for vaccination of patients with pediatric rheumatic diseases (PRDs) are available, their implementation in practice is unknown.ObjectivesTo analyze real-life vaccination coverage in children with PRDs and identify reasons for incomplete vaccination.MethodsUp-to-date information on vaccination status of Slovak children followed at a tertiary pediatric rheumatology center was retrieved from pediatricians over an 18-month period and compared to the standard Slovak Immunization Schedule. Reasons for missed vaccinations were analyzed retrospectively.ResultsVaccination records of 156 patients (median age 10 years, 2–18) with PRDs (JIA n = 108, systemic diseases n = 21, autoinflammatory diseases n = 16, uveitis n = 9, others n = 2) were available for analysis. 117 (75.0%) were completely vaccinated, 2 (1.3%) had not received any vaccine due to reasons unrelated to PRD. 37 (23.7%) remaining patients missed altogether 48 mandatory vaccinations. In 58.3% (n = 28, in 24 patients) no PRD related reasons for missing vaccinations were identified. Only 20 vaccinations (18 live-attenuated and 2 non-live in 19 patients) were missed due to ongoing immunosuppressive treatment or PRD activity. Patients aged 11–14 years were more likely to be incompletely vaccinated than other age groups (48.8% vs. 15.9%, p < 0.001), mainly due to missed MMR booster. Systemic immunosuppressive treatment was a significant predictor for incomplete vaccination status (OR 5.03, 95% CI 1.13–22.31, p = 0.03).ConclusionFull vaccination is possible in a high proportion of PRD patients. In addition to immunosuppressive therapy, reasons unrelated to PRDs are a frequent and possibly inadequate cause of missed vaccinations. Periodic vaccination status assessments are needed in pediatric rheumatology care.

Canadian Rheumatology Association Living Guidelines for the Pharmacological Management of Rheumatoid Arthritis With Disease-Modifying Antirheumatic Drugs.

To provide the initial installment of a living guideline that will provide up-to-date guidance on the pharmacological management of patients with rheumatoid arthritis (RA) in Canada. The Canadian Rheumatology Association (CRA) formed a multidisciplinary panel composed of rheumatologists, researchers, methodologists, and patients. In this first installment of our living guideline, the panel developed a recommendation for the tapering of biologic and targeted synthetic disease-modifying antirheumatic drug (b/ts DMARD) therapy in patients in sustained remission using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach, including a health equity framework developed for the Canadian RA population. The recommendation was adapted from a living guideline of the Australia &amp; New Zealand Musculoskeletal Clinical Trials Network. In people with RA who are in sustained low disease activity or remission for at least 6 months, we suggest offering stepwise reduction in the dose of b/tsDMARD without discontinuation, in the context of a shared decision, provided patients are able to rapidly access rheumatology care and reestablish their medications if needed. In patients where rapid access to care or reestablishing access to medications is challenging, we conditionally recommend against tapering. A patient decision aid was developed to complement the recommendation. This living guideline will provide contemporary RA management recommendations for Canadian practice. New recommendations will be added over time and updated, with the latest recommendation, evidence summaries, and Evidence to Decision summaries available through the CRA website (www.rheum.ca).

Development and test-retest reliability of a screening tool for axial spondyloarthritis.

BackgroundPeople with axial Spondyloarthritis (axSpA) suffer from lengthy diagnostic delays of ~7 years. The usage of screening tools to identify axSpA patients in primary care can reduce diagnostic delays by facilitating early referral to rheumatologic care. The purpose of this study was to examine the psychometric properties of a potential screening tool for patients with axSpA.MethodContent validity was evaluated by soliciting feedback from 7 rheumatologists regarding the relevance and content representativeness of the proposed screening questions. For the test-retest study, participants ≥18 years of age with chronic back pain (≥3 months) without a diagnosis of mechanical or inflammatory back pain (n = 91) were e-recruited through ResearchMatch. Participation included completing identical baseline and follow-up questionnaires ~14 days apart. Weighted quadratic kappa was used to measure test-retest reliability between the two ratings of the ordinal scales. Construct validity was examined using exploratory factor analysis (EFA) and items with factor loadings ≥0.6 were extracted. Scale dimensionality and simplified factorial solutions were measured using Kaiser’s criteria (Eigenvalue >1). Cronbach’s alpha was used to measure internal consistency.ResultsMost participants were women, non-Hispanic white, and had at least some college education, with a mean age of 45 years. On average, the age at onset of back pain was 31 years. Eleven questions yielded test–retest reliabilities ranging from 0.6 to 0.76. Results from EFA extracted two factors relating to: 1) how pain affects daily life functioning and 2) whether pain improves with movement. Internal consistency was high for questions evaluating how pain affects life, with a Cronbach’s alpha of 0.81. Following assessment for validity and reliability, the questionnaire was revised to create the 6-item screening tool.ConclusionsThe 6-item SpA-SED screening tool designed to identify potential cases of axSpA was found to have good test–retest reliability and high internal consistency.