Rheumatology Care Research Articles

How the Russian invasion affects Ukrainian rheumatological health care

How the Russian invasion affects Ukrainian rheumatological health care

The estimation of quality of life of children with diseases of musculoskeletal system.

The study of life quality was carried out covering 432 children aged 6-17 years with diseases of musculoskeletal system on the basis of the cardio-rheumatological department of the Republican Children Clinical Hospital and children polyclinics of the Republic of North Ossetia-Alania. The Russian version of the SF-36 questionnaire was applied which included 11 questions. The physical and emotional state was studied in 4 age groups: 6-8 years old (8.56%), 9-11 years old (20.14%), 12-14 years old (35.65%), 15-17 years old (35. 65%). The average age of children was 13.06±3.9 years. The significant influence of rheumatic diseases on parameters of life-quality of patients was established: physical and psychological state of children suffers, social adaptation is disturbed. According to the study results, the most problematic age group are children aged 15-17 years, who characterize their condition as mediocre (35.1%). Particular attention should be paid to the fact that there was no improvement in health state during a year among significant proportion of patients (65.3%). The obtained results testify limitation of physical state of health in 78.5% of cases, the most noticeable in age group of 15-17 years. The direct correlation between increase in pain syndrome and age of patient is established. In all age groups, there is decrease in emotional state, which increases with age. The indices of physical component of health in all age groups are significantly lower than the mental one. There are no significant gender differences in respondents assessment of life quality. The indices of life quality of children are generally characterized as low and do not reach 50 points on 100-point scale.The identified problematic age groups require increased attention from pediatric service of the Republic. The anxiety is caused by increase of negative symptoms in older age groups. The study results indicates both low efficiency of specialized rheumatological care of children and need for increased attention to dispensary work with this group of patients at early stages of disease.

Patient Acceptance of Nurse Practitioners and Physician Assistants in Rheumatology Care.

To assess whether patients with autoimmune disease would accept advanced practice providers (APPs) as an option to fill the growing shortage of rheumatologists. We administered a cross-sectional survey to 500 patients or parents of children who reported having been diagnosed with qualifying autoimmune conditions and who had seen their primary rheumatology providers in the past 6 months. Respondents self-reported whether their primary providers were rheumatologists or APPs. Our analysis compared the attitude and experience of the patients whose primary rheumatology providers were APPs with those of patients whose primary providers were rheumatologists. Of respondents, 36.8% reported having APPs as primary rheumatology providers. Patients of APPs were significantly more likely to arrive at their provider's office in 15 minutes or less (P < 0.01) and to be able to schedule routine and urgent appointments sooner (P=0.02 and 0.05, respectively). There were no significant differences in overall patient experience of care between provider types. Most patients rated their providers highly, but those who saw rheumatologists rated their providers significantly higher (P < 0.01). Patients of APPs were significantly more likely than patients of rheumatologists to prefer to see APPs over rheumatologists (P < 0.01) and to recommend APPs (P < 0.01). APPs may improve access to care and, regardless of provider type, patients rated their overall experience of care similarly. Overall, patient attitudes toward APPs were positive regardless of provider type, although APP patients held more positive overall attitudes toward APPs than did rheumatologist patients.

A multi-site prospective, observational study of physiotherapist independent prescribing activity across musculoskeletal clinics in the United Kingdom

ObjectiveTo establish how advanced practice physiotherapists in the UK working in the musculoskeletal specialty are utilising their independent non-medical prescribing skills. DesignMulti-site, prospective, descriptive observational study. Ethics reference No: ERN_19–0994). MethodThe study was conducted by seven advanced practitioners, across seven clinical sites representative of advanced musculoskeletal practice in the UK, between 1st October 2019–March 31, 2020. Advanced physiotherapy practitioner independent prescribers working in a variety of musculoskeletal specialty areas collected data across 5 contexts of musculoskeletal clinical service: first contact practice, primary care, community triage, secondary care orthopaedics, secondary care rheumatology and private practice. Quantitative data were analysed descriptively with qualitative data analysed/synthesised via thematic analysis. ResultsPrescribing activity data for n = 2470 patients were collected. Prescribing activity was highest for the treatment of nociceptive pain (51.3%) and inflammation (39.6%). Most prescribing activity occurred in the first 2–6 weeks (34.1%) following onset of condition. Medicines optimisation accounted for most of prescribing activity (18.1%), followed by over-the-counter medication recommendation (15.5%). De-prescribing accounted for 10.8% of all prescribing activity recorded. Qualitative data were synthesised into 4 themes: multimodal physiotherapeutic approach, joint decision making and patient choice, working with complexity, and legal and regulatory restriction. ConclusionsPhysiotherapist independent prescribing was used within all health sectors in conjunction with advanced skills in musculoskeletal physiotherapy as part of a multimodal physiotherapeutic approach. Prescribing activity was dictated by the clinicians' clinical reasoning and use of joint decision-making. Prescribing activity for acute back and neuropathic radicular pain was limited secondary to recent reclassification of gabapentin and pregabalin.

Is telemedicine a golden opportunity or a dangerous roundabout for chronic rheumatic diseases? A narrative review

Introduction: Telemedicine (TM) reported a great increase from 50% to 150% in health care to RMDs patients during the COVID-19 period, but conflicting opinions in the literature are still present.&#x0D; Aim: to investigate the results of literature on TM in terms of feasibility (patients’ satisfaction, accessibility, clinical outcomes and barriers), discussing its integration for the future in a nursing perspective during and after COVID-19 period.&#x0D; Methods: the team that conducted the narrative review was composed by two rheumatology and research nurses (MRM, KEA) and a rheumatologist (MMC), who discussed the relevance of the research question and agreed on the search strategy. Pubmed and Google Scholar databases were searched. The inclusion criteria were: original and quantitative research papers in English with available abstract/full text, on adult patients with RMDs in accordance with the American College of Rheumatology (ACR) and/or European Alliance of Associations of Rheumatology (EULAR) classification criteria, exposed to any kind of technologies during and after COVID19 period, investigating any kind of patient/clinical reported outcomes.&#x0D; Results: TM could be considered as an integration to standard clinical care in Rheumatology, especially for patients with a stable or low disease activity and rheumatic diagnosis. The choice of the candidates and the assessment of their E-health literacy level are necessary prior including them in TM programs. In addition, healthcare professionals need to be trained in this new modality of providing care.&#x0D; Conclusion: hybrid models of telehealthcare might be a balanced solution, improving efficiency of the consultation, continuity of care and providing a patient-centred approach.

A Population-Based Study Evaluating Retention in Rheumatology Care Among Patients With Rheumatoid Arthritis.

ObjectiveThe study objective was to assess adherence to system‐level performance measures measuring retention in rheumatology care and disease modifying anti‐rheumatic drug (DMARD) treatment in rheumatoid arthritis (RA).MethodsWe used a validated health administrative data case definition to identify individuals with RA in Ontario, Canada, between 2002 and 2014 who had at least 5 years of potential follow‐up prior to 2019. During the first 5 years following diagnosis, we assessed whether patients were seen by a rheumatologist yearly and the proportion dispensed a DMARD yearly (in those aged ≥66 for whom medication data were available). Multivariable logistic regression analyses were used to estimate the odds of remaining under rheumatologist care.ResultsThe cohort included 50,883 patients with RA (26.1% aged 66 years and older). Over half (57.7%) saw a rheumatologist yearly in all 5 years of follow‐up. Sharp declines in the percentage of patients with an annual visit were observed in each subsequent year after diagnosis, although a linear trend to improved retention in rheumatology care was seen over the study period (P < 0.0001). For individuals aged 66 years or older (n = 13,293), 82.1% under rheumatologist care during all 5 years after diagnosis were dispensed a DMARD annually compared with 31.0% of those not retained under rheumatology care. Older age, male sex, lower socioeconomic status, higher comorbidity score, and having an older rheumatologist decreased the odds of remaining under rheumatology care.ConclusionSystem‐level improvement initiatives should focus on maintaining ongoing access to rheumatology specialty care. Further investigation into causes of loss to rheumatology follow‐up is needed.

Challenges of caring for homeless patients with inflammatory arthritis: 12-month follow-up observations and identification of certain barriers to care.

Homelessness is a public health crisis and there is a paucity of information about patients with rheumatic disease experiencing homelessness. We sought to develop approaches to improve care for this unique patient population. We previously reported observations on 17 homeless patients with inflammatory arthritis (15 rheumatoid arthritis (RA), 2 psoriatic arthritis (PsA)). We obtained follow-up information from our original 17 patients and compared this to data summarized and published about them from 12 months previously. We also created and administered a 100-question needs assessment survey. Follow-up 12-month clinical information was available from 13/17 homeless and 13/17 non-homeless controls. Homeless patients remained less well with more disease than non-homeless patients—poorer access to clinic appointments (80% vs 91%, p < 0.05), more emergency services use (20 vs 5 ED visits), less DMARDs use (43% vs 100%, p < 0.01), and more steroid use (29% vs 0%, p < 0.01). Homeless patients also had higher inflammatory markers than non-homeless patients (ESR 32 vs 26 mm/h and CRP 17 vs 5 mg/L), although these findings were not statistically significantly different. Seventy-eight percent of homeless patients were stable, 14% improved, and 7% worse; 21% had stable controlled and 57% stable active disease vs 62% and 0% of non-homeless (p < 0.01). Among the homeless, 6 (4 RA, 2 PsA) completed the survey, 2 declined, and 9 could not be reached. All 6 had found housing although all still had housing insecurity; 4 (67%) were homeless in the past. Three out of six (50%) obtained housing from social assistance during hospitalization following disease exacerbation while homeless. The average monthly income was $873. 5/6 (83.3%), were unable to work due to health, and were in considerable pain that adversely impacted their physical and mental health and ability to perform ADLs. Their perceived “greatest need” included dental care, physical therapy, knee surgery, employment, socialization secondary to isolation, and stable housing. Our understanding of the unique challenges of patients with rheumatic disease experiencing homelessness is improved, but not complete. Strengthened collaboration between street medicine providers and rheumatologists is necessary to improve care for homeless patients, especially given poorer outcomes compared with non-homeless counterparts.Key Points• We report 12-month follow-up information from our original 17 homeless patients with inflammatory arthritis (related in this journal in 2021) and their responses to an extensive needs assessment survey designed to identify barriers to care.• Homeless patients with inflammatory arthritis continued to have worse disease outcomes, use more corticosteroids and less DMARDs, and be seen less often in rheumatology clinics and more frequently in emergency departments than their non-homeless counterparts.• Survey data indicated that social assistance during hospitalization was a key area where healthcare providers could intervene to provide housing security for homeless patients and improve outcomes. Patients perceived “greatest needs” went beyond housing and rheumatological care and critically included access to social/specialty services.• Street medicine is the direct delivery of healthcare to people experiencing homelessness wherever they reside. Our observations, obtained in collaboration with street medicine colleagues, suggest important and salutary opportunities for this partnership to improve care for these particular patients.

Rheumatic?-A Digital Diagnostic Decision Support Tool for Individuals Suspecting Rheumatic Diseases: A Multicenter Pilot Validation Study.

IntroductionDigital diagnostic decision support tools promise to accelerate diagnosis and increase health care efficiency in rheumatology. Rheumatic? is an online tool developed by specialists in rheumatology and general medicine together with patients and patient organizations. It calculates a risk score for several rheumatic diseases. We ran a pilot study retrospectively testing Rheumatic? for its ability to differentiate symptoms from existing or emerging immune-mediated rheumatic diseases from other rheumatic and musculoskeletal complaints and disorders in patients visiting rheumatology clinics.Materials and MethodsThe performance of Rheumatic? was tested using in three university rheumatology centers: (A) patients at Risk for RA (Karolinska Institutet, n = 50 individuals with musculoskeletal complaints and anti-citrullinated protein antibody positivity) (B) patients with early joint swelling [dataset B (Erlangen) n = 52]. (C) Patients with early arthritis where the clinician considered it likely to be of auto-immune origin [dataset C (Leiden) n = 73]. In dataset A we tested whether Rheumatic? could predict the development of arthritis. In dataset B and C we tested whether Rheumatic? could predict the development of an immune-mediated rheumatic diseases. We examined the discriminative power of the total score with the Wilcoxon rank test and the area-under-the-receiver-operating-characteristic curve (AUC-ROC). Next, we calculated the test characteristics for these patients passing the first or second expert-based Rheumatic? scoring threshold.ResultsThe total test scores differentiated between: (A) Individuals developing arthritis or not, median 245 vs. 163, P < 0.0001, AUC-ROC = 75.3; (B) patients with an immune-mediated arthritic disease or not median 191 vs. 107, P < 0.0001, AUC-ROC = 79.0; but less patients with an immune-mediated arthritic disease or not amongst those where the clinician already considered an immune mediated disease most likely (median 262 vs. 212, P < 0.0001, AUC-ROC = 53.6). Threshold-1 (advising to visit primary care doctor) was highly specific in dataset A and B (0.72, 0.87, and 0.23, respectively) and sensitive (0.67, 0.61, and 0.67). Threshold-2 (advising to visit rheumatologic care) was very specific in all three centers but not very sensitive: specificity of 1.0, 0.96, and 0.91, sensitivity 0.05, 0.07, 0.14 in dataset A, B, and C, respectively.ConclusionRheumatic? is a web-based patient-centered multilingual diagnostic tool capable of differentiating immune-mediated rheumatic conditions from other musculoskeletal problems. The current scoring system needs to be further optimized.

P184 Are there any ethnic differences in the response to Janus Kinase Inhibitor therapy for the treatment of rheumatoid arthritis?

Abstract Background/Aims Baricitinib is an oral, synthetic Janus Kinase inhibitor. It has become a commonly used drug in the treatment of rheumatoid arthritis (RA), both as combination therapy and monotherapy. Previous studies have compared drug efficacy in different ethnicities, but no studies have compared the efficacy of baricitinib for the treatment of RA in different ethnicities. Given the large South Asian population in Leicestershire, we reviewed our cohort of RA patients on baricitinib to see whether there is any difference in drug response rates between the Asian and Caucasian cohorts. Methods This was a retrospective study. Patients included were those under the care of rheumatology at University Hospitals of Leicester (UHL) with a diagnosis of RA and either receiving baricitinib, or had received it in the past. Data was collected using the UHL IT systems, clinic letters, and pharmacy records. In addition to ethnicity, we reviewed patient age, gender, concurrent DMARDs used, previous biologics used, baseline and post-treatment DAS28, dropout from therapy, baseline biochemical assays (anti-CCP and RF status) and radiographic findings. Independent T-test was used to compare continuous data and the Pearson Chi-Square test was used to compare categorical data. SPSS was used to analyse the results. Results 120 patients were included in the analysis and data was analysed with PFA. There was no statistically significant difference in the mean DAS28 at baseline (Asian 5.17 vs Caucasian 4.65, p value 0.107) and post-treatment (Asian 2.83 vs Caucasian 3.33, p value 0.404) (see table 1). Comparing both ethnicities, there was no statistically significant difference in previous biologics used, the presence or absence of anti-CCP and RF, and radiographic findings of erosions. Limitations of the study include the low proportion of post treatment DAS28 values recorded and absence of data comparing primary or secondary biologic failure. Conclusion This is the first study of its kind and found no significant difference in baricitinib response between the Asian and Caucasian cohorts. Future studies are needed to evaluate this subject further. Such data is important as it can contribute to a body of evidence that may in future help inform clinical decision making. Disclosure A. Jubber: None. W.H.Z. Hussain: None. A. Moorthy: None.

P144 Phalangeal microgeodic syndrome: is this very rare condition becoming more common?

Abstract Background/Aims Phalangeal microgeodic syndrome (PMS) is a rare condition with only a handful of published case reports. Most of these cases are recognised in childhood, typically in Japan. It presents with pain and dusky discolouration in the digits, distinct from Raynaud’s phenomenon in that the colour change is fixed and pain constant. Symptom onset is related to cold exposure with first presentation usually occurring in winter. Features on magnetic resonance imaging (MRI) are striking and characteristic, with a distinct pattern of bone marrow oedema. Methods We report five cases of MRI-proven PMS all identified in the last 12 months, with symptom onset during the winter. The patients were all female, aged between 25 and 79. One patient was already under the care of rheumatology with an established diagnosis of systemic lupus erythematosus (SLE), but the remainder were de novo referrals presenting specifically with pain and discolouration of the digits. One patient developed symptoms 2 days after receiving the first dose of Pfizer/Biontech RNA vaccine against COVID-19. One patient had to self-isolate following a COVID-19 contact and developed symptoms shortly thereafter, although there was no proven infection in the affected individual. Results Four out of five cases were managed conservatively, with advice on maintaining core and peripheral temperature and skin integrity. Without any specific therapy, these four cases improved spontaneously to coincide with increasing seasonal temperatures. The fifth case with existing SLE was treated with intravenous pamidronate and subsequently with a calcium channel blocker, with some improvement in symptoms. Conclusion In these authors’ experience, it would seem PMS is increasing in incidence. It is unclear if this relates to wider availability and image quality of MRI, clinician bias due to personal experience of more cases or a genuine increase. The winter 2020/21 was particularly cold with sub-zero conditions lasting well into May, which may have impacted on this flurry of new cases. We have identified one prior case report which describes PMS in a patient with existing connective tissue disease. Our patient with SLE appeared to have a more severe clinical presentation requiring additional medical therapy to control the symptoms compared with the four cases where PMS was a stand-alone condition. Dermatological manifestations of acute COVID-19 infection are well documented in children and include chilblain-like lesions and acrocyanosis. Any association between COVID-19 and PMS is purely hypothetical and would require more study to identify any true relationship. Disclosure L. Parker: None. M. Ahmad: None. S. Mukherjee: None. P. McAlinden: None.

Real-world data reveals the complexity of disease modifying anti-rheumatic drug treatment patterns in juvenile idiopathic arthritis: an observational study

ObjectivePharmacological treatment is a cornerstone of care for children with juvenile idiopathic arthritis (JIA). The objective of this study is to evaluate prescription patterns of conventional and biologic disease modifying anti-rheumatic drugs (c-DMARDs and b-DMARDs) for patients with JIA.MethodsWe conducted a retrospective cohort study of children diagnosed with JIA at a rheumatology pediatric clinic. Eligibility criteria were defined as children and youth newly diagnosed with enthesis-related arthritis, polyarticular, or oligoarticular JIA between 2011 and 2019, with at least one year of observation. Data on c-DMARDs and b-DMARDs prescriptions were obtained from electronic medical charts. We used descriptive statistics, Kaplan–Meier survival methods, and Sankey diagrams to describe treatment prescription patterns.ResultsA total of 325 patients with JIA were included, with a median observation time of 3.7 years. The most frequently prescribed c-DMARD and b-DMARD were methotrexate and etanercept, respectively. Within the first year of rheumatology care, 62% and 21% of patients had a c-DMARD and a b-DMARD prescribed, respectively. These proportions varied greatly by JIA subtype. Among the 147 (147/325, 45%) patients that had at least one b-DMARD prescribed, 24% were prescribed a second, and 7% a third-line of b-DMARD. A total of 112 unique treatment sequences were observed, with c-DMARD monotherapy followed by the addition of either a b-DMARD (56%) or another c-DMARD (30%) being the two most prevalent patterns in this cohort.ConclusionWe observed a variety of treatment trajectories, with many patients experiencing multiple treatment lines, illustrating the complexity of the overall JIA treatment path.

Rheumatologic inpatient treatment-more than a complex treatment : Data reflecting services and structures

Zur Bestandsaufnahme und Vorbereitung auf bevorstehende Reformen wurden Daten aus dem Institut für das Entgeltsystem im Krankenhaus(InEK)-Datenbrowser und den strukturierten Qualitätsberichten für die akutstationäre Rheumatologie ausgewertet. Die Versorgung ist sowohl in Bezug auf die Diagnosen als auch die Strukturen sehr vielschichtig. Unterschiedliche Formen der Spezialisierung können identifiziert werden. Dabei ist die rheumatologische Komplexbehandlung (RKB) nur eine davon, die im Mittel in knapp über 10 % der Fälle durchgeführt wird. 2020 gingen die Fallzahlen bei ausgewählten rheumatologischen Diagnosen um mehr als 20 % im Vergleich zu 2019 zurück. Bei der RKB war der Rückgang mit über 30 % noch ausgeprägter. Hinweise auf eine höhere Krankheitsschwere fanden sich in den verfügbaren Daten nicht. Es bleibt abzuwarten, ob das Fallzahlniveau der Vor-Corona-Zeit in den nächsten Jahren wieder erreicht wird. Es wurden 146 Organisationseinheiten (OE) mit mehr als 20 Hauptdiagnosen (HD) einer rheumatoiden Arthritis (RA) im Jahr 2019 identifiziert; 47 (32 %) davon haben mehr als 10-mal, 29 (20 %) mehr als 100-mal eine RKB kodiert. Alle 23 OE mit mehr als 300 HD RA sind Mitglieder im Verband rheumatologischer Akutkliniken (VRA); 15 davon nahmen am KOBRA-Qualitätsprojekt teil und tragen das VRA-Gütesiegel. Von den 116 internistischen OE weisen nur 55 (47 %) einen spezifischen rheumatologischen Fachabteilungsschlüssel nach § 301 SGB V auf. Angaben zur fachärztlichen Ausstattung waren zum Teil widersprüchlich. Wie viele Fälle mit entzündlich-rheumatischen Erkrankungen in fachlich spezialisierten Strukturen behandelt werden, kann mit den verfügbaren Daten nicht beantwortet werden. Dennoch können die verfügbaren Daten für die fachlichen, strukturellen und organisatorischen Weiterentwicklungen in der akutstationären Rheumatologie genutzt werden.

The Role of Age in Delays to Rheumatological Care in Juvenile Idiopathic Arthritis.

To investigate the relationship between age and symptom duration at initial presentation to pediatric rheumatology for juvenile idiopathic arthritis (JIA). In children and young people (CYP) enrolled in the Childhood Arthritis Prospective Study prior to March 2018, an association between age at presentation (&lt; 5, 5-11, and &gt; 11 yrs) and symptom duration was tested by multivariable linear regression. In 1577 CYP, 5- to 11-year-olds took 3.2 months longer and &gt; 11-year-olds 6.9 months longer to reach pediatric rheumatology than &lt; 5-year-olds. Adolescents take longer to reach pediatric rheumatology, potentially affecting their longer-term outcomes given the window of opportunity for JIA treatment.

Effectiveness of therapeutic ultrasound for the treatment of carpal tunnel syndrome (the USTINCTS trial): study protocol for a three-arm, prospective, multicentre, randomised controlled trial

IntroductionThere has no consensus on optimal management of carpal tunnel syndrome (CTS), the most common compression neuropathy. Conservative therapy is generally accepted as first-line intervention. Therapeutic ultrasound has been widely...

The impact of introducing multidisciplinary care assessments on access to rheumatology care in British Columbia: an interrupted time series analysis

BackgroundIn 2011 the British Columbia (BC) Ministry of Health introduced a new fee-for-service billing code that allowed “Multidisciplinary Care Assessment” (MCA). This change has the potential to change access to and quality of care for patients. This study aimed to explore the impact on access to rheumatology services in the province.MethodsFee-for-service rheumatology billings were evaluated for each rheumatologist 2 years before and after use of the MCA code. Numbers of 1) unique patients and 2) services provided per month were used as proxy measures of access to care. A multiple-baseline interrupted time series model assessed the impact of the MCA on levels and trends of the access outcomes.ResultsOur analysis consisted of 82,360 patients cared for by 26 rheumatologists who billed for an MCA. In our primary analysis we observed a sustained increase in the mean number of unique patients of 4.9% (95% CI: 0.0% to 9.9%, p = 0.049) and the mean number of services of 7.1% (95% CI: 1.0% to 13.6%, (p = 0.021), per month provided by a rheumatologist, corresponding to the initial use of MCA.ConclusionThe introduction of the MCA code was associated with an initial increase in the measures of access, which was maintained but did not increase over time. Our study suggests that the use of Multidisciplinary Care Assessment can contribute to expanding and/or sustaining access to care for people with complex chronic conditions, like rheumatic diseases.

Puja Mehta: taking the path untrodden

As both a specialist registrar in rheumatology and a clinical research training fellow in respiratory medicine (University College London [UCL], UK), Puja Mehta's curriculum vitae reads like that of several doctors combined. In 2021 alone, she gave talks at the American College of Rheumatology annual meeting and at an intensive care medicine conference, and chaired a scientific session at the winter meeting of the British Thoracic Society. Currently undertaking a basic science PhD on post-COVID-19 interstitial lung disease, Puja's unconventional career path is providing her with an impressive breadth of expertise and unique perspective, combining training across rheumatology, respiratory medicine, haematology, and intensive care medicine.

Healthcare disparities in telemedicine for rheumatology care.

We summarize the recent literature published in the last 2 years on healthcare disparities observed in the delivery of rheumatology care by telemedicine. We highlight recent research dissecting the underpinnings of healthcare disparities and identify potentially modifiable contributing factors. The COVID-19 pandemic has had major impacts on care delivery and has led to a pronounced increase in telemedicine use in rheumatology practice. Telemedicine services are disproportionately underutilized by racial/ethnic minority groups and among patients with lower socioeconomic status. Disparities in telemedicine access and use among vulnerable populations threatens to exacerbate existing outcome inequalities affecting people with rheumatic disease. Telemedicine has the potential to expand rheumatology services by reaching traditionally underserved communities. However, some areas lack the infrastructure and technology to engage in telemedicine. Addressing health equity and the digital divide may help foster more inclusive telemedicine care.

Consensus Approach to a Treat-to-target Strategy in Juvenile Idiopathic Arthritis Care: Report From the 2020 PR-COIN Consensus Conference.

Treat to target (T2T) is a strategy of adjusting treatment until a target is reached. An international task force recommended T2T for juvenile idiopathic arthritis (JIA) treatment. Implementing T2T in a standard and reliable way in clinical practice requires agreement on critical elements of (1) target setting, (2) T2T strategy, (3) identifying barriers to implementation, and (4) patient eligibility. A consensus conference was held among Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN) stakeholders to inform a statement of understanding regarding the PR-COIN approach to T2T. PR-COIN stakeholders including 16 healthcare providers and 4 parents were invited to form a voting panel. Using the nominal group technique, 2 rounds of voting were held to address the above 4 areas to select the top 10 responses by rank order. Incorporation of patient goals ranked most important when setting a treatment target. Shared decision making (SDM), tracking measurable outcomes, and adjusting treatment to achieve goals were voted as the top elements of a T2T strategy. Workflow considerations, and provider buy-in were identified as key barriers to T2T implementation. Patients with JIA who had poor prognostic factors and were at risk for high disease burden were leading candidates for a T2T approach. This consensus conference identified the importance of incorporating patient goals as part of target setting and of the influence of patient stakeholder involvement in drafting treatment recommendations. The network approach to T2T will be modified to address the above findings, including solicitation of patient goals, optimizing SDM, and better workflow integration.

APLAR recommendations on the practice of telemedicine in rheumatology

The COVID-19 pandemic led to rapid and widespread adoption of telemedicine in rheumatology care. The Asia Pacific League of Associations for Rheumatology (APLAR) working group was tasked with developing evidence-based recommendations for rheumatology practice to guide maintenance of the highest possible standards of clinical care and to enable broad patient reach. A systematic review of English-language articles related to telehealth in rheumatology was conducted on MEDLINE/PubMed, Web Of Science and Scopus. The strength of the evidence was graded using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach as well as the Oxford Levels of Evidence. The recommendations were developed using a modified Delphi technique to establish consensus. Three overarching principles and 13 recommendations were developed based on identified literature and consensus agreement. The overarching principles address telemedicine frameworks, decision-making, and modality. Recommendations 1-4 address patient suitability, triage, and when telemedicine should be offered to patients. Recommendations 5-10 cover the procedure, including the means, data safety, fail-safe mechanisms, and treat-to-target approach. Recommendations 11-13 focus on training and education related to telerheumatology. These recommendations provide guidance for the approach and use of telemedicine in rheumatology care to guide highest possible standards of clinical care and to enable equitable patient reach. However, since evidence in telemedicine care in rheumatology is limited and emerging, most recommendations will need further consideration when more data are available.

Outcomes and Quality of Care in Rheumatoid Arthritis With or Without Video Telemedicine Follow-Up Visits.

Telemedicine has been proposed to improve access to care in rheumatology, but few studies of telerheumatology have been published. The objective of this study was to evaluate outcomes and quality of care for rheumatoid arthritis (RA) in patients seen by video telemedicine follow-up compared to in-person only. Individuals in the Alaska Tribal Health System with a diagnosis of RA were recruited when seeing a rheumatologist either in-person or by video telemedicine, both of which were offered as part of usual follow-up care. At baseline, participants completed the Routine Assessment of Patient Index Data 3 (RAPID3) questionnaire and a telemedicine perception survey and agreed to medical record review. Participants repeated surveys by telephone at 6 and 12 months, and medical record abstraction was performed at 12 months for quality measures. At the 12-month outcome assessment, 63 of 122 RA patients (52%) had ever used telemedicine for RA. In univariate analysis, functional status improved over 12 months in the telemedicine group. In multivariate analysis, RAPID3 score and functional status were associated with telemedicine group (higher), with no statistically significant change over the 12-month period. The only quality measure that differed between groups at 12 months in univariate analysis was the proportion of visits in which disease activity was documented (higher in the in-person group, 40% versus 25%; P = 0.02), but this was not significant after multivariate analysis. In short-term follow-up, there was no significant difference in most outcome and quality measures in patients with RA who incorporated telemedicine follow-up in their care compared to in-person only.