ABSTRACT
Background: Axial spondyloarthritis (axSpA) is an important cause of infam-matory back pain (IBP). It is under-recognized, leading to signifcant delays in diagnosis. Early recognition and diagnosis are crucial to achieve the best outcomes for patients and in Malaysia, signifcant gaps in the clinical management of axSpA remain. Therefore, we sought to implement a strategy to improve the time to diagnosis and management of axSpA in Malaysia by collaborating and adopting guidance from an international axSpA expert. Objectives: The objectives were to improve disease recognition among healthcare practitioners (HCPs), reducing time to specialist referral and diagnosis whilst improving disease management by developing and implementing a new patient care model called the Spondyloarthritis Accelerated Management (SAM) and measure its effectiveness in 3 Rheumatology centers in Malaysia. Methods: The SAM initiative was developed by the Malaysian SpA Consortium Working Group involving 8 Malaysian rheumatologists from 3 local centers and 1 international axSpA expert from the UK as part of the steering committee. Selections were based on clinical expertise. The frst local alignment meeting on model structure was held in July 2020 with subsequent meetings held to address key barriers to early axSpA diagnosis and timely access to quality care. A care model with feasible key performance indicators (KPIs) was established, adapted and tracked monthly in the 3 rheumatology centers (Figure 1). Referral tools were developed to facilitate early referrals to rheumatologists. These included a QR-coded '3-R' referral guide1 and a patient self-screening tool with a patient self-referral letter all hosted on the Malaysian Society of Rheumatology (MSR) website, educational talks to HCPs and public awareness forums on IBP and axSpA. Data were collected on referral source, duration of referrals, knowledge on IBP in HCPs by surveys and imaging accessibility at baseline and at 1 year after the initiative was launched. Baseline data collected were from August to October 2020 and 1 year data were from November 2020 to November 2021. Results: At 1 year, the SAM initiative showed a 44.4% (Median: 1.33 [IQR 1-1.7] vs 1.92 [IQR 1.6-2.1]) increase in IBP referrals, a reducing trend from 9.5 (IQR 8-11.1) to 5.9 (IQR 5.1-6.8) weeks of waiting time to a frst Rheumatology visit and an increase of 37.2% (34% vs 71%) in IBP patients who were seen at the rheumatology clinic within 6 weeks. All patients with IBP had X-rays (sacroiliac joints or pelvis). MRI requests in X-ray negative patients suspected of axSpA was increased by 13.9% (77.8% vs 91.7%) and waiting time for MRI was reduced by 3.1 weeks (12 vs 8.9 weeks). The IBP knowledge among 224 HCPs improved by 40.6% (45.7% vs 86.3%). The number of patients newly diagnosed with axSpA increased by 40% (Median: 5 [IQR 4-9.5] vs 7 [IQR 6.5-7]) despite the COVID-19 pandemic. Conclusion: The SAM initiative has shown promising initial results in improving referrals of patients with IBP, promoting earlier diagnosis and establishing the importance of having timely access to optimal care. A nationwide implementation is being planned to improve the recognition of the axSpA in Malaysia.
ABSTRACT
Background: COVID-19 pandemic has been devastating not only medically but also socially and economically. Selangor, an urbanised state in Malaysia, has been severely affected by COVID19. There is concern that patients with rheumatic diseases (RD) may have higher risk of infection, with increased mortality1. Objectives: To investigate patients' characteristics which are associated with 'feeling stressed' among patients with RD during the second wave of COVID19 infection in Selangor. Methods: This is a cross-sectional study conducted over 3 weeks during the second wave of COVID19 infection in Malaysia. Patients with RD, scheduled for rheumatology clinic appointment in a rheumatology referral centre were invited to participate in this study. Personal and clinical data were collected by phone interview and from patients' medical records respectively. Patients were asked to grade their disease activity by giving a score from 0 (not active) to 10 (active). All patients were asked 'are you feeling stressed' and the answer was recorded as yes or no. Reasons explored for a yes answer, included financial, social disruption, physical illness and future uncertainties. Categorical and continuous data were analysed using chi-squared test and student t-test, respectively. A p-value of <0.05 is considered statistically significant. Results: Three hundred and sixty-one patients with various RD participated in this study. The mean age of these was 48.2 years (range between 16-80 years). More than half (54.3%) were Malay and other ethnicities were Chinese (25.5%), Indian (18.2%) and others (2%). A quarter of patients (24.7%) were not working (unemployed, retired and students) and a third of patients (32.1%) had unpaid work (mainly housewife). The other patients' characteristics are shown in Table 1. Eighty-three (23%) admitted to 'feeling stressed' and the stressors identified were physical illness in 34 (40.9%), social disruption in 23 (27.7%), financial problems in 23 (27.7%) and future uncertainties in 19 (22.9%). Patients' characteristics that were significantly different between patients who were 'feeling stressed' and not 'feeling stressed' were age, employment status and perceived disease activity (Table 1). Conclusion: The COVID19 pandemic has caused mental distress in a significant number of RD patients and associations were found with older age, having paid work and perceived disease activity. Issues that may influence patients' responses, including access to rheumatology care, medication and fear of getting infection were not explored in this study.