Flipped Learning: Can Rheumatology Lead the Shift in Medical Education?

OBJECTIVE: To 1. implement flipped classroom rheumatology teaching for undergraduate education. 2. Evaluate outcomes of teaching using OSCE assessment and student perceived effectiveness and satisfaction survey. METHODS: The flipped classroom education, 55-students, was conducted in 3 phases. Phase 1: Carried out in the students' own time. Web links were emailed to assist exposure of the instructional part of the lesson online. Phase 2: Interactive in-class activity to share personal reflection and reinforce the key aspects. Phase 3: A simulated OSCE assessment. A cohort of 56-students, who were taught in the last educational year on the same topics according to standard teaching protocols, were included as control group. The clinical Outcomes were assessed using the scores of the OSCE examination model. Academic outcomes included the engagement measure as well as the students' answers to perceived effectiveness and satisfaction survey. RESULTS: There was no significant difference regarding demographics between the 2 students' groups. There was a significant improvement (p< 0.05) in the flipped learning, in contrast to the control group, in terms of clinical (OSCE score) as well as communication skills. Student perceived effectiveness and satisfaction was significantly higher among the flipped learning (p< 0.05). Scores from the flipped learning cohort showed a state of engagement significantly higher than the control group (p< 0.01). CONCLUSION: Flipped learning implementation musculoskeletal learning successfully demonstrated a promising platform for using technology to make better use of the students' time, and for increasing their satisfaction. Active learning increases student engagement and can lead to improved retention of knowledge.

Toward electronic health recording: evaluation of electronic patient reported outcome measures (e-PROMs) system for remote monitoring of early systemic lupus patients.

The study aimed to assess the value of evaluation of electronic patient reported outcome measures (e-PROMs) in the assessment and management of SLE disease activity flares, its association with adherence to therapy as well as organ damage. A randomized, controlled crossover study was carried out over a 24-month duration. One hundred forty-seven SLE patients meeting the revised American College of Rheumatology (ACR) criteria were enrolled. Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) was used to assess disease activity, whereas organ damage was scored using the Systemic Lupus International Collaborating Clinics (SLICC)/ACR Damage Index. In the first 12 months, the patients were assessed every 3 months. At 12 months, the patients were randomized into a cohort of 73 patients who continued their care in the same style and 74 patients who completed an online e-PROMs questionnaire on monthly basis for another 12-month period. The data captured were then retrospectively analyzed at the end of the 24-month study period. At the end of the first year of the study, the mean SLEDAI and SDI scores were 8.72 (6.1) and 1.9 (2.2). At the end of the second year, the mean SLEDAI and SDI scores in the e-PROMs cohort were 3.1 (2.6) and 1.2 (1.3), whereas in the control group, the scores were 7.63 (6.7) and 1.8 (2.3), respectively (p < 0.01). Adjusting for possible confounding variables, the number of flares, regardless of their severity, was associated with damage accrual (OR 2.03, 95% CI 1.34 to 2.83, p < 0.001). Adherence to therapy was significantly (p < 0.1) higher in the e-PROMs group. e-PROMs was equivalent to PROMs paper format and has a potential disease-modifying effect as it facilitated close monitoring of disease activity with an option of management escalation whenever indicated.

Meaningful patient engagement in inflammatory arthritis: development of the Patient Motivation Questionnaire.

The objective of this study is to develop a questionnaire for evaluating the patient's "motivation" and assess the psychometric properties of that measure in patients with chronic inflammatory arthritis. Using Rasch analysis and questions item pool, content analysis, and semi-structured group discussion, the questionnaire was developed including 10-item scale (0-10 on VAS scale). Construct validity was assessed by correlating the questionnaire score to parameters of disease activity (DAS-28, ASDAS, and DAPSA scores), functional disability, quality of life, patient self-helplessness measure, as well as the patients' compliance to therapy. Reliability and comprehensibility and sensitivity to change were also assessed. The questionnaire was assessed in 432 RA, 415 psoriatic arthritis patients, and 232 ankylosing spondylitis patients. Dimensionality analysis revealed a 1-factor solution, explaining 98% of the total variance. It showed acceptable validity as it correlated significantly with disease activity measures: DAS-28: r = -0.85, ASDAS: r = -0.86, and DAPSA: r = -0.89. It also correlated significantly with functional disability score: r = -0.91, QoL: r = -0.90, as well as patient self-helplessness: r = -0.88. The questionnaire was reliable (Cronbach's alpha 0.958) and had no misfitting items. In addition, it was comprehensible (9.4) and sensitive to change (p < 0.01). The patient motivation score showed significant (p < 0.01) variation with the medication compliance. The measure is a patient-reported tool that is valid, reliable, comprehensible, and unidimensional scale that reflects the patients' motivation and engagement. The measure has good psychometric properties indicating that it can be used at the individual patient level to tailor management and monitor changes.

Patient reported outcomes in ankylosing spondylitis: development and validation of a new questionnaire for functional impairment and quality of life assessment.

OBJECTIVES: To assess validity, reliability and sensitivity to change of a new questionnaire for assessment of functional disability and quality of life in ankylosing spondylitis (AS) patients. METHODS: Using Rasch analysis and 71 questions item pool, content analysis and semi structured group discussion, the combined AS questionnaire (CASQ) was developed including: 10-item scale to assess functional impairment (CASQ-FI), and 10 items to assess quality of life (CASQ-QoL). Construct validity was assessed by correlating the score of the questionnaire to parameters of disease activity namely, the BAS-FI, BAS-DAI, BAS-G, BAS-Metrology Index, and the occupational status. In addition, the CASQ was compared to both HAQS and ASQoL. Sensitivity to change of the developed CASQ was also assessed. RESULTS: The CASQ questionnaire for functional impairment (CASQ-FI: 10 items) and quality of life (CASQ-QoL: 10 items) showed acceptable validity as it correlated significantly with clinical parameters of disease activity: BAS-FI (CASQ-FI: r=0.85, CASQ-QoL: r=0.86), BAS-DAI (CASQ-FI: r=0.71, CASQ-QoL: r=0.87) and BAS-G (CASQ-FI: r=0.64, CASQ-QoL: r=0.79). Compared to HAQS and ASQoL, the CASQ-QoL was as well or better correlated with clinical and outcome measures. The CASQ was also reliable (Cronbach's alpha for CASQ-FI 0.958, and CASQ-QoL 0.966) and had no misfitting items. In addition, both CASQ questionnaires were sensitive to change (p<0.01) CONCLUSIONS: The CASQ is a reliable and valid tool for assessment of functional impairment and quality of life in AS. The CASQ is well accepted by patients, sensitive to change, easy to administer and score. The CASQ-FI and CASQ-QoL questionnaires can either be used and scored separately to assess for functional disability as well as quality of life or in combination as tools to assess for both parameters.