Health Literacy Rates in a Population of Patients with Rheumatoid Arthritis in Southwestern Ontario.

OBJECTIVE: To determine the rate of low health literacy in the rheumatoid arthritis (RA) population in southwestern Ontario. METHODS: For the study, 432 patients with RA were contacted, and 311 completed the assessment. The health literacy levels of the participants were estimated using 4 assessment tools administered in the following order: the Single Item Literacy Screener (SILS), the Medical Term Recognition Test (METER), the Rapid Estimate of Adult Literacy in Medicine (REALM), and the Shortened Test of Functional Health Literacy in Adults (STOFHLA). RESULTS: The rates of low literacy as estimated by STOFHLA, REALM, METER, and SILS were 14.5%, 14.8%, 14.1%, and 18.6%, respectively. All 4 assessment tools were statistically significantly correlated. STOFHLA, REALM, and METER were strongly correlated with each other (r = 0.59-0.79), while SILS only demonstrated moderate correlations with the other assessment tools (r = 0.33-0.45). Multiple linear regression and binary logistic regression analyses revealed that low levels of education and a lack of daily reading activity were common predictors of low health literacy. Using a non-English primary language at home was found to be a strong predictor of low health literacy in STOFHLA, REALM, and METER. Male sex was found to be a significant predictor of poor performance in REALM and METER, but not STOFHLA. CONCLUSION: Low health literacy is an important issue in the southwestern Ontario RA population. About 1 in 7 patients with RA may not have the necessary skills to become involved in making decisions regarding their personal health. Rheumatologists should be aware of the low health literacy levels of patients with RA and should consider identifying patients at risk of low health literacy.

Response to Tumor Necrosis Factor Inhibitors in Rheumatoid Arthritis for Function and Pain is Affected by Rheumatoid Factor.

OBJECTIVES: To investigate differences in response to tumor necrosis factor inhibitor treatment (TNFi) in seropositive (rheumatoid factor positive; RF+) versus seronegative (RF-) patients with established RA as measured by the Health Assessment Questionnaire Disability Index (HAQ-DI) and pain. METHODS: RA patients from an established RA cohort were studied according to rheumatoid factor (RF) status for change in HAQ-DI and pain (0-3 VAS) one year after starting treatment with a TNFi. RESULTS: There were 238 patients treated with TNFi who had follow-up data (178 RF+ and 60 RF-). Disease duration was longer in RF+ vs RF- (12+8 vs 8+8 years) but the proportion of females (82% vs 72%, P=0.7), baseline HAQ-DI (1.44+0.63 vs 1.41+0.63, P=0.8) and pain (1.92+0.67 vs 1.93+0.67, P=0.9) were not different. The mean duration of treatment of first TNFi was 2.8 vs 2.3 years, P=0.1 and 68% of RF+ vs 62% of RF- were still receiving first TNFi at last visit (P=0.5). For patients with data at baseline and one year, the one-year HAQ-DI change was significantly greater in 90 RF+ patients (-0.356) versus 38 RF- patients (-0.126; P=0.04). The mean pain improvement was also greater in 77 RF+ vs 32 RF- patients (-0.725 vs -0.332 respectively; P=0.03). Numbers are small, data are missing and comorbidities, DAS28 and anti-CCP were not collected. CONCLUSION: Despite limitations in the data, in established RA after failure of DMARDs, RF+ patients may be more responsive to TNFi therapy as measured by changes in HAQ-DI and pain. INNOVATION: There may be a better response to TNFi in RA if RF positive for function and pain.

Comprehensive arthritis referral study -- phase 2: analysis of the comprehensive arthritis referral tool.

OBJECTIVE: Rheumatologists triage referrals to assess those patients who may benefit from early intervention. We describe a referral tool and formally evaluate its sensitivity for urgent and early inflammatory arthritis (EIA) referrals. METHODS: All referrals received on a standardized referral tool were reviewed by a rheumatologist and, based on the information conferred, assigned a triage grade using a previously described triage system. Each referral was also dichotomized as suspected EIA or not. After the initial rheumatologic assessment, the diagnosis was recorded and a consultation grade, blinded to referral grade, was assigned to each case. Agreement between referral and consultation grades was assessed. A regression analysis was performed to determine factors that predicted truly urgent referrals including EIA. RESULTS: We evaluated 696 referrals. A total of 210 (30.2%) were categorized as urgent at the time of consultation. The referral tool was able to successfully detect 169 of these referrals (sensitivity 80.5%, specificity 79.4%). EIA occurred in 95 (13.6%); of those referrals, 86 were correctly classified as urgent at the time of triage (sensitivity 90.5%, specificity 69.6%). Items that helped correctly discriminate urgent or EIA referrals included patient age < 60, duration of disease, morning stiffness, patient-reported joint swelling, a personal or family history of psoriasis, urgency as rated by referring physician, prior assessment by a rheumatologist, elevated C-reactive protein, and a positive rheumatoid factor. CONCLUSION: A 1-page referral tool that includes parts completed by the referring physician and patient has good sensitivity to detect urgent referrals including EIA.

Social persuasion in rheumatology: a randomized trial of testimonials on television in the rheumatology clinic waiting room to increase attendance for multidisciplinary education.

Multidisciplinary self-management programs are important in inflammatory arthritis as adjunctive treatment. Patients often have excuses as to why they do not attend these programs. The purpose of this study was to determine whether an intervention of televised testimonials from rheumatologists and allied health professionals increases attendance at a multidisciplinary education day for rheumatology patients seen in a large university hospital clinic. This was an RCT of intervention: playing televised interviews in the waiting room where rheumatology patients were seen versus no TV. There was a total of 6 months (3 months with and 3 without the televised interview playing). All eligible patients who attended the rheumatology outpatient clinic were then tracked to determine whether they attended a subsequent education day over the next 10 months. The sample size was calculated to have a 15% increase in attendance at the education days. There was a 20% increase in attendees at the multidisciplinary education days for patients who saw the televised testimonials. Sixty-three patients who viewed the testimonials (2.17% of 2,908) attended the education day compared to 39 who did not receive the intervention (1.80% of 2,168); however, the increase was not statistically significant (p = 0.36). Attendance of eligible patients increased using televised testimonials; however, the increase was not significant as the rates of attendance were still very low in both groups. Many eligible patients did not attend the program. Other interventions are necessary to encourage attendance in a multidisciplinary program.

Strategies to improve recruitment into rheumatology: results of the Workforce in Rheumatology Issues Study (WRIST).

OBJECTIVE: By 2026, there will be a 64% shortfall of rheumatologists in Canada. A doubling of current rheumatology trainees is likely needed to match future needs; however, there are currently no evidence-based recommendations for how this can be achieved. The Workforce in Rheumatology Issues Study (WRIST) was designed to determine factors influencing the choice of rheumatology as a career. METHODS: An online survey was created and invitations to participate were sent to University of Western Ontario (UWO) medical students, UWO internal medicine (IM) residents, Canadian rheumatology fellows, and Canadian rheumatologists. Surveys sent to each group of respondents were identical except for questions related to demographics and past training. Participants rated factors that influenced their choice of residency and scored factors related to the attractiveness of rheumatology and to recruitment strategies. Statistical significance was determined using chi-squared and factor analysis. RESULTS: The survey went out to 1014 individuals, and 491 surveys were completed (48.4%). Responses indicated the importance of exposure through rotations and role models in considering rheumatology. Significant (p < 0.002) differences between groups were evident regarding what makes rheumatology attractive and effective recruitment strategies, most interestingly with rheumatologists and trainees expressing opposite views on the latter. CONCLUSION: Recommendations are made in 2 broad categories: greater exposure and greater information. As medical students and IM residents progress through their training, their interest in rheumatology lessens, thus it is important to begin recruitment initiatives as early as possible in the training process.

Canadian recommendations for use of methotrexate in patients with rheumatoid arthritis.

OBJECTIVE: To develop recommendations for the use of methotrexate (MTX) in patients with rheumatoid arthritis. METHODS: Canadian rheumatologists who participated in the international 3e Initiative in Rheumatology (evidence, expertise, exchange) in 2007-2008 formulated 5 unique Canadian questions. A bibliographic team systematically reviewed the relevant literature on these 5 topics. An expert committee consisting of 26 rheumatologists from across Canada was convened, and a set of recommendations was proposed based on the results of systematic reviews combined with expert opinions using a nominal group consensus process. RESULTS: The 5 questions addressed drug interactions, predictors of response, strategies to reduce non-serious side effects, variables to assess clinical response, and incorporating patient preference into decision-making. The systematic review retrieved 93 pertinent articles; this evidence was presented to the expert committee during the interactive workshop. After extensive discussion and voting, a total of 9 recommendations were formulated: 2 on drug interactions, 1 on predictors of response, 2 on strategies to reduce non-serious side effects, 3 on variables to assess clinical response, and 1 on incorporating patient preferences into decision-making. The level of evidence and the strength of recommendations are reported. Agreement among panelists ranged from 85% to 100%. CONCLUSION: Nine recommendations pertaining to the use of MTX in daily practice were developed using an evidence-based approach followed by expert/physician consensus with high level of agreement.

Test-retest reliability of patient global assessment and physician global assessment in rheumatoid arthritis.

OBJECTIVE: As a guide to treatment of rheumatoid arthritis (RA), physicians use measurement tools to quantify disease activity. The Patient Global Assessment (PGA) asks a patient to rate on a scale how they feel overall. The Physician Global Assessment (MDGA) is a similar item completed by the assessing physician. Both these measures are frequently incorporated into other indices. We studied reliability characteristics for global assessments and compared test-retest reliability of both the PGA and the MDGA, as well as other commonly used measures in RA. METHODS: We studied 122 patients with RA age 17 years or older. Patients who received steroid injection or change in steroid dose at the visit were excluded. Patients completed the HAQ, PGA, visual analog scale for pain (VAS Pain), VAS Fatigue, and VAS Sleep. After seeing their physician, they received another questionnaire to complete within 2 days at the same time of day as clinic visit. Physicians completed the MDGA at the time of the patient's appointment and at the end of their clinic day. Test-retest results were assessed using intraclass correlations (ICC). "Substantial" reliability is between 0.61-0.80 and "almost perfect" > 0.80. RESULTS: Four rheumatologists and 146 patients participated, with 122 questionnaires returned (response rate 83.6%). Test-retest reliability was 0.702 for PGA, 0.961 for MDGA, and 0.897 for HAQ; VAS results were 0.742 for Pain, 0.741 for Fatigue, and 0.800 for Sleep. The correlation between PGA and MDGA was -0.172. CONCLUSION: PGA, MDGA, HAQ, and VAS Pain, VAS Fatigue, and VAS Sleep all showed good to excellent test-retest reliability in RA. MDGA was more reliable than PGA. The correlation between PGA and MDGA was poor.

Are the 2002 American College of Rheumatology guidelines for the management of rheumatoid arthritis being followed in Canada's largest academic rheumatology center?

OBJECTIVE: To determine whether rheumatologists working in Canada's largest academic rheumatology center (University Health Network/Mount Sinai Hospital) adhere to the 2002 American College of Rheumatology (ACR) guidelines for the management of rheumatoid arthritis (RA). METHODS: Ten patients with RA seen between January 1 and December 30, 2005, were randomly selected from each rheumatologist. A standardized form was used to verify whether the following items were collected at each visit: (1) degree of joint pain, (2) duration of morning stiffness, (3) degree of fatigue, (4) number of tender/swollen joints, and (5) assessment of function. Items recommended for periodic assessment were also collected and included: (1) examination for joint damage, (2) erythrocyte sedimentation rate and/or C-reactive protein, and (3) radiographic assessment of joint damage (radiograph/magnetic resonance imaging). RESULTS: One hundred thirty charts and 313 total visits met inclusion criteria. No rheumatologist consistently assessed each ACR item. Of the recommended items, tender and swollen joint counts and pain were most commonly assessed (95%, 95%, and 69%, respectively). Functional assessment, morning stiffness, and fatigue were least commonly reported (48%, 46%, and 33%, respectively). Items recommended for periodic assessment were not regularly recorded. There was a trend for the recommended items to be reported more regularly for new patients, patients taking a disease modifying antirheumatic drug (DMARD), and patients for whom a DMARD was added or increased in dosage. CONCLUSION: Rheumatologists follow many but not all of the recommendations included in the revised ACR guidelines. The reasons underlying the noncompliance to some of the recommendations are not fully understood. In order to improve the adoption of future clinical practice guidelines, the ACR may have to plan specific dissemination and implementation strategies and fund studies to formally assess the effect of guideline use on clinical outcomes.