Unmet demands for health care among patients with rheumatoid arthritis: Indications for underuse?

Objective

To assess the prevalence of unmet health care demands among rheumatoid arthritis (RA) patients, and to determine if these unmet demands indicate underuse.

Methods

A total of 679 patients with RA participated in a questionnaire survey and clinical examination. Unmet health care demands and health care use were assessed for orthopedic care, allied health care, home care, and psychosocial care. Indications for underuse were determined by comparing health outcomes of patients with unmet health care demands and of health care users.

Results

Of the 679 patients, 28.7% had an unmet demand for 1 of the 4 services: 13.4% for allied health care, 9.7% for orthopedic care, 9.4% for home care, and 6.2% for psychosocial care. Underuse of allied health care, home care and psychosocial care was observed.

Conclusion

Unmet demands for health care are frequent among RA patients. Most unmet demands indicate underuse. Health care professionals should therefore be more responsive to the demands of patients.

     

Unmet demands for health care among patients with rheumatoid arthritis: indications for underuse?

OBJECTIVE: To assess the prevalence of unmet health care demands among rheumatoid arthritis (RA) patients, and to determine if these unmet demands indicate underuse. METHODS: A total of 679 patients with RA participated in a questionnaire survey and clinical examination. Unmet health care demands and health care use were assessed for orthopedic care, allied health care, home care, and psychosocial care. Indications for underuse were determined by comparing health outcomes of patients with unmet health care demands and of health care users. RESULTS: Of the 679 patients, 28.7% had an unmet demand for 1 of the 4 services: 13.4% for allied health care, 9.7% for orthopedic care, 9.4% for home care, and 6.2% for psychosocial care. Underuse of allied health care, home care and psychosocial care was observed. CONCLUSION: Unmet demands for health care are frequent among RA patients. Most unmet demands indicate underuse. Health care professionals should therefore be more responsive to the demands of patients.     

Increased enthesopathy among Behçet's syndrome patients with acne and arthritis: an ultrasonography study

OBJECTIVE: Beh?et's syndrome is characterized by clusters of disease expression, one of which is the coexistence of acne and arthritis. The aim of this study was to test the hypothesis that enthesopathy is increased in this cluster, having features reminiscent of acne-associated arthritis. METHODS: The study group comprised 35 patients with Beh?et's syndrome who had acne and arthritis (BS-AA), 38 patients with Beh?et's syndrome who did not have arthritis (BS-WA), 37 patients with ankylosing spondylitis (AS), 25 patients with rheumatoid arthritis (RA), and 25 healthy control subjects. Five entheseal sites (the superior and inferior poles of the patella, the tibial tuberosity, and the superior and inferior poles of the calcaneus) on both lower extremities were examined by 2 independent observers, using ultrasonography. A previously validated composite score was calculated for each patient. The numbers of entheseal sites giving a positive power Doppler signal in each group were also compared. RESULTS: Patients with AS had the highest enthesopathy score (mean +/- SD 4.1 +/- 2.4; F [4df] = 8.43, P < 0.001) followed by BS-AA patients (3.0 +/- 1.9; F [3df] = 3.63, P = 0.015). The mean +/- SD enthesopathy scores among the remaining 3 groups were similar (for BS-WA, 1.8 +/- 1.4; for RA, 2.2 +/- 1.6; for healthy controls, 2.0 +/- 1.5 [F (2df) = 0.65, P = 0.53]). Power Doppler scores were highest for the BS-AA group (mean +/- SD 3.0 +/- 1.5; F [4df] = 15.54, P < 0.001) followed by the AS group (2.7 +/- 1.8; F [3df] = 14.38, P < 0.001), the RA group (2.6 +/- 1.8; F [2df] = 13.88, P < 0.001), the BS-WA group (1.2 +/- 1.3; F [1df] = 4.48, P = 0.038), and the control group (0.5 +/- 1.1). There was 87% agreement between the 2 observers (kappa = 0.55, intraclass correlation coefficient 0.71). CONCLUSION: The increased presence of enthesopathy among BS-AA patients compared with that among BS-WA patients further supports the hypothesis that patients with Beh?et's syndrome who also have arthritis and acne form a distinct cluster.     

Health care utilization among rheumatoid arthritis patients referred to a rheumatology center: unequal needs, unequal care?

OBJECTIVE: To quantify the utilization of health care by rheumatoid arthritis (RA) patients and to estimate the contribution of patient characteristics to the explanation of the use of care, in order to evaluate whether those in need of care actually receive care. METHODS: A questionnaire survey and a clinical examination were conducted among patients with RA referred to a rheumatology center. Health care utilization was assessed for medical care, allied health care, psychosocial care, and home care. The influence of sociodemographic variables and clinical and health characteristics on health care utilization was assessed by means of logistic regression. RESULTS: Multivariate analyses showed that, for all types of services, disease-related factors explained most of the utilization. However, some sociodemographic variables (age, sex, and living situation) were also related to the utilization of care. CONCLUSION: Most patients received the care they needed. However, for the elderly with RA, problems in access to allied health care and psychosocial care exist.     

Health care utilization among rheumatoid arthritis patients referred to a rheumatology center: unequal needs,unequal care?

Objective

To quantify the utilization of health care by rheumatoid arthritis (RA) patients and to estimate the contribution of patient characteristics to the explanation of the use of care, in order to evaluate whether those in need of care actually receive care.

Methods

A questionnaire survey and a clinical examination were conducted among patients with RA referred to a rheumatology center. Health care utilization was assessed for medical care, allied health care, psychosocial care, and home care. The influence of sociodemographic variables and clinical and health characteristics on health care utilization was assessed by means of logistic regression.

Results

Multivariate analyses showed that, for all types of services, disease‐related factors explained most of the utilization. However, some sociodemographic variables (age, sex, and living situation) were also related to the utilization of care.

Conclusion

Most patients received the care they needed. However, for the elderly with RA, problems in access to allied health care and psychosocial care exist.

     

Anti-tumor necrosis factor-α therapy and changes of flow-mediated vasodilatation in psoriatic and rheumatoid arthritis patients

For a long time, the endothelial covering of the vessels has been considered an inert surface. On the contrary, the endothelial cells are active and dynamic elements in the interaction between blood and tissues. The control of the vessel basal tone is obtained by the complex balance between the relaxing and contracting endothelial factors. Previous clinical studies show that patients suffering from rheumatoid arthritis and other autoimmune rheumatologic pathologies are at high risk of death being prematurely affected by atherosclerosis and cardiovascular diseases. Blocking tumor necrosis factor (TNF)-α by biological drugs improves the endothelial function. The aim of our study was to evaluate the effects of two anti-TNF-α drugs (infliximab and etanercept) on the endothelial function by evaluating the flow-mediated dilatation (FMD), which was measured in the brachial artery before and after treatment and after 8–12 weeks. We enrolled 36 patients (average age 52 ± 9.8 years, 12 men and 24 women), 25 of them were affected by rheumatoid arthritis (RA) and 11 were affected by psoriatic arthritis (PsA) and they were divided into three groups: 10 patients were treated with etanercept, 13 patients were treated with infliximab, 13 patients were treated with DMARDs. We measured the common carotid intimal-medial thickness (ccIMT) and the endothelial function was evaluated by FMD measurement in the brachial artery, before treatment, 1 h after the beginning of treatment and after 8–12 weeks. No statistically significant difference between the three groups was found for the ultrasonographic evaluation of the carotid IMT. On the contrary, the differences between FMD values before and after the treatment in the patients treated with etanercept (13.1 ± 0.01 vs. 18.8 ± 0.01%, p < 0.01) and in the patients treated with infliximab (11.8 ± 0.09 vs. 16.7 ± 0.09%, p < 0.01) were statistically significant. Long-term evaluation for infliximab and etanercept was performed by comparing the FMD values, respectively, 8 and 12 weeks after the first treatment. After 8 weeks, FMD value was similar to the value recorded at enrollment in the infliximab group (11.9 ± 0.03 vs. 13.54 ± 0.04%, p = 0.236) and the FMD values in the etanercept group after 12 weeks showed a not statistically significant reduction of vasodilatating effect (13.01 ± 0.03 vs. 15.67 ± 0.02%, p = 0.197). In conclusion, the use of biological drugs in patients affected by autoimmune arthritis can modify the endothelial function, as indicated by the induced FMD changes, but the long-term effect tends to be considerably reduced.     

Quality of life and functional capacity in patients with rheumatoid arthritis – Cross-sectional study

Objectives

To analyze the Health related Quality of Life (HRQoL) and physical function in rheumatoid arthritis (RA) patients and compare it with the general population. We also intended to analyze about disease activity influence in HRQoL and functional capacity, as well as determine potential determinants for these outcomes.

NMR monitoring of rheumatoid arthritis patients receiving anti-TNF-α monoclonal antibody therapy

The aim of this study was to investigate if dynamic gadolinium-DTPA-supported magnetic resonance (MR) imaging can monitor the therapeutic effect of a fast-acting immuno-modulating drug like anti-tumour necrosis factor alpha (anti-TNF-) monoclonal antibody (moab) in patients with rheumatoid arthritis (RA). Dynamic MR imaging was performed on 64 joints in a total of 18 patients before and after infusion with either a placebo or 1 or 10 mg/kg of anti-TNF- moab. Additionally, treating the placebo group and reinfusing the verum group with either 3 or 10 mg/kg was monitored by quantitative nuclear magnetic resonance (NMR). Time-dependent signal intensity changes were then correlated with a total of five Paulus criteria and with ESR and C-reactive protein (CRP). No changes in either the gadolinium uptake or clinical parameters were seen after the infusion of a placebo. Therapy with 1 mg/kg anti-TNF- moab resulted in a significant decrease in clinical disease activity, as well as in gadolinium-DTPA uptake in dynamic NMR studies. However, correlations between signal intensity changes and Paulus criteria were only demonstrated for the variable doctor's evaluation of disease activity. Patients given 10 mg/kg moab demonstrated a very significant improvement in all clinical manifestations of their disease, as well as a high significant reduction in gadolinium uptake (P=0.004). In addition, the latter group showed significant correlations between time-dependent signal intensity changes and five Paulus criteria: number of swollen joints, number of painful joints, duration of morning stiffness, doctor's evaluation of disease activity and patient's evaluation of disease activity. No differences and correlations were seen for ESR and CRP. We concluded that dynamic NMR studies are suitable to monitor inflammatory activity in RA patients under therapy with biological response modifiers such as anti-TNF- moab.     

A survey of traditional Chinese medicine use among rheumatoid arthritis patients: a claims data–based cohort study

Clinical Rheumatology - Traditional Chinese medicine (TCM) is commonly used for symptom relief in patients with chronic diseases. Nevertheless, large-scale surveys focusing on the utilization of...     

Should anti-TNF therapy be discontinued in rheumatoid arthritis patients undergoing elective orthopaedic surgery? A systematic review of the evidence

Anti-tumour necrosis factor (TNF) therapies have revolutionized the management of rheumatoid arthritis (RA). A high proportion of RA patients are now established users of anti-TNF agents. Unfortunately, many RA patients with longstanding disease still require elective orthopaedic procedures. Published studies on the influence of TNF antagonist on infection rates in RA patients undergoing surgery are conflicting. However, national registries of RA patients on anti-TNF reported an increased risk of infection. The risk of anti-TNF-related infection is highest at the start of treatment with frequent involvement of the skin and subcutaneous tissue. Infection at these sites could negatively influence the healing of surgical wound. Current guidelines suggest that treatment with biologics should be discontinued prior to surgery. Patients with established disease are more likely to flare compared to those with early disease on stopping treatment. Consequently, TNF blockers need to be reinstated promptly after surgery to avoid the risk of RA flare.     

Intra-articular methotrexate versus corticosteroid injections in medium-sized joints of rheumatoid arthritis patients—an intervention study

The effects of intra-articular methotrexate (I/A MTX) in knee synovitis in rheumatoid arthritis have been previously evaluated. I/A MTX has not been studied in other joints. Ultrasonography (US) has been little studied in monitoring the effect of I/A MTX. The aim of the study is to test the efficacy of I/A MTX in suppression of persistent synovitis in medium-sized joints (ankle, wrist, and elbow) in rheumatoid arthritis patients. Patients were divided into two groups: group 1 (methotrexate group): 56 patients in which 84 joints (32 ankles, 28 wrists, and 24 elbows) were injected intra-articularly by 10 mg of methotrexate in the targeted joint on a weekly basis for 8 weeks and group 2 (steroid group): 44 patients in which 70 joints (26 ankles, 24 wrists, and 20 elbows) were injected once by Triamcinolone acetonide 40 mg. Clinical, ultrasonographic, and power Doppler US (PDUS) evaluation was done before the first injection (W0), after 2 months (W8), and after 5 months (W20). Synovial thickness and the intra-articular power Doppler signal were graded on a semiquantitative scale from 0 to 3 during the US examination. Clinical parameters improved significantly in both groups between baselines and 2 months. In both groups, gray-scale US and power Doppler US showed that synovial thickness and intra-articular power signals were reduced significantly between W0 and W8. The improvement of clinical parameters continued in the methotrexate group up to W20, but in the corticosteroid group, clinical parameters at W20 were similar to clinical parameters at W0. In the methotrexate group, there was an insignificant increase in synovial thickness between W8 and W20 while there was a significant increase in power Doppler signals between W8 and W20, p < 0.05. In the corticosteroid group, there was a significant increase in both synovial thickening and power Doppler signals between W8 and W20, p < 0.001. In the MTX group, all patients at week 0 showed that the Doppler signal in grades 2 and 3 is 100%; at 8 weeks, most of the patients showed that the power Doppler in grade 0 is 76%; and at week 20, most of the patients showed that the power Doppler signal in grade 0 is 28% and in grade 1 is 47%, while in grades 2 and 3 is 23.6%, so there is an improvement compared to the baseline of treatment. Repeated I/A MTX resulted in a decrease in the degree of synovitis of medium-sized joints in RA patients both clinically and by power Doppler US.     

The FOOTSTEP self‐management foot care programme: Are rheumatoid arthritis patients physically able to participate?

Background: The FOOTSTEP self‐management foot care programme is a clinical and cost‐effective programme for basic foot care in the elderly. The aim of this study was to determine if patients with rheumatoid arthritis (RA) would be physically able to participate. Methods: A consecutive cohort of RA patients undergoing podiatry care underwent tests for sight, reach and grip strength to determine their physical ability to undertake self‐managed foot care. Results: Thirty RA patients (10 male, 20 female), with a median age of 61 years (range 42 to 84) and disease duration of 10 years (range one to 40), were recruited. All patients passed the sight test, whereas the reach and grip tests were passed by 77% and 67% of patients, respectively. Only 57% of patients passed all the physical tests. Patients who failed the physical tests were older, and had longer disease duration and higher physical disability, pain and general health scores but these were not statistically different. Conclusions: Just over half the patients in this present cohort may be physically able to undertake some aspects of self‐managed foot care, including nail clipping and filing, callus filing and daily hygiene and inspection. Copyright © 2008 John Wiley & Sons, Ltd.     

Leflunomide or methotrexate? Comparison of clinical efficacy and safety in low socio-economic rheumatoid arthritis patients

In order to compare the efficacy and toxicity of methotrexate and leflunomide for the treatment of rheumatoid arthritis, a double-blind randomized clinical trial was carried out at the Department of Medicine, Jinnah Medical College Hospital, Korangi, Karachi. The sample size was 240 patients and the duration of the study was 1 year. The patients enrolled were randomly divided into two groups (methotrexate and leflunomide). RA activity was clinically assessed by noting changes in the four primary (tender joint count, swollen joint count, physician and patient global assessment score) and three secondary (morning stiffness, pain intensity, HAQ) clinical efficacy end-points. Data were expressed as the mean ± SD. A P value of <0.05, calculated by paired t test, was considered significant. A total of 368 subjects were enrolled in this study. Of these, 128 subjects were withdrawn during the screening phase. Of the 240 subjects who were randomized and treated, 129 received leflunomide and 111 received methotrexate. The difference between the baseline and 12 month end-point measurements of all primary clinical efficacy end-points was significantly greater in methotrexate-treated than in leflunomide-treated subjects. Both leflunomide and methotrexate resulted in significant improvements in all secondary clinical efficacy end-points after 1 year of treatment. In both treatment groups, the most common reason for withdrawal during the treatment was adverse events. The results of this study indicate that both leflunomide and methotrexate are effective drugs for the long-term treatment of RA. It was concluded that methotrexate, which is a much cheaper drug than leflunomide, is the drug of choice, especially for patients who belong to low socioeconomic groups.     

Leflunomide or methotrexate? Comparison of clinical efficacy and safety in low socio-economic rheumatoid arthritis patients

Abstract

In order to compare the efficacy and toxicity of methotrexate and leflunomide for the treatment of rheumatoid arthritis, a double-blind randomized clinical trial was carried out at the Department of Medicine, Jinnah Medical College Hospital, Korangi, Karachi. The sample size was 240 patients and the duration of the study was 1 year. The patients enrolled were randomly divided into two groups (methotrexate and leflunomide). RA activity was clinically assessed by noting changes in the four primary (tender joint count, swollen joint count, physician and patient global assessment score) and three secondary (morning stiffness, pain intensity, HAQ) clinical efficacy end-points. Data were expressed as the mean ± SD. A P value of <0.05, calculated by paired t test, was considered significant. A total of 368 subjects were enrolled in this study. Of these, 128 subjects were withdrawn during the screening phase. Of the 240 subjects who were randomized and treated, 129 received leflunomide and 111 received methotrexate. The difference between the baseline and 12 month end-point measurements of all primary clinical efficacy end-points was significantly greater in methotrexate-treated than in leflunomide-treated subjects. Both leflunomide and methotrexate resulted in significant improvements in all secondary clinical efficacy end-points after 1 year of treatment. In both treatment groups, the most common reason for withdrawal during the treatment was adverse events. The results of this study indicate that both leflunomide and methotrexate are effective drugs for the long-term treatment of RA. It was concluded that methotrexate, which is a much cheaper drug than leflunomide, is the drug of choice, especially for patients who belong to low socioeconomic groups.     

Late infection of total knee arthroplasty inflamed by anti-TNFα, Infliximab therapy in rheumatoid arthritis

We report a case of sudden onset of late infection after TKA inflamed by anti-TNFα therapy, Infliximab, in a 54-year-old woman with RA. Infliximab therapy was started 3 years and 8 months after TKAs as a result of multiple arthritides showing high inflammation of RA. One week after the third administration of Infliximab, the patient suffered sudden knee pain and infectious clinical symptoms, and bacteria (MSSA) were detected by joint effusion culture. She was successfully treated by open debridement with antibiotics-loaded calcium phosphate bone paste and cement and the prostheses were retained. Early diagnosis and operative treatment might be the key to controlling infected TKA without removing the implant. This present case might indicate a serious risk of immunosuppressive effects caused by Infliximab.     

Discontinuation of anti-TNF-α therapy in a Chinese cohort of patients with rheumatoid arthritis

The aim of this retrospective study was to examine the predictors of discontinuation of anti-tumor necrosis factor (TNF) therapy due to adverse events in Chinese patients with rheumatoid arthritis (RA). Anti-TNF-related adverse events were recorded and analyzed in 217 consecutive patients with RA followed in our institution from 2003 to 2010. Time to discontinuation of anti-TNF-α therapy was estimated using survival analysis techniques. The anti-TNF agents administered were etanercept in 181 patients and adalimumab in 36 patients. The mean age at diagnosis was 45.2?±?13.5?years, and mean age at initiation of anti-TNF therapy was 51.8?±?13.0?years. The mean duration of anti-TNF agent use was 36.0?±?26.5?months (range, 1.4–87.0; median, 26.4?months). Of the 217 patients, 39 (18.0?%) developed adverse events [etanercept in 34 (18.8?%] and adalimumab in 5 (13.9?%)] during the treatment period (tuberculosis in 5, bacterial infections in 19, virus infection in 7, neuropathy in 3, malignancy in 3, other drug-related events in 1, and appendicitis in 1). In patients with RA, older age (≥55?years) at initiation of anti-TNF therapy [odds ratio (OR), 3.20; 95?% confidence interval (CI), 1.67–6.20; p?<?0.001], Cr ≥1.5?mg/dL (OR, 5.72; 95?% CI, 1.17–27.90; p?=?0.031), and occurrence of adverse events (OR, 3.82; 95?% CI, 1.75–8.35; p?=?0.001) were associated with increased likelihood of discontinuation of anti-TNF treatment. In the present study, a significant proportion (7.8?%, 17/217) of patients with RA discontinued anti-TNF treatment because of adverse events. In the elderly and in patients with renal insufficiency, caution is needed when starting anti-TNF treatment.     

Clinicians’ perspectives of shared care of psoriatic arthritis and psoriasis between rheumatology and dermatology: an interview study

Clinical Rheumatology - Shared care between rheumatologists and dermatologists is advocated for patients with psoriasis and psoriatic arthritis, but care provided by rheumatologists and...