Rheumatologists' adherence to guidelines for misoprostol use in patients at high risk for nonsteroidal antiinflammatory drug gastropathy

OBJECTIVE: To determine the extent of evidence based practice among rheumatologists in the prevention of nonsteroidal antiinflammatory drug (NSAID) associated peptic ulcer disease and to seek ways to improve the management of high risk NSAID users. METHODS: In March 1996 all 7 rheumatologists from Saskatoon participated in a consensus conference to develop local guidelines for the prophylaxis of NSAID associated peptic ulcer disease. We performed a retrospective chart review for September/October 1995 (baseline) and for June/July 1996 (post-consensus guideline) of all patients from Saskatoon rheumatologists who were being treated with NSAID for either rheumatoid arthritis (RA) or undifferentiated inflammatory polyarthritis (IP). A prospective crossover intervention study was performed from January to April 1997 in which 2 subgroups of rheumatologists (university or private practice) had a reminder sheet of gastrointestinal (GI) bleeding risk assessment placed into the front of each patient's chart prior to each office visit. The GI bleeding risk for each patient at time of visit was later determined by chart review. The primary outcome was the proportion of adherence to guidelines for high risk NSAID users in the combined intervention group (reminder sheet) compared to the combined control group (no reminder sheet) in the prospective controlled crossover study. RESULTS: A total of 484 patients with RA or IP received NSAID during the 4 study periods. Of these, 82 patients (16.9%) were at high risk of GI bleed. In 1995, the proportion of high risk patients taking misoprostol was 29% for university and 33% for private practice rheumatologists. The establishment of local consensus guidelines in 1996 temporarily increased adherence to guidelines to 43%, but only for private practice rheumatologists. During the prospective study, adherence to guidelines was significantly greater in the intervention (reminder sheets) group compared to the control (no reminder sheets) group (53% vs 15%; p = 0.014). CONCLUSION: The simple intervention of reminder sheets for GI bleeding risk assessment resulted in a significant increase in rheumatologists' adherence to guidelines, although a substantial number of patients remained untreated with misoprostol. This study illustrates the difficulty of incorporating new knowledge and recommendations into clinical practice. Additional strategies should be investigated to more effectively incorporate new knowledge in the practice of rheumatology.     

Measuring adherence with therapy for chronic diseases: Implications for the treatment of heterozygous familial hypercholesterolemia

The failure of patients to adhere adequately to prescribed medication and behavioral regimens is an important medical problem. Poor adherence is most common when the treatment regimen is preventive rather than curative, when patients are asymptomatic, and when the duration of treatment is long. For these reasons, adherence with dietary therapy for hypercholesterolemia is well recognized to be a significant clinical and research challenge. Medication adherence has been acknowledged to be a problem for those treatments with significant side effects, such as flushing and pruritus or the low palatability of bile acid sequestering agents. The availability of drugs that lack these effects has long been viewed as an important contribution to improving overall patient compliance. However, the literature on patient adherence with life-long treatment regimens that are simple and palatable (e.g., antihypertensives) suggests that while these improved treatments can enhance adherence, the overall rates of patient compliance still average only 50%. The fact that patients with heterozygous familial hypercholesterolemia are at high risk for early coronary artery disease and death if they fail to adhere to therapy is not sufficient to assure high rates of appropriate therapy over long periods of time, as demonstrated by the poor or erratic adherence commonly reported to treatments for other life-threatening diseases, such as advanced renal disease, hemophilia, and type I diabetes. The measurement of patient adherence to hypercholesterolemia therapy is often neglected in clinical practice and inadequate in hypercholesterolemia research. This review will examine issues in the measurement of adherence to therapy for chronic diseases in a clinical setting, and, specifically, the measurement of adherence to treatment for hypercholesterolemia in clinical triale.     

Quality of care in rheumatic diseases: performance measures and improvement

PURPOSE OF REVIEW: To acquaint rheumatologists with pay-for-performance and the American College of Rheumatology quality initiative, and to suggest how practice process redesigns and effective measurement of performance and disease outcomes will help rheumatologists document and improve the quality of rheumatic disease care. RECENT FINDINGS: The options for treating rheumatic diseases have improved, but many patients are not achieving optimal outcomes. Pay for performance programs being introduced by Medicare and other insurers will link provider revenues to quality indicators, requiring rheumatologists to measure, document, and improve their patients' outcomes. Expected rheumatology manpower losses will also require greater practice efficiency and increased reliance on inter-disciplinary care teams. Some publications advocate improving healthcare by expanding research to improve knowledge transfer from clinical studies to clinical practice; others suggest continuous process improvement methods to improve delivery of care processes. Practical disease activity measurements and rheumatology practice improvements are being reported that suggest a positive future. SUMMARY: Rheumatologists need to recognize the need to improve delivery of care and patient outcomes, measure and document clinical performance, and learn the methods for managing clinical process improvement.     

A survey of European and Canadian rheumatologists regarding the treatment of patients with ankylosing spondylitis and extra-articular manifestations

Ankylosing spondylitis (AS) is a disabling inflammatory disease accompanied by a variety of extra-articular manifestations in a significant number of patients. These manifestations, including Crohn’s disease, ulcerative colitis, psoriasis, and uveitis, share a similar inflammatory mechanism with one another and with AS. Extra-articular manifestations are observed in a larger percentage of patients with AS and spondyloarthritides (SpAs) than the normal population; therefore, it is important to identify these and other inflammatory-mediated conditions and consider them when treating SpAs. How rheumatologists approach patients with both AS and extra-articular manifestations may lead to a better understanding of what treatment approaches could be taken to optimize patient outcomes. Rheumatologists (N = 453) from five European countries and Canada who treat AS were surveyed to determine treatment practices and management of both AS and its associated extra-articular manifestations. Most rheumatologists (93%) believe AS could be diagnosed earlier as the average time between symptom onset and diagnosis was approximately 4 years. In total, 60% routinely screen patients with AS for extra-articular manifestations, although this varied considerably across countries. The majority (97%) agrees that controlling inflammation is critical during treatment, and patients with extra-articular manifestations tend to have poorer prognoses than those patients with only axial AS. Treatment considerations varied depending on whether patients presented with only axial AS or had extra-articular manifestations, where use of biologics became more common. Rheumatologists agree that patients with both AS and extra-articular manifestations require a different treatment strategy than patients with AS alone. Results of this survey highlight areas where rheumatologists differ in their clinical management of patients with AS including tools used for disease assessment and the routine screening, or lack thereof, for other inflammatory diseases. This evidence may suggest aspects within clinical practice where modifications may be made in order to optimize patient outcomes.     

Magnetic resonance imaging of rheumatoid arthritis: the evolution of clinical applications through clinical trials

Powerful techniques are being developed for evaluating rheumatoid arthritis with magnetic resonance imaging (MRI). Much of this development is being driven by the pharmaceutical and biotechnology industries searching for novel therapies for this disease. Accordingly, the imaging tools that ultimately will be used to direct patients to specific therapies and then to monitor treatment effectiveness and safety are currently being refined and validated in rigorous multicenter and multinational clinical trials aimed at gaining regulatory approval of these new therapies. As these trials approach completion, rheumatologists can anticipate an increased demand for expertise and experience in evaluating disease progression and treatment response with these techniques and the emergence of MRI systems specifically designed for this market. The following discussion reviews this novel pathway for evolving imaging techniques for clinical use through clinical drug trials, lists the most promising MRI markers available today for evaluating joint destruction in rheumatoid arthritis, and speculates on how these techniques will find their way into clinical practice.     

Does practice mirror the evidence base in the treatment of rheumatoid arthritis?

A large base of evidence exists regarding treatments for rheumatoid arthritis (RA) and how they may be used to preserve long-term function and improve patient outcomes. However, little is known about whether real-life rheumatology practice reflects the evidence base. This survey aimed to capture differing perceptions among rheumatologists in the identification and treatment of patients and to understand how their management of and treatment decisions for patients with RA may be influenced by the current published literature. Rheumatologists from five European countries and Canada participated in a survey between April and May 2006 to establish how rheumatologists identify and treat particular patient types in everyday practice. In total, 458 rheumatologists responded to the online and telephone survey. Rapidly progressing disease was overwhelmingly recognized (97%) as a distinct subtype among patients with RA, and the majority (88%) of respondents make treatment decisions based on this distinction. Most rheumatologists use measures including C-reactive protein, erythrocyte sedimentation rate, tender/swollen joint counts, and X-ray progression to diagnose and monitor this particular group of patients; a minority (30%) used magnetic resonance imaging to identify and monitor patients with rapidly progressing disease. Although treatment goals for these patients were similar among rheumatologists, the treatment approach varied considerably across countries. Overall, rheumatologists agree on the management goals for patients with rapidly progressing RA; however, their treatment patterns have some dissimilarities.     

Influence of guideline adherence on outcome in a randomised controlled trial on the efficacy of methotrexate with folate supplementation in rheumatoid arthritis

OBJECTIVE: To study the influence of rheumatologists' adherence to a methotrexate guideline on efficacy and toxicity in the treatment of rheumatoid arthritis. METHODS: In a 48 week randomised controlled trial of methotrexate, comparing folates with placebo, rheumatologists were advised on methotrexate dosage using a guideline reflecting daily practice. The influence of guideline non-adherence on outcome was analysed using generalised estimating equations and survival analysis. RESULTS: In 51% of the 411 study patients the guidelines were always followed. Non-adherence resulted in lower doses of methotrexate in 25% of cases, and higher doses in 24%. The reduction in the disease activity score was significantly greater (mean -0.4; p = 0.0085) in the adherent group than in the "low dose" group; the "high dose" group did not differ from the adherent group. Dropout caused by severe adverse events did not differ between the three groups. CONCLUSIONS: There is an indication that adherence to guidelines on methotrexate dosage may benefit patients with rheumatoid arthritis by improving disease activity without increasing toxicity. For definite proof, a randomised controlled trial comparing guideline supported dosing with usual care is needed.     

Adherencia a las recomendaciones actuales de inmunización en pacientes con artritis reumatoide en México

BackgroundPatients with RA have a two to four-fold increased risk of developing infections compared to the general population. For this reason, the administration of influenza, pneumococcal and shingles vaccines is recommended for all patients with RA, preferably prior to initiating treatment,Previous studies have demonstrated the low prevalence of vaccination as well as adherence to current recommendations by rheumatologists in other regions.ObjectiveTo determine the knowledge and adherence to the current vaccination recommendations for patients with RA by rheumatology members of the Mexican College of Rheumatology (MCR), and to identify barriers to their application in this population.MethodsA cross-sectional study was conducted through a survey sent to 577 rheumatologists from Mexico in January 2017.ResultsWe received completed surveys from 122 individuals, representing 21.14% of the 577 rheumatologists in our registry.Fifty percent responded that they recommended immunization against influenza to 76%-100% of their patients, 36.07% recommended immunization against pneumococcus to 76%-100% of their patients, and 69.67% of the survey responders did not recommend shingles immunization routinely to their patients.ConclusionsThe data collected in this study show there is poor adherence to immunization schedules recommended for the RA population. This data suggests there is misinformation about the effectiveness, safety and optimal timing of immunization in patients with RA in Mexico.     

Definition of Remission and Disease Activity Assessment in Psoriatic Arthritis: Evidence and Expert-Based Recommendations

ObjectiveWe aimed to reach a consensus on the best instruments to monitor disease activity in patients with psoriatic arthritis (PsA) and to develop a consensus definition of remission.MethodsA modified Delphi approach was used. A scientific committee provided statements addressing the definition of remission and the monitoring of PsA in clinical practice. The questionnaire was evaluated in 2 rounds by rheumatologists with experience in managing PsA patients.ResultsA panel of 77 rheumatologists reached agreement on 62 out of the 86 proposed items (72.0%). The most recommended index for monitoring disease activity was DAPSA (cut-off values: ≤4 for remission and >4–14 for low disease activity ([LDA]), MDA (at least 5/7 criteria). In cases with axial involvement, ASDAS was the preferred index (cut-off values: <1.3 for remission and <2.1 for LDA). BASDAI (cut-off values: ≤2 for remission and ≤4 for LDA) may be used as an alternative. PsAID was the preferred tool to assess disease impact.ConclusionWe propose a definition of remission in PsA as the absence of disease activity evaluated by DAPSA or MDA (ASDAS and/or BASDAI in patients with axial involvement), which would imply absence of signs or symptoms of inflammation, physical well-being, lack of disease impact, and absence of inflammation as measured by biological markers.     

Survey of the awareness of adult rheumatologists regarding transitional care for patients with juvenile idiopathic arthritis in Japan

Abstract

Objectives: To understand the current status of adult rheumatology care for patients who had previously had juvenile idiopathic arthritis (JIA) (excluding systemic JIA), and to identify issues interfering with the transition from pediatric to adult care in Japan.

Methods: Questionnaire-based survey among 30 adult rheumatologists.

Results: Eighty-seven percent of adult rheumatologists responded that they had provided medical care to adults who had had JIA; 44% of them had felt hesitation or anxiety when providing such care. The reasons for this included lack of independence of the patients, lack of knowledge and experience among adult rheumatologists, and lack of preparation for accepting such patients. Many adult rheumatologists believed that the timing of transition from pediatric to adult rheumatology care must be considered based on therapeutic regimens or clinical conditions/disease states, not solely chronological age. A majority of adult rheumatologists showed great interest in transitional care for JIA patients and desired to communicate better with pediatric rheumatologists.

Conclusion: Transitional care for JIA patients is not sufficiently developed in Japan. Education and advocate campaign of transitional care is required for adult rheumatologists as well as patients and their parents.     

National survey of knowledge,attitude and practice of fibromyalgia among rheumatologists in China

Aim

Fibromyalgia (FM) is a chronic disorder characterized by widespread musculoskeletal pain and fatigue. It is a less frequently diagnosed disease in China, thus Chinese rheumatologists may have lower awareness of FM compared with colleagues in Western countries. The aim of this study is to investigate the perceptions of FM in Chinese rheumatologists and analyze their therapeutic approach in clinical practice.

Method

An anonymous questionnaire survey was conducted among a nationwide sample of Chinese rheumatologists at the 15th National Rheumatology Conference in 2010. The 20‐question survey included questions regarding background, work experience, perceptions of diagnosis and behaviors of treatment related to FM. Continuing medical education (CME) information was also collected in the survey.

Results

Seven hundred and seven rheumatologists responded to the questionnaire, a response rate of 60%. Less than one‐fifth of the respondents were experienced in dealing with FM. Although most of the respondents regarded FM as a distinct pathological entity, nearly 30% of Chinese rheumatologists believed that FM was only a psychological disorder. The respondents recognized some of the FM‐related symptoms, but had limited knowledge on the diagnostic criteria. Eighty percent of the respondents declared they had difficulties in treating FM patients. However, nearly all (90.8%) respondents believed that the prognosis of FM patients was usually benign. Our data also showed that most Chinese rheumatologists were eager for CME on FM.

Conclusion

The awareness and perception of FM are still low among Chinese rheumatologists. CME on FM is needed for improving the quality of health care in China.     

Analysis of the reasons for DMARD therapy discontinuation in patients with rheumatoid arthritis in the Czech and Slovak republics

The aim of the study was to evaluate the efficacy and safety of disease-modifying drugs (DMARDs) in everyday clinical practice in Central European States (the Czech and Slovak republics). This was a retrospective, multicentre study. With the help of a special questionnaire, the medical files of 760 patients in 15 centres were analysed looking for reasons for DMARD discontinuation (e.g. insufficient efficacy, toxicity). The secondary endpoints were duration of therapy with individual DMARDs and the influence of other factors (demographic, disease specific, concomitant therapy) on duration of therapy. In 47.1 % of patients therapy was interrupted because of lack of efficacy, in 43.2 % because of adverse events, and in 9 % for undefined reasons. Toxic reactions leading to withdrawal were most common with gold (62.6 %) and methotrexate (62.5 %). Because of insufficient effect, treatment was most frequently interrupted with antimalarials (62.3 %) and penicillamine (53.2 %), but in only 22% treated with methotrexate. The mean duration of one treatment episode with DMARDs was 28.1 t 48.9 months. Surprisingly, it was longest for cyclophosphamide (53.5 + 55.1 months) and shortest for cyclosporin (7.0 t 6.7 months). The mean duration of treatment with methotrexate was only 14.9; t 16.2 months. The mean duration of treatment with one DMARD was statistically longer in patients with positive rheumatoid factor, extra-articular disease and age lower than 50 years. There was no impact of sex, concomitant steroid treatment and high or low sedimentation rate on treatment duration. Considerable differences in everyday clinical practice with DMARDs between Central European states and published data from the US and western Europe have been found. More education about modern strategies in the treatment of RA is probably necessary for practising rheumatologists. Received: 31 January 2001 / Accepted: 22 November 2001     

New insights into culture driven disorders

Rheumatologists frequently encounter patients whose illnesses lack face-value; that is, they lack the typical objective features of pathology that rheumatologists traditionally rely on for diagnosis and developing effective treatment approaches: namely fibromyalgia, chronic fatigue syndrome, Gulf War syndrome, chronic whiplash, chronic low back pain, etc. In this article, we examine this group of illnesses as culture-driven disorders to emphasize the central importance of various societal constraints in the ultimate presentation of patients with these illnesses. We will examine them by first understanding the purpose they serve, the underlying factors that compel societal institutions to sanctify these disorders as diseases, and how research is beginning to examine the behaviour that captures and packages these symptoms to produce their clinical presentation. With this research understanding, rheumatologists may be able to offer patients more useful action plans, but likely changes in societal approaches to the expressions of distress and changes in disability and compensation systems will also be required.     

Changing the model of care for patients with acute coronary syndromes

Acute coronary syndromes (ACS) represent a major cause of morbidity and mortality for patients with cardiovascular disease, but evidence-based therapies shown to improve outcomes for ACS are often underused in clinically eligible patients. Although clinical practice guidelines have been developed to provide standards for the diagnosis and treatment of patients with ACS and to provide physicians with a framework for clinical decision-making, multiple obstacles have hindered their implementation and questions remain about the applicability of guidelines for diverse clinical situations. Systematic reviews of quality-improvement studies have shown that multifaceted approaches using targeted educational interventions, creation of quality standards, and regular performance feedback are needed to ensure sustained improvements in care. Approaches to quality improvement thus are being redirected to focus on multidisciplinary collaborations designed to improve the entire process of care for patients with ACS. Multiple large observational registries and quality-improvement initiatives now are capturing data regarding adherence to practice guidelines and contemporary patterns of care for ACS. This comprehensive evaluation of ACS treatment will help guide efforts designed to promote evidence-based care and ultimately determine the effect of widespread implementation of practice guidelines on clinical outcomes. The shifting model of care for ACS therefore suggests that quality improvement and monitoring of adherence to practice guidelines should be considered components of optimal clinical practice.     

Nonradiographic axial spondyloarthritis: expanding the spectrum of an old disease: A narrative review

Nonradiographic axial spondyloarthritis (nr-axSpA) represents a distinct phenotype within the spectrum of axial spondyloarthritis (axSpA), which is characterized by a range of clinical manifestations. Despite a high disease burden that is comparable to ankylosing spondylitis (also known as radiographic axSpA), there is an unmet need to recognize and effectively manage patients with active nr-axSpA.A targeted literature search was conducted in OVID (MEDLINE and Embase databases) to identify articles on nr-axSpA, including its definition, demographics, epidemiology, burden, diagnosis, clinical presentation, and treatment guidelines.The lack of adequate epidemiological data and incomplete understanding of nr-axSpA among rheumatologists and nonrheumatologists contributes to delayed referrals and diagnosis. This delay results in a substantial burden on patients, physically and psychologically, and the healthcare system. Targeted therapies, such as biologics, including inhibitors of tumor necrosis factor or interleukin-17A, have been approved and utilized for the management of nr-axSpA, and other novel therapeutics with different mechanisms of action are in development. Raising awareness among US internists regarding the prevalence of nr-axSpA, disease burden, clinical presentation, diagnostic tools, and available treatments is important for improved disease management.Future clinical investigations focusing on the development of markers that aid early diagnosis and predict treatment response may also improve the management of nr-axSpA. This review provides an overview of nr-axSpA with the aim of raising awareness of the disease among US internists, with an overarching goal to contribute toward the improved recognition and timely referral of these patients to rheumatologists for diagnosis and management.     

Utility and feasibility of musculoskeletal ultrasonography (MSK US) in rheumatology practice in Canada: needs assessment

The utility of musculoskeletal ultrasound (MSK US) is being extensively explored and evaluated amongst European rheumatologists. However, utilization of MSK US by rheumatologists in Canada is much less common. This study aimed to evaluate the current use of MSK US in Canadian rheumatology practice, to determine beliefs and attitudes towards MSK US, and to determine factors that may encourage or limit its use. A 13-question needs assessment questionnaire was developed. All Canadian rheumatologists were invited via e-mail to participate in the survey. The overall response rate was 156/470 (33%). Fifty-one percent of participants used MSK US in their clinical practice. Lack of training appeared to be the main obstacle to its current use. Eighty-three percent believed that MSK US should be performed by rheumatologists and expressed a willingness to learn the technique. Skills offering greatest clinical utility were the assessment of inflammatory arthritis in small joints (i.e., hands (metacarpophalyngeal and proximal interphalangeal joints), wrists, feet (metatarsophalyngeal), shoulders, and ankles. Limited available time, equipment costs, and difficulties with billing were the main obstacles to MSK US utilization in the clinical setting. There is a great level of interest in learning and applying MSK US in Canadian rheumatology practice. The balance between added clinical value and lack of remuneration, equipment associated costs, and time to complete training is the major limiting factor influencing rheumatologists' willingness to take on MSK US. Training programs must be relevant to rheumatologists' needs before MSK US will be adopted into routine clinical practice in Canada.     

Sicherheit der Rheumatherapie im Alter

Mainly due to the general demographic changes and decreasing mortality in rheumatic diseases based on therapeutic progress, the proportion of older patients treated by rheumatologists is growing. Drug treatment in the elderly, however, harbors certain risks including age-specific pharmacokinetic features and high rates of multimorbidity and polypharmacy resulting in a risk of drug interactions and adherence problems. Nevertheless, older patients suffering from rheumatic diseases ought to be treated with the same intensity and same targets as the younger counterparts. Bearing all these facts in mind it is a balancing act for rheumatologists to find an optimal treatment for the individual elderly patient. Fear of risks should not lead to hesitant use of drugs leaving these patients alone with treatment deficits, as some studies have suggested.     

Adherence to treatment in patients with ankylosing spondylitis

This study aims to determine the level of adherence to treatment in ankylosing spondylitis (AS) patients and to identify possible factors associated to lack of adherence. We included consecutive AS patients (NY modified criteria). Sociodemographic and clinical data were collected. Patients answered auto-reported questionnaires: Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Functional Index, Ankylosing Spondylitis Quality of Life, and Center for Epidemiological Studies Depression scale. Patients with rheumatoid arthritis (RA) (ACR’87 criteria) were assessed as the control group. The adherence of the studied groups to medical treatment and exercises was measured by means of two questionnaires: Compliance Questionnaire on Rheumatology (CQR) and Exercise Attitude Questionnaire-18 (EAQ-18). The study included 59 patients with AS and 53 patients with RA. Of the AS patients, 43 (72.9 %) were male, median age 47 years (interquartile range (IQR) 33–57) and median disease duration of 120 months (IQR 33–57). Of the RA patients, 37 (69.8 %) were female, had a median age of 56 years (IQR 43.5–60) and a median disease duration of 156 months (IQR 96–288). There were no significant differences in the results of the adherence questionnaires between both groups, with a total median of 68.42 for the CQR in both groups and of 40.7 in AS vs. 42.6 in RA for the EAQ. When dichotomizing patients as adherent and non-adherent, taking as good adherence a cut value in the CQR and EAQ higher than 60, adherence to pharmacological treatment was significantly higher in RA vs. AS (92.5 vs. 74.6 %, p?=?0.01) and there were no differences in the EAQ. On the uni- and multivariate analysis, lack of adherence to treatment was not associated to sex, age, disease duration, education, health insurance, depressive status, and disease activity parameters in neither group of patients. AS have an acceptable adherence to pharmacological treatment, although it is lower than RA patients; nonetheless, both groups show a lack of adherence to exercise.