EULAR/eumusc.net standards of care for rheumatoid arthritis: cross-sectional analyses of importance, level of implementation and care gaps experienced by patients and rheumatologists across 35 European countries

Retention rate of biologic and targeted synthetic anti-rheumatic drugs in elderly rheumatoid arthritis patients: data from GISEA registry

Objectives

An increased number of elderly individuals affected by rheumatoid arthritis (RA) has been reported, including both patients with RA onset in advanced age and patients aged with the disease. In this registry-based study, we aimed to analyze the retention rate and cause of discontinuation of biologic (b) and targeted synthetic (ts)-disease-modifying anti-rheumatic drugs (DMARDs) in RA patients over 65 year old.

Methods

RA patients enrolled in the Italian GISEA registry and starting a b- or a ts-DMARD over 65 years of age were included. Demographic, clinical, serologic, and therapeutic features were collected.

Results

A total of 1,221 elderly RA patients were analyzed (mean age 71.6 ± 5.2 years). RA was diagnosed before 65 years in 72.5% of cases, a 60.6% of patients experienced a previous b- or ts-DMARD. In patients older than 65 initiating a new b- or ts-DMARDS, tumor necrosis factor alpha inhibitors (TNFi) were prescribed in 29.6% of patients, abatacept in 24.8%, anti-interleukin 6 receptor antagonists (anti-IL6R) in 16.3%, Janus kinases inhibitors (JAKi) in 24.9%, and rituximab in 4.4%. The main causes of discontinuation were primary or secondary inadequate responses (66.1%). The median retention rate for all treatments was 181.3 weeks. A statistically higher retention rate was observed for abatacept when compared to TNFi (p = 0.02), JAKi (p < 0.001), and anti-IL6R (p < 0.001), and for TNFi vs. JAKi (p = 0.013).

Conclusion

We described, in a real-life setting, elderly RA patients treated with a biologic or a ts-DMARD in Italy. Loss of efficacy was the main cause of discontinuation, and the DMARD safety profile suggests that age does not contraindicate their use. Our study reinforced that the control of disease activity is mandatory.

[Delegation of medical duties to qualified rheumatology assistants : Effect on depression and anxiety in patients with rheumatoid arthritis]

BACKGROUND

At least 1 comorbidity occurs in 80% of patients with rheumatoid arthritis (RA). In addition to cardiovascular comorbidities psychological comorbid conditions are common. The prevalence of depression and anxiety is higher in patients than in the general population. Screening for comorbidities is crucial. A shortage of outpatient specialist care barely allows resources for this. The implementation of team-based care holds the potential to improve the standard of care while simultaneously working against the shortage of care.

OBJECTIVE

The aim of the study was to examine the effects of care on the course of depression and anxiety in patients with seropositive RA and active disease.

MATERIAL AND METHODS

A multicenter pragmatic randomized controlled trial was conducted over the course of 1 year with 224 patients. After baseline, five more visits followed. In the intervention group (IG), three were initially carried out by qualified rheumatological assistants. Depression, anxiety and patient satisfaction with outpatient care were looked at in detail.

RESULTS

In the IG the anxiety symptoms significantly improved over 12 months (p = 0.036). The proportions of patients with anxiety also significantly changed in the IG (p < 0.001), while there was no change in the control group between baseline and month 12. The values of the depression scale did not differ significantly (p = 0.866). In terms of the information dimension of the satisfaction questionnaire, patients in the IG felt significantly better informed after 6 months (p = 0.013) and 12 months (p = 0.003).

CONCLUSION

A positive effect of team-based care on the course of depression and anxiety in patients with seropositive RA and active disease could be shown.

A machine learning model identifies patients in need of autoimmune disease testing using electronic health records

Systemic autoimmune rheumatic diseases (SARDs) can lead to irreversible damage if left untreated, yet these patients often endure long diagnostic journeys before being diagnosed and treated. Machine learning may help overcome the challenges of diagnosing SARDs and inform clinical decision-making. Here, we developed and tested a machine learning model to identify patients who should receive rheumatological evaluation for SARDs using longitudinal electronic health records of 161,584 individuals from two institutions. The model demonstrated high performance for predicting cases of autoantibody-tested individuals in a validation set, an external test set, and an independent cohort with a broader case definition. This approach identified more individuals for autoantibody testing compared with current clinical standards and a greater proportion of autoantibody carriers among those tested. Diagnoses of SARDs and other autoimmune conditions increased with higher model probabilities. The model detected a need for autoantibody testing and rheumatology encounters up to five years before the test date and assessment date, respectively. Altogether, these findings illustrate that the clinical manifestations of a diverse array of autoimmune conditions are detectable in electronic health records using machine learning, which may help systematize and accelerate autoimmune testing.

Better Clinical Results in Rheumatoid Arthritis Patients Treated Under a Multidisciplinary Care Model When Compared with a National Rheumatoid Arthritis Registry

Purpose

To describe clinical characteristics and effectiveness of health care in patients with rheumatoid arthritis (RA) as part of a multidisciplinary care model (MCM) in a specialized rheumatology center, compared with the results of a national registry of RA (NARRA) as evidence of real-world management.

Patients and Methods

We conducted a real-world study (July 1, 2018 to June 30, 2019) based on an analysis of electronic health records of a cohort of RA patients managed with the “Treat-to-Target” strategy in a specialized rheumatology center in Colombia with an MCM, compared with the NARRA that includes different models of usual care.

Results

We have analyzed 7053 subjects with RA treated at a specialized rheumatology center and 81,492 patients from the NARRA. Cohorts were similar in their baseline characteristics, with women in predominance and diagnosis age close to 50 years. At the time of diagnosis, a higher proportion of clinical diagnostic test use and rheumatology consultation access was observed in the specialized rheumatology center than in the national registry (4–6 per year versus three or less). In addition, higher proportions of patients in remission and low disease activity were reported for the specialized rheumatology center, with a >40% amount of data lost in the national registry. Pharmacological management was similar regarding the analgesic use. In the specialized center, Certolizumab was more frequently used than in the NARRA registry; also, there were significant differences in methotrexate, leflunomide, and sulfasalazine use, being higher in the specialized rheumatology center.

Conclusion

The MCM of a specialized center in RA can guarantee comprehensive care, with better access to all the services required to manage the disease. It ensures specialist management and evidence-based care that facilitates the achievement of therapeutic objectives. In addition, better patient records and follow-ups are available to evaluate health outcomes.

Analysis of the implementation of an innovative IT solution to improve waiting times, communication with primary care and efficiency in Rheumatology

OBJECTIVE

To describe in detail an innovative program based on telemedicine for semi-automated prioritization of referrals from Primary Care (PC) to Rheumatology, for reproducibility purposes, and to present the results of the implementation study.

METHODS

The context and situation were carefully analyzed, paying attention to all processes in place, referral numbers, waiting times, and number of complementary tests prior to discharge from Rheumatology. The composition of the team, aims, users, scope, and implementation phases were defined. Eight process indicators were established and measured before and 32 months after the program implementation.

RESULTS

The program, which includes IT circuits, algorithms based on response to specific guideline-based checklists, e-consultation, and appointments based on priority, was fully implemented in our health area after a pilot study in two PC centers. After implementation, 6185 rheumatology referrals showed an e-consultation response delay of 8.95 days, and to first face-to-face visit (after e-consultation) of 12.6 (previous delay before program implementation was 83.1 days). Resolution by e-consultation reached 20% (1195 patients did not need seeing the rheumatologist to have the problem solved), and 1369 patients (32%) were discharged after the first visit. The overall resolution rate was 44.0% (2564 discharges/5830 e-consultations). From a random sample of 100 visits, only 10% of patients needed additional complementary tests to make a diagnosis and decision by Rheumatology (20.9% decrease from previous period).

CONCLUSION

A careful analysis of the situation and processes, with implementation of simple IT circuits, allows for the improvement of the efficiency and resolution of problems in Rheumatology.

Patients' Perceptions of Person-Centered Care in Early Rheumatoid Arthritis: A Qualitative Study

Objective

Most research on patient experiences of rheumatoid arthritis (RA) care is performed with patients who have established RA and less often with patients with early RA. Experiences of and expectations about health care may change over time, which is why the aim was to explore patients’ perceptions of person‐centered care (PCC) early in the RA disease course.

Methods

Thirty‐one patients with early RA were interviewed in this qualitative study. An abductive qualitative content analysis was conducted based on the framework of McCormack and McCance (1,2). The four constructs, prerequisites, care environment, person‐centered processes, and person‐centered outcomes, constituted the four categories in the deductive part of the study. An inductive analysis generated 11 subcategories exploring the content of PCC.

Results

For patients with early RA, PCC was described in terms of 1) prerequisites including being treated with respect, meeting dedicated health care professionals, and meeting professional competence; 2) care environment including having access to a multidisciplinary team, having access to health care, and encountering a supportive organization; 3) person‐centered processes including being listened to, being supported, and being involved in decision‐making; and 4) person‐centered outcomes including being satisfied with received health care and achieving optimal health.

Conclusion

Genuine PCC is important for patients early in the RA disease course, supporting the implementation of a person‐centered approach during all stages in the health care system. This study contributes to information about how to further develop person‐centeredness in rheumatology care.