Phase Specific Health Care Costs Associated with Giant Cell Arteritis in Ontario, Canada

OBJECTIVE

To estimate the additional health care system costs associated with giant cell arteritis (GCA) in the year pre-diagnosis, post diagnosis, and over long-term follow up compared to individuals with similar demographics and comorbidities without GCA.

METHODS

We performed a population-based study using health administrative data. Newly diagnosed cases of GCA (between 2002 and 2017 and ages 66 years and older) were identified using a validated algorithm and matched 1:6 to comparators using propensity scores. Follow up data was accrued until death, outmigration, or March 31, 2020. The costs associated with care were determined across three phases: the year before the diagnosis of GCA, the year after, and ongoing costs thereafter.

RESULTS

The cohort consisted of 6,730 cases of GCA and 40,380 matched non-GCA comparators. The average age was 77 years (interquartile range 72-82) and 68.2% were female. A diagnosis of GCA was associated with an increased cost of $6,619.4 (95% CI 5,964.9 - 7274.0) per patient during the 1-year pre-diagnostic period; $12,150.3 (95% CI 11,233.1 - 13,067.6) per patient in the 1-year post-diagnostic phase, and $20,886.2 (95% CI 17,195.2 - 24,577.2) per patient during ongoing care for year 3 onwards. Increased costs were driven by inpatient hospitalizations, physician services, hospital outpatient clinic services, and emergency department visits.

CONCLUSION

A diagnosis of GCA was associated with increased health care costs during all three phases of care. Given the substantial economic burden, strategies to reduce the healthcare utilization and costs associated with GCA are warranted.

Early versus late onset interstitial lung disease in rheumatoid arthritis: An observational study of risk factors and mortality in Ontario, Canada

BACKGROUND AND OBJECTIVE

Interstitial lung disease (ILD) can occur as a manifestation of rheumatoid arthritis (RA) at various times in the disease course. We aimed to identify factors associated with early versus late onset RA-ILD and how the timing of RA-ILD influenced surgical lung biopsy completion and mortality.

METHODS

We performed a retrospective observational study using health services data from Ontario, Canada. We identified RA cases between 2000 and 2020 using the Ontario Rheumatoid Arthritis Database. RA-ILD diagnosis required repeat physician visits for ILD, with early RA-ILD defined as within 1 year of RA diagnosis. We performed multivariable logistic regression to identify factors associated with early RA-ILD and surgical lung biopsy completion, and multivariable cox-proportional hazards regression to evaluate the association of early versus late RA-ILD on all-cause and RA-ILD related mortality.

RESULTS

In total, we identified 3717 cases of RA-ILD. Older age at RA diagnosis [OR 1.04 (95%CI 1.03-1.05), p < 0.0001], female sex [OR 1.16 (95%CI 1.01-1.35), p = 0.04] and immigrating to Ontario [OR 1.70 (95%CI 1.35-2.14), p < 0.0001] was associated with early RA-ILD. Patients with early versus late RA-ILD experienced similar odds of undergoing a surgical lung biopsy [OR 1.34 (95%CI 0.83-2.16), p = 0.23]. Early RA-ILD was associated with increased all-cause mortality [HR 1.17 (95%CI 1.07-1.29), p = 0.0009], primarily driven by an increase in RA-ILD related mortality [HR 1.45 (95%CI 1.19-1.76), p = 0.0003].

CONCLUSION

Age at RA onset, female sex and immigration status are associated with early RA-ILD. Patients with early RA-ILD experience increased all-cause and RA-ILD related mortality after adjusting for demographics and comorbidities.

Serum Urate Monitoring Among Older Adults With Gout: Initiating Urate-Lowering Therapy in Ontario, Canada

OBJECTIVE

To assess the proportion of, and factors associated with, older adults with gout receiving a serum urate (SUA) test after starting urate-lowering therapy (ULT).

METHODS

We performed a population-based retrospective cohort study in Ontario, Canada in patients ages ≥66 years with gout, newly dispensed ULT between 2010 and 2019. We characterized patients with SUA testing within 6 and 12 months after ULT dispensation. Multilevel logistic regression clustered by ULT prescriber evaluated the factors associated with SUA monitoring within 6 months.

RESULTS

We included 44,438 patients with a mean ± SD age of 76.0 ± 7.3 years and 64.4% male. Family physicians prescribed 79.1% of all ULTs. SUA testing was lowest in 2010 (56.4% at 6 months) and rose over time to 71.3% in 2019 (P < 0.0001). Compared with rheumatologists, family physicians (odds ratio [OR] 0.26 [95% confidence interval (95% CI) 0.23-0.29]), internists (OR 0.34 [95% CI 0.29-0.39]), nephrologists (OR 0.37 [95% CI 0.30-0.45]), and other specialties (OR 0.25 [95% CI 0.21-0.29]) were less likely to test SUA, as were male physicians (OR 0.87 [95% CI 0.83-0.91]). Patient factors associated with lower odds of SUA monitoring included rural residence (OR 0.81 [95% CI 0.77-0.86]), lower socioeconomic status (OR 0.91 [95% CI 0.85-0.97]), and patient comorbidities. Chronic kidney disease, hypertension, diabetes mellitus, and coprescription of colchicine/oral corticosteroids (OR 1.31 [95% CI 1.23-1.40]) were correlated with increased SUA testing.

CONCLUSION

SUA testing is suboptimal among older adults with gout initiating ULT but is improving over time. ULT prescriber, patient, and prescription characteristics were correlated with SUA testing.

An Overview of Reviews to Inform Organization-Level Interventions to Address Burnout in Rheumatologists

OBJECTIVE

To identify organization-directed strategies that could be implemented to prevent burnout among rheumatologists.

METHODS

A search of English language articles published 2011 or later was conducted on Cochrane Database of Systematic Reviews, Embase, Medline, and PsycInfo on January 25, 2022. Included reviews had ≥ 1 primary studies with ≥ 10% of participants who were physicians, recorded burnout as an outcome, and described an organization-directed intervention to prevent burnout. Overlap of primary studies across reviews was assessed. The final review inclusion was determined by study quality, minimization of overlap, and maximization of intervention breadth. The A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 tool was used for quality assessment. Included studies and interventions were assessed by rheumatologists for their applicability to rheumatology.

RESULTS

A total of 17 reviews, including 15 systematic reviews, 1 realist review, and 1 umbrella review were included. AMSTAR 2 quality ratings classified 5 systematic reviews as low quality, 1 as moderate, and 9 as critically low. There was significant heterogeneity between and within reviews. Six conducted a metaanalysis and 11 provided a qualitative summary of findings. The following intervention types were identified as having possible applicability to rheumatology: physician workflow and organizational strategies; peer support and formal communication training; leadership support; and addressing stress, mental health, and mindfulness. Across interventions, mindfulness had the highest quality of evidence to support its effectiveness.

CONCLUSION

Although the quality of evidence for interventions to prevent burnout in physicians is low, promising strategies such as mindfulness have been identified.

Venous Thromboembolism After COVID-19 Infection Among People With and Without Immune-Mediated Inflammatory Diseases

Importance

Immune-mediated inflammatory diseases (IMIDs) and COVID-19 are independently associated with venous thromboembolisms (VTEs).

Objective

To determine if individuals with IMIDs are at higher risk of VTE following COVID-19 infection compared with individuals without IMIDs.

Design, Setting, and Participants

Population-based matched cohort study using multiple deterministically linked health administrative databases from Ontario, Canada, and including patients testing positive for COVID-19 between January 1, 2020, and December 30, 2021, and followed up until March 31, 2022. Individuals with IMIDs (n = 28 440) who tested positive for COVID-19 were matched with up to 5 individuals without an IMID (n = 126 437) who tested positive for COVID-19. Matching was based on year of birth, sex, neighborhood income, and rural/urban residence. Data analysis was performed from August 6, 2022, to August 21, 2023.

Exposure

Diagnosis of an IMID, identified using algorithms based on diagnostic codes, procedures, and specialist visits.

Main Outcome and Measure

The main outcome was estimated age- and sex-standardized incidence of VTE. Proportional cause-specific hazard models compared the risk of VTE in people with and without IMIDs. Death was a competing risk. Models adjusted for history of VTE, 2 or more doses of a COVID-19 vaccine 14 or more days prior to COVID-19 diagnosis, and the Charlson Comorbidity Index. Routinely collected health data were used, so the hypothesis tested was formulated after data collection but prior to being granted access to data.

Results

The study included 28 440 individuals (16 741 [58.9%] female; 11 699 [41.1%] male) with an IMID diagnosed prior to first COVID-19 diagnosis, with a mean (SD) age of 52.1 (18.8) years at COVID-19 diagnosis. These individuals were matched to 126 437 controls without IMIDs. The incidence of VTE within 6 months of COVID-19 diagnosis among 28 440 individuals with an IMID was 2.64 (95% CI, 2.23-3.10) per 100 000 person-days compared with 2.18 (95% CI, 1.99-2.38) per 100 000 person-days among 126 437 matched individuals without IMIDs. The VTE risk was not statistically significantly different among those with vs without IMIDs (adjusted hazard ratio, 1.12; 95% CI, 0.95-1.32).

Conclusions and Relevance

In this retrospective population-based cohort study of individuals with IMIDs following COVID-19, individuals with IMIDs did not have a higher risk of VTE compared with individuals without an IMID. These data provide reassurance to clinicians caring for individuals with IMIDs and COVID-19.

Low Nirmatrelvir/Ritonavir Use Among Patients With Rheumatoid Arthritis: A Signal of Concern

Individuals with rheumatoid arthritis (RA) may be at increased risk of severe coronavirus disease 2019 (COVID-19) outcomes.1 Nirmatrelvir/ritonavir has been shown to reduce the risk for hospitalization and death among patients with COVID-19 at risk for progression to severe disease.2.

Safety and Health Care Use Following COVID-19 Vaccination Among Adults With Rheumatoid Arthritis: A Population-Based Self-Controlled Case Series Analysis

OBJECTIVE

To determine if coronavirus disease 2019 (COVID-19) vaccines were associated with adverse events of special interest (AESIs) and healthcare use among adults with rheumatoid arthritis (RA).

METHODS

Among adults with RA who received at least 1 COVID-19 vaccine, a self-controlled case series (SCCS) analysis was conducted to evaluate relative incidence (RI) rates of AESIs (Bell palsy, idiopathic thrombocytopenia, acute disseminated encephalomyelitis, pericarditis/myocarditis, Guillain-Barré syndrome, transverse myelitis, myocardial infarction, anaphylaxis, stroke, deep vein thrombosis, pulmonary embolism, narcolepsy, appendicitis, and disseminated intravascular coagulation) in any 21-day period following vaccination compared to control periods. Secondary outcomes included emergency department (ED) visits, hospitalizations, and rheumatology visits. A matched non-RA comparator group was created and a separate SCCS analysis was conducted. RI ratios (RIRs) were used to compare RA and non-RA groups.

RESULTS

Among 123,466 patients with RA and 493,864 comparators, the majority received mRNA vaccines. For patients with RA, relative to control periods, AESIs were not increased. ED visits increased after dose 2 (RI 1.06, 95% CI 1.03-1.10) and decreased after dose 3 (RI 0.93, 95% CI 0.89-0.96). Hospitalizations were lower after the first (RI 0.83, 95% CI 0.78-0.88), second (RI 0.86, 95% CI 0.81-0.92), and third (RI 0.89, 95% CI 0.83-0.95) doses. Rheumatology visits increased after dose 1 (RI 1.08, 95% CI 1.07-1.10), and decreased after doses 2 and 3. Relative to comparators, patients with RA had a higher AESI risk after dose 3 (RIR 1.28, 95% CI 1.05-1.56). Patients with RA experienced fewer ED visits (RIR 0.73, 95% CI 0.58-0.90) and hospitalizations (RIR 0.52, 95% CI 0.36-0.75) after dose 4.

CONCLUSION

COVID-19 vaccines in patients with RA were not associated with an increase in AESI risk or healthcare use after every dose.

Derivation of a Multivariable Psoriatic Arthritis Risk Estimation Tool (PRESTO): A Step Towards Prevention

OBJECTIVE

A simple, scalable tool that identifies psoriasis patients at high risk for developing psoriatic arthritis (PsA) could improve early diagnosis. We aimed to develop a risk prediction model for the development of PsA and to assess its performance among patients with psoriasis.

METHODS

We analyzed data from a prospective cohort of psoriasis patients without PsA at enrollment. Participants were assessed annually by a rheumatologist for the development of PsA. Information about their demographics, psoriasis characteristics, comorbidities, medications, and musculoskeletal symptoms was used to develop prediction models for PsA. Penalized binary regression models were used for variable selection while adjusting for psoriasis duration. Risks of developing PsA over 1- and 5-year time periods were estimated. Model performance was assessed by the area under the curve (AUC) and calibration plots.

RESULTS

Among 635 psoriasis patients, 51 and 71 developed PsA during the 1-year and 5-year follow-up periods, respectively. The risk of developing PsA within 1 year was associated with younger age, male sex, family history of psoriasis, back stiffness, nail pitting, joint stiffness, use of biologic medications, patient global health, and pain severity (AUC 72.3). The risk of developing PsA within 5 years was associated with morning stiffness, psoriatic nail lesion, psoriasis severity, fatigue, pain, and use of systemic nonbiologic medication or phototherapy (AUC 74.9). Calibration plots showed reasonable agreement between predicted and observed probabilities.

CONCLUSIONS

The development of PsA within clinically meaningful time frames can be predicted with reasonable accuracy for psoriasis patients using readily available clinical variables.

Rheumatoid arthritis associated interstitial lung disease: Trends in epidemiology and mortality in Ontario from 2000-2018

BACKGROUND

The epidemiology and mortality of rheumatoid arthritis related interstitial lung disease (RA-ILD) have not been described in Canada. Our aim was to describe recent trends in RA-ILD prevalence, incidence, and mortality in Ontario, Canada.

METHODS

This was a retrospective population-based study using repeated cross-sections from 2000 to 2018. We estimated annual age- and sex-standardized rates for RA-ILD prevalence, incidence and mortality.

RESULTS

Among 184,400 RA patients identified between 2000 and 2018, 5722 (3.1%) were diagnosed with RA-ILD. Most RA-ILD patients were women (63.9%) and ≥60 years old (76.9%) at the time of RA-ILD diagnosis. RA-ILD incidence rose from 1.6 (95% confidence interval (CI) 1.3-2.0) to 3.3 (95% CI 3.0-3.6) per 1000 RA patients (204% relative increase, p < 0.0001) during this time. RA-ILD incidence increased in both sexes and all age groups over time. The cumulative prevalence of RA-ILD increased from 8.4 (95% CI 7.6-9.2) to 21.1 (95% CI 20.3-21.8) per 1000 RA patients (250% relative increase, p < 0.0001), increasing in both sexes and all age groups. All-cause and RA-ILD related mortality declined in patients with RA-ILD over time [55.1% relative reduction, (p < 0.0001) and 70.9% relative reduction, (p < 0.0001), respectively]. In RA-ILD patients, RA-ILD contributed to the cause of death in approximately 29% of cases. Men and older patients had higher all-cause and RA-ILD related mortality.

CONCLUSION

In a large, diverse Canadian population, the incidence and prevalence of RA-ILD are increasing. RA-ILD related mortality is declining, but remains an important cause of death in this population.

Systemic autoimmune rheumatic diseases and multiple industrial air pollutant emissions: A large general population Canadian cohort analysis

BACKGROUND

Past investigations of air pollution and systemic autoimmune rheumatic diseases (SARDs) typically focused on individual (not mixed) and overall environmental emissions. We assessed mixtures of industrial emissions of fine particulate matter (PM_2.5), nitrogen dioxide (NO₂), and sulfur dioxide (SO₂) and SARDs onset in Ontario, Canada.

METHODS

We assembled an open cohort of over 12 million adults (without SARD diagnoses at cohort entry) based on provincial health data for 2007-2020 and followed them until SARD onset, death, emigration, or end of study (December 2020). SARDs were identified using physician billing and hospitalization diagnostic codes for systemic lupus, scleroderma, myositis, undifferentiated connective tissue disease, and Sjogren's. Rheumatoid arthritis and vasculitis were not included. Average PM_2.5, NO₂, and SO₂ industrial emissions from 2002 to one year before SARDs onset or end of study were assigned using residential postal codes. A quantile g-computation model for time to SARD onset was developed for the industrial emission mixture, adjusting for sex, age, income, rurality index, chronic obstructive pulmonary disease (as a proxy for smoking), background (environmental overall) PM_2.5, and calendar year. We conducted stratified analyses across age, sex, and rurality.

RESULTS

We identified 43,931 new SARD diagnoses across 143,799,564 person-years. The adjusted hazard ratio for SARD onset for an increase in all emissions by one decile was 1.018 (95% confidence interval 1.013-1.022). Similar positive associations between SARDs and the mixed emissions were observed in most stratified analyses. Industrial PM_2.5 contributed most to SARD risk.

CONCLUSIONS

Industrial air pollution emissions were associated with SARDs risk.

A177 RISK OF VENOUS THROMBOEMBOLISM IN COVID-19 PATIENTS WITH INFLAMMATORY BOWEL DISEASE: A POPULATION-BASED MATCHED COHORT STUDY

Background

Venous thromboembolism (VTE), is associated with significant morbidity and mortality. Inflammation increases the risk of VTE, and it is a well-recognised complication of both inflammatory bowel disease (IBD) and COVID-19.

Purpose

To compare the risk of VTE among individuals with and without IBD following a positive COVID-19 test.

Method

Using health administrative data from Ontario, Canada we conducted a retrospective matched cohort study.All Ontario residents with a positive SARS-CoV-2 PCR test between January 1,2020 and December 30,2021 who had been diagnosed with IBD prior to their COVID-19 infection (identified using a validated algorithm) were matched to 5 individuals without IBD based on year of birth, sex, mean neighbourhood income quintile, date of positive COVID-19 test, and rural/urban residence. Individuals with a cancer diagnosis in the 5 years prior to their first COVID-19 positive test were excluded. Individuals were followed from positive COVID-19 PCR test until VTE event, death, migration out of Ontario or March 31, 2022.VTEs were identified from emergency department or hospitalization data using ICD-10 codes. Incidence rate of VTEs among individuals with IBD were assessed at 1, 6 and 12 months. Proportional cause-specific hazards models compared the risk of VTEs in people with and without IBD, treating death as a competing risk and controlling for vaccination status (2^nd dose ≥14 days prior to positive COVID-19 test) and a history of VTE (VTE in the 5 years prior to infection).

Result(s)

There were 4293 people with IBD (44% Crohn’s disease, mean age ±SD 46.1±17.2 y) matched to 20,207 with out IBD (mean age 45.3±16.8 y) with a positive SARS-CoV-2 PCR test. Within 1 month of a positive COVID-19 test, the crude incidence rate of VTE in individuals with IBD was 4.77(95%CI, 4.75-4.80) per 100,000 person-days compared to 8.25(95%CI, 8.20-8.30) per 100,000 among people without IBD.Within 6 months, these rates were 1.86(95%CI, 1.86-1.87) and 2.12(95%CI, 2.11-2.12) per 100,000 person-days among people with and without IBD, respectivley. Within 12 months, these rates were 1.59(95% CI, 1.58-1.59) and 1.42(95% CI, 1.42-1.42) per 100,000 person-days among people with and without IBD, respectively.After adjusting for vaccination status and history of VTE there was no difference in the risk of VTE for people with and without IBD (HR 1.08, 95%CI, 0.64 to 1.83).

Conclusion(s)

IBD patients with COVID-19 were not more likely to experience a VTE infection compared with the general popluation. The risk of VTE was highest soon after COVID-19 and declined thereafter.

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Disclosure of Interest

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Understanding sex-related differences in healthcare utilisation among patients with inflammatory arthritis: a population-based study

OBJECTIVES

Our aim was to compare patterns of musculoskeletal-related healthcare utilisation between male and female patients before and after the diagnosis of inflammatory arthritis (IA).

METHODS

We used Ontario administrative health data to create three inception cohorts of adult patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA) diagnosed between April 2010 and March 2017. Healthcare utilisation indicators including visits to physicians, and use of musculoskeletal imaging and laboratory tests were assessed in each year for 3 years before and after diagnosis and compared between male and female patients using regression models adjusting for sociodemographic factors and comorbidities. Results were reported as ORs with 95% CIs for female patients compared with male patients.

RESULTS

A total of 41 277 patients with RA (69% female), 8150 patients with AS (51% female) and 6446 patients with PsA (54% female) were analysed.Similar trends of sex-related differences were observed in all three cohorts. Before diagnosis, female patients were more likely to visit rheumatologists (OR 1.32-2.28) and family physicians (OR 1.03-1.15) for musculoskeletal reasons, whereas male patients were more likely to visit the emergency for musculoskeletal reasons (OR 0.76-0.87). A similar female predominance was observed regarding musculoskeletal imaging and laboratory tests before diagnosis. After diagnosis, female patients were more likely to remain in rheumatology care (OR 1.12-1.24).

CONCLUSION

Female patients with IA have higher healthcare utilisation than male patients which may indicate biological differences in disease course or sociocultural differences in healthcare-seeking behaviour.

The Effects of Continuity of Rheumatology Care on Emergency Department Utilization and Hospitalizations for Individuals With Early Rheumatoid Arthritis: A Population-Based Study

OBJECTIVE

To determine if continuity of rheumatology care influences rates of emergency department (ED) visits and hospitalizations in patients with rheumatoid arthritis (RA).

METHODS

A closed inception cohort of patients with RA diagnosed between 2000 and 2009 were followed until December 31, 2019. During the first 5 years following diagnosis, we categorized patients into 3 rheumatology care continuity groups (high, intermediate, and not retained in rheumatology care). Using a landmark analysis, we compared rates of ED visits and hospitalizations during follow-up. Multivariable Poisson regression models were used to estimate rate ratios (RRs), adjusting for demographics, comorbidities, and health services access and supply measures.

RESULTS

The cohort included 38,528 patients, of which 57.7% (n = 22,221) were classified in the high rheumatology continuity group, 17.2% (n = 6636) were in the intermediate group, and 25.1% (n = 9671) were not retained in rheumatology care. Relative to the high continuity group, both the intermediate and nonretention groups had higher ED rates (RR 1.14, 95% CI 1.08-1.20, and RR 1.12, 95% CI 1.08-1.16, respectively). The intermediate group also experienced higher adjusted hospitalization rates (207.4, 95% CI 203.0-211.8 per 1000 person-years [PY]) than the high continuity group (193.5, 95% CI 191.4-195.6 per 1000 PY).

CONCLUSION

Patients with RA with higher continuity of rheumatology care had lower rates of ED visits and hospitalizations compared to those who did not receive continuous rheumatology care during the first 5 years of follow-up. These findings provide evidence to support the value of early and continuous rheumatology care for reducing hospitalizations and ED visits.

Investigating Associations Between Access to Rheumatology Care, Treatment, Continuous Care, and Healthcare Utilization and Costs Among Older Individuals With Rheumatoid Arthritis

OBJECTIVE

To examine the association between rheumatologist access, early treatment, and ongoing care of older-onset rheumatoid arthritis (RA) and healthcare utilization and costs following diagnosis.

METHODS

We analyzed data from a population-based inception cohort of individuals aged > 65 years with RA in Ontario, Canada, diagnosed between 2002 and 2014 with follow-up to 2019. We assessed 4 performance measures in the first 4 years following diagnosis, including access to rheumatology care, yearly follow-up, timely treatment, and ongoing treatment with a disease-modifying antirheumatic drug. We examined annual healthcare utilization, mean direct healthcare costs, and whether the performance measures were associated with costs in year 5.

RESULTS

A total of 13,293 individuals met inclusion criteria. The mean age was 73.7 (SD 5.7) years and 68% were female. Total mean direct healthcare cost per individual increased annually and was CAD $13,929 in year 5. All 4 performance measures were met for 35% of individuals. In multivariable analyses, costs for not meeting access to rheumatology care and timely treatment performance measures were 20% (95% CI 8-32) and 6% (95% CI 1-12) higher, respectively, than where those measures were met. The main driver of cost savings among individuals meeting all 4 performance measures were from lower complex continuing care, home care, and long-term care costs, as well as fewer hospitalizations and emergency visits.

CONCLUSION

Access to rheumatologists for RA diagnosis, timely treatment, and ongoing care are associated with lower total healthcare costs at 5 years. Investments in improving access to care may be associated with long-term health system savings.

System-level performance measures of access to rheumatology care: a population-based retrospective study of trends over time and the impact of regional rheumatologist supply in Ontario, Canada, 2002-2019

OBJECTIVE

To determine whether there were improvements in rheumatology care for rheumatoid arthritis (RA) between 2002 and 2019 in Ontario, Canada, and to evaluate the impact of rheumatologist regional supply on access.

METHODS

We conducted a population-based retrospective study of all individuals diagnosed with RA between January 1, 2002 and December 31, 2019. Performance measures evaluated were: (i) percentage of RA patients seen by a rheumatologist within one year of diagnosis; and (ii) percentage of individuals with RA aged 66 years and older (whose prescription drugs are publicly funded) dispensed a disease modifying anti-rheumatic drug (DMARD) within 30 days after initial rheumatologist visit. Logistic regression was used to assess whether performance improved over time and whether the improvements differed by rheumatology supply, dichotomized as < 1 rheumatologist per 75,000 adults versus ≥1 per 75,000.

RESULTS

Among 112,494 incident RA patients, 84% saw a rheumatologist within one year: The percentage increased over time (adjusted odds ratio (OR) 2019 vs. 2002 = 1.43, p < 0.0001) and was consistently higher in regions with higher rheumatologist supply (OR = 1.73, 95% CI 1.67-1.80). Among seniors who were seen by a rheumatologist within 1 year of their diagnosis the likelihood of timely DMARD treatment was lower among individuals residing in regions with higher rheumatologist supply (OR = 0.90 95% CI 0.83-0.97). These trends persisted after adjusting for other covariates.

CONCLUSION

While access to rheumatologists and treatment improved over time, shortcomings remain, particularly for DMARD use. Patients residing in regions with higher rheumatology supply were more likely to access care but less likely to receive timely treatment.

Changes in service delivery and access to rheumatologists pre- and during the COVID-19 pandemic in a Canadian universal healthcare setting

OBJECTIVE

To describe changes in service delivery and access to rheumatologists pre- and during the COVID-19 pandemic periods.

METHODS

We conducted a population-based study in Ontario, Canada. Patient visits with rheumatologists were ascertained using billing claims data. Contacts with rheumatologists were separately defined by the type of patient encounter (including office visits, telemedicine visits, and new patient consultations). Changes in the total weekly volume of encounters and monthly rates after COVID-19 public health measures were imposed were compared to expected baseline rates determined before pandemic onset (March 17, 2020).

RESULTS

In the year prior to the pandemic, there were 289,202 patients (of which 99,641 were new consults) seen by 239 rheumatologists. In the 1 year following the pandemic onset, there were 276,686 patients (of which 88,777 were new consults) seen by 247 rheumatologists. In March 2020, there was an immediate 75.9% decrease in outpatient office visits and a rapid rise in telemedicine visits. By September 2021, 49.7% of patient encounters remained telemedicine visits. For new patient consultations, there was an immediate 50% decrease in visits at the pandemic onset, with 54.8% diverted to telemedicine visits in the first year of the pandemic versus 37.5% by September 2021. New rheumatology consultation rates continued decreasing over the study period.

CONCLUSION

Rheumatology care delivery has shifted due to the pandemic, with telemedicine sharply increasing early in the pandemic and persisting over time. The pandemic also negatively impacted access to rheumatologists resulting in fewer new consultations, raising concerns for potential delays to diagnosis.

Understanding COVID-19 Risk in Patients With Immune-Mediated Inflammatory Diseases: A Population-Based Analysis of SARS-CoV-2 Testing

OBJECTIVE

To investigate the incidence of and factors associated with SARS-CoV-2 testing and infection in immune-mediated inflammatory disease (IMID) patients versus matched non-IMID comparators from the general population.

METHODS

We conducted a population-based, matched cohort study among adult residents from Ontario, Canada, from January 2020 to December 2020. We created cohorts for the following IMIDs: rheumatoid arthritis (RA), psoriasis, psoriatic arthritis, ankylosing spondylitis, systemic autoimmune rheumatic diseases, multiple sclerosis (MS), iritis, inflammatory bowel disease (IBD), polymyalgia rheumatica, and vasculitis. Each patient was matched with 5 patients without IMIDs based on sociodemographic factors. We estimated the incidence of SARS-CoV-2 testing and infection in IMID patients and non-IMID patients. Multivariable logistic regressions assessed odds of SARS-CoV-2 infection.

RESULTS

We studied 493,499 patients with IMIDs and 2,466,946 patients without IMIDs. Patients with IMIDs were more likely to have at least 1 SARS-CoV-2 test versus patients without IMIDs (27.4% versus 22.7%), but the proportion testing positive for SARS-CoV-2 was identical (0.9% in both groups). Overall, IMID patients had 20% higher odds of being tested for SARS-CoV-2 (odds ratio 1.20 [95% confidence interval 1.19-1.21]). The odds of SARS-CoV-2 infection varied across IMID groups but was not significantly elevated for most IMID groups compared with non-IMID comparators. The odds of SARS-CoV-2 infection was lower in IBD and MS and marginally higher in RA and iritis.

CONCLUSION

Patients across all IMIDs were more likely to be tested for SARS-CoV-2 versus those without IMIDs. The risk of SARS-CoV-2 infection varied across disease subgroups.

Identification of Early Onset Dementia in Population-Based Health Administrative Data: A Validation Study Using Primary Care Electronic Medical Records

BACKGROUND

Early onset dementia (EOD) occurs when symptoms of dementia begin between 45 to 64 years of age.

OBJECTIVE

We developed and validated health administrative data algorithms for EOD and compared demographic characteristics and presence of comorbid conditions amongst adults with EOD, late onset dementia (LOD) and adults with no dementia in Ontario, Canada.

METHODS

Patients aged 45 to 64 years identified as having EOD in their primary care electronic medical records had their records linked to provincial health administrative data. We compared several combinations of physician's claims, hospitalizations, emergency department visits and prescriptions. Age-standardized incidence and prevalence rates of EOD were estimated from 1996 to 2016.

RESULTS

The prevalence of EOD for adults aged 45 to 64 years in our primary care reference cohort was 0.12% . An algorithm of ≥1 hospitalization or ≥3 physician claims at least 30 days apart in a two-year period or ≥1 dementia medication had a sensitivity of 72.9% (64.5-81.3), specificity of 99.7% (99.7-99.8), positive predictive value (PPV) of 23.7% (19.1-28.3), and negative predictive value of 100.0% . Multivariate logistic regression found adults with EOD had increased odds ratios for several health conditions compared to LOD and no dementia populations. From 1996 to 2016, the age-adjusted incidence rate increased slightly (0.055 to 0.061 per 100 population) and the age-adjusted prevalence rate increased three-fold (0.11 to 0.32 per 100 population).

CONCLUSION

While we developed a health administrative data algorithm for EOD with a reasonable sensitivity, its low PPV limits its ability to be used for population surveillance.

Evaluating the time-varying risk of hypertension, cardiac events, and mortality following Kawasaki disease diagnosis

BACKGROUND

This study evaluated the risk of hypertension, major adverse cardiac events (MACE), and all-cause mortality in Kawasaki disease (KD) patients up to young adulthood.

METHODS

An inception cohort of 1169 KD patients between 1991 and 2008 from a tertiary-level hospital in Ontario, Canada was linked with health administrative data to ascertain outcomes up to 28 years of follow-up. Their risk was compared with 11,690 matched population comparators. The primary outcome was hypertension and secondary outcomes were MACE and death.

RESULTS

After a median follow-up of 20 years [IQR: 8.3], the cumulative incidence of hypertension and MACE in the KD group was 3.8% (95% CI: 2.5-5.5) and 1.2% (95% CI: 0.6-2.4%), respectively. The overall survival probability in the KD group was 98.6% (95% CI: 97.2-99.3%). Relative to comparators, KD patients were at an increased risk for hypertension [aHR: 2.2 (95% CI: 1.5-3.4)], death [aHR: 2.5 (95% CI: 1.3-5.0)], and MACE [aHR: 10.7 (95% CI: 6.4-17.9)]. For hypertension and MACE, the aHR was the highest following diagnosis and then the excess risk diminished after 16 and 13 years of follow-up, respectively. MACE occurred largely in KD patients with coronary aneurysms [cumulative incidence: 12.8%].

CONCLUSIONS

KD patients demonstrated a reassuring cardiac prognosis up to young adulthood with low events and excellent survival. KD patients were at increased risk for hypertension, but this excess risk occurred early and declined with time.

IMPACT

With the current standard of care, KD patients demonstrated favorable cardiac prognosis, with low events of hypertension, MACE, and excellent survival. Hypertension and MACE risk appear to be highest around the time of KD diagnosis. MACE occurred primarily in KD patients with coronary aneurysms. Our findings are reassuring to KD patients, families, and their providers. Our study demonstrated an association between KD exposure and hypertension. This association is relatively novel. Previous studies have remained conflicting if KD contributes to long-term atherosclerotic risk.

Survival after surgery for spinal metastases: a population-based study

Background:

There are limited published data on population estimates of survival after spinal surgery for metastatic disease. We performed a population-based study to evaluate survival and complications among patients with cancer who underwent surgery for spinal metastases in Ontario, Canada, between 2006 and 2016.

Methods:

We used health administrative databases to identify all patients who underwent surgery for spinal metastases in Ontario between Jan. 1, 2006, and Dec. 31, 2016. We assessed overall survival, mortality rates according to primary cancer lesion and complications after surgery. We contrast the results to those for a comparable cohort from 1991 to 1998.

Results:

A total of 2646 patients (1194 women [45.1%]; mean age 62.5 yr [standard deviation 12.2 yr]) were identified. The median survival time was 236 (interquartile range 84–740) days. Mortality was highest for patients with melanoma, upper gastrointestinal cancer and lung cancer, with 50% dying within 90 days of surgery. The longest median survival times were observed for primary cancers of the thyroid (906 d) and breast (644 d), and myeloma (830 d). Overall 90-day and 1-year mortality rates were 29% and 59%, respectively.

Conclusion:

We identified differential survivorship based on primary tumour type and a shift in the distribution of operations performed for specific primary cancers over the past 2 decades in Ontario. Overall reductions in mortality associated with this shift in treatment may reflect the use of adjuvant therapies and more personalized treatment approaches.

POS1406 EVALUATING THE QUALITY OF CARE FOR HEART FAILURE HOSPITALIZATIONS IN INFLAMMATORY ARTHRITIS- A POPULATION-BASED COHORT STUDY

Background

Individuals with inflammatory arthritis (IA) have an increased risk of heart failure (HF). Little is known if the quality of HF care differs among patients with IA compared to other chronic diseases such as diabetes mellitus (DM).

Objectives

We examined adherence to quality-of-care indicators for HF hospitalizations among patients with IA compared to those with DM but no IA and the general population (without IA or DM).

Methods

We linked multiple population-based health datasets to construct a cohort of adults living in Ontario, Canada on January 1, 2011 and followed to December 2020. The IA cohort was identified using validated case definitions and included patients with rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis. Comparison cohorts included adults with DM but no IA and general comparators without DM or IA. We included all subjects with a first HF hospitalization and who were alive at the time of discharge. We summarized the percentage of subjects in each of the 3 exposure groups who achieved recommended quality process measures [1]: (1) % receiving echocardiogram, (2) % receiving electrocardiogram, (3) % receiving a chest x-ray; and (4) % seen by a physician within 7 days of discharge. For those over the age of 65 years in whom medication information was universally available, we examined how many were dispensed evidence-based therapies: (5) % prescribed β-blocker, (6) % prescribed angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, (7) % prescribed mineralocorticoid receptor antagonist. We categorized adherence as perfect, moderate, or poor based on the number of measures achieved and compared proportions using pair-wise chi-squared tests.

Results

A first HF hospitalization occurred in 5,836 IA patients, 33,553 DM patients and 62,256 general comparators. The crude incidence rate for HF in IA was 2.70 per 1000/PY and was significantly higher compared to the general population (0.84 per 1000/PY), but lower compared to the DM cohort (5.01 per 1000/PY, p< 0.001). Mean age at time of HF hospitalization was significantly higher in the IA group (78 years) with more females affected (58%) compared to either the DM or general population group (p<0.001). All groups had high achievement of testing process measures and there were no differences in perfect adherence between the IA vs. DM and IA vs. general population comparators (Table 1). For those >65 years of age, patients with IA were less likely to achieve perfect adherence for medication quality indicators compared to either the DM or general population.

Table 1.

Percentage in each of three exposure groups achieving the recommended HF quality measures.

Process MeasureIA GroupDM GroupGeneral Population1.Echocardiogram90.6%91.1%89.5%2.Electrocardiogram97.4%97.4%97.3%3.Chest x-ray99.7%99.6%99.6%4.Health care provider visit within 7 days of discharge39.0%38.9%38.7%Perfect Adherence (achieving 1, 2,3 and 4 above)33.0%33.0% (p=0.43, IA vs. DM)32.2% (p=0.15, IA vs general population)5.Beta-blocker prescribed64.8%70.5%66.6%6.Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker prescribed54.8%61.3%56.2%7.Mineralocorticoid receptor antagonist prescribed20.3%19.9%21.2%Perfect Adherence (achieving 5, 6 and 7 above)10.6%12.0% (p=<0.001, IA vs. DM)12.0% (p=0.02, IA vs general population)

Conclusion

HF quality indicators are adhered to in a high proportion of patients with IA following HF hospitalization. However, reasons for lower HF medication prescribing in IA compared to other high-risk conditions, such as DM, requires further evaluation. It will also be important to determine if adherence to HF quality of care translates to reduced long-term outcomes such as repeat HF hospitalizations and cardiovascular mortality, which we are currently exploring.

References

[1]Ontario HQ. Recommendations for Adoption: Heart Failure Care in the Community 2019 [Available from: http://www.hqontario.ca/Evidence-to-Improve-Care/Quality-Standards

Disclosure of Interests

Bindee Kuriya Speakers bureau: Abbvie, Gilead, Pfizer, Lihi Eder Speakers bureau: Abbvie, UCB, Pfizer, Eli Lily, Novartis and Sandoz, Jessica Widdifield: None declared, Laura Ferreira-Legere: None declared, Irene JH Jeong: None declared, Jiming Fang: None declared, Anna Chu: None declared, Jacob Udell: None declared

Vaccine effectiveness against SARS-CoV-2 infection and severe outcomes among individuals with immune-mediated inflammatory diseases tested between March 1 and Nov 22, 2021, in Ontario, Canada: a population-based analysis

Background

We estimated COVID-19 vaccine effectiveness against SARS-CoV-2 infection and severe COVID-19 outcomes among individuals with immune-mediated inflammatory diseases in Ontario, Canada.

Methods

In this population-based analysis, we used a test-negative design across four immune-mediated inflammatory disease population-based cohorts, comprising individuals with rheumatoid arthritis, ankylosing spondylitis, psoriasis, and inflammatory bowel disease. We identified all SARS-CoV-2 tests done in these populations between March 1 and Nov 22, 2021 (a period in which there was rapid uptake of vaccines, and the alpha [B.1.1.7] and delta [B.1.617.2] SARS-CoV-2 variants were predominantly circulating in Canada) and separately assessed outcomes of SARS-CoV-2 infection and severe COVID-19 outcomes (hospitalisation due to COVID-19 and death due to COVID-19) for each disease group. We used multivariable logistic regression to estimate the effectiveness of one, two, and three doses of mRNA-based COVID-19 vaccine (BNT162b2 [Pfizer–BioNTech], or mRNA-1273 [Moderna]) among individuals at the time of SARS-CoV-2 testing.

Findings

Between March 1 and Nov 22, 2021, we identified 2127 (5·9%) test-positive cases among 36 145 individuals (26 476 [73·2%] were female and 9669 [26·8%] were male) with rheumatoid arthritis tested, 476 (6·1%) test-positive cases among 7863 individuals (4130 [52·5%] were female and 3733 [47·5%] were male) with ankylosing spondylitis tested, 3089 (6·5%) test-positive cases among 47 199 individuals (26 062 [55·2%] were female and 21 137 [44·8%] were male) with psoriasis tested, and 1702 (5·4%) test-positive cases among 31 311 individuals (17 716 [56·6%] were female and 13 595 [43·4%] were male) with inflammatory bowel disease tested. Adjusted vaccine effectiveness of two doses against infection was 83% (95% CI 80–86) in those with rheumatoid arthritis, 89% (83–93) among those with ankylosing spondylitis, 84% (81–86) among those with psoriasis, and 79% (74–82) among those with inflammatory bowel disease. After two vaccine doses, effectiveness against infection generally peaked 31–60 days after vaccination and waned gradually with each additional month. Vaccine effectiveness against severe outcomes after two doses was 92% (95% CI 88–95) in those with rheumatoid arthritis, 97% (83–99) among those with ankylosing spondylitis, 92% (86–95) among those with psoriasis, and 94% (88–97) among those with inflammatory bowel disease. Vaccine effectiveness after a third dose against infection was similar to or higher than after the second dose (ranging from 76% [47–89] to 96% [72–99]), although due to a paucity of events, estimates could not be calculated for some subgroups for severe outcomes.

Interpretation

Two vaccine doses were found to be highly effective against both SARS-CoV-2 infection and severe COVID-19 outcomes in patients with rheumatoid arthritis, ankylosing spondylitis, psoriasis, and inflammatory bowel disease during the study period. Research is needed to determine the durability of effectiveness of three doses over time, particularly against emerging variants.

Funding

Public Health Agency of Canada

POS0159 SEX-RELATED DISPARITIES IN HEALTHCARE UTILIZATION IN PATIENTS WITH INFLAMMATORY ARTHRITIS: A POPULATION-BASED STUDY

Background

Delayed diagnosis of inflammatory arthritis (IA) such as rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA) is associated with joint damage and disability. So regular timely assessment by both family physicians and specialists is necessary for favorable disease outcomes. Sex (biology) and gender (socio-cultural) related factors influence clinical patterns of IA, patient behavior and their interaction with care providers. This influence could be reflected in patterns of healthcare utilization.

Objectives

To compare patterns of musculoskeletal (MSK)-related healthcare utilization before and after diagnosis between male and female patients with IA in Ontario, Canada.

Methods

We assembled 3 inception cohorts of adult RA, AS and PsA patients diagnosed between April 2010 and March 2017 using Ontario health administrative data. MSK-related healthcare utilization patterns in terms of visits to physicians, MSK imaging and laboratory tests were assessed yearly for 3 years before and after the diagnosis date, and compared between male and female patients. Among individuals ≥ 66 years, prescriptions for rheumatic drugs (NSAIDs, corticosteroids, csDMARDs, advanced therapy (bDMARDs and tsDMARDs)) and opioids were ascertained. Regression models were used to compare healthcare utilization indicators between males and females after adjusting for demographics and comorbidities.

Results

A total of 41,277 patients with RA (69% females), 8,150 patients with AS (51% females) and 6,446 patients with PsA (54% female) were analyzed. Male patients were significantly older than female patients only in the RA cohort (mean age M 60.4 y, F 57.1 y). Multimorbidity, depression and osteoporosis were more common in female patients and cardiovascular disease in male patients across the 3 cohorts.

Similar trends of sex-related differences were observed in all three cohorts. Female patients were more likely to visit rheumatologists and family physicians than male patients especially in earlier pre-diagnosis periods (Figure 1). Male patients were more likely to visit emergency department immediately before diagnosis. A similar female predominance was observed in imaging modalities of X-rays and ultrasounds (adjusted ORs for F:M 1.15 - 1.2 for X-rays and 1.07 -1.44 for ultrasounds), and laboratory tests before diagnosis (adjusted ORs for F:M 1.10 to 2.17) across the three cohorts.

Overall DMARD prescription patterns in older male and female patients were similar across the three cohorts except more csDMARD prescriptions in female AS patients (Table 1). Female RA patients were more likely to use NSAIDs and opioids.

Table 1.

Odds ratios for prescription patterns in inflammatory arthritis for older female to male patients after diagnosis

Medication ClassAdjusted Odds Ratio (95% Confidence Interval)Rheumatoid ArthritisAnkylosing SpondylitisPsoriatic ArthritiscsDMARDYr 11.00 (0.92, 1.09)1.82 (1.38, 2.41)1.05 (0.81, 1.37)Yr 21.00 (0.92, 1.08)1.66 (1.24, 2.22)0.94 (0.73, 1.20)Yr 31.05 (0.97, 1.14)1.51 (1.12, 2.04)0.85 (0.66, 1.09)Advanced therapyYr 10.99 (0.78, 1.25)0.79 (0.49, 1.25)0.75 (0.47, 1.19)Yr 21.17 (0.99, 1.39)0.80 (0.53, 1.23)0.91 (0.61, 1.37)Yr 31.23 (1.05, 1.45)1.04 (0.67, 1.61)0.88 (0.6, 1.30)NSAIDYr 11.14 (1.04, 1.25)1.22 (0.91, 1.63)0.94 (0.71, 1.24)Yr 21.1 (0.99, 1.22)1.04 (0.77, 1.43)0.98 (0.73, 1.32)Yr 31.16 (1.04, 1.30)1.35 (0.96, 1.89)1.02 (0.73, 1.41)OpioidYr 11.39 (1.22, 1.58)1.23 (0.85, 1.78)1.32 (0.87, 1.98)Yr 21.51 (1.32, 1.72)1.22 (0.85, 1.76)1.14 (0.75, 1.75)Yr 31.46 (1.27, 1.68)1.42 (0.96, 2.09)1.45 (0.95, 2.23)

Bolded results are statistically significant (p < 0.05)

. Odds ratios for female to male patients adjusted for age, residence, income quintiles, comorbidities and access to rheumatologists

Conclusion

Female patients with IA have higher MSK-related healthcare utilization which may indicate biological differences in disease course or sociocultural differences in healthcare seeking behavior between male and female patients.

References

N/A

Acknowledgements

Dr. Sanjana Tarannum received funds from the Enid Walker Graduate Student Award for Research in Women’s Health for this study.

Dr. Widdifield receives support from the Arthritis Society Stars Career Development Award (STAR-19-0610).

Dr. Johnson has been awarded a Canadian Institutes of Health Research New Investigator Award.

Dr. Paula Rochon holds the RTOERO Chair in Geriatric Medicine at the University of Toronto.

Dr. Lihi Eder has been awarded Early Researcher Award from the Ontario Ministry of Research, Innovation and Science and Canada Research Chair (Tier 2) in Inflammatory Rheumatic Diseases.

Disclosure of Interests

Sanjana Tarannum: None declared, Jessica Widdifield: None declared, Fangyun Wu: None declared, Sindhu Johnson: None declared, Paula Rochon: None declared, Lihi Eder Grant/research support from: UCB, Abbvie, Pfizer, Janssen, Novartis, Eli Lily, Sandoz

Advisory board: Abbvie, Pfizer, Janssen, Novartis, Eli Lily

A Population-Based Study Evaluating Retention in Rheumatology Care Among Patients With Rheumatoid Arthritis

Objective

The study objective was to assess adherence to system‐level performance measures measuring retention in rheumatology care and disease modifying anti‐rheumatic drug (DMARD) treatment in rheumatoid arthritis (RA).

Methods

We used a validated health administrative data case definition to identify individuals with RA in Ontario, Canada, between 2002 and 2014 who had at least 5 years of potential follow‐up prior to 2019. During the first 5 years following diagnosis, we assessed whether patients were seen by a rheumatologist yearly and the proportion dispensed a DMARD yearly (in those aged ≥66 for whom medication data were available). Multivariable logistic regression analyses were used to estimate the odds of remaining under rheumatologist care.

Results

The cohort included 50,883 patients with RA (26.1% aged 66 years and older). Over half (57.7%) saw a rheumatologist yearly in all 5 years of follow‐up. Sharp declines in the percentage of patients with an annual visit were observed in each subsequent year after diagnosis, although a linear trend to improved retention in rheumatology care was seen over the study period (P < 0.0001). For individuals aged 66 years or older (n = 13,293), 82.1% under rheumatologist care during all 5 years after diagnosis were dispensed a DMARD annually compared with 31.0% of those not retained under rheumatology care. Older age, male sex, lower socioeconomic status, higher comorbidity score, and having an older rheumatologist decreased the odds of remaining under rheumatology care.

Conclusion

System‐level improvement initiatives should focus on maintaining ongoing access to rheumatology specialty care. Further investigation into causes of loss to rheumatology follow‐up is needed.

Basketball vs. Hockey-The Changing Face of Sport-Related Injuries in Canada

OBJECTIVE

To characterize and compare the incidence of basketball-related, soccer-related, and hockey-related injuries over a 10-year period.

DESIGN

Cohort analysis of sport-related injuries using multiple Ontario healthcare databases.

SETTING

Emergency department visits in Ontario, Canada.

PATIENTS

Any patient who sustained musculoskeletal injuries sustained while playing basketball, soccer, or hockey between 2006 and 2017 were identified.

ASSESSMENT OF RISK FACTORS

Sport of injury, age, sex, rurality index, marginalization status, and comorbidity score.

MAIN OUTCOME MEASURES

Annual Incidence Density Rates of injury were calculated for each sport, and significance of trends was analyzed by assessing overlap of 95% confidence intervals.

RESULTS

One lakhs eighty five thousand eighty hundred sixty-eight patients (median age: 16 years, interquartile range 13-26) received treatment for sport-related injuries (basketball = 55 468; soccer = 67 021; and hockey = 63 379). The incidence of basketball-related and soccer-related injuries increased from 3.4 (3.3-3.5) to 5.6 (5.5-5.7) and 4.4 (4.3-4.5) to 4.9 (4.8-5) per 10 000 person years, respectively, whereas the incidence of hockey-related injuries decreased from 4.7 (4.6-4.8) to 3.7 (3.6-3.8). Patients with basketball injuries were more marginalized (3.01 ± 0.74) compared with patients with soccer and hockey injuries (2.90 ± 0.75 and 2.72 ± 0.69, respectively).

CONCLUSIONS

Accurate regional epidemiologic information regarding sports injuries can be used to guide policy development for municipal planning and sport program development. The trends and demographic patterns described highlight general and sport-specific injury patterns in Ontario. Populations with the highest incidence of injury, most notably adolescents and men older than 50, may represent an appropriate population for injury risk prevention.

The Long-term Cardiac and Noncardiac Prognosis of Kawasaki Disease: A Systematic Review

CONTEXT

It is uncertain if children with Kawasaki Disease (KD) are at risk for non-cardiac diseases and if children with KD but without coronary artery aneurysms (CAA) are at risk for long-term cardiac complications.

OBJECTIVE

To determine the long-term mortality and prognosis of children after KD.

DATA SOURCES

Medline, Embase, and the Cochrane Central Register.

STUDY SELECTION

Controlled trials and observational studies were included if they included children with KD and reported mortality, major adverse cardiovascular events (MACE), chronic cardiac or other disease over an average follow-up of ≥1 year.

DATA EXTRACTION

Data extracted included sample size, age at diagnosis, the proportion with coronary artery aneurysms (CAA), follow-up duration, and outcome(s).

RESULTS

Seventy-four studies were included. Thirty-six studies reported mortality, 55 reported a cardiac outcome, and 12 reported a noncardiac outcome. Survival ranged from 92% to 99% at 10 years, 85% to 99% at 20 years, and 88% to 94% at 30 years. MACE-free survival, mostly studied in those with CAA, varied from 66% to 91% at 10 years, 29% to 74% at 20 years, and 36% to 96% at 30 years. Seven of 10 studies reported an increased risk in early atherosclerosis. All 6 included studies demonstrated an increased risk in allergic diseases.

LIMITATIONS

Our study may have missed associated chronic comorbidities because short-term studies were excluded. The majority of outcomes were evaluated in East-Asian patients, which may limit generalizability. Studies frequently excluded patients without CAA and did not compare outcomes to a comparison group.

CONCLUSIONS

Studies demonstrate >90% survival up to 30 years follow-up. MACE is observed in children with CAA, but is not well studied in those without CAA.

Results from the 2020 Canadian Rheumatology Association's Workforce and Wellness Survey

Objective

The Canadian Rheumatology Association (CRA) launched the Workforce and Wellness Survey to update the Canadian rheumatology workforce characteristics.

Methods

The survey included demographic and practice information, pandemic impacts, and the Mini-Z questionnaire to assess burnout. French and English survey versions were distributed to CRA members electronically between 10/14/2020-3/5/2021. The number of full-time equivalent (FTE) rheumatologists per 75,000 population was estimated from the median proportion of time in clinical practice multiplied by provincial rheumatologist numbers from the Canadian Medical Association (CMA).

Results

Forty-four percent (183/417) of the estimated practicing rheumatologists (149 adult; 34 pediatric) completed the survey. The median age was 47 years, 62% were female, and 28% planned to retire within the next 5-10 years. Respondents spent a median of 65% of their time in clinical practice. FTE rheumatologists per 75,000 ranged between 0 and 0.70 in each province/territory and 0.62 per 75,000 nationally. This represents a deficit of 1 to 78 FTE rheumatologists per province/territory and 194 FTE rheumatologists nationally to meet the CRA's workforce benchmark. Approximately half of survey respondents reported burnout (51%). Women were more likely to report burnout (OR 2.86, 95%CI: 1.42-5.93). Older age was protective against burnout (OR 0.95, 95%CI: 0.92, 0.99). As a result of the pandemic, 97% of rheumatologists reported spending more time engaged in virtual care.

Conclusion

There is a shortage of rheumatologists in Canada. This shortage may be compounded by the threat of burnout to workforce retention and productivity. Strategies to address these workforce issues are urgently needed.

COVID-19 hospitalizations, intensive care unit stays, ventilation and death among patients with immune mediated inflammatory diseases compared to controls

Objective

To investigate COVID-19 hospitalization risk in patients with immune mediated inflammatory diseases (IMIDs) compared with matched non-IMID comparators from the general population.

Methods

We conducted a population-based, matched cohort study using health administrative data from January to July 2020 in Ontario, Canada. Cohorts for each of the following IMIDs were assembled: rheumatoid arthritis (RA), psoriasis, psoriatic arthritis (PsA), ankylosing spondylitis, systemic autoimmune rheumatic diseases (SARDs), multiple sclerosis (MS), iritis, inflammatory bowel disease, polymyalgia rheumatica and vasculitis. Each patient was matched with 5 non-IMID comparators based on socio-demographic factors. We compared the cumulative incidence of hospitalizations for COVID-19 and their outcomes between IMID and non-IMID patients.

Results

A total of 493,499 IMID patients (417 hospitalizations) and 2,466,946 non-IMID comparators (1,519 hospitalizations) were assessed. The odds of being hospitalized for COVID- 19 was significantly higher in patients with IMIDs compared with their matched non-IMID comparators (matched unadjusted Odds Ratio (OR) 1.37, adjusted OR 1.23). Significantly higher risk of hospitalizations was found in patients with iritis (OR 1.46), MS (OR 1.83), PsA (OR 2.20), RA (OR 1.42), SARDs (OR 1.47) and vasculitis (OR 2.07). COVID-19 hospitalizations were associated with older age, male sex, long-term care residence, multimorbidity, and lower income. The odds of complicated hospitalizations was 21% higher among all IMID versus matched non-IMID patients, but this association was attenuated after adjusting for demographic factors and comorbidities.

Conclusion

Patients with IMIDs were at higher risk of being hospitalized with COVID-19. This risk was explained in part by their comorbidities.

COVID-19 Vaccination Uptake among individuals with Immune-Mediated Inflammatory Diseases in Ontario, Canada between December 2020 and October 2021: A population-based analysis

OBJECTIVE

We assessed COVID-19 vaccine uptake among individuals with immune-mediated inflammatory diseases (IMID) and the Ontario general population.

METHODS

We studied all residents 16 years and older who were alive and enrolled in Ontario's universal health insurance plan as of December 14, 2020 when vaccination commenced (n=12,435,914). Individuals with rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), psoriasis (PsO), and inflammatory bowel disease (IBD) were identified using established disease-specific case definitions applied to health administrative data. Vaccination status was extracted from the provincial COVaxON registry. Weekly cumulative proportions of first and second doses up until October 3, 2021 were expressed as the vaccinated percentage of each disease group, and compared to the general Ontario population, and stratified by age.

RESULTS

By October 3, 2021, the cumulative percentage with at least one dose was 82.1% for the general population, 88.9% for RA, 87.4% for AS, 90.6% for PsA, 87.3% for PsO, and 87.0% for IBD. There was also a higher total cumulative percentage with two doses among IMIDs (83.8-88.2%) vs the general population (78.0%). The difference was also evident when stratifying by age. Individuals with IMIDs in the youngest age group initially had earlier uptake than the general population but remain the lowest age group with two doses (70.6% in the general population vs. 73.7-79.2% across IMID groups).

CONCLUSION

While implementation of COVID-19 vaccination programs has differed globally, these Canadian estimates are the first to reassuringly show higher COVID-19 vaccine uptake among individuals with IMIDs.

Effects of hospital funding reform on wait times for hip fracture surgery: a population-based interrupted time-series analysis

Background

Health care funding reforms are being used worldwide to improve system performance but may invoke unintended consequences. We assessed the effects of introducing a targeted hospital funding model, based on fixed price and volume, for hip fractures. We hypothesized the policy change was associated with reduction in wait times for hip fracture surgery, increase in wait times for non-hip fracture surgery, and increase in the incidence of after-hours hip fracture surgery.

Methods

This was a population-based, interrupted time series analysis of 49,097 surgeries for hip fractures, 10,474 for ankle fractures, 1,594 for tibial plateau fractures, and 40,898 for appendectomy at all hospitals in Ontario, Canada between April 2012 and March 2017. We used segmented regression analysis of interrupted monthly time series data to evaluate the impact of funding reform enacted April 1, 2014 on wait time for hip fracture repair (from hospital presentation to surgery) and after-hours provision of surgery (occurring between 1700 and 0700 h). To assess potential adverse consequences of the reform, we also evaluated two control procedures, ankle and tibial plateau fracture surgery. Appendectomy served as a non-orthopedic tracer for assessment of secular trends.

Results

The difference (95 % confidence interval) between the actual mean wait time and the predicted rate had the policy change not occurred was − 0.46 h (-3.94 h, 3.03 h) for hip fractures, 1.46 h (-3.58 h, 6.50 h) for ankle fractures, -3.22 h (-39.39 h, 32.95 h) for tibial plateau fractures, and 0.33 h (-0.57 h, 1.24 h) for appendectomy (Figure 1; Table 3). The difference (95 % confidence interval) between the actual and predicted percentage of surgeries performed after-hours − 0.90 % (-3.91 %, 2.11 %) for hip fractures, -3.54 % (-11.25 %, 4.16 %) for ankle fractures, 7.09 % (-7.97 %, 22.14 %) for tibial plateau fractures, and 1.07 % (-2.45 %, 4.59 %) for appendectomy.

Conclusions

We found no significant effects of a targeted hospital funding model based on fixed price and volume on wait times or the provision of after-hours surgery. Other approaches for improving hip fracture wait times may be worth pursuing instead of funding reform.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06601-2.

POS0050 ARE PATIENTS WITH IMMUNE MEDIATED INFLAMMATORY DISEASES (IMID) MORE LIKELY TO RECEIVE COVID-19 TESTS AND TEST POSITIVE FOR SARS-COV-2? A MATCHED POPULATION-BASED STUDY

Background:

Population-based data about the COVID-19 risk in patients with IMID remain scarce.

Objectives:

To investigate the cumulative incidence and risk factors for laboratory-confirmed COVID-19 infection and SARS-CoV2 testing in patients with IMID compared with matched non-IMID patients from the general population.

Methods:

A population-based, matched cohort study was conducted using health administrative data from adults living in Ontario, Canada from January to December 2020. Cohorts for each of the following IMID were assembled: rheumatoid arthritis (RA), psoriasis, psoriatic arthritis, ankylosing spondylitis, systemic autoimmune rheumatic diseases (including lupus, systemic sclerosis, Sjogren’s, inflammatory myositis), multiple sclerosis (MS), iritis, inflammatory bowel disease (IBD), polymyalgia rheumatica (PMR) and vasculitis. Each patient was matched with 5 non-IMID comparators based on age, sex, area of residence and living in long term care (LTC). Standardized cumulative rates of testing for SARS-CoV2, and for receiving a positive test between IMID and non-IMID were compared between IMID and non-IMID patients. Multivariable logistic regression analyses assessed sociodemographic factors associated with COVID-19 testing and positivity.

Results:

A total of 493,499 IMID patients and 2,466,946 non-IMID comparators were assessed. Significantly more IMID patients versus non-IMID were tested for SARS-CoV2 (27.4% vs. 22.7%), while the proportions of those positive for COVID-19 were identical (0.9% of all patients in both groups). Overall, IMID patients were more likely to undergo SARS-CoV2 testing (odds ratio (OR) 1.28, 95% CI 1.27, 1.29), but their overall risk of laboratory-confirmed COVID-19 was not elevated (OR 0.97 (95% CI 0.93, 1)). However, the risk of laboratory-confirmed COVID-19 infection was lower in IBD (OR 0.75), MS (OR 0.77) and psoriasis (OR 0.94) and marginally higher in RA (OR 1.07) and iritis (OR 1.13) compared with non-IMID comparators (Figure 1A). The highest standardized rates of COVID-19 infection were found in vasculitis (115 per 10,000 patients) and iritis (109 per 10,000 patients) (Figure 1B). Risk factors for COVID-19 infection included younger age, living in LTC, multimorbidity, urban living and lower income (Table 1).

Conclusion:

Patients across all IMID were more likely to be tested for COVID-19 versus non-IMID patients. IMID patients were not at higher risk for testing positive for COVID-19 as an overall group, yet risk varied across disease subgroups.

Table 1.

Factors associated with COVID-19 infection in IMID vs. Non-IMID – Multivariable Logistic Regression

VariableORCI 95%IMID vs. Non-IMID0.970.93, 1.00Age (10-year increase)0.890.89, 0.90Sex: Female vs. Males0.950.93, 0.97LTC18.6417.9, 19.42ADG score:•5-9 vs. 0-41.401.35, 1.45•10-14 vs. 0-41.731.67, 1.80•15+ vs. 0-41.181.13, 1.23Urban vs. Rural3.493.26, 3.72Income quintile•Quintile 2 vs. 10.920.89, 0.96•Quintile 3 vs. 10.900.86, 0.93•Quintile 4 vs. 10.730.70, 0.76•Quintile 5 vs. 10.600.58, 0.63

ADG - Aggregated Diagnosis Groups; IMIDs – Immune medicated inflammatory disease; LTC – long term care

Acknowledgements:

The study is supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). Parts of this material are based on data and information compiled and provided by MOHLTC and the Canadian Institute for Health Information. The opinions, results and conclusions reported in this paper are those of the authors and are independent of the funding or data sources; no endorsement is intended or should be inferred.

Disclosure of Interests:

None declared.

OP0285 COVID-19 HOSPITALIZATIONS, ICU ADMISSION, AND DEATH AMONG PATIENTS WITH IMMUNE MEDIATED INFLAMMATORY DISEASES (IMID) – A POPULATION-BASED STUDY

Background:

It remains unclear whether patients with IMID are at greater risk for severe COVID-19.

Objectives:

To investigate the risk of COVID-19 hospitalizations and their outcomes in patients with IMID compared with matched non-IMID patents from the general population.

Methods:

A population-based, matched cohort study was conducted in adults living in Ontario, Canada using health administrative data. Ten cohorts of the following IMID were assembled: rheumatoid arthritis, psoriasis, psoriatic arthritis, ankylosing spondylitis, systemic autoimmune rheumatic diseases (SARDs, including systemic lupus, systemic sclerosis, Sjogren’s, myositis), multiple sclerosis (MS), iritis, inflammatory bowel disease, polymyalgia rheumatica (PMR), and vasculitis (including giant cell arteritis and other types of vasculitidies). Each patient was matched with 5 non-IMID comparators based on age, sex, area of residence and living in long-term care (LTC). Patients who were admitted to hospital from January 1st to July 31th, 2020 and had ICD-10 COVID-19 diagnosis codes (U07.2 or U07.1) were identified. Among those with COVID-19 hospitalizations, we determined those with admissions to intensive care unit or required mechanical ventilation or died in hospital (‘complicated hospitalization’). Age-sex-standardized rates were compared between IMID and non-IMID patients and risk factors for hospitalizations were identified by multivariable logistic regression analysis.

Results:

In total, 493,499 IMID (417 hospitalized) and 2,466,946 non-IMID patients (1,519 hospitalized) were assessed. The age-sex-standardized rate of COVID-19 hospitalization was higher in IMID (6.4 per 10,000, 95% confidence interval (CI) 5.8, 7.2) versus non-IMID patients (4.8 per 100,000, 95% CI 4.5, 5). The highest rates of hospitalizations were found in vasculitis (18/10,000), MS (16.7/10,000) and PMR (10.1/10,000). IMID diagnosis was associated with 37% higher risk of being hospitalized for COVID-19 (Odds Ratio (OR) 1.37, 95% CI 1.23, 1.53) (Figure 1). This risk was slightly attenuated after adjusting for sociodemographic factors and comorbidities but remained elevated by 23% compared to non-IMID (OR 1.23, 95% CI 1.10, 1.37). The risk for hospitalizations was increased in RA, vasculitis, SARDs, PsA, MS and iritis (Figure 1). Risk factors for COVID-19 hospitalizations included older age, male sex, lower income, multimorbidity and living in long-term care (Table 1). The risk for complicated COVID-19 hospitalizations was higher by 21% in IMID patients (OR 1.21, 95% CI 1.02, 1.43), however, this association was attenuated after adjustment for demographics and comorbidities (OR 1.08).

Table 1.

Risk Factors for COVID-19 Hospitalizations in IMIDs vs. non-IMIDs

VariableOR95% CIIMIDs vs. Non-IMID1.231.10, 1.37Age (10 yrs)1.491.44, 1.54Sex: Female0.680.62, 0.75Long term care resident8.287.32, 9.37ADG: 5-9 vs. 0-41.451.22, 1.7110-14 vs. 0-42.261.92, 2.6715+ vs. 0-43.232.73, 3.82Income (quintile) Quintile 2 vs. 10.820.73, 0.93 Quintile 3 vs. 10.760.67, 0.86 Quintile 4 vs. 10.560.48, 0.64 Quintile 5 vs. 10.460.40, 0.54Urban vs. rural4.333.32, 5.67

ADG - Aggregated Diagnosis Groups

Conclusion:

Patients with IMID were at higher risk of being hospitalized with COVID-19 and for having complicated hospitalizations. Hospitalization risk was partially independent of their comorbid conditions.

Acknowledgements:

The study is supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). Parts of this material are based on data and information compiled and provided by MOHLTC and the Canadian Institute for Health Information. The opinions, results and conclusions reported in this paper are those of the authors and are independent of the funding or data sources; no endorsement is intended or should be inferred.

Disclosure of Interests:

None declared

Factors influencing rheumatology residents' decision on future practice location

BACKGROUND

There are regional disparities in the distribution of Canadian rheumatologists. The objective of this study was to identify factors impacting rheumatology residents' postgraduate practice decisions to inform Canadian Rheumatology Association workforce recommendations.

METHODS

An online survey was developed, and invitations were sent to all current Canadian rheumatology residents in 2019 (n = 67). Differences between subgroups of respondents were examined using the Pearson χ² test.

RESULTS

A total of 34 of 67 residents completed the survey. Seventy-three percent of residents planned to practice in the same province as their rheumatology training. The majority of residents (80%) ranked proximity to friends and family as the most important factor in planning. Half of participants had exposure to alternative modes of care delivery (e.g. telehealth) during their rheumatology training with fifteen completing a community rheumatology elective (44%).

CONCLUSIONS

The majority of rheumatology residents report plans to practice in the same province as they trained, and close to home. Gaps in training include limited exposure to community electives in smaller centers, and training in telehealth and travelling clinics for underserviced populations. Our findings highlight the need for strategies to increase exposure of rheumatology trainees to underserved areas to help address the maldistribution of rheumatologists.

Evaluation of Rheumatology Workforce Supply Changes in Ontario, Canada, from 2000 to 2030

Rheumatology workforces are increasingly challenged by too few physicians in face of the growing burden of rheumatic and musculoskeletal diseases (RMDs). Rheumatology is one of the most frequent non-surgical specialty referrals and has the longest wait times for subspecialists. We used a population-based approach to describe changes in the rheumatology workforce, patient volumes and geographic variation in the supply of and access to rheumatologists, in Ontario, Canada, between 2000 and 2019, and projected changes in supply by 2030. Over time, we observed greater feminization of the workforce and increasing age of workforce members. We identified a large regional variation in rheumatology supply. Fewer new patients are seen annually, which likely contributes to increasing wait times and reduced access to care. Strategies and policies to raise the critical mass and improve regional distribution of supply to effectively provide rheumatology care and support the healthcare delivery of patients with RMDs are needed.

Fracture Risk in Patients with Myasthenia Gravis: A Population-Based Cohort Study

BACKGROUND

Prednisone is a common treatment for myasthenia gravis (MG), and osteoporosis is a known potential risk of chronic prednisone therapy.

OBJECTIVE

Our aim was to evaluate the risk of serious fractures in a population-based cohort of MG patients.

METHODS

An inception cohort of patients with MG was identified from administrative health data in Ontario, Canada between April 1, 2002 and December 31, 2015. For each MG patient, we matched 4 general population comparators based on age, sex, and region of residence. Fractures were identified through emergency department and hospitalization data. Crude overall rates and sex-specific rates of fractures were calculated for the MG and comparator groups, as well as rates of specific fractures. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox regression.

RESULTS

Among 3,823 incident MG patients (followed for a mean of 5 years), 188 (4.9%) experienced a fracture compared with 741 (4.8%) fractures amongst 15,292 matched comparators. Crude fracture rates were not different between the MG cohort and matched comparators (8.71 vs. 7.98 per 1000 patient years), overall and in men and women separately. After controlling for multiple covariates, MG patients had a significantly lower risk of fracture than comparators (HR 0.74, 95% CI 0.63-0.88).

CONCLUSIONS

In this large, population-based cohort of incident MG patients, MG patients were at lower risk of a major fracture than comparators. The reasons for this finding are unclear but may highlight the importance osteoporosis prevention.

Increased mortality for individuals with Giant Cell Arteritis: a population-based study

BACKGROUND

Reports of mortality risks among individuals with GCA have been mixed. Our aim was to evaluate all-cause mortality among individuals with GCA relative to the general population over time.

METHODS

We performed a population-based study in Ontario, Canada, using health administrative data. We studied a cohort of 22,677 GCA patients aged ≥50 years identified using a validated case definition (with 81% positive predictive value, 100% specificity). General population comparators were residents aged ≥50 years without GCA. Deaths were ascertained from vital statistics. Annual crude, age/sex-standardized and age- and sex-specific all-cause mortality rates were determined for individuals with and without GCA between 2000 and 2018. Standardized mortality ratios (SMRs) were estimated.

RESULTS

Age- and sex-standardized mortality rates were significantly higher for GCA patients than comparators, and trending to increase over time with 50.0 (95% confidence interval (CI) 34.0, 71.1) deaths per 1000 GCA patients in 2000 and 57.6 (95% CI 50.8, 65.2) deaths per 1000 in 2018, whereas mortality rates in the general population significantly declined over time. The annual SMRs for GCA patients generally increased over time with the lowest SMR occurring in 2002 (1.22; 95% CI 1.03, 1.40) and the highest in 2018 (1.92; 95% CI 1.81, 2.03). GCA mortality rates were more elevated for males than females.

CONCLUSION

Over a 19-year period, mortality rates were increased among GCA patients relative to the general population and more premature deaths were occurring in younger age groups. The relative excess mortality for GCA patients did not improve over time.

Incidence and prevalence of giant cell arteritis in Ontario, Canada

OBJECTIVE

To estimate trends in the incidence and prevalence of GCA over time in Canada.

METHODS

We performed a population-based study of Ontario health administrative data using validated case definitions for GCA. Among Ontario residents ≥50 years of age we estimated the annual incidence and prevalence rates between 2000 and 2018. We performed sensitivity analyses using alternative validated case definitions to provide comparative estimates.

RESULTS

Between 2000 and 2018 there was a relatively stable incidence over time with 25 new cases per 100 000 people >50 years of age. Age-standardized incidence rates were significantly higher among females than males [31 cases (95% CI: 29, 34) vs 15 cases (95% CI: 13, 18) per 100 000 in 2000]. Trends in age-standardized incidence rates were stable among females but increased among males over time. Incidence rates were highest among those ≥70 years of age. Standardized prevalence rates increased from 125 (95% CI 121, 129) to 235 (95% CI 231, 239) cases per 100 000 from 2000 to 2018. The age-standardized rates among males rose from 76 (95% CI 72, 81) cases in 2000 to 156 (95% CI 151, 161) cases per 100 000 population in 2018. Between 2000 and 2018, the age-standardized rates among females similarly increased over time, from 167 (95% CI 161, 173) to 304 (95% CI 297, 310) cases per 100 000 population.

CONCLUSION

The incidence and prevalence of GCA in Ontario is similar to that reported in the USA and northern Europe and considerably higher than that reported for southern Europe and non-European populations.

Feminization of the Rheumatology Workforce: A Longitudinal Evaluation of Patient Volumes, Practice Sizes, and Physician Remuneration

OBJECTIVE

To compare differences in clinical activity and remuneration between male and female rheumatologists and to evaluate associations between physician gender and practice sizes and patient volume, accounting for rheumatologists' age, and calendar year effects.

METHODS

We conducted a population-based study in Ontario, Canada, between 2000 to 2015 identifying all rheumatologists practicing as full-time equivalents (FTEs) or above and assessed differences in practice sizes (number of unique patients), practice volumes (number of patient visits), and remuneration (total fee-for-service billings) between male and female rheumatologists. Multivariable linear regression was used to evaluate the effects of gender on practice size and volume separately, accounting for age and year.

RESULTS

The number of rheumatologists practicing at ≥ 1 FTE increased from 89 to 120 from 2000 to 2015, with the percentage of females increasing from 27.0% to 41.7%. Males had larger practice sizes and practice volumes. Remuneration was consistently higher for males (median difference of CAD $46,000-102,000 annually). Our adjusted analyses estimated that in a given year, males saw a mean of 606 (95% CI 107-1105) more patients than females did, and had 1059 (95% CI 345-1773) more patient visits. Among males and females combined, there was a small but statistically significant reduction in mean annual number of patient visits, and middle-aged rheumatologists had greater practice sizes and volumes than their younger/older counterparts.

CONCLUSION

On average, female rheumatologists saw fewer patients and had fewer patient visits annually relative to males, resulting in lower earnings. Increasing feminization necessitates workforce planning to ensure that populations' needs are met.

Trends in mortality and cause-specific mortality among patients with psoriasis and psoriatic arthritis in Ontario, Canada

BACKGROUND

There is limited information about mortality rates among patients with psoriasis and psoriatic arthritis (PsA) in North America and their change over the past 2 decades.

OBJECTIVE

To compare all-cause and cause-specific mortality rates in patients with psoriasis to the general population in Ontario, Canada, from 1996 to 2016.

METHODS

We conducted a population-based, retrospective cohort study of adult residents using administrative health data. All-cause and cause-specific standardized mortality rates, standardized mortality ratios, and excess mortality rates were calculated.

RESULTS

176,858 (2,524 deaths) patients with psoriasis and 15,430 (221 deaths) patients with PsA were identified in 2016. Patients with psoriasis and PsA had standardized excess mortality rates of 1.44 and 2.43 per 1000 population, respectively. Standardized mortality rates decreased by approximately 30% over the study period in both disease groups but remained significantly elevated compared to the general population. The leading causes of death in psoriasis and PsA patients were cancer, circulatory disease, and respiratory conditions.

LIMITATIONS

We were unable to classify patients according to disease severity.

CONCLUSIONS

Despite improvements in psoriasis treatment, the relative excess mortality, which may be related to risk factors for psoriatic disease, remained unchanged, with an average of approximately 1 to 2 extra deaths per 1,000 patients in 2016.

Acute mental health service use is increased in rheumatoid arthritis and ankylosing spondylitis: a population-based cohort study

Background

Rheumatoid arthritis (RA) and ankylosing spondylitis (AS) are associated with mental illness. Whether acute mental health (MH) service utilization (i.e. emergency visits or hospitalizations) is increased in RA or AS is not known.

Methods

Two population-based cohorts were created where individuals with RA (n = 53,240) or AS (n = 13,964) were each matched by age, sex, and year to unaffected comparators (2002-2016). Incidence rates per 1000 person-years (PY) were calculated for a first MH emergency department (ED) presentation or MH hospitalization. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated, adjusting for demographic, clinical, and health service use variables.

Results

Individuals with RA had higher rates of ED visits [6.59/1000 person-years (PY) versus 4.39/1000 PY in comparators] and hospitalizations for MH (3.11/1000 PY versus 1.80/1000 PY in comparators). Higher rates of ED visits (7.92/1000 PY versus 5.62/1000 PY in comparators) and hospitalizations (3.03/1000 PY versus 1.94/1000 PY in comparators) were also observed in AS. Overall, RA was associated with a 34% increased risk for MH hospitalization (HR 1.34, 95% CI 1.22-1.47) and AS was associated with a 36% increased risk of hospitalization (HR 1.36, 95% CI 1.12-1.63). The risk of ED presentation was attenuated, but remained significant, after adjustment in both RA (HR 1.08, 95% CI 1.01-1.15) and AS (HR 1.14, 95% CI 1.02-1.28).

Conclusions

RA and AS are both independently associated with a higher rate and risk of acute ED presentations and hospitalizations for mental health conditions. These findings underscore the need for routine evaluation of MH as part of the management of chronic inflammatory arthritis. Additional research is needed to identify the underlying individual characteristics, as well as system-level variation, which may explain these differences, and to help plan interventions to make MH service use more responsive to the needs of individuals living with RA and AS.

SAT0252 INCREASED MORTALITY FOR INDIVIDUALS WITH GIANT CELL ARTERITIS: A POPULATION-BASED STUDY

Background:

Individuals with giant cell arteritis (GCA) are at increased risk of serious morbidity including cardiovascular disease and stroke. Yet the risk of mortality among individuals with GCA have produced conflicting reports1.

Objectives:

Our aim was to evaluate excess all-cause mortality among individuals with GCA relative to the general population over time.

Methods:

We performed a population-based study in Ontario, Canada, using health administrative data among all individuals 50 years and older. Individuals with GCA were identified using a validated case definition (81% PPV, 100% specificity). All Ontario residents aged 50 and above who do not have GCA served as the General Population comparators. Deaths occurring in each cohort each year were ascertained from vital statistics. Annual crude and age/sex standardized all-cause mortality rates were determined for individuals with and without GCA between 2000 and 2018. Standardized mortality ratios (SMRs) were calculated to measure relative excess mortality over time. Differences in mortality between sexes and ages were also evaluated.

Results:

Population denominators among individuals 50 years and older with GCA and the General Population increased over time with 12,792 GCA patients and 5,456,966 comparators by 2018. Annual standardized mortality rates among the comparators steadily declined over time and were significantly lower than GCA morality rates (Figure). Annual GCA mortality rates fluctuated between 42-61 deaths per 1000 population (with overlapping confidence intervals) during the same time period. SMRs for GCA ranged from 1.28 (95% CI 1.08,1.47) at the lowest in 2002 to 1.96 (95% CI 1.84, 2.07) at the highest in 2018. GCA mortality rates and SMRs were highest among males and younger age groups.

Conclusion:

Over a 19-year period, mortality has remained increased among GCA patients relative to the general population. GCA mortality rates were higher among males and more premature deaths were occurring at younger age groups. In our study, improvements to the relative excess mortality for GCA patients over time (mortality gap) did not occur. Understanding cause-specific mortality and other factors are necessary to inform contributors to premature mortality among GCA patients.

References:

[1]Hill CL, et al. Risk of mortality in patients with giant cell arteritis: a systematic review and meta-analysis. Semin Arthritis Rheum. 2017;46(4):513-9.

Figure.

Acknowledgments: :

This study was supported by a CIORA grant

Disclosure of Interests:

Lillian Barra: None declared, Janet Pope Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly & Company, Merck, Roche, Seattle Genetics, UCB, Consultant of: AbbVie, Actelion, Amgen, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Eicos Sciences, Eli Lilly & Company, Emerald, Gilead Sciences, Inc., Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB, Speakers bureau: UCB, Priscila Pequeno: None declared, Jodi Gatley: None declared, Jessica Widdifield: None declared

The risk of deliberate self-harm following a diagnosis of rheumatoid arthritis or ankylosing spondylitis: A population-based cohort study

Objective

Rheumatoid arthritis (RA) and ankylosing spondylitis (AS) are associated with mental illness. The risk of serious mental illness, including deliberate self-harm (DSH), in these conditions is not well known. We aimed to determine if RA or AS independently increases the risk for DSH.

Methods

We conducted retrospective, population-based cohort studies using administrative health data for the province of Ontario, Canada between April 1, 2002 and March 31, 2014. Individuals with incident RA (N = 53,240) or AS (N = 13,964) were separately matched 1:4 by age, sex, and year with comparators without RA or AS. The outcome was a first DSH attempt identified using emergency department data. We estimated hazard ratios (HR) and 95% confidence intervals (95% CI) for risk of DSH in RA and AS versus comparators, adjusting for demographic, clinical and health service utilization variables.

Results

Subjects with AS were significantly more likely to self-harm (crude incidence rate [IR] of 0.68/1,000 person years [PY] versus 0.32/1,000 PY in comparators), with an adjusted HR of 1.59 (95% CI 1.15 to 2.21). DSH was increased for RA subjects (IR 0.35/1,000 PY) versus comparators (IR 0.24/1,000 PY) only before (HR 1.43, 95% CI 1.16 to 1.74), but not after covariate adjustment (HR 1.07, 95% CI 0.86 to 1.33).

Conclusions

AS carries an increased risk for DSH but no such risk was observed in RA. Further evaluation of at-risk AS subjects is needed, including the longitudinal effects of disease and arthritis therapies on self-harm behaviour. This will inform whether specific risk-reduction strategies for DSH in inflammatory arthritis are needed.