Evaluation of a multidisciplinary care model to improve quality of life in rheumatoid arthritis: a randomised controlled trial.

BACKGROUND AND PURPOSE: Health-Related Quality of Life (HR-QOL) is an important patient-reported domain in patients with rheumatoid arthritis (RA). The uptake of multidisciplinary team (MDT) care in RA is generally low, due to initial high demand for resources. We hypothesised that whilst pharmacological treatments are effective in controlling disease activity, a multipronged intervention in an MDT may have a positive impact on HR-QOL. METHODS: This was a single-centre randomized parallel group, single-blind controlled trial of MDT vs. usual care in an established RA clinic. Data were collected through face-to-face questionnaires, medical records review, and joint counts by a blinded assessor at 0, 3 and 6 months. Adult RA patients were randomly assigned in a single visit to a 6-member MDT (rheumatologist, nurse, social worker, physiotherapist, occupational therapist, and podiatrist) or usual care. MDT providers prescribed medications and counselled patients on managing flares, medication adherence, coping, joint protection, exercise, footwear. The primary outcome was minimal clinically important difference (MCID) in HR-QOL (increase in European QOL-5-Dimension-3-Level, EQ-5D-3L by 0.1) at six months. RESULTS: 140 patients (86.3% female, 53.4% Chinese, median (IQR) age 56.6 (46.7, 62.4) years); 70 were randomized to each arm. Median (IQR) disease duration was 5.5 (2.4, 11.0) years and disease activity in 28 joints (DAS28) was 2.87 (2.08, 3.66). 123 patients completed the study. Twenty-six (40.6%) MDT vs. 23 (34.3%) usual care patients achieved an MCID in EQ-5D-3L, OR 1.3 (0.6, 2.7). In multivariable logistic regression, baseline EQ-5D-3L was the only predictor of achieving MCID. There was more disease modifying anti-rheumatic drug escalation in MDT (34.4% vs. 19.4%). Patients with high disease activity were more likely to achieve MCID in the MDT arm. CONCLUSIONS: A single visit by stable patients with low disease activity to an MDT failed to achieve MCID in the EQ-5D-3L; however, did achieve small but significant improvements in the EQ-5D-3L, DAS28, pain, coping and self-efficacy. To be sustainable, MDT care should be targeted at patients with high disease activity or those with a new diagnosis of RA. TRIAL REGISTRATION: The study is registered on ClinicalTrials.gov, identifier: NCT03099668.

Disabling foot pain and its impact on daily living among people with psoriatic arthritis in Singapore: a cross-sectional observational investigation.

BACKGROUND: Psoriatic Arthritis (PsA)-related foot involvement has been shown to have a profound impact on daily functioning, with most studies having focused on predominantly Caucasian populations. The aim was to describe disabling foot pain (DFP) and its impact on daily living in PsA in Singapore. METHODS: A cross-sectional, retrospective study was conducted using clinical data collected during a single-visit to a rheumatology clinic in Singapore. Records for adults with physician-diagnosed PsA were reviewed for sociodemographic information, disease characteristics, global disease activity and burden. Foot-specific measures included clinical assessment and the Manchester Foot Pain and Disability Index used to define DFP and evaluate between-group differences. RESULTS: Forty-two participants with PsA (83% female, 57% Chinese, 31% Malay, 9.5% Indian, mean (SD) age 54-years (16)) attended the rheumatology clinic over the study-period. The median (IQR) disease duration was 2-years (11) and all were taking current DMARDs. Global disease measures demonstrated mild-to-moderate global disease activity and mild functional impairment, and were significantly higher in those with DFP. Despite 90% reporting to be coping well with their condition, self-care and having emotional support (n = 38), this study sample demonstrated high levels of anxiety/depression (29%), sleep disturbance (34%) and fatigue (24%), and a lack of disease- and drug-specific knowledge (64%). Further management was indicated for medication adherence counselling (48%), occupational therapy (43%), physiotherapy (36%) and podiatry (30%). Nearly half had current foot pain with 40% reporting DFP (n = 17), which caused significantly greater difficulty walking 3 km than those without DFP (p < 0.05). Rearfoot enthesitis (plantar fasciitis, Achilles enthesitis) was the most common cause of DFP (67%) with pain lasting longer than 1-year. 72% were overweight or obese, with a high proportion not engaging in any cardiovascular exercise (70%). Three of 42 participants had previously seen a podiatrist. CONCLUSIONS: People with DFP in PsA experience more severe global disease activity, reduced mobility and higher levels of negative impact on their daily lives in Singapore. In the absence of working in a multidisciplinary-team, there is value in comprehensive assessments that have potential to capture a holistic view of personal impact and improve person-centred care in PsA.

Attitudes and Behaviors of Patients With Rheumatic Diseases During the Early Stages of the COVID-19 Outbreak.

OBJECTIVE: To evaluate attitudes and behaviors of patients with rheumatic diseases during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: An online survey delivered by text message to 4695 patients on follow-up at a tertiary rheumatology center. Latent class analysis was performed on the survey variables. RESULTS: There were 2239 (47.7%) who responded to the survey and 3 clusters were identified. Cluster 3 (C3) was defined by patients who were most worried about COVID-19, more likely to wear face masks, and more likely to alter or stop their medications. Patients in C3 were more likely to be female, Malay, and unemployed. CONCLUSION: We identified 3 clusters with different healthcare beliefs and distinct sociodemographics.

Use of complementary and alternative medicines is associated with delay to initiation of disease-modifying anti-rheumatic drug therapy in early inflammatory arthritis.

OBJECTIVES: To study the predictors of complementary and alternative medicine (CAM) use in patients with early inflammatory arthritis (EIA), and its impact on delay to initiation of disease-modifying anti-rheumatic drugs (DMARD). METHODS: Data were collected prospectively from EIA patients aged ≥ 21 years. Current or prior CAM use was ascertained by face-to-face interview. Predictors of CAM use and its effect on time to DMARD initiation were determined by multivariate logistic regression and Cox proportional hazards, respectively. RESULTS: One hundred and eighty patients (70.6% female, 58.3% Chinese), of median (interquartile range [IQR]) age 51.1 (40.9-59.8) years and symptom duration 16.6 (9.2-26.6) weeks were included: 83.9% had rheumatoid arthritis, 57% were seropositive. Median (IQR) Disease Activity Score in 28-joints (DAS28) was 4.3 (2.8-5.7), modified Health Assessment Questionnaire (mHAQ) was 0.38 (0.0-0.88) and 41.3% were CAM users. Chinese race (odds ratio [OR] 5.76 [95%CI 2.53-13.1]), being non-English speaking (OR 2.68 [95% CI 1.18-6.09]), smoking (OR 3.35 [95% CI 1.23-9.15] and high DAS28 (OR 2.73 [95% CI 1.05-7.09] were independent predictors of CAM use. CAM users initiated DMARD later (median [IQR] 21.5 [13.1-30.4] vs. 15.6 [9.4-22.7] weeks in non-users, P = 0.005). CAM use and higher DAS28 were associated with a longer delay to DMARD initiation (hazard ratio [HR] 0.69, 95% CI 0.50-0.95 and 0.63, 95% CI 0.43-0.91, respectively) while higher mHAQ was associated with a shorter delay (HR 1.59, 95% CI 1.08-2.34) and race, education level, being non-English speaking, smoking and seropositivity were not associated. CONCLUSIONS: Healthcare professionals should be aware of the unique challenges in treating patients with EIA in Asia. Healthcare beliefs regarding CAM may need to be addressed to reduce treatment delay.