Quality Indicators for Evaluating the Health Care of Patients with Rheumatoid Arthritis: a Korean Expert Consensus.

BACKGROUND: There is increasing interest in the quality of health care and considerable efforts are being made to improve it. Rheumatoid arthritis (RA) is a disease that can result in favorable outcomes when appropriate diagnosis and treatment are provided. However, several studies have shown that RA is often managed inappropriately. Therefore, the Korean College of Rheumatology aimed to develop quality indicators (QIs) to evaluate and improve the health care of patients with RA. METHODS: Preliminary QIs were derived based on the existing guidelines and QIs for RA. The final QIs were determined through two separate consensus meetings of experts. The consensus was achieved through a panel of experts who voted using the modified Delphi method. RESULTS: Fourteen final QIs were selected among 70 preliminary QIs. These included early referral to and regular follow-up with a rheumatologist, radiographs of the hands and feet, early initiation and maintenance of disease-modifying anti-rheumatic drug (DMARD) therapy, periodic assessment of disease activity, screening for drug safety and comorbidities, including viral hepatitis and tuberculosis before biologic DMARD therapy, periodic laboratory testing, supplementation with folic acid, assessment of the risk for cervical spine instability before general anesthesia, patient education, and specialized nurse. CONCLUSION: These QIs can be used to assess and improve the quality of health care for patients with RA.

The Brazilian Society of Rheumatology guidelines for axial spondyloarthritis - 2019.

Spondyloarthritis is a group of chronic inflammatory systemic diseases characterized by axial and/or peripheral joints inflammation, as well as extra-articular manifestations. The classification axial spondyloarthritis is adopted when the spine and/or the sacroiliac joints are predominantly involved. This version of recommendations replaces the previous guidelines published in May 2013.A systematic literature review was performed, and two hundred thirty-seven studies were selected and used to formulate 29 recommendations answering 15 clinical questions, which were divided into four sections: diagnosis, non-pharmacological therapy, conventional drug therapy and biological therapy. For each recommendation the level of evidence supporting (highest available), the strength grade according to Oxford, and the degree of expert agreement (inter-rater reliability) is informed.These guidelines bring evidence-based information on clinical management of axial SpA patients, including, diagnosis, treatment, and prognosis.

2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee.

OBJECTIVE: To develop an evidence-based guideline for the comprehensive management of osteoarthritis (OA) as a collaboration between the American College of Rheumatology (ACR) and the Arthritis Foundation, updating the 2012 ACR recommendations for the management of hand, hip, and knee OA. METHODS: We identified clinically relevant population, intervention, comparator, outcomes questions and critical outcomes in OA. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available educational, behavioral, psychosocial, physical, mind-body, and pharmacologic therapies for OA. Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. A Voting Panel, including rheumatologists, an internist, physical and occupational therapists, and patients, achieved consensus on the recommendations. RESULTS: Based on the available evidence, either strong or conditional recommendations were made for or against the approaches evaluated. Strong recommendations were made for exercise, weight loss in patients with knee and/or hip OA who are overweight or obese, self-efficacy and self-management programs, tai chi, cane use, hand orthoses for first carpometacarpal (CMC) joint OA, tibiofemoral bracing for tibiofemoral knee OA, topical nonsteroidal antiinflammatory drugs (NSAIDs) for knee OA, oral NSAIDs, and intraarticular glucocorticoid injections for knee OA. Conditional recommendations were made for balance exercises, yoga, cognitive behavioral therapy, kinesiotaping for first CMC OA, orthoses for hand joints other than the first CMC joint, patellofemoral bracing for patellofemoral knee OA, acupuncture, thermal modalities, radiofrequency ablation for knee OA, topical NSAIDs, intraarticular steroid injections and chondroitin sulfate for hand OA, topical capsaicin for knee OA, acetaminophen, duloxetine, and tramadol. CONCLUSION: This guideline provides direction for clinicians and patients making treatment decisions for the management of OA. Clinicians and patients should engage in shared decision-making that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.

Active Learning Strategies to Improve Progression from Knowledge to Action.

Lectures, a form of passive learning, are a modality of teaching used in medical education. Active learning strategies allow learners and teachers to interact and be more engaged with the subject matter in a manner that encourages discussion, critical thinking, and advanced clinical reasoning skills. Learning to be effective requires vigilance, which promotes memory retention and should afford a way for learners to build on preexisting knowledge via scaffolding and concept mapping that uses critical thinking. Educators should also to use evaluation models that seek to improve patient care, health care systems, and community health.

Care quality for rheumatoid arthritis patients in Quebec.

AIM: The aims of this study were to: (a) measure the proportion of CARTaGENE rheumatoid arthritis (RA) patients fulfilling pre-specified quality indicators (ie disease-modifying antirheumatic drug [DMARD] use, regular follow up, use of folate supplementation, use of vitamin D and calcium, exercise and smoking status); and (b) examine variation in DMARD use with respect to patient age, sex, education and income. METHODS: A cohort of RA patients was constructed based on the CARTaGENE survey and health administrative database. CARTaGENE is a large, established, population-based study which recruited 19 995 participants from four metropolitan regions in Quebec. Six quality indicators (QI) were assessed; four pertained to RA management and treatment received (use of DMARD therapy, annual medical visits, use of folate supplementation with methotrexate therapy, and use of calcium and vitamin D in steroid-exposed patients) and two pertained to lifestyle factors (physical activity and smoking cessation). QI were reported in terms of proportion of patients fulfilling them. Bayesian logistic regression analyses were preformed to investigate potential variation with DMARD use. RESULTS: Our cohort included 142 RA patients. The QI that pertain to RA pharmacotherapy and medical management ranged 60-80%. Regarding the QI focusing on lifestyle factors, 55% of patients reported performing moderate physical activity and only 16.6% reported current smoking. Results from the Bayesian logistic regression showed no definite associations between DMARD use and patient characteristics (age, education, income and sex). CONCLUSION: Our findings suggest a seemingly modest performance of Quebec's health-care system for RA patients, with respect to these QI.

Patient preferences for rheumatoid arthritis treatment.

PURPOSE OF REVIEW: To provide an overview of recent articles discussing patient preferences for rheumatoid arthritis (RA) treatment. RECENT FINDINGS: Recent studies examined patient preferences for RA treatment in several populations, finding that most participants were willing to accept certain risks of adverse effects to gain potential benefits. Perspectives regarding cannabis were studied, with patients describing medical marijuana as an alternative therapy to be used with prescription medications or as means of tapering off these medications. Treatment preferences for different RA therapies were explored using a conjoint analysis survey and five distinct preference phenotypes emerged, with members of the largest group most concerned with the cost of medications. Other discrete choice studies demonstrated route of administration as an important attribute influencing treatment preferences, with patients expressing preference for various modes in different studies. Patient preferences for route of administration have demonstrated preference for newer autoinjectors over prefilled syringes as well as currently marketed autoinjectors. Incorporating patient preferences in clinical practice recommendations was described in the development of the 2015 American College of Rheumatology (ACR) RA treatment guidelines as well as the 2017 ACR/American Association of Hip and Knee Surgeons guidelines for perioperative management of antirheumatic medications. In addition, other studies explored preferences with regard to predictive testing, medication intensification and tapering, treatment goals, and psychological support. SUMMARY: Our review of recent studies show variability in patient preferences for RA treatment, highlighting the importance of incorporating patient input into the treatment approach.

Position Statement: A Pragmatic Approach for Medical Cannabis and Patients with Rheumatic Diseases.

OBJECTIVE: Pain is one reason some rheumatology patients may consider use of medical cannabis, a product increasingly perceived as a safe and neglected natural treatment option for many conditions. Legalization of recreational cannabis in Canada will promote access to cannabis. Physicians must therefore provide patients with the best evidence-based information regarding the medicinal effects and harm of cannabis. METHODS: The Canadian Rheumatology Association (CRA) mandated the development of a position statement for medical cannabis and the rheumatology patient. The current literature regarding the effects of medical cannabis for rheumatology patients was assessed, and a pragmatic position statement to facilitate patient care was developed by the Therapeutics Committee of the CRA and approved by the CRA board. RESULTS: There are no clinical trials of medical cannabis in rheumatology patients. Evidence is insufficient about the benefit of pharmaceutical cannabinoids in fibromyalgia, osteoarthritis, rheumatoid arthritis, and back pain, but there is evidence of a high risk of harm. Extrapolating from other conditions, medical cannabis may provide some symptom relief for some patients. Short-term risks of psychomotor effects can be anticipated, but longterm risks have not been determined and are of concern. CONCLUSION: Despite lack of evidence for use of medical cannabis in rheumatology patients, we acknowledge the need to provide empathetic and pragmatic guidance for patient care. This position statement aims to facilitate the dialogue between patients and healthcare professionals in a mutually respectful manner to ensure harm reduction for patients and society.

Does Systemic Lupus Erythematosus Care Provided in a Lupus Clinic Result in Higher Quality of Care Than That Provided in a General Rheumatology Clinic?

OBJECTIVE: To compare the quality of care received by patients with systemic lupus erythematosus (SLE) in 2 settings within the academic institution (a dedicated lupus clinic and a general rheumatology clinic) using validated SLE quality measures. METHODS: One hundred fifty consenting, consecutive SLE patients receiving longitudinal care at the Rush University general rheumatology clinic (n = 73) or the subspecialty lupus clinic (n = 77) were recruited. An updated quality measure survey and retrospective medical chart review were used to evaluate each quality measure (n = 20). The overall and individual quality measure performance was calculated and compared between the 2 groups. Data on the number of SLE patients seen by each rheumatologist were collected to assess the relationship between SLE patient volume and quality measures. RESULTS: Overall quality measure performance was significantly better in SLE patients receiving care at the lupus clinic (85.8% versus 70.2% of patients receiving care at the general rheumatology clinic; P = 0.001). Differences between the 2 groups were observed for sunscreen counseling (98.7% and 83.6%, respectively; P = 0.001), antiphospholipid antibody testing (71.4% and 37%, respectively; P < 0.001), pneumococcal vaccination (84.8% and 48.8%, respectively; P < 0.001), bone mineral density testing (94.2% and 54.5%, respectively; P < 0.001), drug counseling (92.2% and 80.8%, respectively; P = 0.04), use of a steroid-sparing agent (100% and 82%, respectively; P < 0.007), use of an angiotensin-converting enzyme inhibitor (94.4% and 58.3%, respectively; P = 0.03), and cardiovascular disease risk assessment (40.3% and 15.1%, respectively; P = 0.01). There was a moderate correlation between physician volume and quality measure performance (ρ = 0.48, P < 0.001). CONCLUSION: Compared with the general rheumatology clinic, the dedicated lupus clinic had better quality measure performance in this cross-sectional single-center study. In our health care system, we also observed indicators suggesting that rheumatologists with a higher volume of SLE patients provide higher quality of care.

2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis.

OBJECTIVE: To develop recommendations for prevention and treatment of glucocorticoid-induced osteoporosis (GIOP). METHODS: We conducted a systematic review to synthesize the evidence for the benefits and harms of GIOP prevention and treatment options. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of evidence. We used a group consensus process to determine the final recommendations and grade their strength. The guideline addresses initial assessment and reassessment in patients beginning or continuing long-term (≥3 months) glucocorticoid (GC) treatment, as well as the relative benefits and harms of lifestyle modification and of calcium, vitamin D, bisphosphonate, raloxifene, teriparatide, and denosumab treatment in the general adult population receiving long-term GC treatment, as well as in special populations of long-term GC users. RESULTS: Because of limited evidence regarding the benefits and harms of interventions in GC users, most recommendations in this guideline are conditional (uncertain balance between benefits and harms). Recommendations include treating only with calcium and vitamin D in adults at low fracture risk, treating with calcium and vitamin D plus an additional osteoporosis medication (oral bisphosphonate preferred) in adults at moderate-to-high fracture risk, continuing calcium plus vitamin D but switching from an oral bisphosphonate to another antifracture medication in adults in whom oral bisphosphonate treatment is not appropriate, and continuing oral bisphosphonate treatment or switching to another antifracture medication in adults who complete a planned oral bisphosphonate regimen but continue to receive GC treatment. Recommendations for special populations, including children, people with organ transplants, women of childbearing potential, and people receiving very high-dose GC treatment, are also made. CONCLUSION: This guideline provides direction for clinicians and patients making treatment decisions. Clinicians and patients should use a shared decision-making process that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.

[Biosimilars in rheumatology. Development and results of clinical trials]. / Biosimilars in der Rheumatologie. Entwicklung und Ergebnisse klinischer Studien.

BACKGROUND: This article presents the design of clinical trials for the development of biosimilars in the European Union and the United States, with special focus on inflammatory diseases. METHODS: All information available in PubMed and the Internet relating to the clinical development of biosimilars in inflammatory rheumatic conditions (e.g. rheumatoid arthritis, psoriasis, psoriatic arthritis and ankylosing spondylitis) was collated. The European Medicines Agency (EMA) and US Food and Drug Administration (FDA) websites were screened for guidelines on biosimilars. RESULTS: More than 10 years ago the EMA began to publish guidelines for the development of biosimilars and several biosimilars have now been approved. In the USA the FDA has published guidance for the nonclinical and clinical development of biosimilars but until early 2015 no biosimilar had been approved. CONCLUSION: Clinical trials aim to resolve uncertainties that may remain following nonclinical development regarding the similarity of the proposed biosimilar with the reference product. Pharmacokinetic and pharmacodynamic studies are essential for early clinical development and further phase 3 clinical studies. Factors to be considered in the clinical process include study population, design, endpoints, sample size, duration and analytical methods.

Polymyalgia rheumatica: strategies for efficient practice and quality assurance.

Polymyalgia rheumatica (PMR) is the most common inflammatory rheumatic disease in persons over the age of 50 years. There are many diseases which mimic PMR, for which reason a careful diagnostic approach is required. While it is thought to be exquisitely responsive to glucocorticosteroid therapy, many patients respond incompletely and/or develop serious side effects over the protracted disease course. Improved methods for classification and disease assessment together with standardized treatment approaches and outcome assessments can serve to improve the care of patients with this disease.

[Pharmacotherapy of psoriatic arthritis. Treatment recommendations against the background of limited evidence]. / Pharmakotherapie der Psoriasisarthritis. Behandlungsempfehlungen vor dem Hintergrund limitierter Evidenzen.

International treatment recommendations for assisting the choice of pharmaceutical treatment of psoriatic arthritis are currently available in two different versions. While the group for research and assessment of psoriasis and psoriatic arthritis (GRAPPA) recommendations mainly focus on both the description of treatment options for the different phenotypes of psoriatic arthritis and the listing of evidence grades, the European League against Rheumatism (EULAR) recommendations try to implement the knowledge about drugs into an algorithm for the different treatment steps. However, the presentation of a treatment algorithm suggests comparable evidence levels for the individual treatment steps, which is at present not the case for psoriatic arthritis. This should be borne in mind for each individual treatment option and treatment step when using a predetermined therapy algorithm and in view of the heterogeneous study results (or no study results available). Both recommendations are currently being revised and will allow the latest evidence trends to be included in the updated version.

German guidelines for the sequential medical treatment of rheumatoid arthritis with traditional and biologic disease-modifying antirheumatic drugs.

The German Society of Rheumatology approved new German guidelines for the sequential medical treatment of rheumatoid arthritis (RA) based on the European League Against Rheumatism (EULAR) recommendations for the management of RA published in 2010. An update of the EULAR systematic literature research was performed in Medline, Embase, and Cochrane databases. Meta-analyses, controlled trials, cohort studies, and registry data addressing traditional and biologic disease-modifying antirheumatic drugs, glucocorticoids, and treatment strategies published between January 2009 and August 2011 were included. Two reviewers independently evaluated and compared the additional data that had been published after the time limit set by the EULAR recommendations. A national guideline working group developed an adapted set of recommendations. The new German guidelines were accepted by vote using an informal Delphi approach. Twelve recommendations and the resulting updated treatment algorithm were developed and approved as a practical orientation for rheumatologists. These recommendations are based on a successive treatment with traditional and biologic disease-modifying drugs depending on the individual progress of the disease and distinct patient characteristics. The German guidelines have been developed on the basis of the internationally well-recognized EULAR recommendations. In addition, more recent evidence from a systematic literature research was considered. They have been developed and approved by a group of national experts aiming at guidance for rheumatologists to reach best medical practice.

Consumer perspectives on pediatric rheumatology care and service delivery: a qualitative study.

OBJECTIVES: This study aimed to elicit parental and adolescent perspectives on pediatric rheumatology care and service delivery and to describe the impact of this process on a proposed model of care addressing pediatric rheumatology service delivery. METHODS: Adolescents with juvenile idiopathic arthritis (JIA) and caregivers in New South Wales, Australia, participated in focus groups or semistructured interviews conducted from August to November 2011. Transcripts were coded and thematically analyzed. Changes to the model of care as a result of this process were identified. RESULTS: Thirty-seven parents and 13 adolescents participated. Five main themes were identified including (1) optimize service efficiency (promoting awareness about JIA, minimizing delays in diagnosis and treatment, continuity of care, holistic and integrated care, access to health care providers with JIA expertise, extending pharmacy services, regional outreach programs); (2) transitional care (trust and rapport with the adult rheumatologist, comprehensive information transfer of patient history); (3) psychosocial support (social and financial aid, mental health services, vocational guidance, peer support); (4) informational needs (medicine adverse effects, nutritional guidance, pain management, administering medications, obtaining medical equipment); and (5) school-based support and advocacy (to promote acceptance, provide academic assistance, facilitate environmental modifications, offer alternative activities). The model of care was extended to include consumer-focused concerns. CONCLUSIONS: A well-coordinated network of services, timely and accurate information about the illness, treatment and support services, adequate pharmacy support, and school-based advocacy are proposed to be needed to ensure pediatric rheumatology services that are accessible and responsive to the needs of patients and their families.

Recommendations for the use of biologic therapy in rheumatoid arthritis: update from the Italian Society for Rheumatology II. Safety.

Given the availability of novel biologic agents for the treatment of rheumatoid arthritis (RA), various national scientific societies have developed specific recommendations in order to assist rheumatologists in prescribing these drugs. The Italian Society for Rheumatology (Società Italiana di Reumatologia, SIR) decided to update its recommendations, and, to this end, a systematic literature review was performed and the evidence derived from it was discussed and summarized as expert opinions. Levels of evidence and strength of recommendations were reported. The recommendations reported refer to the safety of biologic agents and are intended to help prescribing rheumatologists to optimise the use of biologic agents in patients with RA seen in everyday practice; they are not to be considered as a regulatory rule.

Recommendations for the use of biologic therapy in the treatment of psoriatic arthritis: update from the Italian Society for Rheumatology.

OBJECTIVES: To update the 2006 Italian Society for Rheumatology recommendations for the use of biologic (TNF-α blocking) agents in the treatment of psoriatic arthritis (PsA). METHODS: A panel of experts performed a literature search and identified the items that required updating on the basis of new published data. A draft of the updated recommendations was circulated to a group of Italian Rheumatologists with a specific expertise in PsA and in therapy with biologic agents, and their suggestions were incorporated in the final version. RESULTS: A consensus was achieved regarding the initiation and the monitoring of anti-TNF-α agents in PsA. Inclusion and exclusion criteria were defined and specific recommendations were made for patients with psoriatic peripheral synovitis, spondylitis, enthesitis, and dactylitis, respectively. We also specified criteria for assessment of response to treatment and for withholding and withdrawal of therapy. CONCLUSIONS: These recommendations may be used for guidance in deciding which patients with PsA should receive biologic therapy. Further updates of these recommendations may be published on the basis of the results of new clinical studies and of data from post-marketing surveillance.