Use of Coordinator Role Improves Access to Rheumatologic Advanced Therapy.

OBJECTIVE: Delays in initiation of advanced therapies, which include biologics and targeted synthetic disease-modifying antirheumatic drugs, contribute to poor patient outcomes. The objective of this quality improvement project was to identify factors that lead to a delay in the initiation of advanced therapy and to perform plan-do-study-act cycles to decrease the time to start advanced therapy. METHODS: A retrospective chart review identified factors involved in delay to start advanced therapy. The primary outcome of the study was the number of days to advanced therapy start as measured by the date of rheumatologist recommendation to the date advanced therapy was initiated by the patient. An Advanced Therapy Coordinator role was created to standardize the workflow, optimize communication, and ensure a safety checklist was instituted. RESULTS: A total of 125 patients were reviewed for the study with 18 excluded. Preintervention median wait time was 82.0 (IQR 46.0-80.5) days. Median wait time during the intervention improved to 49.5 (IQR 34.0-69.5) days (April 2021 to January 2022), with nonrandom variation post intervention. Nonrandom variation was also noted in the latter baseline data (March 2020 to March 2021). CONCLUSION: This study demonstrates improved wait time to advanced therapy initiation through the role of an Advanced Therapy Coordinator to facilitate communication pathways.

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.

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 effects, and the Mini Z survey to assess burnout. French and English survey versions were distributed to CRA members electronically between October 14, 2020, and March 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. 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 population were 0.62 nationally and ranged between 0.00 and 0.70 in each province/territory. This represents a deficit of 1-78 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 needed urgently.

Comparative Efficacy of Different Triage Methods for Psoriatic Arthritis: Results From a Prospective Study in a Rapid Access Clinic.

OBJECTIVE: We undertook this study to identify the optimal combination of triage methods to identify psoriatic arthritis (PsA) among psoriasis patients with musculoskeletal symptoms in a rapid access clinic and to describe their outcome after 1 year. METHODS: Patients with psoriasis and no prior diagnosis of PsA were referred for assessment of their musculoskeletal symptoms. Each patient was assessed by the following 3 triage modalities: 1) assessment by an advanced practice physical therapist; 2) targeted musculoskeletal ultrasound (MSK-US); and 3) PsA screening questionnaires. The patients were then evaluated by a rheumatologist who determined the patient's disease status and classified them into the following groups: not PsA, possibly PsA, or PsA. Patients returned for a 1-year follow-up visit and were reassessed for change in their disease status. Sensitivity and specificity were calculated for each individual modality, as well as for combinations of modalities. RESULTS: A total of 203 patients with psoriasis and musculoskeletal symptoms were enrolled. The percentage of patients classified as having PsA was 8.8%, and 23.6% were converted into the possibly PsA group. There was no significant difference in the individual performance of the modalities. The highest sensitivity was seen with MSK-US (89%), and the highest specificity was found with the Psoriatic Arthritis Screening and Evaluation questionnaire (79%). The addition of MSK-US data improved the performance of the modalities. A total of 9 patients were classified into the PsA group after 1 year. All patient-reported outcome measures had significantly improved at 1 year (P < 0.001). CONCLUSION: Combining MSK-US with a screening questionnaire for PsA improved the triage of patients with suspected PsA.

The Pattern of Musculoskeletal Complaints in Patients With Suspected Psoriatic Arthritis and Their Correlation With Physical Examination and Ultrasound.

OBJECTIVE: To describe the pattern of musculoskeletal (MSK) symptoms and their correlation with clinical and sonographic findings among psoriasis patients with suspected psoriatic arthritis (PsA). METHODS: Patients with psoriasis and no prior diagnosis of PsA were referred for assessment of their MSK complaints. The study included the following steps: (1) assessment by an advanced practice physiotherapist, (2) targeted MSK ultrasound, and (3) assessment by a rheumatologist. In addition, patients were asked to complete questionnaires about the nature and duration of their MSK symptoms and to mark the location of their painful joints on a homunculus. Each patient was classified by a rheumatologist as "Not PsA," "Possible PsA," or "PsA". MSK symptoms and patient-reported outcomes (PRO) were compared between patients with PsA and Possible/Not PsA. Agreement between modalities was assessed using κ statistics. RESULTS: Two hundred three patients with psoriasis and MK symptoms were enrolled (8.8% PsA, 23.6% Possible PsA). Patients classified as PsA had worse scores on the PsA Impact of Disease (P = 0.004) and Functional Assessment of Chronic Illness Therapy-Fatigue scale (P = 0.02). There was no difference between the 2 groups in the presence, distribution, and duration of MSK symptoms. Analysis of agreement in physical examination between modalities revealed the strongest agreement between the rheumatologist and physiotherapist (κ = 0.28). The lowest levels of agreement were found between ultrasound and patient (κ = 0.08) and physiotherapist and ultrasound (κ = 0.08). CONCLUSION: The results of this study suggest that the intensity, rather than the type, duration, or distribution of MSK symptoms, is associated with PsA among patients with psoriasis.

Eosinophilic granulomatosis with polyangiitis presenting with myositis: case based review.

Eosinophilic granulomatosis with polyangitis (EGPA) is a systemic necrotizing small-vessel vasculitis that presents heterogeneously as a multi-organ disease. EGPA evolves through three phases: (1) prodromic phase with asthma, atopy and sinusitis, (2) eosinophilic phase characterized by peripheral eosinophilia and eosinophilic infiltration without necrosis, and (3) vasculitic phase involving organ damage. EGPA often presents with asthma, mononeuritis multiplex, lung infiltrates, sinusitis and constitutional symptoms. Although myalgias are common, EGPA rarely presents with true weakness with elevated creatinine kinase (CK). We describe a rare case of a patient presenting with eosinophilic myositis, who subsequently developed fulminant EGPA. The patient's diagnosis was supported by an initial clinical presentation of weakness and elevated CK, followed by fleeting pulmonary infiltrates and mononeuritis multiplex, peripheral eosinophilia, and strongly positive myeloperoxidase anti-cytoplasmic antibody (MPO-ANCA). Muscle biopsy revealed eosinophilic myositis. The patient responded well to high-dose glucocorticoids and cyclophosphamide with improved symptoms and biochemical markers. Based on our literature review, there are only seven similar cases reported of EGPA presenting with myositis and confirmatory muscle biopsies. There is significant heterogeneity in their clinical findings, histopathology and treatments that were used. Our case report and literature review highlights the importance of recognizing myositis as an initial presenting symptom of EGPA, providing an opportunity for early diagnosis and treatment to reduce risk of further disease progression and morbidity.

Diagnosis and management of psoriasis.

OBJECTIVE: To provide primary care clinicians with an up-to-date and practical overview of the diagnosis and management of psoriasis. QUALITY OF EVIDENCE: PubMed, MEDLINE, EMBASE, and Cochrane databases were searched for relevant meta-analyses, randomized controlled trials, systematic reviews, and observational studies about the diagnosis and management of psoriasis. MAIN MESSAGE: Psoriasis is a chronic, multisystem inflammatory disease with predominantly skin and joint involvement. Beyond the physical dimensions of disease, psoriasis has an extensive emotional and psychosocial effect on patients, affecting social functioning and interpersonal relationships. As a disease of systemic inflammation, psoriasis is associated with multiple comorbidities, including cardiovascular disease and malignancy. The diagnosis is primarily clinical and a skin biopsy is seldom required. Depending on the severity of disease, appropriate treatment can be initiated. For mild to moderate disease, first-line treatment involves topical therapies including corticosteroids, vitamin D3 analogues, and combination products. These topical treatments are efficacious and can be safely initiated and prescribed by primary care physicians. Patients with more severe and refractory symptoms might require further evaluation by a dermatologist for systemic therapy. CONCLUSION: Many patients with psoriasis seek initial evaluation and treatment from their primary care providers. Recognition of psoriasis, as well as its associated medical and psychiatric comorbidities, would facilitate timely diagnosis and appropriate management with effective and safe topical therapies and other medical and psychological interventions, as needed. More severe and refractory cases might warrant referral to a dermatologist for further evaluation and possible systemic therapy.

Triage of Rheumatology Referrals Facilitates Wait Time Benchmarks.

OBJECTIVE: In 2014 the Canadian Rheumatology Association published wait time benchmarks for inflammatory arthritis (IA) and connective tissue disease (CTD) to improve patient outcomes. This study's aim was to determine whether centralized triage and the introduction of quality improvement initiatives would facilitate achievement of wait time benchmarks. METHODS: Referrals from September to November 2012 were retrospectively triaged by an advanced practice physiotherapist (APP) and compared to referrals triaged by an APP from January to March 2014. Each referral was assigned a priority ranking and categorized into one of 2 groups: suspected IA/CTD, or suspected non-IA/CTD. Time to initial consult and time to notification from receipt of referral were assessed. RESULTS: A total of 558 (n = 227 and n = 331 from 2012 and 2014, respectively) referrals were evaluated with 35 exclusions. In 2012, there were 96 (42.5%) suspected IA/CTD and 124 (54.9%) suspected non-IA/CTD patients at the time of the initial consult. Mean wait times in 2012 for patients suspected to have IA was 33.8 days, 95% CI 27.8-39.8, compared to 37.3 days, 95% CI 32.9-41.7 in suspected non-IA patients. In 2014, there were 131 patients (43%) with suspected IA based on information in the referral letter. Mean wait times in 2014 for patients suspected to have IA was 15.5 days, 95% CI 13.85-17.15, compared to 52.2 days, 95% CI 46.3-58.1 for suspected non-IA patients. Time to notification of appointment improved from 17 days to 4.37 days. CONCLUSION: Centralized triage of rheumatology referrals and quality improvement initiatives are effective in improving wait times for priority patients as determined by paper referral.

Office capillaroscopy in systemic sclerosis.

The aims of this study are to assess the reliability of two office techniques, the ophthalmoscope and the Dermlite dermatoscope, and to detect nailfold capillaroscopy abnormalities in systemic sclerosis (SSc). Two separate studies were performed. In the first, the nailfolds of two fingers on one hand of 13 SSc patients and two normals were examined by four rheumatologists using an ophthalmoscope. In the second, the nailfolds of the two fingers of each hand of six SSc patients and two normals were examined by six rheumatologists with a Dermlite dermatoscope. Widefield capillary microscopy was performed by one observer in the ophthalmoscope study to assess validity. The examiners determined the presence or absence of dilated loops, giant capillary loops, and/or avascular areas on each digit. The kappa coefficient was calculated to demonstrate agreement. With the ophtalmoscope, the inter-observer kappa coefficients were 0.43, 0.54, and 0.19; the average intra-observer agreements were 0.61, 0.56, and 0.31; and the ophthalmoscope-microscope agreement were 0.63, 0.52, and <0.1 for dilated capillaries, giant capillaries, and avascular areas, respectively. With the dermatoscope, the kappa values for inter-observer reliability were 0.63, 0.40, and 0.20; and intra-observer reliability was 0.71, 0.55, and 0.40 for dilated capillaries, giant capillaries, and avascular areas, respectively. The ophthalmoscope and the dermatoscope provide moderate to substantial reliability to detect the presence of giant and dilated capillaries but poor inter-observer agreement for avascular areas. The ophthalmoscope is valid when compared to the microscope for detecting giant or dilated capillaries. We conclude that these techniques are useful office tools to detect capillary abnormalities in SSc.

The effect of menopause on disease activity in systemic lupus erythematosus.

OBJECTIVE: To determine the effect of menopause on disease activity and course of systemic lupus erythematosus (SLE). METHODS: Patients were identified from the University of Toronto lupus clinic database. Menopause was diagnosed on the basis of 12 months of amenorrhea. A 3 part study was carried out. Part 1 included an inception cohort of 190 women with SLE diagnosed in the premenopausal years (Group A) and an inception cohort of 55 women with SLE diagnosed in the postmenopausal years (Group B), both followed for a minimum of 3 years. Part 2 included 49 patients followed in the clinic for at least 3 years before and 3 years after their menopause (Group C). Part 3 included 193 patients followed for 6 years entirely in the premenopausal period (Group D) and 76 patients followed for 6 years entirely in the postmenopausal period (Group E). Disease activity was measured by the SLE Disease Activity Index 2000 (SLEDAI-2K) and the adjusted mean SLEDAI-2K (AMS). Damage was assessed by the Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) damage index. Comparisons were made using t-tests and chi-square and McNemar tests. A multivariate linear regression model was used to establish the impact of menopausal status on change in disease related features. RESULTS: In the first 3 years of disease, AMS was higher in Group A than Group B (6.6 +/- 3.8 vs 5.0 +/- 3.3, p = 0.003). Damage accrual was higher in Group B than in Group A both in the first year and at 3 years. For Group C, AMS and the number of flares per 3 year interval were lower in the postmenopausal period. SLICC/ACR damage index was greater during the 3 years in the postmenopausal period then in the premenopause (p = 0.006). SLEDAI-2K was higher among Group D than Group E at the start of the study (6.71 vs 4.86, p = 0.04). AMS for the 6 years was higher in the premenopausal than postmenopausal women (5.14 vs 3.54, p

Frequency of adverse drug reactions in patients with systemic lupus erythematosus.

OBJECTIVE: The literature suggests that patients with systemic lupus erythematosus (SLE) have a higher frequency of adverse drug reactions (ADR). We performed this case control study to compare the prevalence of ADR in patients with SLE and controls with inflammatory arthritis. METHODS: We surveyed 249 patients, 145 with SLE and 104 age and sex matched controls with other types of inflammatory arthritis, such as rheumatoid arthritis (RA), probable RA, and psoriatic arthritis. We asked about exposure and ADR to the following classes of drugs: (1) beta-lactam antibiotics, (2) sulfonamides, (3) other antibiotics, (4) disease modifying antirheumatic drugs (DMARD), and (5) nonsteroidal antiinflammatory drugs (NSAID). Personal and family atopic histories were obtained. The 2 groups were obtained from a single rheumatologic practice and had similar characteristics and drug exposures. RESULTS: The response rate was 63% in the SLE patients and 64% in the control group. The mean age was 47.8 +/- 1.5 years in patients with SLE and 46.1 +/- 1.7 years in controls (p < 0.51). Ninety-two percent of SLE patients and 88% of controls were female (p < 0.42). Both groups had been exposed similarly to all antibiotics, as there were no significant differences between groups (exposure to sulfa antibiotics 53% in SLE patients vs 46% in controls), and to NSAID (84% SLE group vs 93% controls). Few patients from the SLE group had DMARD exposure, with the exception of plaquenil (65% SLE group vs 30% controls; p < 0.0001) and azathioprine (18% SLE group vs 4% controls; p < 0.006). There were between-groups differences with respect to total number of ADR with sulfa antibiotics (exposed had 25/48 reactions in SLE group vs 6/31 in controls; p < 0.003), but not with other drugs. Most ADR to sulfa antibiotics were cutaneous (rash). Subjects with an allergic or atopic history had more ADR (p < 0.0005). There were no differences between SLE patients and controls in having an allergic history (p < 0.88). Subjects with a positive family history of allergies were more likely to have ADR (p < 0.0043). SLE patients and controls with a personal versus family history of environmental allergies did not differ in having ADR (p < 0.16 and p < 0.83, respectively). CONCLUSION: Both intolerances and true allergic reactions were not dissimilar in patients with SLE compared to controls with inflammatory arthritis, with the exception of cutaneous reactions to sulfa antibiotics in SLE patients. This has not been the experience of other investigators (with increased ADR with several antibiotics in SLE groups) who used healthy, best friend, and relative controls with dissimilar frequencies of drug exposures. Perhaps differences observed in the past (where SLE patients have more ADR than healthy controls) are true of other inflammatory arthritis subjects (who have different drug exposures than healthy individuals) rather than just SLE. Differences could also exist in the pharmacogenetics, as our sample population was mostly Caucasian.