The Effect of Triage Assessments on Identifying Inflammatory Arthritis and Reducing Rheumatology Wait Times in Ontario.

OBJECTIVE: We evaluated the influence of triage assessments by extended role practitioners (ERP) on improving timeliness of rheumatology consultations for patients with suspected inflammatory arthritis (IA) or systemic autoimmune rheumatic diseases (SARD). METHODS: Rheumatologists reviewed primary care providers' referrals and identified patients with inadequate referral information, so that a decision about priority could not be made. Patients were assessed by an ERP to identify those with IA/SARD requiring an expedited rheumatologist consult. The time from referral to the first consultation was determined comparing patients who were expedited to those who were not, and to similar patients in a usual care control group identified through retrospective chart review. RESULTS: Seven rheumatologists from 5 communities participated in the study. Among 177 patients who received an ERP triage assessment, 75 patients were expedited and 102 were not. Expedited patients had a significantly shorter median (interquartile range) wait time to rheumatologist consult: 37.0 (24.5-55.5) days compared to non-expedited patients [105 (71.0-135.0) days] and controls [58.0 (24.0-104.0) days]. Accuracy comparing the ERP identification of IA/SARD to that of the rheumatologists was fair (κ 0.39, 95% CI 0.25-0.53). CONCLUSION: Patients triaged and expedited by ERP experienced shorter wait times compared to usual care; however, some patients with IA/SARD were missed and waited longer. Our findings suggest that ERP working in a triage role can improve access to care for those patients correctly identified with IA/SARD. Further research needs to identify an ongoing ERP educational process to ensure the success of the model.

Getting a Grip on Arthritis Online: Responses of rural/remote primary care providers to a web-based continuing medical education programme.

INTRODUCTION: Physicians are often challenged with accessing relevant up-to-date arthritis information to enable the delivery of optimal care. An online continuing medical education programme to disseminate arthritis clinical practice guidelines (CPGs) was developed to address this issue. METHODS: Online learning modules were developed for osteoarthritis (OA) and rheumatoid arthritis (RA) using published CPGs adapted for primary care (best practices), input from subject matter experts and a needs assessment. The programme was piloted in two rural/remote areas of Canada. Knowledge of best practice guidelines was measured before, immediately after completion of the modules and at 3-month follow-up by assigning one point for each appropriate best practice applied to a hypothetical case scenario. Points were then summed into a total best practice score. RESULTS: Participants represented various professions in primary care, including family physicians, physiotherapists, occupational therapists and nurses (n = 89) and demonstrated significant improvements in total best practice scores immediately following completion of the modules (OA pre = 2.8/10, post = 3.8/10, P < 0.01; RA pre = 3.9/12, post = 4.6/12, P < 0.01). The response rate at 3 months was too small for analysis. CONCLUSIONS: With knowledge gained from the online modules, participants were able to apply a greater number of best practices to OA and RA hypothetical case scenarios. The online programme has demonstrated that it can provide some of the information rural/remote primary care providers need to deliver optimal care; however, further research is needed to determine whether these results translate into changes in practice.

Introduction: Il est souvent difficile pour les médecins d'accéder à de l'information pertinente et à jour sur l'arthrite dans le but de dispenser des soins optimaux. Un programme en ligne de formation médicale continue visant à disséminer les lignes directrices de pratique clinique sur l'arthrite a été créé pour résoudre ce problème. Méthodes: Des modules d'apprentissage en ligne sur l'arthrose et la polyarthrite rhumatoïde (PR) ont été élaborés à l'aide des lignes directrices de pratique clinique publiées ayant été adaptées pour les soins de première ligne (pratiques exemplaires), des commentaires des spécialistes en la matière et d'une évaluation des besoins. Le programme a été mis à l'essai dans deux régions rurales et éloignées du Canada. La connaissance des lignes directrices de pratique exemplaire a été mesurée avant, immédiatement après avoir terminé les modules et au suivi de trois mois en accordant un point à chaque pratique exemplaire appropriée appliquée à un scénario de cas hypothétique. La somme des points indiquait le score de pratique exemplaire. Résultats: Les participants représentaient diverses professions de première ligne, dont médecins de famille, physiothérapeutes, ergothérapeutes et infirmières (n = 89) et ont affiché une amélioration significative des scores totaux de pratique exemplaire immédiatement après avoir terminé les modules (arthrose avant = 2,8/10, après = 3,8/10, P < 0,01; PR avant = 3,9/12, après = 4,6/12, P < 0,01). Le taux de réponse à trois mois était trop faible pour l'analyse. Conclusions: Grâce aux connaissances acquises dans les modules en ligne, les participants ont pu appliquer un plus grand nombre de pratiques exemplaires aux scénarios de cas hypothétiques d'arthrose et de PR. Le programme en ligne a montré pouvoir fournir une part de l'information que les fournisseurs de soins en région rurale et éloignée ont besoin pour dispenser des soins optimaux, cependant des recherches plus poussées sont nécessaires pour déterminer si ces résultats se traduisent par des changements de la pratique. Mots-clés: Polyarthrite rhumatoïde, arthrose, lignes directrices de pratique clinique, système en ligne, évaluation des besoins.

Telemedicine delivery of patient education in remote Ontario communities: feasibility of an Advanced Clinician Practitioner in Arthritis Care (ACPAC)-led inflammatory arthritis education program.

OBJECTIVE: Telemedicine-based approaches to health care service delivery improve access to care. It was recognized that adults with inflammatory arthritis (IA) living in remote areas had limited access to patient education and could benefit from the 1-day Prescription for Education (RxEd) program. The program was delivered by extended role practitioners with advanced training in arthritis care. Normally offered at one urban center, RxEd was adapted for videoconference delivery through two educator development workshops that addressed telemedicine and adult education best practices. This study explores the feasibility of and participant satisfaction with telemedicine delivery of the RxEd program in remote communities. MATERIALS AND METHODS: Participants included adults with IA attending the RxEd program at one of six rural sites. They completed post-course program evaluations and follow-up interviews. Educators provided post-course feedback to identify program improvements that were later implemented. RESULTS: In total, 123 people (36 in-person and 87 remote, across 6 sites) participated, attending one of three RxEd sessions. Remote participants were satisfied with the quality of the video-conference (% agree/strongly agree): could hear the presenter (92.9%) and discussion between sites (82.4%); could see who was speaking at other remote sites (85.7%); could see the slides (95.3%); and interaction between sites adequately facilitated (94.0%). Educator and participant feedback were consistent. Suggested improvements included: use of two screens (speaker and slides); frontal camera angles; equal interaction with remote sites; and slide modifications to improve the readability on screen. Interview data included similar constructive feedback but highlighted the educational and social benefits of the program, which participants noted would have been inaccessible if not offered via telemedicine. CONCLUSION: Study findings confirm the feasibility of delivering the RxEd program to remote communities by using telemedicine. Future research with a focus on the sustainability of this and other models of technology-supported patient education for adults with IA across Ontario is warranted.

A prospective comparison of telemedicine versus in-person delivery of an interprofessional education program for adults with inflammatory arthritis.

Introduction We evaluated two modes of delivery of an inflammatory arthritis education program ("Prescription for Education" (RxEd)) in improving arthritis self-efficacy and other secondary outcomes. Methods We used a non-randomized, pre-post design to compare videoconferencing (R, remote using telemedicine) versus local (I, in-person) delivery of the program. Data were collected at baseline (T1), immediately following RxEd (T2), and at six months (T3). Self-report questionnaires served as the data collection tool. Measures included demographics, disorder-related, Arthritis Self-Efficacy Scale (SE), previous knowledge (Arthritis Community Research and Evaluation Unit (ACREU) rheumatoid arthritis knowledge questionnaire), coping efficacy, Illness Intrusiveness, and Effective Consumer Scale. Analysis included: baseline comparisons and longitudinal trends (R vs I groups); direct between-group comparisons; and Generalized Estimating Equations (GEE) analysis. Results A total of 123 persons attended the program (I: n = 36; R: n = 87) and 111 completed the baseline questionnaire (T1), with follow-up completed by 95% ( n = 117) at T2 and 62% ( n = 76) at T3. No significant baseline differences were found across patient characteristics and outcome measures. Both groups (R and I) showed immediate effect (improved arthritis SE, mean change (95% confidence interval (CI)): R 1.07 (0.67, 1.48); I 1.48 (0.74, 2.23)) after the program that diminished over six months (mean change (95% CI): R 0.45 (-0.1, 0.1); I 0.73 (-0.25, 1.7)). For each of the secondary outcomes, both groups showed similar trends for improvement (mean change scores (95% CI)) over time. GEE analysis did not show any meaningful differences between groups (R vs I) over time. Discussion Improvements in arthritis self-efficacy and secondary outcomes displayed similar trends for I and R participant groups.

Internet-based implementation of non-pharmacological interventions of the "people getting a grip on arthritis" educational program: an international online knowledge translation randomized controlled trial design protocol.

BACKGROUND: Rheumatoid arthritis (RA) affects 2.1% of the Australian population (1.5% males; 2.6% females), with the highest prevalence from ages 55 to over 75 years (4.4-6.1%). In Canada, RA affects approximately 0.9% of adults, and within 30 years that is expected to increase to 1.3%. With an aging population and a greater number of individuals with modifiable risk factors for chronic diseases, such as arthritis, there is an urgent need for co-care management of arthritic conditions. The increasing trend and present shifts in the health services and policy sectors suggest that digital information delivery is becoming more prominent. Therefore, it is necessary to further investigate the use of online resources for RA information delivery. OBJECTIVE: The objective is to examine the effect of implementing an online program provided to patients with RA, the People Getting a Grip on Arthritis for RA (PGrip-RA) program, using information communication technologies (ie, Facebook and emails) in combination with arthritis health care professional support and electronic educational pamphlets. We believe this can serve as a useful and economical method of knowledge translation (KT). METHODS: This KT randomized controlled trial will use a prospective randomized open-label blinded-endpoint design to compare four different intervention approaches of the PGrip-RA program to a control group receiving general electronic educational pamphlets self-management in RA via email. Depending on group allocation, links to the Arthritis Society PGrip-RA material will be provided either through Facebook or by email. One group will receive feedback online from trained health care professionals. The intervention period is 6 weeks. Participants will have access to the Internet-based material after the completion of the baseline questionnaires until the final follow-up questionnaire at 6 months. We will invite 396 patients from Canadian and Australian Arthritis Consumers' Associations to participate using online recruitment. RESULTS: This study will build on a pilot study using Facebook, which revealed promising effects of knowledge acquisition/integration of the evidence-based self-management PGrip educational program. CONCLUSIONS: The use of online techniques to disseminate knowledge provides an opportunity to reduce health care costs by facilitating self-management of people with arthritis. Study design strengths include the incorporation of randomization and allocation concealment to ensure internal validity. To avoid intergroup contamination, the Facebook group page security settings will be set to "closed", thus allowing only invited participants to access it. Study limitations include the lack of participant blinding due to the characteristics of this KT randomized controlled trial and a potential bias of recruiting patients only online, though this was proven effective in the previous pilot study. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12614000397617; http://www.anzctr.org.au/TrialSearch.aspx (Archived by WebCite at http://www.webcitation.org/6PrP0kQf8).

Proof-of-concept study of a Web-based methotrexate decision aid for patients with rheumatoid arthritis.

OBJECTIVE: To assess the extent to which an online patient decision aid reduced decisional conflict and improved self-management knowledge/skills in patients who were considering methotrexate for rheumatoid arthritis (RA). METHODS: We used a mixed-methods pre-post study design. Eligible participants had a diagnosis of RA, had been prescribed methotrexate but were unsure about starting it, and had access to the internet. Outcome included the Decisional Conflict Scale, the Methotrexate in RA Knowledge Test, and the Effective Consumer Scale. Paired t-tests were used to assess changes before and after the intervention. Randomly selected participants were interviewed at the end of the study about their experiences with the decision aid. RESULTS: Of 30 participants, 23 were women. Mean ± SD age was 54.9 ± 14.9 years and the median disease duration was 1 year (interquartile range 0.3-5.0 years). Mean ± SD decisional conflict changed from 49.50 ± 23.17 preintervention to 21.83 ± 24.12 postintervention (change -27.67 [95% confidence interval -39.89, -15.44]; P < 0.001). Knowledge of methotrexate improved (mean ± SD 30.62 ± 9.26 preintervention and 41.67 ± 6.81 postintervention; P < 0.001), but there was no change in effective consumer attributes (mean ± SD 68.24 ± 12.46 preintervention and 72.94 ± 12.74 postintervention; P = 0.15). Three themes emerged from interviews of 11 participants: seeking confirmation of one's own knowledge of methotrexate, amplifying reluctance when they encountered information contradicting their own experiences, and clarifying thoughts about the next step during the process. CONCLUSION: Patients' decisional conflict and knowledge improved after using the patient decision aid. Interview findings further highlighted the power of patients' prior knowledge and experiences with RA on how they approach the information presented in a decision aid.

System integration and clinical utilization of the Advanced Clinician Practitioner in Arthritis Care (ACPAC) Program-Trained Extended Role Practitioners in Ontario: a two-year, system-level evaluation.

BACKGROUND: The Advanced Clinician Practitioner in Arthritis Care (ACPAC) program was developed in 2005 to prepare experienced physical and occupational therapists to function as extended role practitioners (ERPs) within models of arthritis care across Ontario, Canada. PURPOSE: To examine the system-level integration and clinical utilization of the ACPAC program-trained ERP. METHOD: A longitudinal survey was administered to all ACPAC graduates over a two-year period (n=30). RESULTS: The majority of ERPs were physical therapists working in urban settings. Family physicians or physician specialists referred the majority of patients. The longest median wait time to access ERPs' services was 22 days. Half of the ERPs triaged patients, and most of those who did triage (75%) worked under medical directives. Approximately half (51.6%) of the patients seen had a diagnosis of osteoarthritis, followed by rheumatoid arthritis (14.7%). CONCLUSION: Understanding the system-level impact of this unique human resource can help to shape healthcare planning and delivery of care.

Capitalizing on the teachable moment: osteoarthritis physical activity and exercise net for improving physical activity in early knee osteoarthritis.

BACKGROUND: Practice guidelines emphasize the use of exercise and weight reduction as the first line of management for knee osteoarthritis (OA). However, less than half of the people with mild OA participate in moderate intensity physical activity. Given that physical activities have been shown to reduce pain, improve quality of life, and have the potential to reduce the progression of joint damage, many people with OA are missing the benefits of this inexpensive intervention. OBJECTIVE: The objectives of this study are (1) to develop a behavioral theory-informed Internet intervention called Osteoarthritis Physical Activity & Exercise Net (OPEN) for people with previously undiagnosed knee OA, and (2) to assess the efficacy of the OPEN website for improving physical activity participation through a proof-of-concept study. METHODS: OPEN was developed based on the theory of planned behavior. Efficacy of this online intervention is being assessed by an ongoing proof-of-concept, single-blind randomized controlled trial in British Columbia, Canada. We are currently recruiting participants and plan to recruit a total of 252 sedentary people with previously undiagnosed knee OA using a set of validated criteria. Half of the participants will be randomized to use OPEN and receive an OA education pamphlet. The other half only will receive the pamphlet. Participants will complete an online questionnaire at baseline, 3 months, and 6 months about their participation in physical activities, health-related quality of life, and motivational outcomes. In addition, we will perform an aerobic fitness test in a sub-sample of participants (n=20 per study arm). In the primary analysis, we will use logistic regression to compare the proportion of participants reporting being physically active at or above the recommended level in the 2 groups, adjusting for baseline measurement, age, and sex. RESULTS: This study evaluates a theory-informed behavioral intervention at a time when people affected with OA tend to be more motivated to adopt an active lifestyle (ie, at the early stage of OA). Our approach, which consisted of the identification of early knee OA followed immediately by an online intervention that directly targets physical inactivity, can be easily implemented across communities. CONCLUSIONS: Our online intervention directly targets physical inactivity at a time when the joint damage tends to be mild. If OPEN is found to be effective in changing long-term physical activity behaviors, it opens further opportunities to promote early diagnosis and to implement lifestyle interventions. TRIAL REGISTRATION: Clinicaltrial.gov: NCT01608282; http://clinicaltrials.gov/ct2/show/NCT01608282 (Archived by WebCite at http://www.webcitation.org/6G7sBBayI).

Influence of discipline of provider and model of care on an arthritis educational intervention in primary care.

OBJECTIVE: To identify both provider and organizational characteristics that predicted outcomes following an educational intervention (9-hour workshop and followup reinforcement activities) developed to improve the management of arthritis in primary care. METHODS: Providers completed a survey at baseline and at 6 months postworkshop, including a case scenario for early rheumatoid arthritis. Providers were asked how they would manage the case and their responses were coded to calculate a best practice score, ranging from 0-7. Two-level hierarchical linear modeling was used to determine which of the measured provider and organizational factors predicted best practice scores at followup. RESULTS: A total of 275 multidisciplinary providers from 131 organizations completed both baseline and followup surveys. Best practice scores increased by 17% (P < 0.01); however, the mean score at 6-month followup remained relatively low (2.68). Significant predictors of best practice scores at followup were discipline of provider and model of primary care in which they worked (P < 0.05), adjusting for baseline practice scores and clustering of providers within organizations. Physicians, nurse practitioners, and rehabilitation therapists scored higher than nurses, students, and other health care providers (P < 0.01). Physician networks scored significantly lower than providers from multidisciplinary-oriented models of care (P = 0.02). CONCLUSION: These results have implications for the education of health professionals and the design of models of care to enhance arthritis care delivery.

Management of early- and late-stage rheumatoid arthritis: are physiotherapy students' intended behaviours consistent with canadian best practice guidelines?

PURPOSE: This study examined whether physiotherapy students in a problem-based learning (PBL) curriculum intend to implement best practices for management of clients with rheumatoid arthritis (RA). METHOD: Physiotherapy students (n=49) completed a subsection of the ACREU Primary Care Survey to evaluate the concordance between intended behaviours and Canadian best practices for early- and late-stage RA, before and after completing the relevant PBL content. Changes in scores were assessed using McNemar's test for dependent proportions. RESULTS: Most students indicated that they would recommend treatments or referrals for physiotherapy/exercise, education, and occupational therapy or joint protection pre- and post-PBL (>83% and >95%, respectively). Post-PBL, more students recommended referral to a rheumatologist and disease-modifying anti-rheumatic drugs (DMARDs) for both early and late RA; however, the increase was significant only for early RA (p=0.013 and 0.031 for referral to rheumatologist and DMARDs, respectively). More students recommended psychosocial support at both stages of RA post-PBL (early RA: p<0.001; late RA: p=0.031). Although more students recommended DMARDs post-PBL, only 8 students in total made this recommendation (16%), and fewer students considered use of non-steroidal anti-inflammatory drugs. Most students (94%) did not recommend referral to a surgeon for early or late RA. CONCLUSION: Intended behaviour of physiotherapy students was more consistent with Canadian best practice guidelines for managing clients with early- and late-stage RA following the PBL curriculum. Further study is required to determine whether the students were less aware of best practices related to pharmacologic interventions and timely referral to appropriate specialists, or whether they considered these issues to be outside their scope of practice.

Objectif : Avec cette étude, on souhaitait voir si les étudiants en physiothérapie, dans le cadre de cours qui font appel à une méthode d'apprentissage axée sur les problèmes, tentaient de mettre en pratique les pratiques exemplaires pour la gestion des clients aux prises avec la polyarthrite rhumatoïde. Méthode : Des étudiants en physiothérapie (n=49) ont rempli une sous-section du sondage de l'ACREU sur les soins de santé primaires en vue d'évaluer la concordance entre les comportements recherchés et les pratiques exemplaires canadiennes pour les patients en stade précoce et avancé de polyarthrite rhumatoïde avant et après avoir complété le contenu de la formation axée sur les problèmes. Les variations dans les pointages obtenus ont été évaluées à l'aide du test de McNemar sur les proportions dépendantes. Résultats : La plupart des étudiants ont indiqué qu'ils recommanderaient des traitements ou une consultation en physiothérapie pour des exercices, de l'éducation et de l'ergothérapie ou une protection des articulations, avant et après leur apprentissage axé sur les problèmes (>83 % et >95 %, respectivement). Pour la polyarthrite en stade précoce ou avancé, plus d'étudiants ont recommandé une consultation auprès d'un rhumatologue et de DMARD (disease-modifying anti-rheumatic drugs ; médicaments antirhumatismaux) à la suite de leur formation ; toutefois, l'augmentation était considérable uniquement pour les cas de polyarthrite précoce (p=0,013 et 0,031 pour les consultations chez un rhumatologue et les DMARD, respectivement). Après leur formation, plus d'étudiants ont recommandé un soutien psychosocial aux deux stades de la maladie (PA précoce : p<0,001 ; PA avancée : p=0,031). Même si plus d'étudiants ont recommandé le recours à des DMARD après leur apprentissage axé sur les problèmes, 8 étudiants seulement ont formulé cette recommandation (16 %) et encore moins d'étudiants ont envisagé le recours à des anti-inflammatoires non stéroïdiens. La plupart des étudiants (94 %) n'ont pas recommandé une consultation par un chirurgien pour la PA précoce ou avancée. Conclusion : Les comportements recherchés chez les étudiants en physiothérapie étaient plus fidèles aux lignes directrices canadiennes sur les pratiques exemplaires pour la gestion de clients avec PR en stade précoce ou avancé une fois qu'ils avaient reçu la formation axée sur les problèmes. Des études supplémentaires seront nécessaires pour déterminer si les étudiants étaient moins bien informés des pratiques exemplaires touchant les interventions pharmacologiques et le renvoi en consultation chez les spécialistes appropriés, ou s'ils considèrent ces tâches comme étant hors de la portée de leur pratique.

Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.

BACKGROUND AND PURPOSE: The objective of this review was to construct an updated evidence-based clinical practice guideline on the use of physical activity and diet for the management of osteoarthritis (OA) in adults (>18 years of age) who are obese or overweight (body mass index ≥25 kg/m(2)). DATA SOURCES: Articles were extracted from the following databases: MEDLINE, EMBASE (Current Contents), SPORTDiscus, SUM, Scopus, CINAHL, AMED, BIOMED, PubMed, ERIC, the Cochrane Controlled Trials, and PEDro. STUDY SELECTION: The Ottawa Panel and research assistance team strictly applied the inclusion and exclusion criteria from previous Ottawa Panel publications. DATA EXTRACTION: An a priori literature search was conducted for articles related to obesity and OA of the lower extremities that were published from January 1, 1966, to November 30, 2010. Inclusion criteria and the methods to grade the recommendations were created by the Ottawa Panel. RECOMMENDATIONS: were graded based on the strength of evidence (A, B, C, C+, D, D+, or D-) as well as experimental design (I for randomized controlled trials and II for nonrandomized studies). In agreement with previous Ottawa Panel methods, Cochrane Collaboration methods were utilized for statistical analysis. Clinical significance was established by an improvement of ≥15% in the experimental group compared with the control group. There were a total of 79 recommendations from 9 articles. From these recommendations, there were 36 positive recommendations: 21 grade A and 15 grade C+. There were no grade B recommendations, and all recommendations were of clinical benefit. LIMITATIONS: Further research is needed, as more than half of the trials were of low methodological quality. CONCLUSIONS: This review suggests that physical activity and diet programs are beneficial, specifically for pain relief (9 grade A recommendations) and improved functional status (6 grade A and 7 grade C+ recommendations), for adults with OA who are obese or overweight. The Ottawa Panel was able to demonstrate that when comparing physical activity alone, diet alone, physical activity combined with diet, and control groups, the intervention including physical activity and diet produced the most beneficial results.

Evaluation of an inter-professional educational intervention to improve the use of arthritis best practices in primary care.

OBJECTIVE: To describe the evaluation of a community-based continuing health education program designed to improve the management of rheumatoid arthritis (RA) and osteoarthritis (OA), and to examine the results by discipline. METHODS: The Getting a Grip on Arthritis(©) program was based on clinical practice guidelines adapted for the primary care environment (best practices). The program consisted of an accredited inter-professional workshop and 6 months of activities to reinforce the learning. Analyses compared best practice scores derived from responses to 3 standardized case scenarios (early and late RA; moderate knee OA) at baseline and 6 months post-workshop using the ACREU Primary Care Survey. RESULTS: In total, 553 primary care providers (nurses/licensed practical nurses 30.9%, rehabilitation professionals 22.5%, physicians 22.5%, nurse practitioners 10.9%, other healthcare providers/non-clinical staff/students 13.1%) attended one of 27 workshops across Canada; 275 (49.7%) completed followup surveys. Best practice scores varied by discipline at baseline (p < 0.05) and improved for all 3 case scenarios, with nurse practitioners and rehabilitation therapists improving the most (p ≤ 0.05). CONCLUSION: Results suggest that inter-professional education may be an effective method for dissemination of guidelines and has potential to improve the delivery of arthritis care, particularly when nurse practitioners and rehabilitation therapists are involved in the care of patients.

Arthritis extended-role practitioners: impact on community practice (an exploratory study).

PURPOSE: We compared practice of extended role practitioners and experienced therapists without extended practice training to determine differences in assessment and management of clients with inflammatory arthritis, in preparation for a randomized controlled trial. METHODS: Retrospective review of randomly selected charts of extended-role trained occupational therapists or physiotherapists and from experienced therapists matched on therapist discipline, geographical location, and time of referral. Three trained reviewers used standardized forms to extract data independently. RESULTS: We reviewed 58 charts of adult clients with inflammatory arthritis. Compared with experienced therapists, extended-role practitioners were more likely to receive referrals specifically for assessments (52% vs. 14%); to treat clients with undifferentiated arthritis (48% vs. 10%); to document comorbidities (90% vs. 66%); to advocate on behalf of the client with the client's family, physician, or specialist (52% vs. 21%); to recommend or provide exercise or physical activity (86% vs. 62%); to educate clients about pain management (41% vs. 28%), energy conservation (24% vs. 14%), and posture (21% vs. 7%); to recommend splints (41% vs. 31%); and to refer for or recommend radiologic or laboratory assessments (14% vs. 3%). Experienced therapists were more likely to provide education about joint protection (41% vs. 31%), community resources (31% vs. 7%), and assistive devices (45% vs. 21%). CONCLUSIONS: We identified possible differences in practice between extended-role practitioners and experienced therapists without training for extended practice. Capturing these details in future studies evaluating the efficacy of extended role practitioner interventions will be important.

Educational interventions for implementation of arthritis clinical practice guidelines in primary care: effects on health professional behavior.

OBJECTIVE: The dissemination and adoption of clinical practice guidelines (CPG) has been suggested as one method for improving arthritis care delivery. This article provides a review and synthesis of studies evaluating the influence of educational programs designed to implement CPG for osteoarthritis (OA) and rheumatoid arthritis (RA) in primary care. METHODS: A systematic literature search was conducted to identify relevant educational interventions that reported behavioral outcomes that ensured actual knowledge utilization in primary care. A standardized approach was used to assess the quality of the individual studies and a modified version of the Philadelphia Panel methodology allowed for grading of studies based on strength of design, clinical relevance, and statistical significance. RESULTS: The search identified 485 articles; 7 studies were selected for review. In OA, peer facilitated workshops with nurse case-management support for patients decreased the number of referrals to orthopedics by 23%, and educational outreach by trained physicians improved prescribing of analgesics. Interprofessional peer facilitated workshops were successful in increasing referrals to rehabilitation services for people with OA and RA. CONCLUSION: There was sparse literature on educational programs for the implementation of arthritis CPG in the primary care environment. Future studies are needed to evaluate which specific organizational, provider, patient, and system level factors influence the uptake of arthritis CPG in primary care.

Implementing arthritis clinical practice guidelines in primary care.

BACKGROUND: Multi-faceted interventions are among the strongest methods for changing provider behavior. AIMS: This paper reports the design, implementation and process evaluation of an educational program to disseminate clinical practice guidelines (CPGs) on the management of rheumatoid arthritis (RA) and osteoarthritis (OA) in primary care. METHODS: Organizations were invited to participate in inter-professional workshops on OA and RA followed by six months of activities to support the delivery of care in the community. Confidence in ability to manage arthritis was assessed at baseline using a 10 point numerical rating scale. Qualitative assessments were done immediately and 3-12 months post workshop. RESULTS: 646 multidisciplinary providers from 216 organizations attended one of 30 workshops. Providers (n = 584) reported moderate confidence in managing arthritis: family physicians: mean: SD = 7.46(1.42), n = 145; nurse practitioners: 6.10(1.84), n = 73; other health care professionals: 5.23(2.83), n = 389. Participants identified team learning, the opportunity to network and the involvement of trained patient educators as strong features of the workshops. At follow-up, participants indicated the greatest impact of the program was on collaborative care (83%) and patient self-management (79%). CONCLUSIONS: Qualitative results suggest that inter-professional learning may be a successful strategy for improving the delivery of collaborative arthritis care and supporting patient self-management.

Reliability and construct validity of the client-centred rehabilitation questionnaire.

PURPOSE: A key component in assessing the performance of rehabilitation services is the client's perspective. The purpose of this paper is to report on the development of a publicly available measure of client-centred rehabilitation (CCRQ) that can be used for discriminative and evaluative purposes. METHOD: Mixed qualitatative and quantitative methods were used. Phase 1: Identification of seven domains of client-centred rehabilitation based on a literature review, focus groups with clients, and review by content experts. Phase 2: Item generation for the seven conceptually derived subscales and cognitive interviews with inpatient rehabilitation patients. Phase 3: Psychometric testing for internal reliability, test-retest reliability and discriminative construct validity using data from a mailed, self-administered survey to 1,568 patients discharged from two large inpatient rehabilitation facilities. RESULTS: The seven conceptually derived subscales all have strong internal (0.72 - 0.87) and test-retest reliability (0.74 - 0.85). Discriminative construct validity is demonstrated by the ability of subscales to identify significant differences between programs within two rehabilitation facilities. CONCLUSIONS: The results for the reliability and validity of this measure support its value for use in clinical and quality improvement work as well as research.

Primary therapist model for patients referred for rheumatoid arthritis rehabilitation: a cost-effectiveness analysis.

OBJECTIVE: To estimate the incremental cost-effectiveness (ICE) of services from a primary therapist compared with traditional physical therapists and/or occupational therapists for managing rheumatoid arthritis (RA), from the societal perspective. METHODS: Patients with RA were randomly assigned to the primary therapist model (PTM) or traditional treatment model (TTM) for approximately 6 weeks of rehabilitation treatment. Health outcomes were expressed in terms of quality-adjusted life years (QALYs), measured with the EuroQol instrument at baseline, 6 weeks, and 6 months. Direct and indirect costs, including visits to health professionals, use of investigative tests, hospital visits, use of medications, purchases of adaptive aids, and productivity losses incurred by patients and their caregivers, were collected monthly. RESULTS: Of 144 consenting patients, 111 remained in the study after the baseline assessment: 63 PTM (87.3% women, mean age 54.2 years, disease duration 10.6 years) and 48 TTM (79.2% women, mean age 56.8 years, disease duration 13.2 years). From a societal perspective, PTM generated higher QALYs (mean +/- SD 0.068 +/- 0.22) and resulted in a higher mean cost ($6,848 Canadian, interquartile range [IQR] $1,984-$9,320) compared with TTM (mean +/- SD QALY -0.017 +/- 0.24; mean costs $6,266, IQR $1,938-$10,194) in 6 months, although differences were not statistically significant. The estimated ICE ratio was $13,700 per QALY gained (95% nonparametric confidence interval -$73,500, $230,000). CONCLUSION: The PTM has potential to be an alternative to traditional physical/occupational therapy, although it is premature to recommend widespread use of this model in other regions. Further research should focus on strategies to reduce costs of the model and assess the long-term economic consequences in managing RA and other rheumatologic conditions.

Effectiveness of the primary therapist model for rheumatoid arthritis rehabilitation: a randomized controlled trial.

OBJECTIVE: To compare the primary therapist model (PTM), provided by a single rheumatology-trained primary therapist, with the traditional treatment model (TTM), provided by a physical therapy (PT) and/or occupational therapy (OT) generalist, for treating patients with rheumatoid arthritis (RA). METHODS: Eligible patients were adults requiring rehabilitation treatment who had not received PT/OT in the past 2 years. Participants were randomized to the PTM or TTM group. The primary outcome was defined as the proportion of clinical responders who experienced a > or =20% improvement in 2 of the following measures from baseline to 6 months: Health Assessment Questionnaire, pain visual analog scale, and Arthritis Community Research and Evaluation Unit RA Knowledge Questionnaire. RESULTS: Of 144 consenting patients, 33 (10 PTM participants, 23 TTM participants) dropped out without completing any followup assessment, leaving 111 for analysis (63 PTM participants, 48 TTM participants). The majority were women (PTM 87.3%, TTM 79.2%), with a mean age of 54.2 years and 56.8 years for the PTM and TTM groups, respectively. Average disease duration was 10.6 years and 13.2 years for each group, respectively. At 6 months, 44.4% of patients in the PTM group were clinical responders versus 18.8% in the TTM group (chi(2) = 8.09, P = 0.004). CONCLUSION: Compared with the TTM, the PTM was associated with better outcomes in patients with RA. The results, however, should be interpreted with caution due to the high dropout rate in the TTM group.

Getting a Grip on Arthritis: an educational intervention for the diagnosis and treatment of arthritis in primary care.

OBJECTIVE: To evaluate a community-based educational intervention designed to improve the diagnosis and treatment of arthritis in primary care. METHODS: The educational intervention, entitled "Getting a Grip on Arthritis", consisted of a 2-day workshop and followup reinforcement activities for healthcare providers (providers) and was supported by a toolkit of written materials for providers and clients. The content of the intervention was designed around 10 arthritis best practices derived from published arthritis guidelines. Five community health centers (CHC) participated as intervention sites and 2 as control sites. Intervention impact was determined through a mailed survey to clients with arthritis. Primary outcome analysis compared responses to questions about arthritis best practices between intervention and control sites at baseline and followup. RESULTS: The workshop was attended by 21 multidisciplinary providers from intervention CHC. At baseline, 423 of 624 eligible and consenting clients completed the survey and 376 of 593 completed the followup survey. At followup clients in the intervention group reported significantly higher referrals to The Arthritis Society therapy program, and were more often provided information on type of arthritis, medications and their side effects, disease management strategies, and arthritis community resources. CONCLUSION: This demonstration project is one of the first to show changes in the management of arthritis in a primary care setting. This project has recently received funding from Health Canada's Primary Health Care Transition Fund for implementation across Canada and is expected to provide a template for use in other chronic diseases.