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1.
J Rheumatol ; 47(3): 461-467, 2020 03.
Artículo en Inglés | MEDLINE | ID: mdl-31154411

RESUMEN

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.


Asunto(s)
Artritis/diagnóstico , Enfermedades Reumáticas/diagnóstico , Reumatólogos/psicología , Reumatología/métodos , Triaje/métodos , Listas de Espera , Adulto , Anciano , Femenino , Accesibilidad a los Servicios de Salud , Humanos , Masculino , Persona de Mediana Edad , Ontario , Estudios Prospectivos , Derivación y Consulta , Estudios Retrospectivos , Factores de Tiempo
3.
Can J Rural Med ; 24(2): 52-60, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-30924461

RESUMEN

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.


Asunto(s)
Artritis Reumatoide/terapia , Educación a Distancia , Educación Médica Continua , Osteoartritis/terapia , Atención Primaria de Salud , Servicios de Salud Rural , Adolescente , Adulto , Anciano , Canadá , Femenino , Humanos , Masculino , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto , Evaluación de Programas y Proyectos de Salud , Adulto Joven
4.
BMJ Open ; 7(9): e015872, 2017 09 18.
Artículo en Inglés | MEDLINE | ID: mdl-28928177

RESUMEN

OBJECTIVES: Subcutaneous tumour necrosis factor alpha TNFαinhibitors (SC-TNFis) such as golimumab (GLM), adalimumab (ADA), etanercept (ETA) and certolizumab pegol (CZP) have been used for many years for the treatment of inflammatory arthritis. Non-adherence to therapy is an important modifiable factor that may compromise patient outcomes. The aim of this analysis was to compare adherence and dosing interval of SC-TNFis in the treatment of people with inflammatory arthritis. DESIGN: We used the IMS Brogan database combining both Canadian private and public drug plan databases of Ontario and Quebec. Target drugs included SC-TNFis for inflammatory arthritis. The index period was from 1 January 2010 to 30 June 2012 and patients were followed for 24 months through 30 June 2014. Inclusion criteria were adult patients newly prescribed a SC-TNFis with at least three prescriptions and retained on therapy at 24 months.Dosing regimens as per the product monographs were used to compare actual versus expected drug utilisation. The mean possession ratio was used as a marker for adherence. Patients who scored >80% were considered adherent. The average days between units was estimated by taking the total days on therapy and divided by the number of units the patient received. RESULTS: 4035 patients were included: 683 (16.9%), 1400 (34.7%), 1765 (43.7%) and 187 (4.6%) were treated with GLM, ADA, ETA and CZP, respectively. The proportion of adherent patients in the GLM cohort (n=595/683, 87%, p<0.0001) was greater compared with ADA (n=1044/1400, 75%), ETA (n=1285/1765, 73%) and CZP-treated patients (132/187, 71%). In addition, the number of patients receiving biological drug at a shorter dosing interval was similar between cohorts, and was 5%, 6%, 12% and 4% in GLM (≤26 days), ADA (≤12 days), ETA (≤6 days) and CZP-treated patients (≤12 days), respectively. CONCLUSIONS: In this real-life administrative database, GLM had better adherence compared with other SC-TNFis.


Asunto(s)
Antiinflamatorios/administración & dosificación , Artritis Psoriásica/tratamiento farmacológico , Artritis Reumatoide/tratamiento farmacológico , Productos Biológicos/administración & dosificación , Cumplimiento de la Medicación/estadística & datos numéricos , Espondilitis Anquilosante/tratamiento farmacológico , Factor de Necrosis Tumoral alfa/antagonistas & inhibidores , Adalimumab/administración & dosificación , Adolescente , Adulto , Anticuerpos Monoclonales/administración & dosificación , Certolizumab Pegol/administración & dosificación , Bases de Datos Factuales , Esquema de Medicación , Etanercept/administración & dosificación , Humanos , Inyecciones Subcutáneas , Ontario , Quebec , Adulto Joven
5.
J Rheumatol ; 42(4): 682-9, 2015 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-25641889

RESUMEN

OBJECTIVE: To develop a list of 5 tests or treatments used in rheumatology that have evidence indicating that they may be unnecessary and thus should be reevaluated by rheumatology healthcare providers and patients. METHODS: Using the Delphi method, a committee of 16 rheumatologists from across Canada and an allied health professional generated a list of tests, procedures, or treatments in rheumatology that may be unnecessary, nonspecific, or insensitive. Items with high content agreement and perceived relevance advanced to a survey of Canadian Rheumatology Association (CRA) members. CRA members ranked these top items based on content agreement, effect, and item ranking. A methodology subcommittee discussed the items in light of their relevance to rheumatology, potential effect on patients, and the member survey results. Five candidate items selected were then subjected to a literature review. A group of patient collaborators with rheumatic diseases also reviewed these items. RESULTS: Sixty-four unique items were proposed and after 3 Delphi rounds, this list was narrowed down to 13 items. In the member-wide survey, 172 rheumatologists responded (36% of those contacted). The respondent characteristics were similar to the membership at large in terms of sex and geographical distribution. Five topics (antinuclear antibodies testing, HLA-B27 testing, bone density testing, bone scans, and bisphosphonate use) with high ratings on agreement and effect were chosen for literature review. CONCLUSION: The list of 5 items has identified starting points to promote discussion about practices that should be questioned to assist rheumatology healthcare providers in delivering high-quality care.


Asunto(s)
Pruebas Diagnósticas de Rutina/economía , Enfermedades Reumáticas/diagnóstico , Reumatología/economía , Canadá , Análisis Costo-Beneficio , Humanos , Enfermedades Reumáticas/economía
6.
Rheumatology (Oxford) ; 52(11): 2077-85, 2013 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-23962625

RESUMEN

OBJECTIVES: To determine the comprehensibility, internal consistency, test-retest reliability and discriminative properties of an early inflammatory arthritis (IA) detection tool. METHODS: Four groups were recruited from outpatient clinics at two tertiary care hospitals: early IA, established IA, non-IA musculoskeletal conditions (MSK) and non-MSK. Participants attended a study visit where they completed the 11-item tool with binary yes/no response options. Comprehensibility was assessed for each tool item on a 5-point Likert scale. For test-retest assessment, the tool was mailed to participants following a 2-week recall washout interval. Two items were randomly selected to test internal consistency. Discriminative properties compared tool item responses with blinded rheumatologist clinical assessments. A previously developed rheumatology triage algorithm was externally validated. RESULTS: A total of 170 participants were enrolled in the study. Comprehensibility approached unity for all tool items. The internal consistency Kuder-Richardson Formula 20 was 0.985 (P < 0.0001). The mean test-retest reliability kappa (S.D.) was 0.81 (0.02). The intraclass correlation coefficient (ICC) (95% CI) for summed yes responses between test and retest phases was 0.94 (0.93, 0.95) and for algorithm scores was 0.97 (0.96, 0.98). Patient responses were significantly associated with the corresponding clinical evaluations (P < 0.0001, respectively). The sum of yes responses and rheumatology triage algorithm scores both differentiated early IA from each of the other three groups (P < 0.004, respectively). The scoring algorithm receiver operating characteristic plot area under the curve (S.E.) was 0.829 (0.003). CONCLUSION: The tool has favourable measurement and discriminative properties. The discriminative properties of the rheumatology triage scoring algorithm were externally validated.


Asunto(s)
Artritis Reumatoide/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Estudios de Cohortes , Diagnóstico Diferencial , Diagnóstico Precoz , Femenino , Humanos , Masculino , Persona de Mediana Edad , Psicometría , Reproducibilidad de los Resultados , Encuestas y Cuestionarios , Triaje/métodos , Adulto Joven
7.
BMJ Open ; 3(3)2013 Mar 01.
Artículo en Inglés | MEDLINE | ID: mdl-23457326

RESUMEN

OBJECTIVES: To examine the feasibility and potential benefits of early peer support to improve the health and quality of life of individuals with early inflammatory arthritis (EIA). DESIGN: Feasibility study using the 2008 Medical Research Council framework as a theoretical basis. A literature review, environmental scan, and interviews with patients, families and healthcare providers guided the development of peer mentor training sessions and a peer-to-peer mentoring programme. Peer mentors were trained and paired with a mentee to receive (face-to-face or telephone) support over 12 weeks. SETTING: Two academic teaching hospitals in Toronto, Ontario, Canada. PARTICIPANTS: Nine pairs consisting of one peer mentor and one mentee were matched based on factors such as age and work status. PRIMARY OUTCOME MEASURE: Mentee outcomes of disease modifying antirheumatic drugs (DMARDs)/biological treatment use, self-efficacy, self-management, health-related quality of life, anxiety, coping efficacy, social support and disease activity were measured using validated tools. Descriptive statistics and effect sizes were calculated to determine clinically important (>0.3) changes. Peer mentor self-efficacy was assessed using a self-efficacy scale. Interviews conducted with participants examined acceptability and feasibility of procedures and outcome measures, as well as perspectives on the value of peer support for individuals with EIA. Themes were identified through constant comparison. RESULTS: Mentees experienced improvements in the overall arthritis impact on life, coping efficacy and social support (effect size >0.3). Mentees also perceived emotional, informational, appraisal and instrumental support. Mentors also reported benefits and learnt from mentees' fortitude and self-management skills. The training was well received by mentors. Their self-efficacy increased significantly after training completion. Participants' experience of peer support was informed by the unique relationship with their peer. All participants were unequivocal about the need for peer support for individuals with EIA. CONCLUSIONS: The intervention was well received. Training, peer support programme and outcome measures were demonstrated to be feasible with modifications. Early peer support may augment current rheumatological care. TRIAL REGISTRATION NUMBER: NCT01054963, NCT01054131.

8.
Postgrad Med J ; 89(1050): 231-40, 2013 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-23483130

RESUMEN

BACKGROUND: Despite the importance of timely management of patients with inflammatory arthritis (IA), delays exist in its diagnosis and treatment. OBJECTIVE: To perform a systematic literature review to identify strategies addressing these delays to inform an American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) taskforce. METHODS: The authors searched literature published between January 1985 and November 2010, and ACR and EULAR abstracts between 2007-2010. Additional information was obtained through a grey literature search, a survey conducted through ACR and EULAR, and a hand search of the literature. RESULTS: (1) From symptom onset to primary care, community case-finding strategies, including the use of a questionnaire and autoantibody testing, have been designed to identify patients with early IA. Several websites provided information on IA but were of varying quality and insufficient to aid early referral. (2) At a primary care level, education programmes and patient self-administered questionnaires identified patients with potential IA for referral to rheumatology. Many guidelines emphasised the need for early referral with one providing specific referral criteria. (3) Once referred, early arthritis clinics provided a point of early access for rheumatology assessment. Triage systems, including triage clinics, helped prioritise clinic appointments for patients with IA. Use of referral forms standardised information required, further optimising the triage process. Wait times for patients with acute IA were also reduced with development of rapid access systems. CONCLUSIONS: This review identified three main areas of delay to care for patients with IA and potential solutions for each. A co-ordinated effort will be required by the rheumatology and primary care community to address these effectively.

9.
J Rheumatol ; 40(4): 417-24, 2013 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-23378469

RESUMEN

OBJECTIVE: The benefits of early intensive treatment of inflammatory arthritis (IA) are dependent on timely and accurate case identification. In our study, a scoring algorithm for a self-administered IA detection tool was developed and validated for the rheumatology triage clinical setting. METHODS: A total of 143 consecutive consenting adults, newly referred to 2 outpatient rheumatology practices, completed the tool. A scoring algorithm was derived from the best-fit logistic regression model using age, sex, and responses to the 12 tool items as candidate predictors of the rheumatologists' blinded classification of IA. Bootstrapping was used to internally validate and refine the model. RESULTS: The 30 IA cases were younger than the 113 non-cases (p < 0.0001) and included clinical diagnoses of early IA (n = 10), rheumatoid arthritis (n = 9), and spondyloarthropathies (n = 11). Non-cases included osteoarthritis (n = 46), pain syndromes (n = 19), systemic lupus erythematosus (n = 5), and miscellaneous, noninflammatory musculoskeletal complaints (n = 43). The best-fit model included younger age, male sex, "trouble making a fist," "morning stiffness," "ever told you have RA," and "psoriasis diagnosis." The overall predictive performance (standard error, SE) of the derivation model was 0.91 (0.03). Internal validation of the derivation model across 200 bootstrap samples resulted in a mean predictive performance (SE) of 0.904 (0.002). The refined tool had a mean predictive performance (SE) of 0.915 (0.002), a sensitivity of 0.855 (0.005), and specificity of 0.873 (0.003). CONCLUSION: A simple, self-administered tool was developed and internally validated for the sensitive and specific detection of IA in a rheumatology waiting list sample. The tool may be used to triage IA from rheumatology referrals.


Asunto(s)
Artritis Reumatoide/diagnóstico , Autoevaluación Diagnóstica , Dolor/diagnóstico , Espondiloartropatías/diagnóstico , Triaje/métodos , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Femenino , Humanos , Lupus Eritematoso Sistémico/diagnóstico , Masculino , Persona de Mediana Edad , Osteoartritis/diagnóstico , Valor Predictivo de las Pruebas , Reumatología/métodos , Sensibilidad y Especificidad
11.
Ann Rheum Dis ; 72(1): 13-22, 2013 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-22532640

RESUMEN

BACKGROUND: Despite the importance of timely management of patients with inflammatory arthritis (IA), delays exist in its diagnosis and treatment. OBJECTIVE: To perform a systematic literature review to identify strategies addressing these delays to inform an American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) taskforce. METHODS: The authors searched literature published between January 1985 and November 2010, and ACR and EULAR abstracts between 2007-2010. Additional information was obtained through a grey literature search, a survey conducted through ACR and EULAR, and a hand search of the literature. RESULTS: (1) From symptom onset to primary care, community case-finding strategies, including the use of a questionnaire and autoantibody testing, have been designed to identify patients with early IA. Several websites provided information on IA but were of varying quality and insufficient to aid early referral. (2) At a primary care level, education programmes and patient self-administered questionnaires identified patients with potential IA for referral to rheumatology. Many guidelines emphasised the need for early referral with one providing specific referral criteria. (3) Once referred, early arthritis clinics provided a point of early access for rheumatology assessment. Triage systems, including triage clinics, helped prioritise clinic appointments for patients with IA. Use of referral forms standardised information required, further optimising the triage process. Wait times for patients with acute IA were also reduced with development of rapid access systems. CONCLUSIONS: This review identified three main areas of delay to care for patients with IA and potential solutions for each. A co-ordinated effort will be required by the rheumatology and primary care community to address these effectively.


Asunto(s)
Artritis Reumatoide/diagnóstico , Diagnóstico Precoz , Derivación y Consulta , Artritis Reumatoide/terapia , Humanos
12.
J Rheumatol ; 39(11): 2088-97, 2012 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-22896027

RESUMEN

OBJECTIVE: To determine the proportion of patients with rheumatoid arthritis (RA) under rheumatologic care treated with disease-modifying antirheumatic drugs (DMARD) within 6 months from symptom onset and the components of time to treatment and its predictors. METHODS: A historical inception cohort of 339 patients with RA randomly selected from 18 rheumatology practices was audited. The proportion that initiated DMARD treatment within 6 months from symptom onset was estimated using Kaplan-Meier analysis. Time to each component of the care pathway was estimated. Multivariable modeling was used to determine predictors of early treatment using 12 preselected variables available in the clinical charts. Bootstrapping was used to validate the model. RESULTS: Within 6 months from symptom onset, 41% (95% CI 36%-46%) of patients were treated with DMARD. The median time to treatment was 8.4 (interquartile range 3.8-24) months. Events preceding rheumatology referral accounted for 78.1% of the time to treatment. The most prominent predictor of increased time to treatment was a concomitant musculoskeletal condition, such as osteoarthritis or fibromyalgia. The significance of other variables was less consistent across the models investigated. Included variables accounted for 0.69 ± 0.03 of the variability in the model. CONCLUSION: Fewer than 50% of patients with RA are treated with DMARD within 6 months from symptom onset. Time to referral to rheumatology represents the greatest component delay to treatment. Concomitant musculoskeletal condition was the most prominent predictor of delayed initiation of DMARD. Implications of these and other findings warrant further investigation.


Asunto(s)
Antirreumáticos/uso terapéutico , Artritis Reumatoide/tratamiento farmacológico , Manejo de la Enfermedad , Adulto , Artritis Reumatoide/epidemiología , Canadá , Estudios de Cohortes , Comorbilidad , Femenino , Fibromialgia/epidemiología , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Osteoartritis/epidemiología , Estudios Retrospectivos , Factores de Tiempo
13.
J Rheumatol ; 38(11): 2342-5, 2011 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-21885485

RESUMEN

OBJECTIVE: To describe early rheumatologic management for newly diagnosed rheumatoid arthritis (RA) in Canada. METHODS: A retrospective cohort of 339 randomly selected patients with RA diagnosed from 2001-2003 from 18 rheumatology practices was audited between 2005-2007. RESULTS: The most frequent initial disease-modifying antirheumatic drugs (DMARD) included hydroxychloroquine (55.5%) and methotrexate (40.1%). Initial therapy with multiple DMARD (15.6%) or single DMARD and corticosteroid combinations (30.7%) was infrequent. Formal assessment measures were noted infrequently, including the Health Assessment Questionnaire (34.6%) and Disease Activity Score for 28 joints (8.9%). CONCLUSION: Initial pharmacotherapy is consistent with guidelines from the period. The infrequent reporting of multiple DMARD combinations and formal assessment measures has implications for current clinical management and warrants contemporary reassessment.


Asunto(s)
Antirreumáticos/uso terapéutico , Manejo de la Enfermedad , Pautas de la Práctica en Medicina , Fiebre Reumática/tratamiento farmacológico , Adulto , Canadá/epidemiología , Estudios de Cohortes , Evaluación de la Discapacidad , Quimioterapia Combinada , Femenino , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Estudios Retrospectivos , Fiebre Reumática/diagnóstico , Fiebre Reumática/epidemiología , Índice de Severidad de la Enfermedad , Resultado del Tratamiento
14.
BMC Med Educ ; 11: 65, 2011 Sep 23.
Artículo en Inglés | MEDLINE | ID: mdl-21939562

RESUMEN

BACKGROUND: Despite the high burden of musculoskeletal (MSK) diseases, few generalists are comfortable teaching MSK physical examination (PE) skills. Patient Partners® in Arthritis (PP®IA) is a standardized patient educator program that could potentially supplement current MSK PE teaching. This study aims to determine if differences exist in MSK PE skills between non-MSK specialist physician and PP®IA taught students. METHODS: Pre-clerkship medical students attended 2-hour small group MSK PE teaching by either non-MSK specialist physician tutors or by PP®IA. All students underwent an MSK OSCE and completed retrospective pre-post questionnaires regarding comfort with MSK PE and interest in MSK. RESULTS: 83 students completed the OSCE (42 PP®IA, 41 physician taught) and 82 completed the questionnaire (42 PP®IA, 40 physician taught). There were no significant differences between groups in OSCE scores. For all questionnaire items, post-session ratings were significantly higher than pre-session ratings for both groups. In exploratory analysis PP®IA students showed significantly greater improvement in 12 of 22 questions including three of five patient-centred learning questions. CONCLUSIONS: PP®IA MSK PE teaching is as good as non-MSK specialist physician tutor teaching when measured by a five station OSCE and provide an excellent complementary resource to address current deficits in MSK PE teaching.


Asunto(s)
Competencia Clínica , Educación de Pregrado en Medicina/métodos , Enfermedades Musculoesqueléticas/diagnóstico , Sistema Musculoesquelético , Participación del Paciente , Examen Físico/métodos , Educación de Pregrado en Medicina/normas , Humanos , Relaciones Médico-Paciente , Quebec , Estudiantes de Medicina , Enseñanza/métodos
15.
Med Teach ; 33(5): e227-35, 2011.
Artículo en Inglés | MEDLINE | ID: mdl-21517674

RESUMEN

BACKGROUND: Musculoskeletal (MSK) complaints comprise 12-20% of primary healthcare; however, practicing physicians' MSK physical examination (PE) skills are weak. Further, there is a shortage of specialists able to effectively teach this subject. Previous evaluations of patient educators have yielded mixed results. AIMS: The aim of this study is to document how teaching by patient educators and physician tutors in MSK PE skills differs. METHODS: A qualitative researcher observed, video-recorded, and took notes during preclerkship MSK PE teaching sessions given by patient educators or physician tutors. The researcher identified themes which were evaluated by collective case study methods. RESULTS: Two patient educator and four physician groups were evaluated. The patient educators were more consistent regarding content and style than the physicians. There appeared to be a continuum in teaching organization from patient educator to novice physician tutors to experienced physician tutors. The patient educators consistently covered all major joints (physicians did not); physicians were more likely to request verbalization of actions, relate findings to history, receive questions, and use opportunistic teaching moments. CONCLUSIONS: Understanding preclerkship MSK teaching by patient educators compared to physician tutors is necessary for appropriate targeting of the existing Patient Partners® in Arthritis patient educator program and to guide the development of future MSK teaching initiatives.


Asunto(s)
Educación de Pregrado en Medicina/métodos , Docentes Médicos/organización & administración , Enfermedades Musculoesqueléticas/diagnóstico , Examen Físico , Enseñanza/métodos , Competencia Clínica , Estudios de Cohortes , Comunicación , Humanos
16.
J Rheumatol ; 38(5): 931-7, 2011 May.
Artículo en Inglés | MEDLINE | ID: mdl-21285165

RESUMEN

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.


Asunto(s)
Artritis Reumatoide/terapia , Benchmarking , Educación Continua , Personal de Salud/educación , Comunicación Interdisciplinaria , Osteoartritis/terapia , Atención Primaria de Salud , Evaluación de Programas y Proyectos de Salud , Canadá , Servicios de Salud Comunitaria , Humanos , Guías de Práctica Clínica como Asunto
17.
Arthritis Care Res (Hoboken) ; 62(10): 1407-14, 2010 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-20506530

RESUMEN

OBJECTIVE: Interrater variability limits rheumatologic opinion as a reference standard for early inflammatory arthritis (IA) classification. The study objectives were to determine whether rheumatologic opinion is associated with potential early IA classification methods despite high interrater variability, and to compare the relative strengths of those associations. METHODS: Eighteen rheumatologists independently classified 30 initial rheumatology presentation summaries as early IA or not and recommended a pharmacotherapy. Case fulfillment of the following classification methods was independently determined: early referral to rheumatology recommendation for rheumatoid arthritis (ERRR), common early IA cohort inclusion criteria (CEAC), and prevalent IA classification criteria (American College of Rheumatology [ACR]/European Spondylarthropathy Study Group [ESSG]). Associations between rheumatologic opinion, disease-modifying antirheumatic drug (DMARD) recommendation, and each classification method were determined. RESULTS: Participating rheumatologists published on early IA and represented 3 continents. The median case was age 43 (interquartile range [IQR] 30-53) years, had 40 (IQR 24-104) weeks of symptoms, 60 (IQR 18-120) minutes of morning stiffness, a swollen joint count of 6 (IQR 1-13), and an erythrocyte sedimentation rate of 25 (IQR 10-51) mm/hour. The mean ± SD multiple-rater kappa for rheumatologic opinion on early IA was 0.16 ± 0.02. The common odds ratios for associations between rheumatologic opinion and ERRR, CEAC, and ACR/ESSG were 10.3 (95% confidence interval [95% CI] 4.6-23.2), 4.4 (95% CI 2.5-7.7), and 0.7 (95% CI 0.4-1.1), respectively. Odds ratios for associations between DMARD recommendation and ERRR, rheumatologic opinion, CEAC, and ACR/ESSG were 18.7 (95% CI 8.1-43.2), 10.6 (95% CI 6.0-18.8), 2.8 (95% CI 1.7-4.6), and 0.5 (95% CI 0.3-0.7), respectively. CONCLUSION: Classification methods can be used to harmonize rheumatologic opinion of early IA despite high interrater variability. The ERRR is very strongly associated with both rheumatologic opinions of early IA and DMARD treatment recommendations.


Asunto(s)
Artritis Reumatoide/diagnóstico , Artritis Reumatoide/patología , Médicos/normas , Reumatología/normas , Adulto , Factores de Edad , Antirreumáticos/uso terapéutico , Artritis Reumatoide/tratamiento farmacológico , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto/normas , Reumatología/métodos , Método Simple Ciego
18.
BMC Musculoskelet Disord ; 11: 50, 2010 Mar 17.
Artículo en Inglés | MEDLINE | ID: mdl-20236522

RESUMEN

BACKGROUND: Barriers to care limit the potential benefits of pharmacological intervention for inflammatory arthritis. A self-administered questionnaire for early inflammatory arthritis (EIA) detection may complement contemporary triage interventions to further reduce delays to rheumatologic care. The objective of this study was to develop a self-administered EIA detection tool for implementation in pre-primary care settings. METHODS: A core set of dimensions and constructs for EIA detection were systematically derived from the literature and augmented by investigative team arbitration. Identified constructs were formulated into lay language questions suitable for self-administration. A three-round Delphi consensus panel of EIA experts and stakeholders evaluated the relevance of each question to EIA detection and suggested additional items. Questions accepted by less than 70% of respondents in rounds one or two were eliminated. In round three, questions accepted by at least 80% of the panel were selected for the tool. RESULTS: Of 584 citations identified, data were extracted from 47 eligible articles. Upon arbitration of the literature synthesis, 30 constructs encompassing 13 dimensions were formulated into lay language questions and posed to the Delphi panel. A total of 181 EIA experts and stakeholders participated on the Delphi panel: round one, 60; round two, 59; and, round three, 169; 48 participated in all three rounds. The panel evaluated the 30 questions derived from the literature synthesis, suggested five additional items, and eliminated a total of 24. The eleven-question instrument developed captured dimensions of articular pain, swelling, and stiffness, distribution of joint involvement, function, and diagnostic and family history. CONCLUSIONS: An eleven-question, EIA detection tool suitable for self-administration was developed to screen subjects with six to 52 weeks of musculoskeletal complaints. Psychometric and performance property testing of the tool is ongoing.


Asunto(s)
Artritis Reumatoide/diagnóstico , Autoevaluación (Psicología) , Encuestas y Cuestionarios , Diagnóstico Precoz , Encuestas Epidemiológicas , Humanos , Aceptación de la Atención de Salud , Educación del Paciente como Asunto/métodos , Valor Predictivo de las Pruebas , Psicometría , Reproducibilidad de los Resultados , Sensibilidad y Especificidad
19.
J Clin Epidemiol ; 63(5): 566-74, 2010 May.
Artículo en Inglés | MEDLINE | ID: mdl-19896801

RESUMEN

OBJECTIVES: The ability of the Bellamy et al. Low-Intensity Symptom State-attainment (BLISS) Index to differentiate between treatment groups (hylan G-F 20 vs. appropriate care) at low and very low levels of state attainment in patients with knee osteoarthritis was explored using the stiffness, function, and total index (TI) components of the WOMAC. STUDY DESIGN AND SETTING: Six different BLISS measures were analyzed using five WOMAC score thresholds:

Asunto(s)
Materiales Biocompatibles/uso terapéutico , Ácido Hialurónico/análogos & derivados , Osteoartritis de la Rodilla/tratamiento farmacológico , Índice de Severidad de la Enfermedad , Anciano , Femenino , Humanos , Ácido Hialurónico/uso terapéutico , Masculino , Persona de Mediana Edad , Osteoartritis de la Rodilla/fisiopatología , Dimensión del Dolor/métodos , Recuperación de la Función , Resultado del Tratamiento
20.
Quintessence Int ; 40(4): e1-6, 2009 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-19417866

RESUMEN

OBJECTIVES: This double-blind study examined the bleaching effectiveness of two 30% carbamide peroxide bleaching gels: one with 5% potassium nitrate (treatment A) and one without (treatment B). The treatment time was reduced for this pilot study to one hour per day for 10 days to determine whether the higher concentration would whiten teeth and to ascertain the tooth sensitivity and gingival effects of the 30% solution. METHOD AND MATERIALS: Forty subjects were selected with an initial tooth shade corresponding to Bioform shade guide B65 or darker. After obtaining consent, subjects were randomly divided into two groups (n = 20). Custom-fabricated bleaching trays were made for each subject. Trays did not extend onto the gingiva. Each subject was instructed in the placement and wear of the tray and bleach and supplied with one of the two bleaching gels. Subjects had 10 hours of treatment time with the bleaching gel. Photographs and shades (using a standardized Bioform shade guide) were taken at baseline and at final recall to determine bleaching effectiveness. Tooth sensitivity was measured at baseline and final recall by applying a pellet saturated with skin refrigerant to the tooth for 2 seconds. The sensitivity was recorded on a scale ranging from 1 to 10. Gingival index was also measured at baseline and at final recall. Data was analyzed with Wilcoxon rank-sum and Wilcoxon signed rank tests. RESULTS: No significant differences were found for changes in color, tooth sensitivity, and gingival condition between the two bleaching gels (P = .899, P = .375, and P = .056, respectively). Within each group, bleaching gel A and B significantly whitened teeth (P < .0001 for both groups). There were no significant changes in tooth sensitivity and gingival condition for gel A (P = .057 and .063, respectively) or gel B (P = .911 and .510, respectively). CONCLUSION: Thirty percent carbamide bleaching gels effectively whiten teeth without causing a significant increase in tooth sensitivity or changes in gingival condition. Potassium nitrate has little effect in sensitivity when treatment time is short.


Asunto(s)
Nitratos/administración & dosificación , Oxidantes/administración & dosificación , Peróxidos/administración & dosificación , Compuestos de Potasio/administración & dosificación , Blanqueamiento de Dientes/métodos , Urea/análogos & derivados , Peróxido de Carbamida , Dispositivos para el Autocuidado Bucal , Sensibilidad de la Dentina/inducido químicamente , Sensibilidad de la Dentina/prevención & control , Método Doble Ciego , Combinación de Medicamentos , Gingivitis/inducido químicamente , Humanos , Nitratos/efectos adversos , Oxidantes/efectos adversos , Índice Periodontal , Peróxidos/efectos adversos , Proyectos Piloto , Compuestos de Potasio/efectos adversos , Blanqueamiento de Dientes/efectos adversos , Resultado del Tratamiento , Urea/administración & dosificación , Urea/efectos adversos
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