"What Came First?" Population-Based Evaluation of Health Care Encounters for Depression and Anxiety Before and After Inflammatory Arthritis Diagnosis: Disentangling the Relationship Between Mental Health and Arthritis.

OBJECTIVE: The study objective was to describe patterns of depression and anxiety health care use before and after diagnosis among patients with inflammatory arthritis (IA), namely, ankylosing spondylitis, psoriatic arthritis, and rheumatoid arthritis. METHODS: We used population-based linked administrative health data from British Columbia, Canada, to build a cohort of individuals (≥18 years) with incident IA and individuals without IA ("IA-free controls") matched on age and sex. We computed the proportion of individuals with IA and controls who had one or more depression or one or more anxiety health care encounters and the use of one or more antidepressants or one or more anxiolytics in each yearly interval five years before and after IA diagnosis. We used multivariable logistic regression models to evaluate the association between IA status and aforementioned depression and anxiety health care use outcomes in each yearly interval. RESULTS: A total of 80,238 individuals with IA (62.9% female; mean ± SD age 56.2 ± 16.7 years) and 80,238 IA-free controls (62.9% female; mean ± SD age 56.2 ± 16.6 years) were identified between January 1, 2001, and March 31, 2018. Individuals with IA had significantly increased odds of depression and anxiety health care encounters and dispensation of antidepressants and anxiolytics for each yearly interval before and after diagnosis. Adjusted odds ratios (ORs) were highest in the year immediately before (one or more depression visits: adjusted OR 1.61, 95% confidence interval [CI] 1.55-1.66; one or more anxiolytics: adjusted OR 1.71, 95% CI 1.66-1.77) or after (one or more antidepressants: adjusted OR 1.95, 95% CI 1.89-2.00) IA diagnosis. CONCLUSION: Findings suggest a role for depression and anxiety in characterizing the IA prodrome period and generate hypotheses regarding overlapping biopsychosocial processes that link IA and mental health comorbidities.

Impact of Loneliness and Social Isolation on Mental Health Outcomes Among Individuals With Rheumatic Diseases During the COVID-19 Pandemic.

OBJECTIVE: The study objective was to assess mental and social health outcomes for individuals with rheumatic disease during the COVID-19 pandemic and evaluate the relationship of loneliness and social isolation with depression and anxiety. METHODS: We administered an international cross-sectional online survey to individuals with rheumatic disease(s) (≥18 years) between April 2020 and September 2020, with a follow-up survey from December 2020 to February 2021. We used questionnaires to evaluate loneliness (3-item UCLA Loneliness Scale [UCLA-3]), social isolation (Lubben Social Network Scale [LSNS-6]), depression (Patient Health Questionnaire [PHQ-9]), and anxiety (Generalized Anxiety Disorder 7-item [GAD-7] Scale). We used multivariable linear regression models to evaluate the cross-sectional associations of loneliness and social isolation with depression and anxiety at baseline. RESULTS: Seven hundred eighteen individuals (91.4% women, mean age: 45.4 ± 14.2 years) participated in the baseline survey, and 344 completed the follow-up survey. Overall, 51.1% of participants experienced loneliness (UCLA-3 score ≥6) and 30.3% experienced social isolation (LSNS-6 score <12) at baseline. Depression (PHQ-9 score ≥10) and anxiety (GAD-7 score ≥10) were experienced by 42.8% and 34.0% of participants at baseline, respectively. Multivariable models showed that experiencing both loneliness and social isolation, in comparison to experiencing neither, was significantly associated with an average 7.27 higher depression score (ß = 7.27; 95% confidence interval [CI]: 6.08-8.47) and 5.14 higher anxiety score (ß = 5.14; 95% CI: 4.00-6.28). CONCLUSION: Aside from showing substantial experience of loneliness and social isolation during the COVID-19 pandemic, our survey showed significant associations with depression and anxiety. Patient supports to address social health have potential implications for also supporting mental health.

Onset of depression and anxiety among patients with gout after diagnosis: a population-based incident cohort study.

BACKGROUND: Gout may be associated with an increased incidence of mental health disorders, however, published findings have been limited and inconsistent. Therefore, our objective was to conduct a population-based cohort study to evaluate the incidence of depression and anxiety after gout diagnosis. METHODS: We used linked population-based administrative health data in British Columbia, Canada that includes information on demographics, outpatient visits, and inpatient visits from the period of January 1, 1990 to March 31, 2018. We assessed depression and anxiety using validated International Classification of Diseases, 9th and 10th Revision coding algorithms. We applied multivariable Cox proportional hazard models to evaluate incident depression and anxiety among patients with gout in comparison to non-gout controls, adjusting for age, sex, neighbourhood income quintile, residence, comorbidities, and health care utilization. RESULTS: We included 157,426 incident cases of gout (60.2% male; mean age 57.1 years) and 157,426 non-gout controls (60.2% male; mean age 56.9 years). The incidence rate of depression among individuals with gout and non-gout controls was 12.9 (95% confidence interval [CI] 12.7-13.2) and 11.1 (95% CI 10.9-11.4) per 1000 person-years, respectively. The incidence rate of anxiety for those with gout was 5.4 (95% CI 5.3-5.5) per 1000 person-years and for non-gout controls was 4.6 (95% CI 4.4-4.7) per 1000 person-years. Individuals with gout had an increased onset of depression (adjusted hazard ratio [aHR], 1.08; 95% CI 1.05-1.11) and anxiety (aHR, 1.10; 95% CI 1.05-1.14) compared to non-gout controls. CONCLUSION: Our population-based study shows an increased incidence of depression and anxiety following gout diagnosis in comparison to non-gout controls. Findings suggest the importance of considering psychiatric impacts in addition to the physical impacts of gout.

Risk of Anxiety and Depression after Diagnosis of Young-Onset Colorectal Cancer: A Population-Based Cohort Study.

Given the increasing incidence of young-onset colorectal cancer (yCRC; <50 years), we aimed to evaluate the risk of depression and anxiety in individuals with yCRC in comparison to average-age-onset CRC (aCRC; ≥50 years) and to cancer-free controls, with stratification by sex. Our cohort study identified individuals (≥18 years) with CRC and cancer-free controls (10:1) matched on age and sex using population-based linked administrative health databases in British Columbia, Canada. We assessed depression and anxiety using validated algorithms. We evaluated the risk of depression and anxiety using multivariable Cox proportional hazard models. The cohort included 54,634 individuals with CRC (46.5% female, mean age 67.9 years) and 546,340 controls (46.5% female, mean age 67.9 years). Those with yCRC as compared to aCRC had an increased risk for depression (adjusted hazard ratio [aHR] 1.41; 95% confidence interval [CI] 1.25 to 1.60), and when stratified by sex, the risk was only significant among males (aHR 1.76; 95% CI 1.48 to 2.10). When comparing individuals with yCRC to cancer-free controls, the overall risk of depression (aHR 1.00; 95% CI 0.92 to 1.10) and anxiety (aHR 1.10; 95% CI 0.95 to 1.27) was non-significant; however, males had a significantly higher risk for mental health disorders, specifically depression (aHR 1.17; 95% CI 1.03 to 1.33). Altogether, our findings that individuals with yCRC experience higher risk of depression compared to those with aCRC as well as cancer-free controls, particularly among males, suggest effects of age and sex on mental health outcomes.

Virtual Oncology Appointments during the Initial Wave of the COVID-19 Pandemic: An International Survey of Patient Perspectives.

There has been rapid implementation of virtual oncology appointments in response to the COVID-19 pandemic, particularly in its first wave. Our objective was to assess patterns and perspectives towards virtual oncology appointments during the pandemic among patients with cancer undergoing active treatment. We conducted an international Internet-based cross-sectional survey. Participants were eligible if they (1) were ≥18 years of age; (2) had been diagnosed with cancer (3) were currently undergoing cancer treatment, and (4) spoke English or French. Between 23 April 2020 and 9 June 2020, 381 individuals accessed the survey, with 212 actively undergoing treatment for cancer, including 27% with colorectal, 21% with breast, 7% with prostate and 7% with lung cancer. A total of 52% of respondents were from Canada and 35% were from the United States. Many participants (129, 62%) indicated having had a virtual oncology appointment during the COVID-19 pandemic and most were satisfied with their experience (83%). We found older participants (≥50 years; adjusted OR 0.22, 95% CI 0.06 to 0.85 compared to <50 years) and those with shortest duration of treatment (≤3 months; adjusted OR 0.06; 95% CI 0 to 0.69 compared to >12 months) were less likely to be satisfied with virtual oncology appointments. Virtual health platforms used differed across countries with higher telephone use in Canada (87%) and other countries (86%) as compared to the United States (54%; p-value < 0.05), where there was higher use of video conferencing. Altogether, our findings demonstrate favorable patient perspectives towards virtual oncology appointments experienced during the first wave of the COVID-19 pandemic.

Trends in the Incidence of Young-Onset Colorectal Cancer With a Focus on Years Approaching Screening Age: A Population-Based Longitudinal Study.

BACKGROUND: With recent evidence for the increasing risk of young-onset colorectal cancer (yCRC), we had the objective to evaluate the incidence of yCRC in 1-year age increments, particularly focusing around the screening age of 50 years. METHODS: We conducted a longitudinal study using linked administrative health databases in British Columbia, Canada, including a provincial cancer registry, inpatient and outpatient visits, and vital statistics from January 1, 1986, to December 31, 2016. We calculated incidence rates per 100 000 at every age from 20 to 60 years and estimated annual percent change in incidence (APCi) of yCRC using joinpoint regression analysis. RESULTS: We identified 3614 individuals with yCRC (49.9% women). The incidence of CRC steadily increased from 20 to 60 years, with a marked increase from 49 to 50 years (incidence rate ratio = 1.19, 95% confidence interval [CI] = 1.04 to 1.34). Furthermore, there was a trend of increased incidence of yCRC among women (APCi = 0.79%, 95% CI = 0.22% to 1.36%) and men (APCi = 2.17%, 95% CI = 1.59% to 2.76%). Analyses stratified by age yielded APCis of 2.49% (95% CI = 1.36% to 3.63%) and 0.12% (95% CI = -0.54% to 0.79%) for women aged 30-39 years and 40-49 years, respectively, and 2.97% (95% CI = 1.65% to 4.31%) and 1.86% (95% CI = 1.19% to 2.53%) for men. CONCLUSIONS: Our findings indicate a steady increase over 1-year age increments in the risk of yCRC during the years approaching and beyond screening age. These findings highlight the need to raise awareness as well as continue discussions regarding considerations of lowering the screening age.

Epidemiology of Depression and Anxiety in Gout: A Systematic Review and Metaanalysis.

OBJECTIVE: To conduct a systematic review of depression and anxiety among patients with gout that specifically evaluates the prevalence, incidence, determinants, and effects of these mental health comorbidities. METHODS: We conducted a literature search in Medline, Embase, Cochrane Database of Systematic Reviews, CINAHL, and PsycINFO using indexed terms and key words to identify studies reporting on depression/anxiety in patients with gout. This review included full-text articles published in English that reported on patients with gout, evaluated depression/anxiety using a routinely reported measure, and provided estimates or sufficient data on the prevalence, incidence, determinants, or effects of depression/anxiety. Metaanalyses were conducted using random effects models. RESULTS: Twenty of 901 articles identified through the search strategy met our inclusion criteria. All 20 studies evaluated depression, while only 10 assessed anxiety (50%). Metaanalyses suggest a positive association between mental health disorders and gout, as resultant pooled OR were 1.29 (95% CI 1.07-1.56) for depression and 1.29 (95% CI 0.96-1.73) for anxiety. Findings from four studies reporting on the incidence of depression in patients with gout resulted in a pooled HR of 1.17 (95% CI 1.01-1.36). Significant determinants of depression included number of tophi, frequency of flares, and oligo/polyarticular gout. CONCLUSION: Our systematic review suggests that depression and anxiety are significantly associated with gout, highlighting the need for future research to focus on the onset of mental disorders after gout diagnosis. We also identify potential targets for intervention.

Insights on mental health when living with rheumatoid arthritis: a descriptive qualitative study of threads on the Reddit website.

BACKGROUND: Reddit is a highly visited social news and discussion website where individuals anonymously ask questions, post opinions and share experiences, which provide a valuable pool of publicly available data. Our objective was to systematically search and analyze threads on the social news website, Reddit, to understand experiences of individuals with rheumatoid arthritis (RA) regarding their mental health. METHODS: We conducted a patient-oriented descriptive qualitative study. We identified threads from two subreddits, "r/Thritis" and "r/Rheumatoid", using keywords such as "mood", "mental health", "stressed", "depressed", "anxious" over a 1-year period between June 2018 and June 2019. For included threads, we extracted the title, original post, and corresponding comments and responses. We applied thematic analysis using an inductive approach. RESULTS: Of 81 threads identified, we included 27. We identified four themes: 1) Navigating the management of RA explores how the physical impacts of the disease, lack of health resources/support and the complexity of medications affect mental health; 2) Experiencing impact on relationships and social isolation includes experiencing misconceptions of RA, feeling misunderstood and feeling guilt; 3) Experiencing loss, touches on the helplessness brought by challenges with performing self-defining activities such as self-care, work, and childbearing/parenting; and finally, 4) Experiencing emotional struggles captures how tension between fighting through and despair has led some to suicide ideation and thoughts of death. CONCLUSIONS: Online forums and communities such as Reddit have created opportunities for individuals with RA to share experiences on mental health matters, which they may not necessarily be able to share with others.

Impact of arthritis on the perceived need and use of mental healthcare among Canadians with mental disorders: nationally representative cross-sectional study.

OBJECTIVE: To evaluate the association between having arthritis and the perceived need for mental healthcare and use of mental health support among individuals with mental disorders. DESIGN: A cross-sectional analysis using data from Canadian Community Health Survey-Mental Health (2012). SETTING: The survey was administered across Canada's 10 provinces using multistage cluster sampling. PARTICIPANTS: The study sample consisted of individuals reporting depression, anxiety or bipolar disorder. STUDY VARIABLES AND ANALYSIS: The explanatory variable was self-reported doctor-diagnosed arthritis, and outcomes were perceived need for mental healthcare and use of mental health support. We computed overall and gender-stratified multivariable binomial logistic regression models adjusted for age, gender, race/ethnicity, income and geographical region. RESULTS: Among 1774 individuals with a mental disorder in the study sample, 436 (20.4%) reported having arthritis. Arthritis was associated with increased odds of having a perceived need for mental healthcare (adjusted OR (aOR) 1.71, 95% CI 1.06 to 2.77). In the gender-stratified models, this association was increased among men (aOR 2.69, 95% CI 1.32 to 5.49) but not women (aOR 1.48, 95% CI 0.78 to 2.82). Evaluation of the association between arthritis and use of mental health support resulted in an aOR of 1.50 (95% CI 0.89 to 2.51). Individuals with arthritis tended to use medications and professional services as opposed to non-professional support. CONCLUSION: Comorbid arthritis among individuals with a mental disorder was associated with an increased perceived need for mental healthcare, especially in men, underscoring the importance of understanding the role of masculinity in health seeking. Assessing the mental health of patients with arthritis continues to be essential for clinical care.

The incidence of depression and anxiety in patients with ankylosing spondylitis: a systematic review and meta-analysis.

BACKGROUND: As awareness for the importance of mental health continues to expand in rheumatology, it is important to understand the epidemiology of psychiatric complications in ankylosing spondylitis (AS) with the ultimate goal of future prevention and improved quality of care. This study aims to review evidence on the incidence and determinants of depression and/or anxiety among patients with AS. METHODS: We searched Medline, Embase, Cochrane Database of Systematic Reviews, CINAHL Complete, and PsycINFO for full-length observational studies that involved a sample or population of patients with AS and assessed depression and/or anxiety. Primary outcomes extracted were: 1) risk estimates for depression and/or anxiety (e.g., relative risk [RR]); and 2) determinants or factors identified as independent predictors of depression and/or anxiety using multivariable regression approaches and corresponding estimates (e.g., odds ratios [OR]). Where relevant, we pooled estimates using random effects models. RESULTS: Out of 783 titles from our search strategy, we reviewed 39 manuscripts. Four studies assessed the incidence of depression and meta-analyzing reported estimates from three of these studies yielded a pooled RR of 1.51 (95% CI 1.28 to 1.79). Differences in risk of depression among men and women with AS were inconclusive, suggesting need for further study. The incidence of anxiety was comparatively less studied with only one included study reporting a hazard ratio of 1.85 (95% CI 1.37 to 2.49). Education level was a key determinant, with lower levels associated with higher odds of depression (OR 6.65; 9% CI 1.36 to 32.51) and anxiety (OR 9.31; 9% CI 1.39 to 62.19) among AS patients. CONCLUSIONS: Our systematic review and meta-analysis shows an increased risk of depression and anxiety among patients with AS. These findings suggest the importance of monitoring and care for psychiatric conditions in AS.

Epidemiology of depression and anxiety in patients with psoriatic arthritis: A systematic review and meta-analysis.

OBJECTIVE: To conduct a systematic review and meta-analysis of the prevalence, incidence, and medication treatment of depression and anxiety among patients with psoriatic arthritis (PsA). METHODS: We searched Medline, Embase, Cochrane Database of Systematic Reviews, CINAHL and PsycINFO for full-length studies that: utilized an observational design; included patients with PsA with/without a comparator group; evaluated depression and/or anxiety as an outcome, comorbidity, or predictor of a health outcome; and reported relevant estimates. We pooled estimates using random effects models. RESULTS: Of 683 titles identified in our search, 18 studies met inclusion criteria. The pooled prevalence proportion for depression based on 11 studies was 17% (95% confidence interval [CI], 13% to 21%). In addition, a meta-analysis of four studies comparing the prevalence of depression in patients with PsA to those without PsA yielded a pooled odds ratio (OR) of 1.68 (95% CI, 1.37 to 2.08). The incidence of depression in PsA patients compared to the general population yielded a pooled incidence rate of 21.27 (95% CI, 16.28 to 26.27) per 1,000 person-years and a pooled incidence rate ratio of 1.44 (95% CI, 1.20 to 1.73). The pooled prevalence proportion of anxiety based on seven studies was 19% (95% CI, 11% to 29%) and a meta-analysis of two studies comparing the prevalence of anxiety in patients with PsA to those without PsA yielded a pooled OR of 1.49 (95% CI, 1.39 to 1.59). Only a small proportion of patients, between 2.4% and 13.5%, were reported to be taking antidepressant or antianxiety medications. CONCLUSIONS: We identified substantial prevalence of depression and anxiety as well as elevated incidence of depression among patients with PsA. These findings should raise awareness of the importance of mental health care in this population.

Perinatal exposure to conventional synthetic disease-modifying anti-rheumatic drugs in women with rheumatic disease and neonatal outcomes: a population-based study.

OBJECTIVES: Epidemiologic studies evaluating associations between specific arthritis medications and perinatal outcomes are limited. We evaluated the association between conventional synthetic DMARD (csDMARD) use among women with rheumatic disease (RD) and neonatal outcomes. METHODS: We linked population-based data in British Columbia, Canada from 01/01/2002 to 12/31/2012 on all inpatient/outpatient visits and medications with a perinatal registry. For small-for-gestational-age (SGA) births, we assessed csDMARD exposure 90 days preconception or during pregnancy until date of delivery. For congenital anomalies, we determined csDMARD exposure 90 days preconception or during the first trimester. We used multivariable logistic regression models fitted with generalised estimating equations and calculated post-hoc power. RESULTS: There were 185 pregnancies in 175 women (31.3±5.4 years) and 6,064 pregnancies in 4,387 women (31.1±5.4 years) in the csDMARD exposed and unexposed groups, respectively. Hydroxychloroquine, azathioprine, sulfasalazine, and methotrexate exposure before or during pregnancy were not associated with SGA births. The most sufficiently powered analyses were those for hydroxychloroquine, where exposure during pregnancy resulted in an adjusted odds ratio (aOR) of 1.12 (95% confidence interval [CI], 0.65-1.94) for SGA births. Although post-hoc power calculations indicate less power to detect associations between csDMARDs and congenital anomalies, results indicate methotrexate exposure during the first trimester is associated with elevated odds for congenital anomalies (aOR 6.58, 95% CI 1.15-37.75). CONCLUSIONS: Findings are consistent with current guidelines regarding specific csDMARD use during the perinatal period for women with RD. It is important to report well-designed epidemiologic studies to facilitate future RD/csDMARD-specific meta-analyses.

Defining Depression and Anxiety in Individuals With Rheumatic Diseases Using Administrative Health Databases: A Systematic Review.

OBJECTIVE: To conduct a systematic review to describe how administrative health databases have been used to study depression and anxiety in patients with rheumatic diseases and to synthesize the case definitions that have been applied. METHODS: Search strategies to identify articles evaluating depression and anxiety among individuals with rheumatic diseases were employed in Medline, Embase, CINAHL, Cochrane Database of Systematic Reviews, and PsycINFO. Studies included were those using administrative health data and reporting case definitions for depression and anxiety using International Classification of Diseases (ICD) codes. We extracted information on study design and objectives, administrative health database, specific data sources (e.g., inpatient, pharmacy records), ICD codes, operational definitions, and validity of case definitions. RESULTS: Of the 36 studies included in this review, all studies assessed depression, and 13 studies (36.1%) evaluated anxiety. A number of specific ICD-9/10 codes were consistently applied to identify depression and anxiety, but the overall combination of ICD codes and operational definitions varied across studies. Twenty-four studies reported operational definitions, and 19 of these studies (79.2%) combined claims from more than 1 type of administrative data source (e.g., inpatient, outpatient). Validated case definitions were used by 6 studies (16.7%), with sensitivity estimates for depression and anxiety case definitions ranging from 33% to 74% and 42% to 76%, respectively. CONCLUSION: We identified numerous case definitions used to evaluate depression and anxiety among individuals with rheumatic diseases within administrative health databases. Recommendations include using case definitions with demonstrated validity as well as operationalizing case definitions within multiple data sources.

Medication adherence teaching activity for first year pharmacy students in a Canadian university: Description and evaluation.

BACKGROUND AND PURPOSE: Medication non-adherence is a significant health problem in Canada and pharmacists are ideally positioned to help patients adhere to their regimens. There is an urgent need for pharmacy schools to ensure graduates receive training in this area. In this paper, we describe a medication taking simulation activity for first year pharmacy students using a multi-method approach to evaluation. EDUCATIONAL ACTIVITY AND SETTING: Students were provided with placebo capsules and instructed to take one capsule twice per day for two weeks, complete the Beliefs About Medications Questionnaire (BMQ) before the activity, and provide a pill count and reflection on their experiences afterwards. Quantitative analysis involved calculation of percent adherence from pill counts and establishing beliefs about medications from BMQ scores. Perceptions of the teaching activity were determined using qualitative inductive content analysis of a sub-set of student reflections. FINDINGS: All 224 students participated and complete pill count and BMQ data was obtained from 190 students (85%). Applying a cut-off of 80% to categorize adherence status, 51.8% of students were adherent. BMQ analyses indicated collective student uncertainty in three BMQ sub-scales (specific-necessity, specific-concern, and general-overuse) and a significant difference between adherent and non-adherent students in the specific-necessity sub-scale. Qualitative analyses of a set of student reflections resulted in two major themes: (1) developing empathy and (2) learning about adherence. SUMMARY: This activity provided opportunities for students to experience the challenges involved in medication-taking from the patient's perspective and to realize the pharmacist's role to facilitate medication adherence.

eHealth-supported decentralized multi-disciplinary care for gout involving rheumatology, pharmacy, and dietetics: proof-of-concept study.

OBJECTIVE: To conduct quantitative and qualitative evaluation of an electronic health (eHealth)-supported decentralized multi-disciplinary care model for gout involving rheumatologists, pharmacist, and dietitian. METHODS: We conducted a 12-month proof-of-concept study. Gout patients with ≥ 1 flare in the past year and serum urate (SUA) ≥ 360 µmol/L within the previous 2 months were followed by participating community rheumatologists on an as-needed basis, received monthly telephone consults with a pharmacist, and one telephone consult with a dietitian. Healthcare professionals were not co-located but had shared access to the rheumatologists' electronic medical records (EMR) for remote communication and collaboration. In quantitative evaluation, the primary outcome was the proportion of patients with SUA < 360 µmol/L at 12 months. In qualitative evaluation, we conducted semi-structured interviews with a subset of patients and applied constructivist grounded theory to gather patients' perspectives. RESULTS: Overall, 35 gout patients (86% males, mean age 60.9 ± 14.9 years) participated. At 12 months, 72% of patients achieved target SUA < 360 µmol/L. Qualitative analysis of interviews with a subset of 12 patients resulted in two themes: (1) experiences with receiving care, including categories of improved knowledge about gout, receiving personalized support, and knowing someone cares, and (2) practical considerations, including categories of optimizing timing of care and coordination and accessibility. CONCLUSION: Our multi-method study shows that a decentralized, multi-disciplinary care for gout involving rheumatology, pharmacy, and dietetics with shared EMR access led to gout patients achieving target SUA. It was well-received by patients who perceived better education about gout and personalized care.Key Points• We demonstrated the feasibility and impact of an eHealth-supported, decentralized collaborative care model for gout involving rheumatology, pharmacy, and dietetics• Although prior multi-disciplinary models of care for gout have been reported, the novelty of our model is that healthcare providers are not co-located, lending to potential efficiencies and outreach to patients in rural areas.

Management of Inflammatory Arthritis in pregnancy: a National Cross-Sectional Survey of Canadian rheumatologists.

BACKGROUND: With improved therapies and management, more women with inflammatory arthritides (IA) are considering pregnancy. Our objective was to survey rheumatologists across Canada about their IA management in pregnancy to identify practice patterns and knowledge gaps. METHODS: We administered an online survey with questions regarding medications for IA treatment including conventional synthetic disease modifying antirheumatic drugs (csDMARDs) and biologics/small molecules in planned and unplanned pregnancies. Email invitations were sent to members of the Canadian Rheumatology Association. We calculated responses frequencies and a priori set a cut-off of ≥75% to define consensus. RESULTS: Ninety rheumatologists participated in the survey (20% participation rate); 57% have been practicing for > 10 years, 32% for ≤10 years, and 11% in training. There was consensus on discontinuation of 4 csDMARDs - cyclophosphamide (100%), leflunomide (98%), methotrexate (96%), and mycophenolate mofetil (89%) - in planned pregnancies but varied responses on when to discontinue them or what to do in unplanned pregnancies. Respondents agreed that 3 csDMARDs - azathioprine (84%), hydroxychloroquine (95%), and sulfasalazine (77%) - were safe to continue in planned and unplanned pregnancies. There was consensus with use of 4 biologics - adalimumab (81%), certolizumab (80%), etanercept (83%), and infliximab (76%) - in planned pregnancies but uncertainty on when they should be discontinued and their use in unplanned pregnancies. CONCLUSIONS: This national survey shows consensus among rheumatologists on the use of some csDMARDs and biologics/small molecules in IA patients planning pregnancy but varied knowledge on when to discontinue and what to do in unplanned pregnancies.

Mobile Phone Apps Targeting Medication Adherence: Quality Assessment and Content Analysis of User Reviews.

BACKGROUND: With the accessibility and widespread use of mobile phones, mobile phone apps targeting medication adherence may be useful tools to help patients take medications as prescribed. OBJECTIVE: Our objectives were to (1) characterize and assess mobile phone medication adherence apps guided by a conceptual framework on the focus of adherence interventions and (2) conduct a content analysis of Web-based reviews to explore users' perspectives and experiences with mobile phone medication adherence apps. METHODS: We searched for mobile phone medication adherence apps using keyword searches in Apple and Android operating systems. We characterized all apps in terms of number of downloads, ratings, languages, cost, and disease target. We categorized apps according to 4 key features of (1) alerting to take medication, (2) tracking medication taking, (3) reminding to refill or indicating amount of medication left, and (4) storing medication information. We then selected representative apps from each operating system for detailed quality assessment and user testing. We also downloaded Web-based reviews for these selected apps and conducted a qualitative content analysis using an inductive approach involving steps of initial open coding, construction of categories, and abstraction into themes. RESULTS: We identified 704 apps (443 from Apple and 261 from Android). The majority of apps across both operating systems had 1 or 2 features-specifically, 37.2% (165/443) and 38.1% (169/443) of Apple apps, respectively, and 41.4% (108/261) and 31.4% (108/261) of Android apps, respectively. Quality assessment and user testing of 20 selected apps revealed apps varied in quality and commonly focused on behavioral strategies to enhance medication adherence through alerts, reminders, and logs. A total of 1323 eligible Web-based reviews from these 20 selected apps were analyzed, and the following themes emerged: (1) features and functions appreciated by users, which included the ability to set up customized medication regimen details and reminders, monitor other health information (eg, vitals, supplements, and manage multiple people or pets), support health care visits (eg, having a list of medications and necessary health information in 1 app); (2) negative user experiences that captured technical difficulties (glitches, confusing app navigation, and poor interoperability), dosage schedule, and reminder setup inflexibility; and (3) desired functions and features related to optimization of information input, improvement of reminders, and upgrading app performance (better synchronization or backup of data and interoperability). CONCLUSIONS: A large number of mobile phone medication adherence apps are currently available. The majority of apps have features representing a behavioral approach to intervention. Findings of the content analysis offer mostly positive feedback as well as insights into current limitations and improvements that could be addressed in current and future medication adherence apps.

Exploring strategies to support medication adherence in patients with inflammatory arthritis: a patient-oriented qualitative study using an interactive focus group activity.

OBJECTIVE: Medication non-adherence is a substantial problem among patients with inflammatory arthritis (IA). Our aim was to explore IA patients' perspectives on strategies to support medication adherence. METHODS: We collaborated with a leading arthritis patient group and conducted a qualitative study on individuals with IA who were taking at least one medication for their IA. An experienced facilitator led participants through a focus group exercise where participants were asked to design, and then discuss, strategies and/or tools supporting medication use. We applied thematic analysis using an iterative, constant comparative approach. RESULTS: We studied six focus groups with 27 participants diagnosed with rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and comparatively under-represented conditions in this research area such as Sjögren's syndrome. Five themes emerged throughout the analysis. Two themes - 1) adapting to life with IA and 2) the complexities and dynamic nature of taking medications - describe learning to live with a chronic condition and the challenges encountered when using long-term medications. Three themes - 3) developing lifestyle strategies for medication use (eg, having physical reminders and prompts), 4) becoming informed about medications (eg, information at time of diagnosis, means of receiving information) and 5) receiving support (eg, from health care team members, from family) - offer perspectives on facilitators to medication use. From the relationship between the latter themes, a framework was developed that encompasses means of receiving information and support as actionable targets for patient-oriented adherence interventions for IA. CONCLUSION: This patient-oriented study highlights the importance of developing timely adherence interventions for IA. Our findings also led to a framework describing means of receiving information, such as through digital media and support, including from health care team members and family, as actionable targets for patient-oriented adherence interventions for IA.

Botulinum Toxin Type A Versus Placebo for Idiopathic Clubfoot: A Two-Center, Double-Blind, Randomized Controlled Trial.

BACKGROUND: Congenital idiopathic clubfoot is a condition that affects, on average, approximately 1 in 1,000 infants. One broadly adopted method of management, described by Ponseti, is the performance of a percutaneous complete tenotomy when hindfoot stall occurs. The use of onabotulinum toxin A (BTX-A) along with the manipulation and cast protocol described by Ponseti has been previously reported. Our goal was to compare the clinical outcomes between BTX-A and placebo injections into the gastrocnemius-soleus muscle at the time of hindfoot stall in infants with idiopathic clubfoot treated with the Ponseti method of manipulation and cast changes. METHODS: This was a double-blind, placebo-controlled, parallel-group study with balanced randomization. RESULTS: At 6 weeks after the study injection (T1), 66% of the 32 feet in the BTX-A arm and 63% of the 30 in the placebo arm responded to the treatment (i.e., obtained ≥15° of dorsiflexion). Seven of the 11 patients in the BTX-A arm and all of the 11 in the placebo arm who had not responded at T1 responded to a rescue BTX-A injection at 12 weeks after the first injection (T2). The combined response rate at T2, which included the first-time responders as well as the patients who did not respond at T1 but did at T2, was 88% in the BTX-A arm and 100% in the placebo arm, culminating in a 94% response rate at T2. At T3 (2 years of age), 89% of the feet continued to respond and there was an 8% surgical rate. CONCLUSIONS: There was no difference in outcomes between the BTX-A and placebo groups when the injection was performed at the time of hindfoot stall. Overall, 92% of the clubfeet in this study responded to a manipulation and cast protocol alone, with or without BTX-A injection, by 12 weeks after hindfoot stall, or we can say that 92% of the clubfeet did not require percutaneous Achilles tendon lengthening by 2 years of age. The need for tenotomy is limited to those who have not responded to treatment at this point, and the need for surgery is limited to those for whom all attempts at treatment with sequential casts, BTX-A, and percutaneous Achilles tendon lengthening have failed. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.