An Advanced Clinician Practitioner in Arthritis Care (ACPAC) Maintains a Positive Patient Experience While Increasing Capacity in Rheumatology Community Care.

PURPOSE: This study describes patient care experiences of solo-rheumatologist and co-managed care models utilizing an Advanced Clinician Practitioner in Arthritis Care-trained Extended Role Practitioner (ACPAC-ERP) in three community rheumatology practices. MATERIALS AND METHODS: Patients with inflammatory arthritis (IA) were assigned to care provided by one of three (2 senior, 1 early-career) community-based rheumatologists (usual care), or an ACPAC-ERP (co-managed care) for the 6-months following diagnosis. Patient experiences were surveyed using validated measures of patient satisfaction (Patient Doctor Interaction Scale-PDIS), global ratings of confidence and satisfaction, referral patterns, disease activity (RADAI) and self-perceived disability (HAQ-Disability) as well as demographic information. Practice capacity was evaluated 18-months prior to, and across, the study period. RESULTS: Of 55 participants (mean age 56.6 years, 61.8% female), 33 received co-managed care. Most participants were diagnosed with rheumatoid arthritis (65.5%) with a median symptom duration of 1.1 years. At 6-months, patients from both models of care were equally satisfied in terms of the information provided (usual care 4.6 vs co-managed care 4.7/5=greater satisfaction), rapport with health-care provider (4.6 vs 4.6/5) and having needs met (4.7 vs 4.5/5). Overall satisfaction was high (87.2 vs 85.3/100=completely satisfied) as was confidence in the system by which care was received (85.0 vs 82.1/100=completely confident). Usual care patients reported higher perceived disability than co-managed patients (HAQ-Disability 0.5 vs 0.2/3=unable to do). Significant differences in overall RADAI score (p=0.014) were found between the two models. The senior rheumatologist, with a previously saturated practice, attained a 37% capacity increase for new patients utilizing the co-managed care model. CONCLUSION: The ACPAC-ERP model was equivalent to the solo-rheumatologist model with regard to patient experience and satisfaction. A co-management model utilizing a highly trained ACPAC-ERP can increase capacity in community rheumatology clinics for patients newly diagnosed with IA while maintaining confidence and satisfaction with their care.

Cost-Utility Analysis of the Ontario Fracture Screening and Prevention Program.

BACKGROUND: The Fracture Screening and Prevention Program (FSPP), a fracture liaison service (FLS), was implemented in the province of Ontario, Canada, in 2007 to prevent recurrent fragility fractures and to improve post-fracture care. The objective of this analysis was to determine the cost-effectiveness of the current model of the FSPP compared with usual care (no program) from the perspective of the universal public health-care payer (Ontario Ministry of Health and Long-Term Care [MOHLTC]), over the lifetime of older adults who presented with a fragility fracture of the proximal part of the femur, the proximal part of the humerus, or the distal part of the radius and were not taking medications to prevent or slow bone loss and reduce the risk of fracture (bone active medications). METHODS: We developed a state-transition (Markov) model to conduct a cost-effectiveness analysis of the FSPP in comparison with usual care. The model simulated a cohort of patients with a fragility fracture starting at 71 years of age. Model parameters were obtained from published literature and from the FSPP. Quality-adjusted life-years (QALYs) and costs in 2018 Canadian dollars were predicted over a lifetime horizon using a 1.5% annual discount rate. Health outcomes included subsequent proximal femoral, vertebral, proximal humeral, and distal radial fractures. Scenario and subgroup analyses were reported. RESULTS: The FSPP had lower expected costs ($277 less) and higher expected effectiveness (by 0.018 QALY) than usual care over the lifetime horizon. Ninety-four percent of the 10,000 Monte Carlo simulated incremental cost-effectiveness ratios (ICERs) demonstrated lower costs and higher effectiveness of the FSPP. CONCLUSIONS: The FSPP appears to be cost-effective compared with usual care over a lifetime for patients with fragility fracture. This information may help to quantify the value of the FSPP and to assist policy-makers in deciding whether to expand the FSPP to additional hospitals or to initiate similar programs where none exist. LEVEL OF EVIDENCE: Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence.

Factors associated with screening positive for high falls risk in fragility fracture patients: a cross-sectional study.

BACKGROUND: We sought to report the prevalence of fragility fracture patients who were screened at high falls risk using a large provincial database, and to determine the characteristics associated with being screened at high falls risk. METHODS: The study population included fragility fracture patients 50+ years of age who were screened at 35 hospital fracture clinics in Ontario over a 3.5 year period. The outcome was based on two screening questions measuring the risk of falling, both adapted from the STEADI (Stopping Elderly Accidents, Deaths & Injuries) tool. Multivariable associations of sociodemographic, fracture-related, and health-related characteristics were evaluated using logistic regression. RESULTS: Of the sample, 9735 (44.5%) patients were classified as being at high falls risk, and 12,089 (55.3%) were not. In the multivariable logistic regression, being 80+ years of age (vs. 50-64 years of age), non-community dwelling (vs. living with spouse, family member, roommate), having a mental/physical impairment (vs. none), and taking multiple medications, were all strongly associated with being screened at high falls risk. CONCLUSIONS: Living in a non-community dwelling and taking 4+ medications were the variables most strongly associated with being screened at high falls risk. These are potentially modifiable characteristics that should be considered when assessing falls risk in fragility fracture patients, and particularly when designing interventions for preventing subsequent falls. Ongoing work to address the higher risk of falls in the fragility fracture population is warranted.

Measuring Advanced/Extended Practice Roles in Arthritis and Musculoskeletal Care in Canada.

OBJECTIVE: Our objective was to characterize Canadian workforce attributes of extended role practitioners (ERPs) in arthritis care. METHODS: We used an exploratory, mixed-methods study that was based on the Canadian Rheumatology Association's Stand Up and Be Counted Rheumatologist Workforce Survey (2015). An anonymous online survey was deployed to groups of non-physician health care professionals across Canada who potentially had post-licensure training in arthritis care. Demographic and practice information were elicited. Qualitative responses were analyzed using grounded theory techniques. RESULTS: Of 141 respondents, 91 identified as practicing in extended role capacities. The mean age of ERP respondents was 48.7; 87% were female, and 41% of ERPs planned to retire within 5 to 10 years. Respondents were largely physical or occupational therapists by profession and practiced in urban/academic (46%), community (39%), and rural settings (13%). Differences in practice patterns were noted between ERPs (64.5%) and non-ERPs (34.5%), with more ERPs working in extended role capacities while retaining activities reflective of their professional backgrounds. Most respondents (95%) agreed that formal training is necessary to work as an ERP, but only half perceived they had sufficient training opportunities. Barriers to pursuing training were varied, including personal barriers, geographic barriers, patient-care needs, and financial/remuneration concerns. CONCLUSION: To our knowledge, no previous studies have assessed the workforce capacity or the perceived need for the training of ERPs working in arthritis and musculoskeletal care. Measurement is important because in these health disciplines, practitioners' scopes of practice evolve, and ERPs integrate into the Canadian health care system. ERPs have emerged to augment provision of arthritis care, but funding for continuing professional development opportunities and for role implementation remains tenuous.

PROM-ED: Development and Testing of a Patient-Reported Outcome Measure for Emergency Department Patients Who Are Discharged Home.

STUDY OBJECTIVE: Common outcomes of care valued by emergency department (ED) patients who are not hospitalized have been characterized, but no measurement instrument has been developed to date. We developed and validated a patient-reported outcome measure for use with adult ED patients who are discharged home (PROM-ED). METHODS: In previous research, 4 main outcomes of importance to ED patients were defined: symptom relief, understanding, reassurance, and having a plan. We developed a bank of potential questions (phase 1) that were first tested for suitability through cognitive debriefing with patients (phase 2). Revised questions were then tested quantitatively with a large panel of participants who had recently received ED care (phase 3). Informed by these results, a panel of experts used a modified Delphi process to make decisions on item reduction. The resulting instrument (PROM-ED 1.0) was then evaluated for its measurement properties (structural validity, hypothesis testing, and reliability). RESULTS: Sixty-seven questions divided among 4 scales (1 for each outcome domain) were assembled. In accordance with cognitive debriefing with 8 patients (phase 2), 15 questions were modified and 13 removed. Testing of these questions with 444 participants (phase 3) identified problematic floor or ceiling effects (n=10), excessive correlations between items (n=11), and low item-total correlations (n=7). The expert panel (22 participants, phase 4) made decisions using this information on the exclusion of items, resulting in 22 questions across 4 scales that together constitute the PROM-ED 1.0. Testing provided good evidence of validity and test-retest reliability (n=200). CONCLUSION: The PROM-ED enables the measurement of patient-centered outcomes of importance to patients receiving care in the ED who are not hospitalized. These data could have important applications in research and care improvement.

An advanced clinician practitioner in arthritis care can improve access to rheumatology care in community-based practice.

OBJECTIVE: To facilitate access and improve wait times to a rheumatologist's consultation, this study aimed to 1) determine the ability of an advanced clinician practitioner in arthritis care (ACPAC)-trained extended role practitioner (ERP) to triage patients with suspected inflammatory arthritis (IA) for priority assessment by a rheumatologist and 2) determine the impact of an ERP on access-to-care as measured by time-to-rheumatologist-assessment and time-to-treatment-decision. MATERIALS AND METHODS: A community-based ACPAC-trained ERP triaged new referrals for suspected IA. Patients with suspected IA were booked to see the rheumatologist on a priority basis. Diagnostic accuracy of the ERP to correctly identify priority patients; the level of agreement between ERP and rheumatologist (Kappa coefficient and percent agreement); and the time-to-treatment-decision for confirmed cases of IA were investigated. Retrospective chart review then compared time-to-rheumatologist-assessment and time-to-treatment-decision in the solo-rheumatologist versus the ERP-triage model. RESULTS: One hundred twenty-one patients were triaged. The ERP designated 54 patients for priority assessment. The rheumatologist confirmed IA in 49/54 (90.7% positive predictive value [PPV]). Of the 121 patients, 67 patients were designated as nonpriority by the ERP, and none were determined to have IA by the rheumatologist (100% negative predictive value [NPV]). Excellent agreement was found between the ERP and the rheumatologist (Kappa coefficient 0.92, 95% CI: 0.84-0.99). In the ERP-triage model, time-from-referral-to-treatment-decision for patients with IA was 73.7 days (SD 40.4, range 12-183) compared with 124.6 days (SD 61.7, range 26-359) in the solo-rheumatologist model (40% reduction in time-to-treatment-decision). CONCLUSION: A well-trained and experienced ERP can shorten the time-to-Rheumatologist-assessment and time-to-treatment-decision for patients with suspected IA.

Treatment recommendations based on fracture risk status are not consistently provided in osteoporosis guidelines.

We examined international osteoporosis guidelines to determine the tools used to assess fracture risk, the classification of fracture risk presented, and the recommendations based on fracture risk status. We conducted a document analysis of guidelines from the International Osteoporosis Foundation (IOF) website retrieved as of May 10, 2018, focusing on guidelines written in English only. Two reviewers independently reviewed each document and the following data were extracted: (1) fracture risk tool(s) endorsed; (2) classification system used to describe fracture risk status (e.g., low, moderate, high); and (3) recommendations based on risk status (e.g., pharmacological treatment). Two additional reviewers verified all data extraction. A total of 112 guidelines were listed on the IOF website, of which 94 were located either through the provided link or through a PubMed search. Of 70 guidelines written in English, 63 guidelines discussed the concept of fracture risk of which, 39 endorsed FRAX. Twenty-eight guidelines defined fracture risk categories or thresholds which determined recommendations. In total, 26 provided a risk category or threshold which constituted an indication for pharmacotherapy. Twelve guidelines reported a moderate, medium, or intermediate risk category which was associated with variable recommendations for testing and treatment. Despite the generally accepted international shift to fracture risk as a basis for treatment decisions, the majority of guidelines in English did not provide treatment recommendations based on fracture risk status. In guidelines with recommendations based on fracture risk status, thresholds and recommendations varied making international comparisons of treatment difficult.

Symptom Resolution and Patient-Perceived Recovery Following Ankle Arthroplasty and Arthrodesis.

BACKGROUND: Patients' perception of outcomes is not always defined by the absence of limitations/symptoms (resolution), but can also be characterized by behavioral adaptation and cognitive coping arising in cases with residual deficits. Patient-reported outcome measures (PROs) are designed to measure levels of function or symptoms, largely missing whether patients are coping with ongoing limitations. This study aimed to broaden the conventional definition of a "satisfactory" outcome following ankle reconstruction by comparing patient-reported outcomes of patients with and without residual symptoms and limitations. METHODS: The study consisted of a cross-sectional survey of ankle arthroplasty (n = 85) and arthrodesis (n = 15) patients. Outcome measures included the Ankle Osteoarthritis Scale, Short Musculoskeletal Function Assessment, Short Form-12, and EuroQol-5 Dimension. Patients also completed measures of pain (0-10), stiffness (0-10), satisfaction (0-3), and ability to complete activities of daily living (ADL) (0-6). Based on a self-reported question regarding recovery and coping, patients were categorized as "Recovered-Resolved" (better with no symptoms or residual effects), "Recovered, not Resolved" (RNR, better with residual effects), or "Not Recovered" (not better). Recovery groups were compared across measures. RESULTS: Only 15% of patients were categorized Recovered-Resolved. Most were RNR (69%), leaving 14% Not Resolved. Recovered-Resolved experienced lower rates of pain (1.4 ± 2.3), stiffness (1.1 ± 2.6), and difficulty performing ADLs (0.9 ± 1.2). Overall, outcome measure scores were high (ie, better health) for Recovered-Resolved patients, midrange for RNR patients, and low for Not Recovered patients, thus confirming predefined hypotheses. Recovered-Resolved and RNR patients had similarly high satisfaction summary scores (3.0 ± 0.0 vs 2.6 ± 0.6). CONCLUSION: Most patients reported positive outcomes, but few (15%) experienced resolution of all symptoms and limitations. Current PROs focus on achieving low levels of symptoms and limitations, but miss an important achievement when patients are brought to a level of residual deficits with which they can cope. Patients' perceptions of satisfactory outcomes were not predicated on the resolution of all limitations; thus, the conventional definition of "satisfactory" outcomes should be expanded accordingly. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Bone Mineral Density Reporting Underestimates Fracture Risk in Ontario.

OBJECTIVE: Analysis of clinical documents such as bone mineral density (BMD) reports is an important component of program evaluation because it can provide insights into the accuracy of assessment of fracture risk communicated to patients and practitioners. Our objective was to compare fracture risk calculations from BMD test reports to those based on the 2010 Canadian guidelines. METHODS: We retrieved BMD reports from fragility fracture patients screened through a community hospital fracture clinic participating in Ontario's Fracture Clinic Screening Program. Fracture risk was determined according to the 2010 Canadian guidelines using age, sex, and T-score at the femoral neck, in addition to three clinical factors. Three researchers classified patients' fracture risk until consensus was achieved. RESULTS: We retrieved reports for 17 patients from nine different BMD clinics in the Greater Toronto Area. Each patient had a different primary care physician and all BMD tests were conducted after the 2010 Canadian guidelines were published. The fracture risk of 10 patients was misclassified with 9 of the 10 reports underestimating fracture risk. Nine reports acknowledged that the prevalence of a fragility fracture raised the risk category by one level but only four of these reports acknowledged that the patient had, or may have sustained, a fragility fracture. When we raised fracture risk by one level according to these reports, eight patients were still misclassified. Fracture risk in the majority of these patients remained underestimated. Inconsistent classification was found in the majority of cases where reports came from the same clinic. Four reports described risk levels for two different types of risk. CONCLUSIONS: More than half of patients received BMD reports which underestimated fracture risk. Bone health management recommendations based on falsely low fracture risk are likely to be sub-optimal.

Reliability and validity of 6 measures of pain, function, and disability for ankle arthroplasty and arthrodesis.

BACKGROUND: Patient-reported outcome measures are increasingly used evaluating clinical care. Many measures used to assess operative hindfoot interventions vary in content, and some have not been psychometrically validated in this population. The purpose of this study was to compare measurement properties of 6 lower-extremity patient-reported outcome measures, and to evaluate their reliability and validity in light of patients' preferences. METHODS: Cross-sectional survey of 42 preoperative and 100 postoperative patients completed 6 lower-extremity outcome measures on 2 occasions: Foot Function Index (FFI), Ankle Osteoarthritis Scale (AOS), patient-reported items of the American Orthopaedic Foot & Ankle Society Questionnaire (AOFAS), Lower Extremity Functional Scale (LEFS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Short Musculoskeletal Function Assessment (SMFA), as well as measures of preference, and symptoms. RESULTS: Internal consistency was good to excellent for all scales and subscales (α = .84-.97; ICC [2,1] = .81-.96). Correlations between scales ranged from .50 (WOMAC(Stiffness) and FFI(Activity) Limitations) to .92 (LEFS and SMFA(Overall), WOMAC(Pain) and AOS(Overall), FFI(Overall) and AOFAS(Overall)). Higher correlations occurred within instruments (r = .97 AOS(Pain) and AOS(Overall)) and between similar subscales from different instruments (r = .91 WOMAC(Pain) and AOS(Pain)). Construct validity showed moderate to high correlations to global ratings of Pain, Stiffness, and difficulty performing Daily Activities. The highest correlations (r > .75) occurred between Pain and AOS(Overall) (r = .84), stiffness and WOMAC(Stiffness) (r = .81), and Daily Activities and AOS(Disability) (r = .87). Patients rated instruments by preference. FFI, WOMAC, LEFS, and SMFA rated favorably for length. FFI, WOMAC, LEFS, and AOFAS rated high for understandability. FFI was rated by postoperative patients as most likely to capture change due to surgery. SMFA rated the best overall. CONCLUSIONS: Direct comparison of instruments revealed similarity between scales in construct validity and reliability. Patient preferences supported the use of these scales. Foot-specific instruments offered no clear advantage over lower-extremity instruments. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Measurement properties of the QuickDASH (disabilities of the arm, shoulder and hand) outcome measure and cross-cultural adaptations of the QuickDASH: a systematic review.

PURPOSE: To identify and synthesize evidence for the measurement properties of the QuickDASH, a shortened version of the 30-item DASH (Disabilities of the Arm, Shoulder and Hand) instrument. METHODS: This systematic review used a best evidence synthesis approach to critically appraise the measurement properties [using COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN)] of the QuickDASH and cross-cultural adaptations. A standard search strategy was conducted between 2005 (year of first publication of QuickDASH) and March 2011 in MEDLINE, EMBASE and CINAHL. RESULTS: The search identified 14 studies to include in the best evidence synthesis of the QuickDASH. A further 11 studies were identified on eight cross-cultural adaptation versions. CONCLUSIONS: Many measurement properties of the QuickDASH have been evaluated in multiple studies and across most of the measurement properties. The best evidence synthesis of the QuickDASH English version suggests that this tool is performing well with strong positive evidence for reliability and validity (hypothesis testing), and moderate positive evidence for structural validity testing. Strong negative evidence was found for responsiveness due to lower correlations with global estimates of change. Information about the measurement properties of the cross-cultural adaptation versions is still lacking, or the available information is of poor overall methodological quality.

The ability of outcome questionnaires to capture patient concerns following ankle reconstruction.

BACKGROUND: The objective of this study was to compare questions from outcome questionnaires with items generated by preoperative and postoperative ankle reconstruction patients (using the open-ended questions of self-reported Patient-Specific Index [PASI]) to determine whether existing questionnaires address patients' concerns. METHODS: Patients (n = 142) completed the PASI. Questions from 6 standardized questionnaires (American Academy of Orthopaedic Surgeons Foot and Ankle Questionnaire [AAOS], patient-reported portion of the American Orthopaedic Foot and Ankle Society Clinical Rating System Ankle-Hindfoot Scale [AOFAS], Foot Function Index [FFI], Lower Extremity Functional Scale [LEFS], Short Musculoskeletal Function Assessment [SMFA], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) and PASI were matched by 3 reviewers to corresponding categories in the International Classification of Functioning, Disability and Health (ICF). Standardized questionnaires were then compared with the patient responses produced by the PASI. RESULTS: Patients identified 690 items corresponding to 45 ICF categories. Most PASI concepts fell into Activities and Participation (60.3%) and Body Functions (29.0%) components, including the categories "walking" (19.1%), "pain" (16.5%), and "recreation and leisure" (15.4%); 237 items were identified in questionnaires and linked to 39 ICF categories. Core issues in questionnaires ("pain," "walking," "stairs") were important concerns for patients, but other key patient concerns ("swelling," "recreation and leisure," "sports") were seldom included in questionnaires. CONCLUSION: No single questionnaire captured all patient concerns, and standardized questionnaires differed largely in content. This analysis may help guide development of a more comprehensive instrument for evaluating outcomes following ankle reconstruction. CLINICAL RELEVANCE: When choosing an outcome questionnaire, clinicians and researchers should consider the targeted outcome because no one questionnaire captures the full patient experience.

Prevalence of inflammatory back pain in a cohort of patients with anterior uveitis.

PURPOSE: To determine the prevalence of inflammatory back pain in an anterior uveitis cohort. DESIGN: Retrospective cohort study. METHODS: Patients with anterior uveitis were recruited from the clinic of an ophthalmologist to complete a survey between March and December 2008. Patients were classified with inflammatory back pain if they had ≥2 positive responses to 4 validated inflammatory back pain questions: presence of morning stiffness >30 minutes in duration; improvement in back pain with exercise but not with rest; awakening from back pain during the second half of the night only; and presence of alternating buttock pain. Disease activity was assessed using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). The impact of disease on quality of life was measured using the EuroQOL (EQ-5D) questionnaire. Twenty-five patients underwent further rheumatologic examination. RESULTS: One hundred forty-one of 167 patients (84.4%) completed the survey. Sixty-six of 141 patients (46.8%) were classified to have inflammatory back pain. Mean BASDAI (4.2, SD 2.41) and EQ-5D scores (0.73, SD 0.21) were lower than patients with no inflammatory back pain (0.82, SD 0.16, P = .0048). In the subgroup that underwent rheumatologic assessment, a classification of inflammatory back pain was 92% sensitive and 67% specific for a diagnosis of inflammatory back pain. CONCLUSIONS: The prevalence of inflammatory back pain in a cohort of anterior uveitis patients was found to be 46.8%. Patients with inflammatory back pain had worse quality of life than those without. Ophthalmologists may use these questions on back pain to select patients classified to have inflammatory back pain to refer for early rheumatologic assessment.

Validity and reliability of the Fear-Avoidance Beliefs Questionnaire (FABQ) in workers with upper extremity injuries.

INTRODUCTION: Fear Avoidance Beliefs (FAB) have been associated with increased pain, dysfunction and difficulty returning to work in Upper Extremity (UE) injures. The FABQ is used to assess FAB, but its measurement properties have not been established in UE. The purpose of this study is to evaluate the reliability and validity of the FABQ to screen UE compensated injured workers for FAB. METHODS: Consenting workers attending a specialty clinic completed a modified FABQ, QuickDASH (Disability), SPADI Pain Score and von Korff Chronic Pain Grade (Pain), SF-36v2 (General Health), and Work Instability Scale (Job Instability). A sub-sample of workers (n = 48) completed the FABQ 2 weeks later for test-retest reliability. RESULTS: 187 workers; 54.0% male; mean age 45.2 (sd 9.68); 56% were currently working. Mean subscale scores (FABQ-Work [FABQ-W]/FABQ-Physical Activity [FABQ-PA]) were 35/42 and 20/24. Ceiling effects (23%/38%) existed in both subscales. Cronbach's alphas were 0.75/0.78. Test-retest analysis (ICC(2,1)) was lower than desired (0.52/0.59). Construct validation was supported by a moderate correlation between FABQ-W/FABQ-PA and QuickDASH Work Module (0.51/0.42) and WIS (0.46/0.38) in those currently working. Low correlations were found between the subscales measures of pain (SPADI: 0.24/0.23; Chronic Pain Grade: 0.25/0.25), and SF-36 MCS (-0.25/-0.30). CONCLUSIONS: Although FAB is an important concept to measure in compensated UE injured workers, the FABQ had limitations in this population as there was a high ceiling effect, and lower than desired reliability for individual discrimination. A priori hypotheses around construct validity were rejected for 16/22 concepts tested.