Team-based care in specialist practice: a path to improved physician experience in British Columbia.

BACKGROUND: Specialist physicians in the province of British Columbia commonly work on teams in acute care settings such as operating rooms or inpatient hospital units. However, while the implementation of team-based care (TBC) has been supported in primary care clinics, no formal mechanisms have supported specialist physicians in adopting TBC in their private outpatient offices. Adopting TBC models is associated with improving physician experience, efficiency, and patient experience. METHODS: The Institute for Healthcare Improvement Breakthrough Series guided a program to support 11 specialist physicians, representing nine different specialties, to develop and implement TBC in outpatient offices. Participants were supported through resources including funding, mentorship, and learning opportunities. To determine whether the program improved physician experience, quantitative data were collected using the validated Mini Z survey and qualitative data were collected through monthly reports, semi-structured interviews, and focus groups. Patient experience data were collected through surveys and follow-up calls. RESULTS: The fifteen-month program was successful, with 10 of the 11 specialists implementing TBC in their offices. The Mini Z results demonstrated that physician experience improved over the course of the program, with scores on job satisfaction, work pace, and time spent on the electronic medical record improving the most. Interviews with specialists and focus groups with specialists' team members support these findings, with participants stating that TBC modulates workloads, begins to affect burnout, improves work-life balance, and increases the efficiency of care. Patients reported positive experiences while receiving TBC. Patients were less likely to visit the emergency department after consultations with specialist teams, and providers agreed that their patients would be less likely to seek acute care because of the new practice models. CONCLUSION: TBC is a viable model for specialist physicians and their health care teams practicing in British Columbia to foster well-being, job satisfaction, and efficiency, and to improve patient experience. These findings may be of interest to specialists, health care providers, policymakers, and administrators looking to better support and retain specialist practices that are integral to patient care.

Multidisciplinary members' perspectives on a pharmacist joining a rheumatology practice team.

BACKGROUND: Pharmacist participation in chronic disease management benefits patients in many ambulatory settings. We explored the attitudes and perceptions among multidisciplinary members of a rheumatology team towards the skills and responsibilities of a pharmacist joining their practice. METHODS: The physicians, nurse, physiotherapist and staff of a rheumatology clinic were invited to participate in focus group and semistructured interviews. Practice members also completed an inventory of perceived health professional roles in the medication use process. RESULTS: Discussions with 2 physicians, a nurse, physiotherapist and 1 office administrator were conducted. Concepts related to 3 key themes included positively viewed pharmacist roles broadly related to activities that encompass provision of medication-related services for the patients, the providers and the practice. Examples of such care included educational tasks related to therapies (rheumatological and otherwise) and maintenance of accurate drug histories. These findings were reflected in high scores for perceived pharmacist roles in education and medication review responsibilities using the Medication Use Processes Matrix instrument. Most members were not comfortable with pharmacists conducting physical assessments and emphasized the need for a team member who could adapt to variations in workflow preferences across rheumatologists in the practice. INTERPRETATION: Perceived pharmacist roles expressed by existing rheumatology team members were largely consistent with the scope of pharmacist knowledge, skills and responsibilities in primary care. CONCLUSION: Overall, existing multidisciplinary staff exhibited favourable attitudes towards a pharmacist joining their practice setting. Data from this job analysis exercise were used to inform the development of a job description for a rheumatology clinical pharmacist.

Using FibroScan to Assess for the Development of Liver Fibrosis in Patients With Arthritis on Methotrexate: A Single-center Experience.

OBJECTIVE: Methotrexate (MTX) is often the primary medication to treat various rheumatic diseases (RDs) because of its low cost and its demonstrated efficacy in controlling disease activity. However, a concern has been the potential for hepatic fibrosis associated with long-term MTX usage. This study investigated the association between cumulative MTX intake and development of liver fibrosis by utilizing noninvasive transient elastography (FibroScan). METHODS: All patients with inflammatory arthritis treated with MTX were offered screening with FibroScan. A certified technician measured liver stiffness after patients adhered to a fast. Relevant clinical information was obtained by patient survey and medical records review. The population was divided into quartiles based on participants' cumulative dosage of MTX. RESULTS: Five hundred twenty patients with RD were included in this study. The prevalence of stages F3 or F4 liver fibrosis was 13.3% in the control group and 12.7% in the entire sample. Compared with subgroup 1 (control with cumulative MTX exposure of ≤ 499 mg), MTX subgroups 2 to 4 were not significantly correlated with higher FibroScan scores (P = 0.82, 0.59, and 0.18, respectively). In multivariable linear regression analysis, statistically significant factors for liver stiffness were BMI, waist circumference, male sex, and age. CONCLUSION: No significant correlation between the cumulative MTX dosage and liver stiffness, even at high MTX doses, was observed. The analyses showed significant correlations between the FibroScan score and BMI. These findings were reassuring in that current rheumatology practice appears to be safe and effective in screening for liver fibrosis in patients on long-term low-dose MTX therapy.

Results From the 2020 Canadian Rheumatology Association's Workforce and Wellness Survey.

OBJECTIVE: The Canadian Rheumatology Association (CRA) launched the Workforce and Wellness Survey to update the Canadian rheumatology workforce characteristics. METHODS: The survey included demographic and practice information, pandemic effects, and the Mini Z survey to assess burnout. French and English survey versions were distributed to CRA members electronically between October 14, 2020, and March 5, 2021. The number of full-time equivalent (FTE) rheumatologists per 75,000 population was estimated from the median proportion of time in clinical practice multiplied by provincial rheumatologist numbers from the Canadian Medical Association. RESULTS: Forty-four percent (183/417) of the estimated practicing rheumatologists (149 adult; 34 pediatric) completed the survey. The median age was 47 years, 62% were female, and 28% planned to retire within the next 5-10 years. Respondents spent a median of 65% of their time in clinical practice. FTE rheumatologists per 75,000 population were 0.62 nationally and ranged between 0.00 and 0.70 in each province/territory. This represents a deficit of 1-78 FTE rheumatologists per province/territory and 194 FTE rheumatologists nationally to meet the CRA's workforce benchmark. Approximately half of survey respondents reported burnout (51%). Women were more likely to report burnout (OR 2.86, 95% CI 1.42-5.93). Older age was protective against burnout (OR 0.95, 95% CI 0.92-0.99). As a result of the pandemic, 97% of rheumatologists reported spending more time engaged in virtual care. CONCLUSION: There is a shortage of rheumatologists in Canada. This shortage may be compounded by the threat of burnout to workforce retention and productivity. Strategies to address these workforce issues are needed urgently.

Use of rituximab in idiopathic retroperitoneal fibrosis.

BACKGROUND: Retroperitoneal fibrosis (RPF) is characterized by the proliferation of fibrous tissue in the retroperitoneum. The majority of RPF cases are due to idiopathic or IgG4-related disease. Recent studies on IgG4-related disease have shown rituximab to be an effective treatment. The current first-line treatment for idiopathic RPF (iRPF) is glucocorticoid therapy. Relapse rates vary widely in the literature, and DMARDs remain poorly studied. We sought to evaluate the efficacy of rituximab in idiopathic RPF by quantifying changes in iRPF diameter on imaging pre- and post-rituximab therapy and response by lab parameters in 10 iRPF patients. METHODS: We selected 10 patients diagnosed with iRPF and previously treated with rituximab (1000 mg) in two doses approximately 2 weeks apart. Pre- and post-therapy contrast enhanced cross-sectional abdomen and pelvis imaging were compared. In all patients, the thickest portion of the peri-aortic disease was measured in the axial and coronal planes. The presence of acute or long standing back pressure related renal findings were documented. Details of clinical visits including patient demographics and laboratory evaluations were collected pre- and post-therapy. Statistical analysis was performed using a Wilcoxon signed rank test. RESULTS: The RPF diameter around the aorta before and after therapy decreased from a mean of 15.9 ± 4.9 mm to 10.6 ± 6.1 mm, respectively (p < 0.01). The craniocaudal iRPF mean length decreased from 108.6 mm ± 40.4 mm to 90.6 mm ± 45.9 mm (p = 0.02). CONCLUSION: A comparison of pre and post-rituximab imaging studies revealed a statistically significant decrease in iRPF diameter following treatment with rituximab.

Adalimumab-associated antiphospholipid syndrome: a case report and review of the literature.

This study aims for the presentation of the first reported case of adalimumab-associated antiphospholipid syndrome (APS) and review of the literature on adalimumab-induced vasculitis and APS. A case of APS associated with adalimumab use in a 67-year-old woman is reported. The English medical literature was reviewed for antitumor necrosis factor (TNF) agents and their association with APS and vasculitis. Adalimumab is a fully humanized monoclonal antibody targeted against TNF alpha that is widely used in the treatment of rheumatoid arthritis, juvenile idiopathic arthritis, ankylosing spondylitis, psoriatic arthritis, psoriasis, and Crohn's disease. Literature review reveals several cases of anti-TNF-induced vasculitis including cases associated with adalimumab. We report the first case of adalimumab-induced APS in a 67-year-old woman who developed APS and vasculitis associated with de novo positive anti-cardiolipin (aCL) antibody following the third dose of adalimumab therapy for the treatment of spondyloarthropathy. This is the first case demonstrating that a short course of adalimumab therapy may induce immunoglobulin M aCL autoantibodies leading to APS. With the growing use of anti-TNF medications in immune-mediated and inflammatory diseases, adalimumab and other anti-TNF medications should be considered as a possible explanation for APS.

Posterior reversible encephalopathy syndrome--an underrecognized manifestation of systemic lupus erythematosus.

OBJECTIVE: Posterior reversible encephalopathy syndrome (PRES) is a rare, recently described neurologic condition identifiable by clinical presentation and magnetic resonance image (MRI) appearance. It is associated with renal insufficiency, hypertension, and rheumatologic diseases. Patients present with headache, seizures, loss of vision and altered mental function, and a pattern on imaging studies of predominantly transient, posterior cerebral hyperintensities on T2-weighted MRI. There is a high likelihood of presentation of this syndrome to a rheumatologist. METHODS: Three recent cases of systemic lupus erythematosus (SLE) with PRES, along with 9 previously reported cases, are reviewed. RESULTS: All 3 patients presented with seizures and subacute visual changes in association with lupus nephritis. The first presented with hypertension, complete visual field loss, and status epilepticus 2 weeks after starting oral cyclosporine therapy for refractory lupus nephritis. The second patient was normotensive and presented with seizures and visual symptoms while in hospital with SLE-related pancreatitis and nephritis. The third patient had headache and seizures with severe lupus disease activity including nephritis, pancytopenia, and pulmonary hemorrhage. Cranial MRI showed predominantly posterior signal abnormalities on T2-weighted images, which resolved after cessation of cyclosporine in the first case, treatment with IV cyclophosphamide in the second case, and treatment with cyclophosphamide and plasmapheresis in the final case. Literature review showed that PRES is a manifestation of SLE or a consequence of therapy with calcineurin inhibitors or rituximab. The hallmark features are visual loss and seizures. Severe hypertension (> 170/110 mm Hg) and renal failure were present in the majority of previously identified cases of SLE and PRES. Our second case was normotensive but had marked lupus disease activity. PRES can lead to cerebral infarction. CONCLUSION: With increasing availability of MRI, PRES will be identified more frequently. Swift action to identify potential offending agents, controlling hypertension, and treating active disease can lead to reversal of radiologic and neurologic findings.