Identifying flares in rheumatoid arthritis: Reliability and construct validation of the OMERACT RA Flare Core Domain Set

Objective: To evaluate the reliability of concurrent flare identification using 3 methods (patient, rheumatologist and Disease Activity Score (DAS)28 criteria), and construct validity of candidate items representing the Outcome Measures in Rheumatology Clinical Trials (OMERACT) RA Flare Core Domain Set. Methods: Candidate flare questions and legacy measures were administered at consecutive visits to Canadian Early Arthritis Cohort (CATCH) patients between November 2011 and November 2014. The American College of Rheumatology (ACR) core set indicators were recorded. Concordance to identify flares was assessed using the agreement coefficient. Construct validity of flare questions was examined: convergent (Spearman's r); discriminant (mean differences between flaring/non-flaring patients); and consequential (proportions with prior treatment reductions and intended therapeutic change postflare). Results: The 849 patients were 75% female, 81% white, 42% were in remission/low disease activity (R/LDA), and 16-32% were flaring at the second visit. Agreement of flare status was low-strong (κ's 0.17-0.88) and inversely related to RA disease activity level. Flare domains correlated highly (r's≥0.70) with each other, patient global (r's≥0.66) and corresponding measures (r's 0.49-0.92); and moderately highly with MD and patient-reported joint counts (r's 0.29-0.62). When MD/patients agreed the patient was flaring, mean flare domain between-group differences were 2.1-3.0; 36% had treatment reductions prior to flare, with escalation planned in 61%. Conclusions: Flares are common in rheumatoid arthritis (RA) and are often preceded by treatment reductions. Patient/MD/DAS agreement of flare status is highest in patients worsening from R/LDA. OMERACT RA flare questions can discriminate between patients with/without flare and have strong evidence of construct and consequential validity. Ongoing work will identify optimal scoring and cut points to identify RA flares

A comparative study on the utility of telehealth in the provision of rheumatology services to rural and northern communities

Introduction. There is a critical shortage of specialty rheumatology services in Canada. The impact is felt more in rural and northern regions than on urban areas of the country. In response to the need, this study was conducted to compare the satisfaction of referring physicians with rheumatology services through conventional visiting specialty clinics; email consults and regularly scheduled videoconference. Methods. Three rural communities of similar size and availability of physician services were assigned to one of the following means of providing outreach rheumatology services: visiting rheumatologist clinics, email access to rheumatologist and scheduled videoconference consults. A case based pre/post test, and post satisfaction questionnaire were administered to the primary care physicians in these communities. Patient outcomes, and physician ability and confidence in managing specific arthritis problems, were measured. Results. Physicians responded positively to all methods of rheumatology service provision. The videoconference group were the most positive. The reasons were: immediate feedback to referring physician and patient, effective case based learning and transfer of knowledge, and improved accessibility. Conclusion. Videoconference is preferred to visiting clinics and email as a method for rheumatology services to rural/northern communities. It is cost effective and there is knowledge transfer between the rheumatologist and the referring physicians