“They just scraped off the calluses”: a mixed methods exploration of foot care access and provision for people with rheumatoid arthritis in south-western Sydney, Australia

Background: There is little indication that foot health services in Australia are meeting modern day recommendations for Rheumatoid Arthritis (RA) patients. The overall objective of this study was to explore the current state of foot health services for patients with RA with an emphasis on identifying barriers to the receipt of appropriate foot care in South-West Sydney, New South Wales, Australia.Methods: A mixed (quantitative and qualitative) approach was adopted. Indications for appropriate access to foot care were determined by comparing the foot health, disease and socio-demographic characteristics of patients with unmet foot care demands, foot care users and patients with no demands for foot care. Perceptions of provision of, and access to, foot care were explored by conducting telephone-based interviews using an interpretative phenomenology approach with thematic analysis.Results: Twenty-nine participants took part in the cross-sectional quantitative research study design, and 12 participants took part in the interpretative phenomenological approach (qualitative study). Foot care access appeared to be driven predominantly by the presence of rearfoot deformity, which was significantly worse amongst participants in the foot care user group (p = 0.02). Five main themes emerged from the qualitative data: 1) impact of disease-related foot symptoms, 2) footwear difficulties, 3) medical/rheumatology encounters, 4) foot and podiatry care access and experiences, and 5) financial hardship.Conclusions: Foot care provision does not appear to be driven by appropriate foot health characteristics such as foot pain or foot-related disability. There may be significant shortfalls in footwear and foot care access and provision in Greater Western Sydney. Several barriers to adequate foot care access and provision were identified and further efforts are required to improve access to and the quality of foot care for people who have RA. Integration of podiatry services within rheumatology centres could resolve unmet needs of people with RA by permitting rapid access to expert-led multidisciplinary foot care for people with RA

Elevating the role of carers in rheumatoid arthritis management in the Asia-Pacific region

Aim: Carers may offer valuable insight into the true health status of patients with rheumatoid arthritis (RA). This multinational, multi-stakeholder, exploratory study in Australia, China and Japan aimed to enrich our understanding of the role and potential impact of carers on RA management. Method: This study used a 2-phase sequential mixed methods approach involving 3 key stakeholder groups: rheumatologists, RA patients and carers. The first phase involved an in-depth qualitative exploratory survey (n = 30), which informed the development of the subsequent quantitative validation survey (n = 908). In both phases, patients and carers provided self-assessments of disease and support parameters. Results: In the qualitative phase, patients usually understated the amount of physical support required, compared to carers. Rheumatologists underestimated the amount of physical and emotional care required, compared to carers and patients; however, in the quantitative phase, rheumatologists overestimated the level of support provided by carers. Levels of support provided by carers increased as disease severity increased. Active participation of carers in clinical consultations and treatment decision-making was deemed important by 55% of all patients and 82% of all carers. All stakeholders believed carers’ insights into the physical and emotional conditions of patients were useful and should be considered in clinical decision-making. Over 95% of rheumatologists reported soliciting input from the carer. Conclusion: Carers provide valuable input that can give clinicians greater insight into the patients’ physical and emotional states, and treatment adherence. Development of standardized carer-reported outcomes that correlate with patient-reported outcomes and clinical parameters will ensure clinical meaningfulness and external validity

Provision of foot health services for people with rheumatoid arthritis in New South Wales: a web-based survey of local podiatrists

Background: It is unclear if podiatric foot care for people with rheumatoid arthritis (RA) in New South Wales (NSW) meets current clinical recommendations. The objective of this study was to survey podiatrists' perceptions of the nature of podiatric foot care provision for people who have RA in NSW.Methods: An anonymous, cross-sectional survey with a web-based questionnaire was conducted. The survey questionnaire was developed according to clinical experience and current foot care recommendations. State registered podiatrists practising in the state of NSW were invited to participate. The survey link was distributed initially via email to members of the Australian Podiatry Association (NSW), and distributed further through snowballing techniques using professional networks. Data was analysed to assess significant associations between adherence to clinical practice guidelines, and private/public podiatry practices.Results: 86 podiatrists participated in the survey (78% from private practice, 22% from public practice). Respondents largely did not adhere to formal guidelines to manage their patients (88%). Only one respondent offered a dedicated service for patients with RA. Respondents indicated that the primary mode of accessing podiatry was by self-referral (68%). Significant variation was observed regarding access to disease and foot specific assessments and treatment strategies. Assessment methods such as administration of patient reported outcome measures, vascular and neurological assessments were not conducted by all respondents. Similarly, routine foot care strategies such as prescription of foot orthoses, foot health advice and footwear were not employed by all respondents.Conclusions: The results identified issues in foot care provision which should be explored through further research. Foot care provision in NSW does not appear to meet the current recommended standards for the management of foot problems in people who have RA. Improvements to foot care could be undertaken in terms of providing better access to examination techniques and treatment strategies that are recommended by evidence based treatment paradigms. © 2013 Hendry et al.; licensee BioMed Central Ltd

Methotrexate

This publication does not have an abstract. The Introduction is displayed as the abstract.\ud \ud Methotrexate (MTX) is a folate analogue originally developed in the 1940s as a highly selective inhibitor of dihydrofolate reductase (DHFR). Its use in the reduction\ud of rheumatoid arthritis (RA) synovitis was first reported in a 1951 paper on six RA patients by Gubner and Ginsburg and explained as a cytotoxic effect on proliferating\ud lymphocytes. Subsequently its efficacy in RA was proven in a series of papers in the mid 1980s and it is now the mainstay of RA therapy, both alone and in combination,\ud as recommended in the guidelines of the American College of Rheumatology 2002 [1]

Methotrexate

This publication does not have an abstract. The Introduction is displayed as the abstract. Methotrexate (MTX) is a folate analogue originally developed in the 1940s as a highly selective inhibitor of dihydrofolate reductase (DHFR). Its use in the reduction of rheumatoid arthritis (RA) synovitis was first reported in a 1951 paper on six RA patients by Gubner and Ginsburg and explained as a cytotoxic effect on proliferating lymphocytes. Subsequently its efficacy in RA was proven in a series of papers in the mid 1980s and it is now the mainstay of RA therapy, both alone and in combination, as recommended in the guidelines of the American College of Rheumatology 2002 [1]

Treatment of early undifferentiated arthritis

Undifferentiated arthritis progresses to RA in one third of cases and spontaneously remits in up to half of patients, with disease persistence and the development of RA more likely in those with the greater clinical burden of synovitis. Clinical and laboratory characteristics can be utilized within algorithms to more accurately predict disease progression and a need for disease modifying therapy. Biological agents are not required as first line therapy with excellent results from traditional DMARDs if a treat to target approach is used and early intense escalation of therapy undertaken when outcome targets are not achieved

Osteoarthritis: analgesics, lubricants and vitamins

Biomechanical review of weight, occupation, splints and footwear is a key step in osteoarthritis (OA) management and prevention. Non- steroidal anti-inflammatory drugs (NSAIDs) and specific cyclooxygenase- 2 (COX-2) inhibitors provide pain relief in OA. Intra-articular hyaluronic acid has a major placebo response but appears to be effective for knee OA. Vitamins C and D appear to reduce pain and radiological progression of OA but do not influence the development of new OA changes

Problem Solving in Rheumatology

This book identifies and resolves a selection of typical individual patient management problems that will confront the GP or rheumatologist in his daily work. More than 50 problems and solutions covering all the major areas of rheumatic disorders are included: rheumatoid arthritis, ankyklosing spondylitis, joint replacement surgery, gout, pain management, fibromyalgia, carpel tunnel syndrome, tennis elbow, autoimmune disease and vascular complications, osteoporosis, diet, infections and tumours. In style of the series, each case is accompanied by introductory questions, key references and a management algorithm. The practice of rheumatology is constantly changing with new ways to manage disorders. Problem Solving in Rheumatology shows how recent developments in clinical and pharmaceutical research may be implemented in daily clinical practice. This book will be an invaluable desk reference for the doctor