1 Rat Bite Fever Resembling Rheumatoid Arthritis in a 46 Year Old Female

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Objectives: Patient satisfaction has increased with pharmacist intervention in general outpatient clinics and with nurse-led care in rheumatology clinics; however, there is no known data demonstrating increased patient satisfaction for pharmacist care in a rheumatology clinic. The aim of this study was to describe and compare patient satisfaction with two different types of care, a pharmacist-physician collaborative model and physician alone model in a rheumatology clinic setting.
Methods: A cross sectional survey of inflammatory arthritis patients seen during a follow-up visit in Edmonton, Alberta was conducted over a 10-week period. Patient satisfaction was measured using a modified version of the validated Leeds Satisfaction Questionnaire, which uses a 5-point Likert scale to measure 6 dimensions of satisfaction, and compared between two care groups: physician-alone (PA) and pharmacist-physician collaborative care (CC). A sub-group analysis of patient satisfaction between first-visit and subsequent-visit patients in the collaborative care (CC) group was also performed. 
Results: A total of 75 patients completed the questionnaire (15 in the CC and 60 in the PA group). The average age of respondents was 54 years and the majority were female. The mean score for satisfaction across the 6 dimensions was 4.63 in the CC group and 4.42 in the PA group (p=0.09). Patient satisfaction in the CC group was consistently higher across dimensions and both groups demonstrated the highest average score in Technical Quality and Competence (CC: 4.75, PA 4.63).  No difference was noted for between participants seen for the first time compared to those seen 2 or more times by the pharmacist.
Conclusion: Both care groups were highly satisfied in each dimension indicating that patients were satisfied overall with the care they receive. Our findings support the role of pharmacists using a collaborative care approach to care for patients in rheumatology clinics.
Temporal Trends in Drug Prescription, Utilization and Costs Among Rheumatoid Arthritis (RA) Patients Show Wide Regional Variation Despite Universal Drug Coverage
Mark Tatangelo (University of Toronto, Toronto); Michael Paterson (Institute for Clinical Evaluative Sciences, Toronto); George Tomlinson ( University of Toronto, Departments of Health Policy, Management, and Evaluation, and Medicine, Department of Medicine, Toronto); Nick Bansback (University of British Columbia/Arthritis Research Canada, Vancouver); Jessica Widdifield (McGill University, Montreal); Tara Gomes (Institute for Clinical Evaluative Sciences, Toronto); Claire Bombardier (University of Toronto, Toronto)
Objectives: Monitoring of drug use and costs can: describe trends in expenditures over time, identify regional variations in access and indicate physicians’ uptake of best-practice guidelines. Our aim was to describe drug use and costs of biologic (bDMARD) and conventional synthetic Disease Modifying Anti-Rheumatic drug (csDMARDs) in the context of single-payer universal drug coverage.
Methods: We performed a population-based analysis, identifying all RA patients (from 1995 to 2013) who were aged 65 years and older using a validated algorithm (n=37,012). All patients received identical public drug coverage from a single public payer. Prescriptions were determined using the pharmacy claims database of the Ontario Drug Benefit Program. For each patient we recorded the annual number of prescriptions and costs for csDMARDs and bDMARDs and region of residence. Trends in annual drug use and costs were graphed by drug class and regional health authority.
Results: The total number of patients receiving RA medications tripled from 14,222 in 1995 to 37,012 in 2013. During that same time period csDMARD use and costs increased from $2.1M in 1995 to $8.5M in 2013. When bDMARDs were introduced in 2001, 105 patients received bDMARDs (0.4%) increasing to 3226 patients (11%) in 2013. During that period the costs of bDMARDS increased from $0.78M to $54.6M. In 1995, per-patient drug costs in each regional health authority were an average of $500 per patient per year. Since the introduction of bDMARDs in 2001, total cost and per-patient cost variation among regions has increased considerably, with drug expenditure in 2013 ranging from $1200 per patient per year to $2500 per patient per year.  
Conclusion: The number of patients with RA increased linearly over time from 1995 to 2013. The proportion of patients receiving csDMARDs grew at the same rate as the population of patients with RA. The introduction of bDMARDs was associated with an exponential rise of bDMARD use and cost over time driving the increase in total drug costs however the use of bDMARDs was lower than in the US where 27% of patients with a mean age of 70 received bDMARDs. When analyzed by region, adoption of bDMARDs was associated with differential and widening variation in regional drug costs over time, indicating unequal use of bDMARD not explained by differences in reimbursement criteria. We hypothesize that regional access to rheumatology care and rheumatologist’s varying propensity to prescribe bDMARDs are the primary drivers of inequitable utilization of bDMARDs.  
Persistence with Biologic Monotherapy in Comparison with Combination Therapy with Disease-Modifying Antirheumatic Drugs in Patients with Rheumatoid Arthritis; Results from a Rheumatoid Arthritis Cohort
Arthur Lau (McMaster University, St. Joseph`s Healthcare Hamilton, Hamilton); Mohammad Movahedi (JSS Medical Research, Toronto General Hospital Research Institute, University Health Network, Toronto); Mark Tatangelo (University of Toronto, Toronto); Claire Bombardier (University of Toronto, Toronto); OBRI Ontario Best Practices Research Initiative (Toronto)
Objectives: Clinical evidence suggests concomitant treatment with a biologic Disease-Modifying Antirheumatic Drug (bDMARD) and a conventional synthetic DMARD (csDMARD), especially with methotrexate (MTX) has greater efficacy than treatment with a bDMARD as monotheapy in patients with rheumatoid arthritis (RA). However, not all patients are able to tolerate a csDMARD. Our objective was to compare the persistence of a bDMARD used as monotherapy, versus combination therapy in patients with active RA.  
Methods: Physician data were collected from the Ontario Best Practices Research Initiative Rheumatoid Arthritis Registry (OBRI- RA), a clinical registry of RA patients followed in routine care. Inclusion criteria comprised of patients over age 18 years, active RA (defined as ≥1 swollen joint) and started on their 1st bDMARD within 30 days before registry enrolment, or started after enrolment. Combination therapy was defined as treatment with a bDMARD plus at least one csDMARD, while monotherapy was defined as treatment with only a bDMARD. The primary outcome was persistence with 1st bDMARD therapy, which was defined as the length of time the patients continued to receive their first bDMARD therapy. Persistence treatment was examined using Kaplan-Meier survival analysis. Patients were censored at date of 1st bDMARD stop, switch to another bDMARD or at date of last follow-up, whichever came first.  
Results: Among 2591 RA patients, 701 patients started their 1st bDMARD within 30 days before cohort enrolment or after enrolment with the mean (standard deviation) of follow-up 1.9 (1.6) person-years.   A total of 598 (85.3%) patients were on combination therapy, and 103 (14.7%) patients were on monotherapy. At baseline, there was a similar mean age, proportion of females between the two groups. A TNFα inhibitor was the biologic used in 22.6% and 14.5% of the monotherapy and combination group respectively.   The mean time to failure of 1st bDMARD was 4.3 years (95%CI: 3.7-4.9) and 4.6 years (95%CI: 4.3-4.8) in the monotherapy and combination group respectively. At 12 months follow-up, 74% (95%CI: 64-81) in the monotherapy group and 81% (95%CI:  77 -84) in the combination group remained on their first bDMARD.
Conclusion: Our study demonstrates that a higher proportion of patients on monotherapy failed therapy at 12 months, and the mean time to treatment failure was shorter with monotherapy, but these Results were not statistically significant. Although combination therapy is recommended, these real-world Results suggest that patients who are unable/unwilling to continue on a csDMARD, bDMARD monotherapy can still provide an efficacious option.
Attrition and Participant Characteristics in the Ontario Best Practices Research Initiative (OBRI)
Angela Cesta (University Health Network, Toronto); Xiuying Li (Toronto General Hospital, University Health Network, Toronto); Mark Tatangelo (University of Toronto, Toronto); Claire Bombardier (University of Toronto, Toronto)
Objectives: The purpose of this analysis was to assess the generalizability of the Ontario Best Practices Research Initiative (OBRI), by comparing patient characteristics and disease activity of rheumatoid arthritis patients who continue to participate to those who drop out prior to reaching their 3 year follow-up.  
Methods: Sixty-one rheumatologists in Ontario recruit patients into the OBRI. As of January 2015, 2650 patients had consented to participate and 1533 of these patients should have reached their 3 year follow-up assessment at this time. A total of 175 (11.4%) patients dropped out before their 3 yr follow-up. Among the drop outs, 109 (7.1%) withdrew consent, 38 (2.5%) were lost to follow-up, and 28 (1.8%) refused to re-consent after 2 yrs of follow-up. In addition to the drop outs, 38 (2.5%) patients had died. 1320 (86.1%) patients remained active participants. Patient characteristics and disease activity at enrollment were compared in the drop outs versus those who remained active.  A survival curve was generated to look at time of drop out over the 3 year follow-up period.  
Results: Patients who dropped out were similar to those who remained active with respect to age, gender, race, education, employment status, having private insurance, disease duration, number of comorbidities, and living alone. Compared to patients who remained active at their 3 year follow-up, those who dropped out had lower household incomes (17% vs 26% ≥ 75,000), higher disease activity scores, mean  (SD), (DAS28: 4.9(4.4) vs 4.4(1.6), CDAI: 25.7(14.7) vs 20.9(14.3), HAQ: 1.44(0.78) vs 1.22(0.76), Pain Score: 1.76(0.89) vs 1.48(0.87), RADAI: 4.8(2.2) vs 4.0(2.2)) and were less likely to be taking a biologic at the time of enrolment (8% vs 15%).   The survival curve showed the attrition rate to be 11.4% over the first three years of follow-up, with 4.7% of patients dropping out in the first year, 3.5% in the second year, and 3.2% in the third year.  
Conclusion: Patients with higher disease activity at enrollment were more likely to drop out. The majority of patients dropped out within the first two years. The OBRI attrition rates were lower than those reported in the BRASS cohort (4.31% per 6 month follow-up cycle)1 and the ARAMIS cohort (6% per year)2. The lower number of drop outs in the OBRI cohort could be attributed to the time invested in rheumatologist site visits by our study monitors and the biannual follow-up by our OBRI telephone interviewers.  

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