Introduction
DMARDs, or ‘disease-modifying anti-rheumatic drugs’ are the #1 recommended treatment for RA (rheumatoid arthritis). In recent years, RA treatment guidelines have shifted toward early and aggressive management with DMARD therapy (1). This shift was prompted by long-term observational studies showing that delaying DMARD therapy leads to poorer long term outcomes including severe functional decline (3), radiographic progression (4), considerable economic losses (7), work disability (5) and premature mortality (6). Rheumatologists prescribe them to most patients they see. Yet, more than half of RA patients in British Columbia do no see RA specialists. Instead, they see their family doctors who seldom prescribe DMARDs (2). In fact, only 1 out of 10 RA patients treated by their family doctors receive DMARDs. Because of the shortage of rheumatologists in BC, family doctors will need to continue providing RA care. Therefore, the best way to increase DMARD use is to encourage family doctors to prescribe them.This suggest that many family physicians may not be aware of changes to RA treatment guidelines.
“Falling through the cracks: using a multidisciplinary strategy to expand DMARD use in RA” investigates how to encourage family doctors to prescribe DMARDs. Since pharmacists are medication experts, and physiotherapists are trained to give physical exams, we think they can be utilized to improve clinical outcomes for RA patients through expanded community-based services.
Aims/Objectives
Demonstrate the feasibility of
A) using pharmacists to identify RA patients not treated with DMARDs
B) using physiotherapists to identify active inflammation
C) Measure the proportion of RA patients identified by pharmacists who Qualify or May Qualify for DMARDs
D) Measure the proportion of participants prescribed a DMARD within 6 months of the PT exam
E) Measure the proportion of patients referred to a rheumatologist
F) Measure the proportion of patients initiating non-pharmacological RA treatments
G) Measure changes in health status, RA symptoms, and quality of life over the 6 month follow-up
The following three steps are involved in the study:
Step 1:
Complementary CPPD accredited training, study materials, advertisements and tools are provided to all participating pharmacies.
Step 2:
Pharmacist will provide a letter of information, collect a consent form, and take information from any interested patients who have been diagnosed with RA but are not receiving DMARD therapy. The collected forms will be faxed or mailed back to UBC CORE. Pharmacist will refer patient who meet the study criteria to a physiotherapist at the Mary Pack Arthritis Centre who will assess for active inflammation through a physical examination.
Step 3:
Pharmacists will contact family doctors to confirm RA diagnoses and DMARD appropriateness, and provide information on DMARDs and current RA treatment guidelines.
Participant Recruitment:
Ads will be printed on flyers in newspapers and placed in pharmacies. The ads will ask RA patients who were diagnosed by a doctor to speak to the pharmacist if they are interested in participating in a study about RA care. Flyers will also be placed in the packages of patients’ prescription medications for RA (such as NSAIDs and/or corticosteroids). Pharmacists will also identify participants through normal pharmacist-patient interactions.
Time Frame and Results:
This study will start in the summer/fall of 2010, and results should be available by spring 2012.
Why should Pharmacists participate:
Pharmacists will gain an increased understanding of rheumatoid arthritis, RA medication management and health services research studies which can help them better serve their patient population. Although pharmacists are not financially remunerated outside their regular salaries for participating, pharmacists have a chance to participate in research that could support the multidisciplinary model of care. The results may inform health policies and encourage the billing model for clinical services. Each pharmacist will also receive 1.75 CPPD (Continuing Pharmacy Professional Development) credits for their participation.
“DMARDs are medications that have been proven to slow the progression of rheumatoid arthritis thereby reducing work disability. It is critical to improve the dismal record of DMARD use for rheumatoid arthritis patients here in BC. This initiative is poised to improve patient care through interdisciplinary collaboration and, if successful, could be a model for other provinces.”
Dr. Kam Shojania,
Clinical Associate Professor,
Head of the Division of Rheumatology,
Faculty of Medicine, UBC
References
1) Guidelines for the Management of Rheumatoid Arthritis American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines. Arthritis & Rheumatism 2002;46(2):328-346.
2) Lacaille D, Anis AH, Guh DP, Esdaile JM. Gaps in care for rheumatoid arthritis: A population study. Arthritis Rheum 2005 Apr 15;53(2):241-8.
3) Pincus T, Callahan LF, Sale WG, Brooks AL, Payne LE, Vaughn WK. Severe functional declines, work disability, and increased mortality in seventy-five rheumatoid arthritis patients studied over nine years. Arthritis Rheum 1984 Aug;27(8):864-72.
4) Scott DL, Grindulis KA, Struthers GR, Coulton BL, Popert AJ, Bacon PA. Progression of radiological changes in rheumatoid arthritis. Ann Rheum Dis 1984 Feb;43(1):8-17.
5) Yelin E, Meenan R, Nevitt M, Epstein W. Work disability in rheumatoid arthritis: Effects of disease, social, and work factors. Ann Intern Med 1980 Oct;93(4):551-6.
6) Mitchell DM, Spitz PW, Young DY, Bloch DA, McShane DJ, Fries JF. Survival, prognosis, and causes of death in rheumatoid arthritis. Arthritis Rheum 1986 Jun;29(6):706-14.
7) Wolfe F, Kleinheksel SM, Spitz PW, Lubeck DP, Fries JF, Young DY, Mitchell D, Roth S. A multicenter study of hospitalization in rheumatoid arthritis. frequency, medical-surgical admissions, and charges. Arthritis Rheum 1986 May;29(5):614-9.
1) BC guidelines for RA
2) RA information and clinical resources
3) Search for a Physiotherapist by name or workplace Physiotherapy Association of British Columbia 604 736-5130. www.bcphysio.org or www.bcphysio.org/app/index.cfm?fuseaction=public.home
4) The Arthritis Society Toll free phone number: 1 800 321-1433
5) 2008 ACR Recommendations for DMARD Use
