Kevin D Deane, Christopher C Striebich, Barbara L Goldstein, Lezlie A Derber, Mark C Parish, Marie L Feser, Elaine M Hamburger, Stacey Brake, Cindy Belz, James Goddard, Jill M Norris, Elizabeth W Karlson, V Michael Holers
Objective: To identify individuals with undiagnosed inflammatory arthritis (IA) and rheumatoid arthritis (RA) in a community health fair screen, and to establish in a health fair setting the diagnostic accuracy of combinations of the Connective Tissue Disease Screening Questionnaire (CSQ) and autoantibody testing for IA.
Methods: Screening for IA/RA was performed at health fair sites using a combination of the CSQ, joint examination, rheumatoid factor, and anti-cyclic citrullinated peptide (anti-CCP) antibody testing. IA was defined as > or =1 swollen joint suggestive of synovitis on joint examination by a trained clinician.
Results: Six hundred one subjects were screened; 51.0% participated because of joint symptoms (pain, stiffness, or swelling). Eighty-four subjects (14.0%) had > or =1 swollen joint, designated as IA on joint examination. Of the 601 subjects screened, 9 (1.5%) had IA and met > or =4 of 7 American College of Rheumatology criteria for RA but had no prior diagnosis of RA, and 15 (2.5%) had IA and RF and/or anti-CCP positivity, suggesting early RA. The diagnostic accuracy of combinations of the CSQ and autoantibody testing for the identification of IA yielded maximal sensitivity, specificity, and positive and negative predictive values of 95.3%, 99.2%, 71.4%, and 97.7%, respectively.
Conclusion: Health fair screening may be an effective approach for the identification of individuals with undiagnosed IA/RA. A combination of the CSQ and autoantibody testing alone has clinically useful diagnostic accuracy for the detection of IA. Decisions regarding which methodology to use for future health fair IA/RA screening will depend on goals of screening and funding.
目的:在社区卫生公平筛查中识别未确诊的炎症性关节炎(IA)和类风湿关节炎(RA)个体,并建立结缔组织疾病筛查问卷(CSQ)和自身抗体检测联合诊断IA的准确性。方法:在卫生博览会现场,采用综合CSQ、关节检查、类风湿因子和抗环瓜氨酸肽(anti-CCP)抗体检测进行IA/RA筛查。经训练有素的临床医生进行关节检查,将IA定义为>或=1的关节肿胀提示滑膜炎。结果:共筛选受试者601人;51.0%是因为关节症状(疼痛、僵硬或肿胀)而参加的。84例(14.0%)有>或=1个关节肿胀,关节检查为IA。在筛选的601名受试者中,9名(1.5%)患有IA,符合美国风湿病学会(American College Of Rheumatology) 7项RA标准中的>或=4项,但之前没有诊断过RA, 15名(2.5%)患有IA和RF和/或抗ccp阳性,提示早期RA。结合CSQ和自身抗体检测对IA的诊断准确性最高,分别为95.3%、99.2%、71.4%和97.7%的敏感性、特异性和阳性预测值。结论:健康公平筛查可能是鉴别未确诊IA/RA患者的有效方法。单独结合CSQ和自身抗体检测对IA的检测具有临床有用的诊断准确性。关于使用哪种方法进行未来健康公平的IA/RA筛查的决定将取决于筛查的目标和资金。
{"title":"Identification of undiagnosed inflammatory arthritis in a community health fair screen.","authors":"Kevin D Deane, Christopher C Striebich, Barbara L Goldstein, Lezlie A Derber, Mark C Parish, Marie L Feser, Elaine M Hamburger, Stacey Brake, Cindy Belz, James Goddard, Jill M Norris, Elizabeth W Karlson, V Michael Holers","doi":"10.1002/art.24834","DOIUrl":"https://doi.org/10.1002/art.24834","url":null,"abstract":"<p><strong>Objective: </strong>To identify individuals with undiagnosed inflammatory arthritis (IA) and rheumatoid arthritis (RA) in a community health fair screen, and to establish in a health fair setting the diagnostic accuracy of combinations of the Connective Tissue Disease Screening Questionnaire (CSQ) and autoantibody testing for IA.</p><p><strong>Methods: </strong>Screening for IA/RA was performed at health fair sites using a combination of the CSQ, joint examination, rheumatoid factor, and anti-cyclic citrullinated peptide (anti-CCP) antibody testing. IA was defined as > or =1 swollen joint suggestive of synovitis on joint examination by a trained clinician.</p><p><strong>Results: </strong>Six hundred one subjects were screened; 51.0% participated because of joint symptoms (pain, stiffness, or swelling). Eighty-four subjects (14.0%) had > or =1 swollen joint, designated as IA on joint examination. Of the 601 subjects screened, 9 (1.5%) had IA and met > or =4 of 7 American College of Rheumatology criteria for RA but had no prior diagnosis of RA, and 15 (2.5%) had IA and RF and/or anti-CCP positivity, suggesting early RA. The diagnostic accuracy of combinations of the CSQ and autoantibody testing for the identification of IA yielded maximal sensitivity, specificity, and positive and negative predictive values of 95.3%, 99.2%, 71.4%, and 97.7%, respectively.</p><p><strong>Conclusion: </strong>Health fair screening may be an effective approach for the identification of individuals with undiagnosed IA/RA. A combination of the CSQ and autoantibody testing alone has clinically useful diagnostic accuracy for the detection of IA. Decisions regarding which methodology to use for future health fair IA/RA screening will depend on goals of screening and funding.</p>","PeriodicalId":8405,"journal":{"name":"Arthritis and rheumatism","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2009-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/art.24834","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"28539018","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Each measure of patient-reported change provides useful information and is susceptible to bias: the need to combine methods to assess their relative validity.","authors":"Pythia T Nieuwkerk, Mirjam A G Sprangers","doi":"10.1002/art.25030","DOIUrl":"https://doi.org/10.1002/art.25030","url":null,"abstract":"","PeriodicalId":8405,"journal":{"name":"Arthritis and rheumatism","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2009-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/art.25030","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"28539020","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jasper F C Wolfs, Margreet Kloppenburg, Michael G Fehlings, Maurits W van Tulder, Maarten Boers, Wilco C Peul
Objective: Rheumatoid arthritis commonly involves the upper cervical spine and can cause significant neurologic morbidity and mortality. However, there is no consensus on the optimal timing for surgical intervention: whether surgery should be performed prophylactically or once neurologic deficits have become apparent.
Methods: A systematic review of the literature was performed to analyze neurologic outcome (Ranawat) and survival time (Kaplan-Meier) after surgical or conservative treatment using the MOOSE (Meta-analysis Of Observational Studies in Epidemiology) and GRADE (Grading of Recommendations, Assessment, Development and Evaluation system) criteria.
Results: Twenty-five observational studies were selected. No randomized controlled trials (RCTs) could be found. All of the studies had a high risk of bias. Twenty-three studies reported the neurologic outcome after surgery for 752 patients. Neurologic deterioration rarely occurred in Ranawat I and II patients. Ranawat III patients did not fully recover. The 10-year survival rates were 77%, 63%, 47%, and 30% for Ranawat I, II, IIIA, and IIIB, respectively. The Ranawat IIIB patients had a significantly worse outcome. Another 185 patients treated conservatively were described in 7 studies. Neurologic deterioration rarely occurred in Ranawat I patients, but was almost inevitable in Ranawat II, IIIA, and IIIB patients. The Kaplan-Meier analysis showed a 10-year overall survival rate of 40%.
Conclusion: There are no RCTs that compared surgery with conservative treatment. In observational studies, surgical neurologic outcomes were better than conservative treatment in all patients with cervical spine involvement, and in asymptomatic patients with no neurologic impairment (Ranawat I) the outcomes were similar; however, the evidence is weak. Survival time of surgical and conservative treatment could not be compared.
目的:类风湿关节炎通常累及上颈椎,可引起显著的神经系统发病率和死亡率。然而,对于手术干预的最佳时机没有达成共识:是否应该进行手术预防或一旦神经功能缺陷变得明显。方法:采用MOOSE (Meta-analysis of Observational Studies in Epidemiology)和GRADE (Grading of Recommendations, Assessment, Development and Evaluation system)标准系统回顾文献,分析手术或保守治疗后的神经预后(Ranawat)和生存时间(Kaplan-Meier)。结果:选取了25项观察性研究。未发现随机对照试验(rct)。所有的研究都有很高的偏倚风险。23项研究报告了752例患者手术后的神经系统预后。Ranawat I型和II型患者很少发生神经功能恶化。Ranawat III型患者没有完全康复。Ranawat I、II、IIIA和IIIB的10年生存率分别为77%、63%、47%和30%。Ranawat IIIB组患者的预后明显较差。另有185例患者在7项研究中接受了保守治疗。神经功能恶化很少发生在Ranawat I患者中,但在Ranawat II、IIIA和IIIB患者中几乎是不可避免的。Kaplan-Meier分析显示10年总生存率为40%。结论:没有比较手术与保守治疗的随机对照试验。在观察性研究中,所有颈椎受损伤患者的手术神经预后优于保守治疗,无神经功能损害的无症状患者(Ranawat I)的预后相似;然而,证据不足。手术与保守治疗的生存时间无法比较。
{"title":"Neurologic outcome of surgical and conservative treatment of rheumatoid cervical spine subluxation: a systematic review.","authors":"Jasper F C Wolfs, Margreet Kloppenburg, Michael G Fehlings, Maurits W van Tulder, Maarten Boers, Wilco C Peul","doi":"10.1002/art.25011","DOIUrl":"https://doi.org/10.1002/art.25011","url":null,"abstract":"<p><strong>Objective: </strong>Rheumatoid arthritis commonly involves the upper cervical spine and can cause significant neurologic morbidity and mortality. However, there is no consensus on the optimal timing for surgical intervention: whether surgery should be performed prophylactically or once neurologic deficits have become apparent.</p><p><strong>Methods: </strong>A systematic review of the literature was performed to analyze neurologic outcome (Ranawat) and survival time (Kaplan-Meier) after surgical or conservative treatment using the MOOSE (Meta-analysis Of Observational Studies in Epidemiology) and GRADE (Grading of Recommendations, Assessment, Development and Evaluation system) criteria.</p><p><strong>Results: </strong>Twenty-five observational studies were selected. No randomized controlled trials (RCTs) could be found. All of the studies had a high risk of bias. Twenty-three studies reported the neurologic outcome after surgery for 752 patients. Neurologic deterioration rarely occurred in Ranawat I and II patients. Ranawat III patients did not fully recover. The 10-year survival rates were 77%, 63%, 47%, and 30% for Ranawat I, II, IIIA, and IIIB, respectively. The Ranawat IIIB patients had a significantly worse outcome. Another 185 patients treated conservatively were described in 7 studies. Neurologic deterioration rarely occurred in Ranawat I patients, but was almost inevitable in Ranawat II, IIIA, and IIIB patients. The Kaplan-Meier analysis showed a 10-year overall survival rate of 40%.</p><p><strong>Conclusion: </strong>There are no RCTs that compared surgery with conservative treatment. In observational studies, surgical neurologic outcomes were better than conservative treatment in all patients with cervical spine involvement, and in asymptomatic patients with no neurologic impairment (Ranawat I) the outcomes were similar; however, the evidence is weak. Survival time of surgical and conservative treatment could not be compared.</p>","PeriodicalId":8405,"journal":{"name":"Arthritis and rheumatism","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2009-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/art.25011","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"28539969","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Andrew B Lemmey, Samuele M Marcora, Kathryn Chester, Sally Wilson, Francesco Casanova, Peter J Maddison
Objective: To confirm, in a randomized controlled trial (RCT), the efficacy of high-intensity progressive resistance training (PRT) in restoring muscle mass and function in patients with rheumatoid arthritis (RA). Additionally, to investigate the role of the insulin-like growth factor (IGF) system in exercise-induced muscle hypertrophy in the context of RA.
Methods: Twenty-eight patients with established, controlled RA were randomized to either 24 weeks of twice-weekly PRT (n = 13) or a range of movement home exercise control group (n = 15). Dual x-ray absorptiometry-assessed body composition (including lean body mass [LBM], appendicular lean mass [ALM], and fat mass); objective physical function; disease activity; and muscle IGFs were assessed at weeks 0 and 24.
Results: Analyses of variance revealed that PRT increased LBM and ALM (P < 0.01); reduced trunk fat mass by 2.5 kg (not significant); and improved training-specific strength by 119%, chair stands by 30%, knee extensor strength by 25%, arm curls by 23%, and walk time by 17% (for objective function tests, P values ranged from 0.027 to 0.001 versus controls). In contrast, body composition and physical function remained unchanged in control patients. Changes in LBM and regional lean mass were associated with changes in objective function (P values ranged from 0.126 to <0.0001). Coinciding with muscle hypertrophy, previously diminished muscle levels of IGF-1 and IGF binding protein 3 both increased following PRT (P < 0.05).
Conclusion: In an RCT, 24 weeks of PRT proved safe and effective in restoring lean mass and function in patients with RA. Muscle hypertrophy coincided with significant elevations of attenuated muscle IGF levels, revealing a possible contributory mechanism for rheumatoid cachexia. PRT should feature in disease management.
{"title":"Effects of high-intensity resistance training in patients with rheumatoid arthritis: a randomized controlled trial.","authors":"Andrew B Lemmey, Samuele M Marcora, Kathryn Chester, Sally Wilson, Francesco Casanova, Peter J Maddison","doi":"10.1002/art.24891","DOIUrl":"https://doi.org/10.1002/art.24891","url":null,"abstract":"<p><strong>Objective: </strong>To confirm, in a randomized controlled trial (RCT), the efficacy of high-intensity progressive resistance training (PRT) in restoring muscle mass and function in patients with rheumatoid arthritis (RA). Additionally, to investigate the role of the insulin-like growth factor (IGF) system in exercise-induced muscle hypertrophy in the context of RA.</p><p><strong>Methods: </strong>Twenty-eight patients with established, controlled RA were randomized to either 24 weeks of twice-weekly PRT (n = 13) or a range of movement home exercise control group (n = 15). Dual x-ray absorptiometry-assessed body composition (including lean body mass [LBM], appendicular lean mass [ALM], and fat mass); objective physical function; disease activity; and muscle IGFs were assessed at weeks 0 and 24.</p><p><strong>Results: </strong>Analyses of variance revealed that PRT increased LBM and ALM (P < 0.01); reduced trunk fat mass by 2.5 kg (not significant); and improved training-specific strength by 119%, chair stands by 30%, knee extensor strength by 25%, arm curls by 23%, and walk time by 17% (for objective function tests, P values ranged from 0.027 to 0.001 versus controls). In contrast, body composition and physical function remained unchanged in control patients. Changes in LBM and regional lean mass were associated with changes in objective function (P values ranged from 0.126 to <0.0001). Coinciding with muscle hypertrophy, previously diminished muscle levels of IGF-1 and IGF binding protein 3 both increased following PRT (P < 0.05).</p><p><strong>Conclusion: </strong>In an RCT, 24 weeks of PRT proved safe and effective in restoring lean mass and function in patients with RA. Muscle hypertrophy coincided with significant elevations of attenuated muscle IGF levels, revealing a possible contributory mechanism for rheumatoid cachexia. PRT should feature in disease management.</p>","PeriodicalId":8405,"journal":{"name":"Arthritis and rheumatism","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2009-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/art.24891","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"28539971","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Miriam G Cisternas, Edward Yelin, Jeffrey N Katz, Daniel H Solomon, Elizabeth A Wright, Elena Losina
Objective: To estimate the proportion of adults with osteoarthritis (OA) seeing various medical providers and ascertain factors affecting the likelihood of a patient seeing an OA specialist.
Methods: We used data from the Medical Expenditures Panel Survey, a stratified random sample of the noninstitutionalized civilian population. We classified adults as having symptomatic OA if their medical conditions included at least 1 occurrence of the International Classification of Diseases, Ninth Revision Clinical Modification, codes 715, 716, or 719, and if they reported joint pain, swelling, or stiffness during the previous 12 months. For the purpose of our analysis, we defined rheumatologists, orthopedists, and physical therapists as OA specialists. We first estimated the proportion of OA individuals seen by OA specialists and other health care providers in a 1-year period. We then used logistic regression to estimate the impact of demographic and clinical factors on the likelihood of an individual seeing an OA specialist.
Results: A total of 9,933 persons met the definition of OA, representing 22.5 million adults in the US. Of these persons, 92% see physicians during the year, 34% see at least 1 OA specialist, 25% see an orthopedist, 11% see a physical therapist, and 6% see a rheumatologist. Higher educational attainment, having more comorbidities, and residing in the northeastern US are significant positive predictors for a patient seeing an OA specialist. Significant negative predictors for seeing an OA specialist are being unmarried but previously married and having no health insurance.
Conclusion: Most adults with OA do not visit OA specialists. Those without insurance and with lower levels of education are less likely to see these specialists.
目的估计患有骨关节炎(OA)的成年人看各种医疗机构的比例,并确定影响患者看 OA 专家的可能性的因素:我们使用了医疗支出小组调查(Medical Expenditures Panel Survey)的数据,该调查是对非住院平民人口的分层随机抽样。如果成年人的病症至少包含一次《国际疾病分类》第九版临床修订代码 715、716 或 719,并且在过去 12 个月中报告有关节疼痛、肿胀或僵硬,我们就将其归类为有症状的 OA。为便于分析,我们将风湿病学家、矫形外科医生和理疗师定义为 OA 专家。我们首先估算了 1 年内接受过 OA 专家和其他医疗服务提供者诊治的 OA 患者的比例。然后,我们使用逻辑回归法估算了人口统计学和临床因素对患者看 OA 专家的可能性的影响:共有 9,933 人符合 OA 的定义,代表了美国 2250 万成年人。在这些人中,92%的人在一年中看过医生,34%的人至少看过一名OA专科医生,25%的人看过骨科医生,11%的人看过理疗师,6%的人看过风湿病医生。教育程度较高、合并症较多、居住在美国东北部是患者看 OA 专科医生的重要积极预测因素。未婚但曾结过婚以及没有医疗保险则是影响患者去看 OA 专科医生的重要负面因素:结论:大多数患有 OA 的成年人都不会去看 OA 专科医生。结论:大多数患有 OA 的成年人都没有去看 OA 专科医生,那些没有医疗保险和教育水平较低的人更不可能去看这些专科医生。
{"title":"Ambulatory visit utilization in a national, population-based sample of adults with osteoarthritis.","authors":"Miriam G Cisternas, Edward Yelin, Jeffrey N Katz, Daniel H Solomon, Elizabeth A Wright, Elena Losina","doi":"10.1002/art.24897","DOIUrl":"10.1002/art.24897","url":null,"abstract":"<p><strong>Objective: </strong>To estimate the proportion of adults with osteoarthritis (OA) seeing various medical providers and ascertain factors affecting the likelihood of a patient seeing an OA specialist.</p><p><strong>Methods: </strong>We used data from the Medical Expenditures Panel Survey, a stratified random sample of the noninstitutionalized civilian population. We classified adults as having symptomatic OA if their medical conditions included at least 1 occurrence of the International Classification of Diseases, Ninth Revision Clinical Modification, codes 715, 716, or 719, and if they reported joint pain, swelling, or stiffness during the previous 12 months. For the purpose of our analysis, we defined rheumatologists, orthopedists, and physical therapists as OA specialists. We first estimated the proportion of OA individuals seen by OA specialists and other health care providers in a 1-year period. We then used logistic regression to estimate the impact of demographic and clinical factors on the likelihood of an individual seeing an OA specialist.</p><p><strong>Results: </strong>A total of 9,933 persons met the definition of OA, representing 22.5 million adults in the US. Of these persons, 92% see physicians during the year, 34% see at least 1 OA specialist, 25% see an orthopedist, 11% see a physical therapist, and 6% see a rheumatologist. Higher educational attainment, having more comorbidities, and residing in the northeastern US are significant positive predictors for a patient seeing an OA specialist. Significant negative predictors for seeing an OA specialist are being unmarried but previously married and having no health insurance.</p><p><strong>Conclusion: </strong>Most adults with OA do not visit OA specialists. Those without insurance and with lower levels of education are less likely to see these specialists.</p>","PeriodicalId":8405,"journal":{"name":"Arthritis and rheumatism","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2009-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2836231/pdf/nihms178425.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"28539021","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jessica R Berman, Deana Lazaro, Theodore Fields, Anne R Bass, Elena Weinstein, Chaim Putterman, Edward Dwyer, Svetlana Krasnokutsky, Stephen A Paget, Michael H Pillinger
Objective: Traditional means of testing rheumatology fellows do not adequately assess some skills that are required to practice medicine well, such as humanistic qualities, communication skills, or professionalism. Institution of the New York City Rheumatology Objective Structured Clinical Examination (ROSCE) and our sequential 5 years of experience have provided us with a unique opportunity to assess its usefulness and objectivity as a rheumatology assessment tool.
Methods: Prior to taking the examination, all of the fellows were rated by their program directors. Fellows from the participating institutions then underwent a multistation patient-interactive examination observed and rated by patient actors and faculty raters. Assessments were recorded by all of the participants using separate but overlapping sets of instruments testing the Accreditation Council of Graduate Medical Education (ACGME) core competencies of patient care, interpersonal and communication skills, professionalism, and overall medical knowledge.
Results: Although the program directors tended to rate their fellows more highly than the ROSCE raters, typically there was agreement between the program directors and the ROSCE faculty in distinguishing between the highest- and lowest- performing fellows. The ROSCE faculty and patient actor assessments of individual trainees were notable for a high degree of concordance, both quantitatively and qualitatively.
Conclusion: The ROSCE provides a unique opportunity to obtain a patient-centered assessment of fellows' ACGME-mandated competencies that traditional knowledge-based examinations, such as the rheumatology in-service examination, cannot measure. The ability of the ROSCE to provide a well-rounded and objective assessment suggests that it should be considered an important component of the rheumatology training director's toolbox.
{"title":"The New York City Rheumatology Objective Structured Clinical Examination: five-year data demonstrates its validity, usefulness as a unique rating tool, objectivity, and sensitivity to change.","authors":"Jessica R Berman, Deana Lazaro, Theodore Fields, Anne R Bass, Elena Weinstein, Chaim Putterman, Edward Dwyer, Svetlana Krasnokutsky, Stephen A Paget, Michael H Pillinger","doi":"10.1002/art.24738","DOIUrl":"https://doi.org/10.1002/art.24738","url":null,"abstract":"<p><strong>Objective: </strong>Traditional means of testing rheumatology fellows do not adequately assess some skills that are required to practice medicine well, such as humanistic qualities, communication skills, or professionalism. Institution of the New York City Rheumatology Objective Structured Clinical Examination (ROSCE) and our sequential 5 years of experience have provided us with a unique opportunity to assess its usefulness and objectivity as a rheumatology assessment tool.</p><p><strong>Methods: </strong>Prior to taking the examination, all of the fellows were rated by their program directors. Fellows from the participating institutions then underwent a multistation patient-interactive examination observed and rated by patient actors and faculty raters. Assessments were recorded by all of the participants using separate but overlapping sets of instruments testing the Accreditation Council of Graduate Medical Education (ACGME) core competencies of patient care, interpersonal and communication skills, professionalism, and overall medical knowledge.</p><p><strong>Results: </strong>Although the program directors tended to rate their fellows more highly than the ROSCE raters, typically there was agreement between the program directors and the ROSCE faculty in distinguishing between the highest- and lowest- performing fellows. The ROSCE faculty and patient actor assessments of individual trainees were notable for a high degree of concordance, both quantitatively and qualitatively.</p><p><strong>Conclusion: </strong>The ROSCE provides a unique opportunity to obtain a patient-centered assessment of fellows' ACGME-mandated competencies that traditional knowledge-based examinations, such as the rheumatology in-service examination, cannot measure. The ability of the ROSCE to provide a well-rounded and objective assessment suggests that it should be considered an important component of the rheumatology training director's toolbox.</p>","PeriodicalId":8405,"journal":{"name":"Arthritis and rheumatism","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2009-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/art.24738","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"28539079","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Saskia van Koulil, Floris W Kraaimaat, Wim van Lankveld, Piet L C M van Riel, Andrea W M Evers
Objective: Increasing attention is devoted to the patient's perspective in clinical research and practice. However, the relationship between the patient's view on treatment progress and standardized pre-post changes in health outcomes is not well understood. The objective of this study was to investigate whether the patient's perception of treatment gain converges with pre-post treatment effects of a multidisciplinary treatment as assessed by standardized self-report measures.
Methods: During a tailored multidisciplinary treatment for fibromyalgia, validated self-report questionnaires were assessed at baseline and posttreatment on the outcome measures of pain, functional disability, fatigue, anxiety, and negative mood. In addition, the participants were asked to fill in a questionnaire at the end of the treatment assessing the patient's perception of improvement on core outcomes, as well as satisfaction and usefulness of the treatment.
Results: Moderate to relatively high correlations were found between the patient's perception of improvement and pre-post changes on the physical outcomes, in contrast to small or nonsignificant correlations for psychological outcomes. In addition, satisfaction and usefulness were significantly related to pre-post changes on physical outcomes, but no relationship was found with respect to psychological outcomes.
Conclusion: Results suggest that the patient's perception of treatment gain and pre-post changes in outcomes during treatment assess different aspects of the patient's treatment progress, particularly with regard to psychological functioning. Future research on clinical improvements should consider the patient's perception of treatment gain as an independent and clinically relevant outcome, in addition to standardized trial data of pre-post assessments of health outcomes.
{"title":"A patient's perspective on multidisciplinary treatment gain for fibromyalgia: an indicator for pre-post treatment effects?","authors":"Saskia van Koulil, Floris W Kraaimaat, Wim van Lankveld, Piet L C M van Riel, Andrea W M Evers","doi":"10.1002/art.24792","DOIUrl":"https://doi.org/10.1002/art.24792","url":null,"abstract":"<p><strong>Objective: </strong>Increasing attention is devoted to the patient's perspective in clinical research and practice. However, the relationship between the patient's view on treatment progress and standardized pre-post changes in health outcomes is not well understood. The objective of this study was to investigate whether the patient's perception of treatment gain converges with pre-post treatment effects of a multidisciplinary treatment as assessed by standardized self-report measures.</p><p><strong>Methods: </strong>During a tailored multidisciplinary treatment for fibromyalgia, validated self-report questionnaires were assessed at baseline and posttreatment on the outcome measures of pain, functional disability, fatigue, anxiety, and negative mood. In addition, the participants were asked to fill in a questionnaire at the end of the treatment assessing the patient's perception of improvement on core outcomes, as well as satisfaction and usefulness of the treatment.</p><p><strong>Results: </strong>Moderate to relatively high correlations were found between the patient's perception of improvement and pre-post changes on the physical outcomes, in contrast to small or nonsignificant correlations for psychological outcomes. In addition, satisfaction and usefulness were significantly related to pre-post changes on physical outcomes, but no relationship was found with respect to psychological outcomes.</p><p><strong>Conclusion: </strong>Results suggest that the patient's perception of treatment gain and pre-post changes in outcomes during treatment assess different aspects of the patient's treatment progress, particularly with regard to psychological functioning. Future research on clinical improvements should consider the patient's perception of treatment gain as an independent and clinically relevant outcome, in addition to standardized trial data of pre-post assessments of health outcomes.</p>","PeriodicalId":8405,"journal":{"name":"Arthritis and rheumatism","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2009-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/art.24792","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"28539080","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Andy Judge, Nicky J Welton, Jat Sandhu, Yoav Ben-Shlomo
Objective: To explore inequalities in the need for hip/knee replacement surgery using a 2-stage cross-cohort approach.
Methods: In the first stage, a small-area population-based survey, the Somerset and Avon Survey of Health, was used to provide a high-quality measure of need for hip/knee replacement using the New Zealand (NZ) score. Receiver operating characteristic curve analyses were used to validate a simplified NZ score, excluding information from clinical examination. In the second stage, a nationally representative population-based survey, the English Longitudinal Study of Ageing, was used to explore inequalities in need for hip/knee replacement using the simplified NZ score. Multilevel Poisson regression modeling was used to estimate rates of need for surgery. Exposures considered were age, sex, social class, ethnicity, obesity, Index of Multiple Deprivation 2004 deprivation quintiles, rurality, and ethnic mix of area.
Results: Rates of need for hip/knee replacement increase with age and are lower in men than in women (rate ratio [RR] 0.7, 95% confidence interval [95% CI] 0.6-0.9 for hips; RR 0.8, 95% CI 0.7-1.0 for knees). Those of lowest social class have greater need. Need was greatest for people living in more deprived areas. Individual ethnic group did not predict the need for surgery. For hip replacement, there was no rurality effect; for knee replacement, those in town and fringe areas had greater need. Obesity was a strong predictor of need for surgery (RR 2.3, 95% CI 1.9-2.8 for hips; RR 2.4, 95% CI 2.0-2.8 for knees).
Conclusion: This study provides evidence of greater variations of inequalities in need for hip/knee replacement than previous studies. Further research should explore geographic variation and produce small-area estimates of need to inform local health planning. It is important to complement data on need with willingness to undergo surgery.
{"title":"Modeling the need for hip and knee replacement surgery. Part 1. A two-stage cross-cohort approach.","authors":"Andy Judge, Nicky J Welton, Jat Sandhu, Yoav Ben-Shlomo","doi":"10.1002/art.24892","DOIUrl":"https://doi.org/10.1002/art.24892","url":null,"abstract":"<p><strong>Objective: </strong>To explore inequalities in the need for hip/knee replacement surgery using a 2-stage cross-cohort approach.</p><p><strong>Methods: </strong>In the first stage, a small-area population-based survey, the Somerset and Avon Survey of Health, was used to provide a high-quality measure of need for hip/knee replacement using the New Zealand (NZ) score. Receiver operating characteristic curve analyses were used to validate a simplified NZ score, excluding information from clinical examination. In the second stage, a nationally representative population-based survey, the English Longitudinal Study of Ageing, was used to explore inequalities in need for hip/knee replacement using the simplified NZ score. Multilevel Poisson regression modeling was used to estimate rates of need for surgery. Exposures considered were age, sex, social class, ethnicity, obesity, Index of Multiple Deprivation 2004 deprivation quintiles, rurality, and ethnic mix of area.</p><p><strong>Results: </strong>Rates of need for hip/knee replacement increase with age and are lower in men than in women (rate ratio [RR] 0.7, 95% confidence interval [95% CI] 0.6-0.9 for hips; RR 0.8, 95% CI 0.7-1.0 for knees). Those of lowest social class have greater need. Need was greatest for people living in more deprived areas. Individual ethnic group did not predict the need for surgery. For hip replacement, there was no rurality effect; for knee replacement, those in town and fringe areas had greater need. Obesity was a strong predictor of need for surgery (RR 2.3, 95% CI 1.9-2.8 for hips; RR 2.4, 95% CI 2.0-2.8 for knees).</p><p><strong>Conclusion: </strong>This study provides evidence of greater variations of inequalities in need for hip/knee replacement than previous studies. Further research should explore geographic variation and produce small-area estimates of need to inform local health planning. It is important to complement data on need with willingness to undergo surgery.</p>","PeriodicalId":8405,"journal":{"name":"Arthritis and rheumatism","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2009-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/art.24892","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"28539973","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"US bone and joint decade prepares for the future.","authors":"Joshua J Jacobs, Toby King","doi":"10.1002/art.24974","DOIUrl":"https://doi.org/10.1002/art.24974","url":null,"abstract":"","PeriodicalId":8405,"journal":{"name":"Arthritis and rheumatism","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2009-11-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/art.24974","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"28101623","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Lindsay J Ledwich, Thomas M Harrington, William T Ayoub, Jennifer A Sartorius, Eric D Newman
Objective: To examine whether an electronic health record (EHR) best practice alert (BPA), a clinical reminder to help guideline adherence, improved vaccination rates in rheumatology patients receiving immunosuppressants. Guidelines recommend yearly influenza and pneumococcal vaccination with revaccination for patients age >65 years who are taking immunosuppressive medications.
Methods: A vaccination BPA was developed based on immunosuppressant treatment, age, and prior vaccinations. At site 1, a hospital-based academic practice, physicians ordered vaccinations. At site 2, a community-based practice, physicians signed orders placed by nurses. Demographics, vaccination rates, and documentation (vaccination or no administration) were obtained. Chi-square and Fisher's exact test analysis compared vaccination and documentation rates for October 1 through December 31, 2006 (preBPA), and October 1 through December 31, 2007 (postBPA). Breslow-Day statistics tested the odds ratio of improvement across the years between the sites.
Results: PostBPA influenza vaccination rates significantly increased (47% to 65%; P < 0.001), with significant improvement at both sites. PostBPA pneumococcal vaccination rates likewise significantly increased (19% to 41%; P < 0.001). PostBPA documentation rates for influenza and pneumococcal vaccinations also increased significantly. Site 2 (nurse-driven) had significantly higher preBPA vaccination rates for influenza (69% versus 43%; P < 0.001) than pneumococcal (47% versus 15%; P < 0.001).
Conclusion: The use of a BPA significantly increased influenza and pneumococcal vaccination and documentation rates in rheumatology patients taking immunosuppressants. A nurse-driven process offered higher efficacy. An EHR programmed to alert providers is an effective tool for improving quality of care for patients receiving immunosuppressants.
{"title":"Improved influenza and pneumococcal vaccination in rheumatology patients taking immunosuppressants using an electronic health record best practice alert.","authors":"Lindsay J Ledwich, Thomas M Harrington, William T Ayoub, Jennifer A Sartorius, Eric D Newman","doi":"10.1002/art.24873","DOIUrl":"https://doi.org/10.1002/art.24873","url":null,"abstract":"<p><strong>Objective: </strong>To examine whether an electronic health record (EHR) best practice alert (BPA), a clinical reminder to help guideline adherence, improved vaccination rates in rheumatology patients receiving immunosuppressants. Guidelines recommend yearly influenza and pneumococcal vaccination with revaccination for patients age >65 years who are taking immunosuppressive medications.</p><p><strong>Methods: </strong>A vaccination BPA was developed based on immunosuppressant treatment, age, and prior vaccinations. At site 1, a hospital-based academic practice, physicians ordered vaccinations. At site 2, a community-based practice, physicians signed orders placed by nurses. Demographics, vaccination rates, and documentation (vaccination or no administration) were obtained. Chi-square and Fisher's exact test analysis compared vaccination and documentation rates for October 1 through December 31, 2006 (preBPA), and October 1 through December 31, 2007 (postBPA). Breslow-Day statistics tested the odds ratio of improvement across the years between the sites.</p><p><strong>Results: </strong>PostBPA influenza vaccination rates significantly increased (47% to 65%; P < 0.001), with significant improvement at both sites. PostBPA pneumococcal vaccination rates likewise significantly increased (19% to 41%; P < 0.001). PostBPA documentation rates for influenza and pneumococcal vaccinations also increased significantly. Site 2 (nurse-driven) had significantly higher preBPA vaccination rates for influenza (69% versus 43%; P < 0.001) than pneumococcal (47% versus 15%; P < 0.001).</p><p><strong>Conclusion: </strong>The use of a BPA significantly increased influenza and pneumococcal vaccination and documentation rates in rheumatology patients taking immunosuppressants. A nurse-driven process offered higher efficacy. An EHR programmed to alert providers is an effective tool for improving quality of care for patients receiving immunosuppressants.</p>","PeriodicalId":8405,"journal":{"name":"Arthritis and rheumatism","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2009-11-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/art.24873","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"28102729","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}