+

Bridging the rural-urban divide for patients with rheumatoid arthritis

Brenna BathSchool of Physical TherapyUniversity of Saskatchewan

+Research Team/ Co-authors Dr. Regina Taylor-Gjevre, Professor, Rheumatologist (PI);

Dr. Bindu Nair, Associate Professor, Rheumatologist;

Dr. Samuel Stewart, Research Associate, Biostatistician;

Dr. Regan Arendse, Clinical Assistant Professor, Rheumatologist;

Dr. Latha Naik, Clinical Assistant Professor, Rheumatologist;

Dr. Catherine Trask, Assistant Professor;

Dr. Erika Penz, Assistant Professor;

Meenu Sharma, Research Assistant;

Katie Crockett, Clinical Research Associate

+Outline

Background

Research objectives

Design and measures

Significance/ relevance

What have we learned so far?

Questions/ Discussion

+Background

Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting approximately 1% of the Canadian population.

Current standard of care includes use of disease modifying anti-rheumatic drugs and often biological agents, which require ongoing monitoring for toxicity and efficacy.

+Background

People with RA often require regular rheumatology follow-up to ensure their disease is well-controlled and optimally treated.Up to a frequency of every 3 months Includes history and physical

examination.

This may lead to substantial travelling for RA patients who live in rural/remote regions.

+Background

30% of Saskatchewan’s (SK) population lives in rural and remote regions

over 50% of RA patients attending a Saskatoon rheumatology clinic reside in health regions other than Saskatoon Health Region

36% of rheumatoid arthritis (RA) patients in SK consider location of their place of residence negatively impact ability to access health care

+

*ALL SK Rheumatologists and 90% of PTs practice in urban centres

+Our Challenge:How can we improve access to follow-up rheumatology care in rural SK communities?

1. Teams PTs travelling to rural communities to complete history/ “hands on” physical examination with rural RA patients

2. Technology Telehealth/ Videoconferencing to link to urban-based rheumatologist

+Health Care Team

3 Rheumatologists

1 Nurse Educator

3 PTs travelling to clinics in 5 rural SK communities

+

Rural Communities:Prince AlbertNorth BattlefordRosetownWynyard Arborfield

+Technology: VIDYO (Secure VC)

+Research Objectives

1) To determine whether disease-specific activity measures are equivalent for patients evaluated longitudinally by telehealth/VC compared to those seen in traditional rheumatology clinics over a nine-month period.

2) To evaluate quality-of-life and health-status measures as well as patient/healthcare provider levels of satisfaction for each care model.

+Research Objectives

3) To determine incremental costs (direct and indirect) associated with distance telehealth/VC compared with traditional in-person rheumatology clinics.

4) To determine the validity/ accuracy of Rheumatologist/ PT team RA assessment through VC versus Rheumatologist in person.

+Participants: RCT

160 patients living outside 100 km or more outside of Saskatoon, age over 18 years, and rheumatologist established diagnosis of RA will be recruited

Participants will be randomly assigned to one of two arms:1) followed by telehealth/VC in or near their home community 2) continue travelling to Saskatoon rheumatology clinic.

RCT Design

+RCT measures: Primary

DAS-28 CRP (at 9 months)Physical examination (swollen and

tender joint count)Examiner global score (100mm VAS)C-reactive Protein (CRP)

+RCT measures: Secondary

Provider categorical assessment related to disease activity (inactive/stable; mildly active; very active)

Modified health assessment questionnaire (mHAQ)

RA disease activity index (RADAI)Quality of life (EQ5D)Cost diariesPatient satisfaction (VSQ-9)Patient and provider experience with VC/

telehealth (survey and interviews)

+Validation study

Purpose to demonstrate that there is not a greater difference between disciplines than there is within disciplines for appendicular joint examination accuracy or for assessment of disease activity status.

50 participants with RA from Saskatoon region

+Validation study

Each will be undergo physical examination (joint count) by 3 Rheumatologists and 3 PTs

The comparison groups will be:1. Rheumatologist A. to Rheumatologist B.2. Physiotherapist A. to Physiotherapist B.3. Rheumatologist A/B to Physiotherapist C/teleconferenced Rheumatologist C.

+Significance/ Relevance

No previous reported studies of telehealth/VC based care for longitudinal rheumatologic follow up in RA patients

No reported studies utilizing interdisciplinary care teams in the telehealth/VC assessment process for this population.

+Where is the project at?

Recruited approximately 50 patients for RCT

First VC team visits started in March 2015

Anticipate recruiting until September, 2015, with 9 month completion by June 2016

Validation study (Fall 2015)

+What have we learned so far?

Technology: hardware, software, connectivity, support

Team:scope and collaborative practicescheduling

Recruitment:“near” home community“Costco” effect

+Where to from here?

Combined experience and learning from this project and PT/ NP models for chronic low back pain

Mapping of primary care service (PT/ GP/ NP) to identify geographical care gaps

Rural and Remote musculoskeletal clinic Primary/ secondary interface careMultidisciplinary & InterprofessionalCombination of in-person and VC triage

or follow-up care

+Acknowledgements

+Questions/ Discussion