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We estimated COVID-19 vaccine effectiveness against SARS-CoV-2 infection and severe COVID-19 outcomes among individuals with immune-mediated inflammatory diseases in Ontario, Canada.In this population-based analysis, we used a test-negative design across four immune-mediated inflammatory disease population-based cohorts, comprising individuals with rheumatoid arthritis, ankylosing spondylitis, psoriasis, and inflammatory bowel disease. We identified all SARS-CoV-2 tests done in these populations between March 1 and Nov 22, 2021 (a period in which there was rapid uptake of vaccines, and the alpha [B.1.1.7] and delta [B.1.617.2] SARS-CoV-2 variants were predominantly circulating in Canada) and separately assessed outcomes of SARS-CoV-2 infection and severe COVID-19 outcomes (hospitalisation due to COVID-19 and death due to COVID-19) for each disease group. We used multivariable logistic regression to estimate the effectiveness of one, two, and three doses of mRNA-based COVID-19 vaccine (BNT162b2 [Pfizer-BioNTech], or mRNA-1273 [Moderna]) among individuals at the time of SARS-CoV-2 testing.Between March 1 and Nov 22, 2021, we identified 2127 (5·9%) test-positive cases among 36 145 individuals (26 476 [73·2%] were female and 9669 [26·8%] were male) with rheumatoid arthritis tested, 476 (6·1%) test-positive cases among 7863 individuals (4130 [52·5%] were female and 3733 [47·5%] were male) with ankylosing spondylitis tested, 3089 (6·5%) test-positive cases among 47 199 individuals (26 062 [55·2%] were female and 21 137 [44·8%] were male) with psoriasis tested, and 1702 (5·4%) test-positive cases among 31 311 individuals (17 716 [56·6%] were female and 13 595 [43·4%] were male) with inflammatory bowel disease tested. Adjusted vaccine effectiveness of two doses against infection was 83% (95% CI 80-86) in those with rheumatoid arthritis, 89% (83-93) among those with ankylosing spondylitis, 84% (81-86) among those with psoriasis, and 79% (74-82) among those with inflammatory bowel disease. After two vaccine doses, effectiveness against infection generally peaked 31-60 days after vaccination and waned gradually with each additional month. Vaccine effectiveness against severe outcomes after two doses was 92% (95% CI 88-95) in those with rheumatoid arthritis, 97% (83-99) among those with ankylosing spondylitis, 92% (86-95) among those with psoriasis, and 94% (88-97) among those with inflammatory bowel disease. Vaccine effectiveness after a third dose against infection was similar to or higher than after the second dose (ranging from 76% [47-89] to 96% [72-99]), although due to a paucity of events, estimates could not be calculated for some subgroups for severe outcomes.Two vaccine doses were found to be highly effective against both SARS-CoV-2 infection and severe COVID-19 outcomes in patients with rheumatoid arthritis, ankylosing spondylitis, psoriasis, and inflammatory bowel disease during the study period. Research is needed to determine the durability of effectiveness of three doses over time, particularly against emerging variants.Public Health Agency of Canada.

Introduction In collaboration with the Alberta Medical Association’s Physician Learning Program we developed individualized physician reports and held a group feedback session on rheumatoid arthritis (RA) performance measures (PM) to facilitate treat-to-target (T2T) strategies and evaluated physician experiences with this process. Methods 5 PMs addressing T2T concepts from an established Canadian quality framework were operationalized for physician practice reports at 2 university-affiliated rheumatology clinics. Rheum4U, a quality improvement and research platform, was the data source. The audit results were reviewed in a facilitated group feedback session. Rheumatologists provided experiential feedback on the process through survey and/or an interview. Transcripts from interviews were analyzed using a 6-step thematic analysis. Results 11 of 12 eligible rheumatologists consented to receive practice reports and provided feedback through surveys (n = 5) and interviews (n = 6). The practice reports from Rheum4U (n = 448 patients) revealed high rates of yearly follow-up (> 85%, PM1) and 100% performance on documentation of disease activity at ≥ 50% of visits (PM2). Only 34% of patients were seen within 3 months if not in remission (PM3) with 62% (2017) and 69% (2018) of those with active RA achieving a LDA state within 6 months (PM4). Approximately 70% of patients were in remission at any time point (PM5). All survey respondents agreed or strongly agreed comparison to peers was valuable and helped them reflect on their practice. Several strategies for improvement were identified, including but not limited to, leveraging of electronic records for future audit and feedback reports, providing additional granularity of results, additional stratification of results, and using high-performing peers as the comparator rather than the group mean. Conclusions Audit and feedback was perceived by clinicians as a useful strategy for evaluating T2T efforts in RA. Future work will focus on longitudinal evaluation of the clinical impact of this quality improvement initiative. Electronic Supplementary Material The online version of this article (10.1007/s40744-020-00237-0) contains supplementary material, which is available to authorized users.

Most recommendations for the use of methotrexate (MTX) in rheumatoid arthritis (RA) are issued by developed countries. It is unknown whether they are relevant globally. We reviewed existing recommendations on the use of MTX for the treatment of RA and summarized areas of agreement that could be relevant for least developed countries (LDCs).Electronic databases and registries were searched for recommendations on MTX use in RA, duplicates were eliminated, and the most updated version adopted when there were several versions on the same recommendation. Reviewers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument for study quality assessment. Similarities and discrepancies of recommendations are reported.After deduplication, 1693 unique citations were found; 25 full texts were screened and 12 included in the narrative synthesis. Average scores for the AGREE II domains ranged from 33.3 to 83.3%. Recommendations targeted rheumatologists and health care providers involved in RA care. Most covered some but not all of the following areas: baseline "pre-MTX" assessment (7/12;58%), prescription of MTX (10/12;83.3%), management of MTX side effects (6/12;50%), and special considerations (e.g., peri-operative management) (8/12; 66.7%). Recommendations agreed on baseline tests prior to starting MTX, monitoring, and need for folic acid supplementation. These aspects can serve as the foundation for the development of MTX recommendations relevant to LDCs. Recommendations disagreed on the MTX starting dose, optimal route, titration, and intervals to monitor toxicity.Existing recommendations do not uniformly address all aspects related to the use of MTX and disagree in relevant aspects of MTX use. Adaptations to these recommendations are needed to facilitate their implementation in LDCs. Key Points • This paper summarizes current recommendations on the use of methotrexate for the treatment of rheumatoid arthritis. • Areas of agreement between recommendations include the following: pre-methotrexate patient assessment, need for folic acid supplementation, and toxicity monitoring. • Areas of disagreement relate to methotrexate starting and maximal dose, titration, and frequency of assessments.

Objective.The aim of this study was to develop a patient-centered quality measurement framework to address a predefined vision statement and 7 strategic objectives for rheumatoid arthritis (RA) care that was developed in prior qualitative work with arthritis stakeholders.Methods.One hundred forty-seven RA-related performance measures (PMs) were identified from a systematic review. A candidate list of 26 PMs meeting predefined criteria and addressing the strategic objectives previously defined was then assessed during a 3-round (R) modified Delphi. Seventeen panelists with expertise in RA, quality measurement, and/or lived experience with RA rated each PM on a 1–9 scale based on the items of importance, feasibility, and priority for inclusion in the framework during R1 and R3, with a moderated discussion in R2. PMs with median scores ≥ 7 on all 3 items without disagreement were included in the final set, which then underwent public comment.Results.Twenty-one measures were included in the final framework (15 PMs from the Delphi and 6 published system-level measures on access to care and treatment). The measures included 4 addressing early access to care and timely diagnosis, 12 evidence-based care for RA and related comorbidities, 1 addressing patient participation as an informed partner in care, and 4 on patient outcomes.Conclusion.The proposed framework builds upon existing measures capturing early access to care and treatment in RA and adds important PMs to promote high-quality RA care and outcome measurement. In the next phase, the authors will test the framework in clinical practice in addition to addressing certain areas where no suitable PMs were identified.

We evaluated the potential temporal association between hydroxychloroquine (HCQ) use and cardiovascular (CV) events among patients with systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA).We conducted a nested case-control study within inception cohorts of SLE and RA patients using administrative health databases including the entire population of British Columbia, Canada. We identified cases with incident CV events, including myocardial infarction (MI), stroke, or venous thromboembolism (VTE). We matched each case with up to 3 controls on age, sex, and rheumatic disease. HCQ exposure was categorized by the time between the last HCQ prescription date covered and the index date as current use, recent use, remote use, or never used. We used conditional logistic regression to assess the association between HCQ exposure and CV events, using remote use as the reference group.We identified 10,268 cases and 29,969 controls. Adjusted conditional odd ratios (cORs) and 95% confidence intervals (95% CIs) for current HCQ use relative to remote use were 0.86 (0.77-0.97) for combined CV events, 0.88 (0.74-1.05) for MI, 0.87 (0.74-1.03) for stroke, and 0.74 (0.59-0.94) for VTE. Recent HCQ users and nonusers had similar odds of combined CV events as remote users (cORs 0.93, 95% CI 0.77-1.13 and 0.96, 95% CI 0.88-1.04, respectively).In this nested case-control study of patients with SLE and RA, we found a reduced risk of overall CV events associated with current HCQ use, including reductions in VTE and trends toward reductions in MI and stroke. These findings suggest a possible cardiovascular preventative benefit of HCQ use.

To assess rheumatology health care providers' (HCPs) knowledge, beliefs, self-efficacy, practices, and perceived barriers pertaining to weight management and smoking cessation counselling in patients with rheumatoid arthritis (RA).We administered an online survey to collect self-reported data on rheumatology HCPs' knowledge, beliefs, self-efficacy, perceived barriers, and practices related to weight management and smoking cessation counselling. Participants were recruited through invitation emails (with anonymous survey links) sent by three Canadian rheumatology organizations.Fifty-nine rheumatology HCPs (15 nurses, 44 physicians) completed the survey (response rate: 11%). Over 85% correctly identified associations between obesity, or smoking, and more severe or active RA, as well as poorer response to treatment. All but one participant agreed that it was part of their responsibility to discuss these issues with patients, but 78% (46/59) felt not or slightly confident in their ability to help patients quit smoking or achieve clinically significant weight loss. The majority did not routinely assist patients in accessing appropriate resources or providers (only 42% did for obesity, 36% for smoking), send referrals (2-44%, depending on referral), or offer relevant educational materials (15% for obesity, 20% for smoking). Common barriers included competing demands and lack of time, training, access to expertise, and knowledge of available programs.Most rheumatology HCPs understood the implications of cigarette smoking and obesity in RA and accepted responsibility in addressing these issues. However, they lacked the time, training, confidence, and knowledge of local resources to do so effectively. There is a need to bridge this gap. Key Points • Training through medical and nursing school as well as residency on weight management and smoking cessation counselling was nearly unanimously described as poor or fair. • Most rheumatology health care providers understood the implications of cigarette smoking and obesity in rheumatoid arthritis and accepted responsibility in addressing these issues; however, they lacked the time, training, confidence, and knowledge of local resources to do so effectively. • There is a need to bridge the gap between health care providers' intentions and actions, and this may include the development of guides outlining local weight management and smoking cessation expertise, programs, referral processes, and educational materials.

Objective To evaluate secular trends in 10-year risk of incident cerebrovascular accidents (CVA), in incident RA relative to the general population. Methods We conducted a retrospective study of a population-based incident cohort with RA onset from 1997 to 2004 in British Columbia, Canada, with matched general population controls (2:1), using administrative health data. RA and general population cohorts were divided according to year of RA onset, defined according to the first RA visit of the case definition. Incident CVA was defined as the first CVA occurring within 10 years from the first RA visit. Secular trend was assessed using delayed-entry Cox models with a two-way interaction term between the year of RA onset and indicator of RA vs general population. Linear, quadratic and spline functions of year of RA onset were compared with assess non-linear effects. The model with the lowest Akaike Information Criterion was selected. Results Overall, 23 545 RA and 47 090 general population experienced 658 and 1220 incident CVAs, respectively. A spline Cox model with a knot at year of onset 1999 was selected. A significant decline in risk of CVA was observed in individuals with RA onset after 1999 [0.90 (0.86, 0.95); P = 0.0001]. The change in CVA risk over time differed significantly in RA with onset from 1999 onwards compared with the general population (P-value of interaction term = 0.03), but not before 1999 (P = 0.06). Conclusion Our findings suggest that people with RA onset from 1999 onwards, had a significantly greater decline in 10-year risk of CVA compared with the general population.

Background Precision medicine, as a personalized medicine approach based on biomarkers, is a booming field. In general, physicians and patients have a positive attitude toward precision medicine, but their knowledge and experience are limited. In this study, we aimed at assessing the expectations and educational needs for precision medicine among rheumatologists, rheumatology fellows and patients with rheumatic diseases in Canada. Methods We conducted two anonymous online surveys between June and August 2018, one with rheumatologists and fellows and one with patients assessing precision medicine expectations and educational needs. Descriptive statistics were performed. Results 45 rheumatologists, 6 fellows and 277 patients answered the survey. 78% of rheumatologists and fellows and 97.1% of patients would like to receive training on precision medicine. Most rheumatologists and fellows agreed that precision medicine tests are relevant to medical practice (73.5%) with benefits such as helping to determine prognosis (58.9%), diagnosis (79.4%) and avoid treatment toxicity (61.8%). They are less convinced of their usefulness in helping to choose the most effective treatment and to improve patient adherence (23.5%). Most patients were eager to take precision medicine tests that could predict disease prognosis (92.4%), treatment response (98.1%) or drug toxicity (93.4%), but they feared potential negative impacts like loss of insurability (62.2%) and high cost of the test (57.5%). Conclusions Our study showed that rheumatologists and patients in Canada are overall interested in getting additional precision medicine education. Indeed, while convinced of the potential benefits of precision medicine tests, most physicians don’t feel confident in their abilities and consider their training insufficient to incorporate them into clinical practice.

Editor's note The Editors of the 5 journals of the American College of Rheumatology and European Alliance of Associations for Rheumatology have been reminded by this editorial that ACR and EULAR have jointly agreed on various classification criteria, definitions, recommendations, or points to consider, which do not always find reflection in manuscripts submitted to the journals. Consequently, in the future, the Editors will enforce the use of the products obtained in the course of joint ACR/EULAR or EULAR/ACR activities in all respective papers. For rheumatoid arthritis this would mean use of the ACR/EULAR or EULAR/ACR classification criteria, remission definitions, recommendations on what to report in clinical trials, and others, as pertinent. The same applies to other diseases. There are valid and important reasons that these activities have been undertaken by ACR and EULAR, and therefore, the conclusions of the various task forces, which have been endorsed by ACR and EULAR, should be respected by investigators and study administrators. This does not mean other methods could not be used in a study, but at the least, the reports should address the methods agreed upon by the 2 organizations. Maintaining uniformity across major publications regarding rheumatoid arthritis remission or other definitions not only allows for more appropriate comparison across analyses, but also enhances readers' ability to interpret results. Author instructions across the 5 journals will more strongly reflect this requirement. Over the last 30 years, treatment for RA has improved dramatically. By the early 2000s, disease remission had become a realistic goal, although definitions of remission varied widely, making it difficult to compare treatment strategies and gauge how often remission occurred. In 2009, the ACR and the EULAR created a joint committee whose charge was to recommend a definition of remission. Members of the committee suggested a large number of candidate definitions and using …

Objective.The Outcome Measures in Rheumatology (OMERACT) Worker Productivity Group continues efforts to assess psychometric properties of measures of presenteeism.Methods.Psychometric properties of single-item and dual answer multiitem scales were assessed, as well as methods to evaluate thresholds of meaning.Results.Test-retest reliability and construct validity of single item global measures was moderate to good. The value of measuring both degree of difficulty and amount of time with difficulty in multiitems questionnaires was confirmed. Thresholds of meaning vary depending on methods and external anchors applied.Conclusion.We have advanced our understanding of the performance of presenteeism measures and have developed approaches to describing thresholds of meaning.

ObjectivesTo assess the risk of severe COVID-19 outcomes in patients with autoimmune rheumatic diseases (ARDs) and transplant recipients compared with matched general population comparators.DesignPopulation-based matched cohort study using administrative health data sets.SettingBritish Columbia, Canada.ParticipantsAll adults with test-positive SARS-CoV-2 infections. SARS-CoV-2-positive patients with ARDs and those with transplantation were matched to SARS-CoV-2-positive general population comparators on age (±5 years), sex, month/year of initial positive SARS-CoV-2 test and health authority.Outcome measuresCOVID-19-related hospitalisations, intensive care unit (ICU) admissions, invasive ventilation and COVID-19-specific mortality. We performed multivariable conditional logistic regression models adjusting for socioeconomic status, Charlson Comorbidity Index, hypertension, rural address and number of previous COVID-19 PCR tests.ResultsAmong 6279 patients with ARDs and 222 transplant recipients, all SARS-CoV-2 test positive, risk of hospitalisation was significantly increased among patients with ARDs (overall ARDs (adjusted OR (aOR) 1.30; 95% CI 1.19 to 1.43)); highest within ARDs: adult systemic vasculitides (aOR 2.18; 95% CI 1.17 to 4.05) and transplantation (aOR 10.56; 95% CI 6.88 to 16.22). Odds of ICU admission were significantly increased among patients with ARDs (overall ARDs (aOR 1.30; 95% CI 1.11 to 1.51)); highest within ARDs: ankylosing spondylitis (aOR 2.03; 95% CI 1.18 to 3.50) and transplantation (aOR 8.13; 95% CI 4.76 to 13.91). Odds of invasive ventilation were significantly increased among patients with ARDs (overall ARDs (aOR 1.60; 95% CI 1.27 to 2.01)); highest within ARDs: ankylosing spondylitis (aOR 2.63; 95% CI 1.14 to 6.06) and transplantation (aOR 8.64; 95% CI 3.81 to 19.61). Risk of COVID-19-specific mortality was increased among patients with ARDs (overall ARDs (aOR 1.24; 95% CI 1.05 to 1.47)); highest within ARDs: ankylosing spondylitis (aOR 2.15; 95% CI 1.02 to 4.55) and transplantation (aOR 5.48; 95% CI 2.82 to 10.63).ConclusionsThe risk of severe COVID-19 outcomes is increased in certain patient groups with ARDs or transplantation, although the magnitude differs across individual diseases. Strategies to mitigate risk, such as booster vaccination, prompt diagnosis and early intervention with available therapies, should be prioritised in these groups according to risk.

Editor's note The Editors of the 5 journals of the American College of Rheumatology and European Alliance of Associations for Rheumatology have been reminded by this editorial that ACR and EULAR have jointly agreed on various classification criteria, definitions, recommendations, or points to consider, which do not always find reflection in manuscripts submitted to the journals. Consequently, in the future, the Editors will enforce the use of the products obtained in the course of joint ACR/EULAR or EULAR/ACR activities in all respective papers. For rheumatoid arthritis this would mean use of the ACR/EULAR or EULAR/ACR classification criteria, remission definitions, recommendations on what to report in clinical trials, and others, as pertinent. The same applies to other diseases. There are valid and important reasons that these activities have been undertaken by ACR and EULAR, and therefore, the conclusions of the various task forces, which have been endorsed by ACR and EULAR, should be respected by investigators and study administrators. This does not mean other methods could not be used in a study, but at the least, the reports should address the methods agreed upon by the 2 organizations. Maintaining uniformity across major publications regarding rheumatoid arthritis remission or other definitions not only allows for more appropriate comparison across analyses, but also enhances readers' ability to interpret results. Author instructions across the 5 journals will more strongly reflect this requirement. Over the last 30 years, treatment for RA has improved dramatically. By the early 2000s, disease remission had become a realistic goal, although definitions of remission varied widely, making it difficult to compare treatment strategies and gauge how often remission occurred. In 2009, the ACR and the EULAR created a joint committee whose charge was to recommend a definition of remission. Members of the committee suggested a large number of candidate definitions and using …

Chapter 1 provides an overview of the five core domains for the appropriate assessment of patients with systemic lupus erythematosus (SLE) for research and clinical settings: disease activity, chronic damage resulting from lupus activity or its treatment, health-related quality of life (HRQoL), adverse events, and economic impact. Emerging concepts in SLE such as frailty are also introduced along with deep insights on selected existing concepts, in particular cognition, depression, and anxiety as well as fatigue. Having explored what needs to be measured in SLE, this chapter then outlines the decision-making process by which candidate instruments are identified and determined to be a match for the target construct (e.g., disease activity).

ObjectiveTo determine the prevalence of physician burnout during the pandemic and differences by gender, ethnicity or sexual orientation.Design, setting and participantsWe conducted a cross-sectional survey (August–October in 2020) of internal medicine physicians at two academic hospitals in Vancouver, Canada.Primary and secondary outcomesPhysician burnout and its components, emotional exhaustion, depersonalisation and personal accomplishment were measured using the Maslach Burnout Inventory.ResultsThe response rate was 38% (n=302/803 respondents, 49% women,). The prevalence of burnout was 68% (emotional exhaustion 63%, depersonalisation 39%) and feeling low personal accomplishment 22%. In addition, 21% reported that they were considering quitting the profession or had quit a position. Women were more likely to report emotional exhaustion (OR 2.00, 95% CI: 1.07 to 3.73, p=0.03) and feeling low personal accomplishment (OR 2.26, 95% CI: 1.09 to 4.70, p=0.03) than men. Visible ethnic minority physicians were more likely to report feeling lower personal accomplishment than white physicians (OR 1.81, 95% CI: 1.28 to 2.55, p=0.001). There was no difference in emotional exhaustion or depersonalisation by ethnicity or sexual orientation. Physicians who reported that COVID-19 affected their burnout were more likely to report any burnout (OR: 3.74, 95% CI: 1.99 to 7.01, pConclusionBurnout affects 2 out of 3 internal medicine physicians during the pandemic. Women, ethnic minority physicians and those who feel that COVID-19 affects burnout were more likely to report components of burnout. Further understanding of factors driving feelings of low personal accomplishment in women and ethnic minority physicians is needed.

The Rheumatoid Arthritis (RA) Quality of Care Survey (RAQCS) was developed to measure care quality according to a previously developed national RA quality improvement framework.The development of the RAQCS occurred over 3 phases. First, the survey was developed by a team of healthcare providers, researchers, and two patient partners based on the existing national quality framework's 21 performance measures (PMs) and strategic objectives. Second, cognitive debriefing interviews were conducted with individuals living with RA to identify survey clarity, appropriateness of survey questions, and response options. Third, the survey was revised and distributed to participants recruited from Rheum4U (rheumatology longitudinal cohort). Results were tabulated and compared with a chart audit of participant medical records.Fifty-three participants completed the RAQCS. High performance (i.e., ≥70% meeting PM) was observed for 13 of 20 PMs. Lower performance was seen for the remaining PMs, which included documentation of body mass index (BMI) and smoking status, discussion of physical activity goals, comorbidity management including risk assessments for cardiovascular health and fragility fractures and disease activity assessment. There was high agreement (≥70%) between the RAQCS and chart review for 9 of 20 PMs.High agreement was observed between the RAQCS and chart review for selected PMs. The RAQCS may also be a valuable tool for quality improvement for measures where data are not usually available through other sources. Further testing of the RAQCS is needed to ascertain its reliability and validity as a patient self-reported tool to measure RA care quality.

ObjectiveTo elucidate the essential elements of high-quality rheumatoid arthritis (RA) care in order to develop a vision statement and a set of strategic objectives for a national RA quality framework.MethodsFocus groups and interviews were conducted by experienced qualitative researchers using a semistructured interview or focus group guide with healthcare professionals, patients, clinic managers, healthcare leaders, and policy makers to obtain their perspectives on elements essential to RA care. Purposive sampling provided representation of stakeholder types and regions. Recorded data was transcribed verbatim. Two teams of 2 coders independently analyzed the deidentified transcripts using thematic analysis. Strategic objectives and the vision statement were drafted based on the overarching themes from the qualitative analysis and finalized by a working group.ResultsA total of 54 stakeholders from 9 Canadian provinces participated in the project (3 focus groups and 19 interviews). Seven strategic objectives were derived from the qualitative analysis representing the following themes: (1) early access and timeliness of care; (2) evidence-informed, high-quality care for the ongoing management of RA and comorbidities; (3) availability of patient self-management tools and educational materials for shared decision making; (4) multidisciplinary care; (5) patient outcomes; (6) patient experience and satisfaction with care; and (7) equity, the last of which emerged as an overarching theme. The ultimate vision obtained was “ensuring patient-centered, high-quality care for people living with rheumatoid arthritis.”ConclusionThe 7 strategic objectives that were identified highlight priorities for RA quality of care to be used in developing the National RA Quality Measurement Framework.

ObjectiveWe evaluated 4 national rheumatoid arthritis (RA) system-level performance measures (PM) in Alberta, Canada.MethodsIncident and prevalent RA cases ≥ 16 years of age since 2002 were identified using a validated case definition applied in provincial administrative data. Performance was ascertained through analysis of health data between fiscal years 2012/13–2015/16. Measures evaluated were as follows: proportion of incident RA cases with a rheumatologist visit within 1 year of first RA diagnosis code (PM1); proportion of prevalent RA patients who were dispensed a disease-modifying antirheumatic drug (DMARD) annually (PM2); time from first visit with an RA code to DMARD dispensation and proportion of incident cases where the 14-day benchmark for dispensation was met (PM3); and proportion of patients seen in annual follow-up (PM4).ResultsThere were 31,566 prevalent and 2730 incident RA cases (2012/13). Over the analysis period, the proportion of patients seen by a rheumatologist within 1 year of onset (PM1) increased from 55% to 63%; however, the proportion of RA patients dispensed DMARD annually (PM2) remained low at 43%. While the median time to DMARD from first visit date in people who received DMARD improved over time from 39 days to 28 days, only 38–41% of patients received treatment within the 14-day benchmark (PM3). The percentage of patients seen in yearly follow-up (PM4) varied between 73–80%.ConclusionThe existing Alberta healthcare system for RA is suboptimal, indicating barriers to accessing specialty care and treatment. Our results inform quality improvement initiatives required within the province to meet national standards of care.

Objectives To estimate the overall risk of venous thromboembolism (VTE), pulmonary embolism (PE) and deep vein thrombosis (DVT) among patients newly diagnosed with RA compared with the general population without RA; and to estimate the risk trends of VTE, PE and DVT after RA diagnosis up to 5 years compared with the general population. Methods Using previously validated RA case definition, we conducted a matched cohort study using the population-based administrative health database from the province of British Columbia, Canada. We calculated incidence rates (IRs) and fully adjusted hazard ratios (HRs) for the risk of VTE, DVT and PE after RA index date. Results Among 39 142 incident RA patients (66% female, mean age 60), 1432, 543 and 1068 developed VTE, PE and DVT, respectively. IRs for the RA cohort were 3.79, 1.43 and 2.82 per 1000 person-years vs 2.70, 1.03 and 1.94 per 1000 person-years for the non-RA cohort. After adjusting for VTE risk factors, the HRs (95% CI) were 1.28 (1.20, 1.36), 1.25 (1.13, 1.39) and 1.30 (1.21, 1.40) for VTE, PE and DVT, respectively. The fully adjusted HRs for VTE during the first five years after RA diagnosis were 1.60, 1.47, 1.40, 1.30 and 1.28, respectively. A similar trend was shown in PE. Conclusion This population-based study demonstrates that RA patients have an increased risk of VTE, PE and DVT after diagnosis compared with the general population. This risk is independent of traditional VTE risk factors and is highest during the first year after RA diagnosis, then progressively declined.

BackgroundArthritis is a highly prevalent disease and leading cause of disability in the Indigenous population. A novel model of care consisting of a rheumatology outreach clinic in an on-reserve primary healthcare center has provided service to an Indigenous community in Southern Alberta since 2010. Despite quality assessments suggesting this model of care improves accessibility and is effective in meeting treatment targets, substantial improvements in patient-reported outcomes have not been realized. Therefore, the objective of this study was to explore the experiences of Indigenous persons with arthritis and healthcare providers involved in this model of care to inform the development of health service improvements that enhance patient outcomes.MethodsThis was a narrative-based qualitative study involving a purposeful sample of 32 individuals involved in the Indigenous rheumatology model of care. In-depth interviews were conducted to elicit experiences with the existing model of care and to encourage reflections on opportunities to improve it. A two-stage analysis was conducted. The first stage aimed to produce a narrative synthesis of concepts through a dialogical method comparing people with arthritis and health providers’ narratives. The second stage involved a collective effort to synthesize concepts and propose specific recommendations to improve the quality of the current model of care. Triangulation, through participant checking and discussion among researchers, was used to increase the validity of the final recommendations.ResultsTen Indigenous people with arthritis lived experience, 14 health providers and 8 administrative staff were interviewed. One main overarching theme was identified, which reflected the need to provide services that improve people’s physical and mental functioning. Further, the following specific recommendations were identified: 1) enhancing patient-provider communication, 2) improving the continuity of the healthcare service, 3) increasing community awareness about the presence and negative impact of arthritis, and 4) increasing peer connections and support among people living with arthritis.ConclusionsImproving the quality of the current Indigenous rheumatology model of care requires implementing strategies that improve functioning, patient-provider communication, continuity of care, community awareness and peer support. A community-based provider who supports people while navigating health services could facilitate the implementation of these strategies.

Across the globe, concerns of hydroxychloroquine (HCQ) supply shortages for patients with rheumatic disease are growing,1 in part as a consequence of the immense scientific and public enthusiasm for HCQ as a potential COVID-19 therapy.2 3 However, published data on the occurrence of HCQ shortages during the COVID-19 pandemic are presently lacking. Therefore, we conducted a national survey of 531 Canadian rheumatologists between 14 and 24 April 2020. The 5-question electronic survey (French or English) included province of practice, whether respondents were concerned about HCQ shortages in their province, and whether they had been contacted by patients or pharmacies regarding difficulties renewing HCQ prescriptions during the COVID-19 pandemic. Physicians who answered ‘yes’ to the latter question were asked to estimate for how many patients this occurred. The McGill University Health Centre research ethics board approved this survey. Of 134 rheumatologists who completed the survey (25% response rate), three quarters (n=102, 76%) were concerned about HCQ shortages, while 81 (60%) had been contacted by pharmacies or patients …

The health benefits of regular physical activity have been well established. The Canadian Physical Activity Guidelines (CPAG) specify that adults should accumulate at least 150 minutes of moderate-to-vigorous intensity physical activity (MVPA) per week. Our study objectives were to: 1) determine the proportion of RA patients in British Columbia (BC) who meet the CPAG, 2) identify the determinants of meeting the recommendations, and 3) compare the duration of time spent in MVPA relative to general population controls using self-reported data. A cross-sectional study was conducted using 2015 data from an annual survey administered to an RA cohort in BC. Normative physical activity data was obtained from the Canadian Community Health Survey. Adjusting for age and sex, the proportion of RA patients who met the guidelines was compared to the general population. Multivariable logistic regression analysis was used to identify significant determinants of meeting these guidelines and an ordinary least squares (OLS) model evaluated differences in average MVPA time. A two-part model evaluated the overall amount of MVPA performed by both the RA sample and the general population. After standardization, the sample of 169 RA patients was 21% less likely to meet the CPAG than controls (p=0.028). Individuals who were Caucasian (p=0.019), had better physical function (p=0.003), were an ex-smoker (p=0.022), and had more pain (p=0.018) were more likely to meet guidelines. Although, overall, RA patients spent significantly (p

Various studies have demonstrated how rheumatoid arthritis (RA) patients perform less physical activity than the general population, likely due to joint pain and impaired physical function. However, physical activity (PA) may have beneficial effects on reducing inflammation and RA disease activity. The objective of this study was to evaluate the association between baseline PA levels and self-reported changes in measures of RA disease activity. We conducted a longitudinal study using 2015-2017 data from an annual survey administered to an RA cohort in BC. Subjects were grouped into three levels (Low, Medium and High) of PA at the baseline year (2015) according to the specifications of the International Physical Activity Questionnaire. Subsequently, we examined whether baseline PA was associated with changes in RA disease activity outcomes over 2015 to 2017, using fitted linear mixed models for each measure and adjusting for age, sex and other covariates. Of the 169 patients who responded to the 2015 survey, 29.6%, 42.0%, and 28.4% were grouped into Low, Medium, and High levels of PA, respectively. Our results demonstrated that the Low PA group experienced significant worsening of disease activity outcomes over the three years, including those of the Rheumatoid Arthritis Disease Activity Index (RADAI) (p=0.007), Fatigue (p=0.007), and Pain (p=0.007). Those in the Medium and High PA groups at baseline experienced either a decrease or no change in their disease activity outcomes over time. These results add to the accumulating evidence that physical activity may reduce disease activity and is essential to RA management.

Objective To evaluate compliance with hyperlipidaemia screening guidelines for cardiovascular disease prevention in RA compared with the general population. Methods We conducted a longitudinal study of a population-based RA cohort including all prevalent cases in British Columbia between 1996 and 2006, followed up until 2010, with matched general population controls. Using administrative data, we measured compliance with general population guidelines (testing lipids every 5 years for women ⩾50 and men ⩾40), after excluding individuals with previous diabetes, coronary artery disease or hyperlipidaemia. Compliance was measured as the proportion of 5-year eligibility periods with one or more lipid test. Compliance rates in RA and controls were compared by Chi-square test. Odds ratio (95% CI) of compliance in RA (vs controls) was estimated using generalized estimating equation models, adjusting for age and sex. Mean compliance rate per patient was also calculated and compared using Mann-Whitney U test. Results Analyses included 5587 RA individuals and 5613 controls, contributing 6993 and 7208 5-year eligibility periods, respectively. Lipids were measured in 56.6 and 59.5% of eligibility periods in RA and controls, respectively [adjusted odds ratio (95% CI): 0.97 (0.90, 1.06)]. Screening improved over time in RA relative to the general population, but remained suboptimal even after 2003, at 65.8%. Mean (s.d.) compliance rate per patient was 56.6 (47.2)% for RA and 59.5 (46.6)% for controls. Family physicians ordered almost all the lipid tests. Conclusion Compliance with general population guidelines for hyperlipidaemia screening in RA was poor and did not differ from the general population, despite a higher risk of cardiovascular diseases.

To assess adherence to 3 system-level performance measures in a national early rheumatoid arthritis (RA) cohort.Patients enrolled in the Canadian Early Arthritis Cohort (2007-2015) who met 1987 or 2010 American College of Rheumatology/European League Against Rheumatism criteria with1 year of symptom duration and ≥1 year of followup after enrollment were included. Performance measures assessed were the percentage of RA patients seen in yearly followup, and the number of gaps between visits of12 or14 months, the percentage of RA patients treated with a disease-modifying antirheumatic drug (DMARD), and days from RA diagnosis to initiation of a DMARD. Results are shown stratified by enrollment year to assess for temporal changes in performance.A total of 1,763 early RA patients were included (mean age 54 years, 73% female, and 82% white). At enrollment, mean ± SD disease duration was 6 ± 3 months, and Disease Activity Score in 28 joints was 5.1 ± 1.5. Over 8 years, the proportion of patients seen in annual followup declined from 100% to 91%. Over followup, 42% of patients had 0 gaps in care of12 months, and 64% had 0 gaps14 months. The percentage of DMARD-treated early RA patients was and remained high (95-87%), and the percentage receiving DMARDs within 14 days of diagnosis was 75%. Median time-to-DMARD therapy was 1 day, indicating DMARDs were initiated at diagnosis (90th percentile 93 days).There was evidence of high adherence to system-level performance measures in this early RA cohort following a protocol. Small declines in performance were noted with increasing length of patient followup. Our findings are useful for performance measure benchmarking.

OBJECTIVE: Participation in society of persons with chronic diseases receives increasing attention. However, little is known which components of participation are most relevant to life satisfaction. This study examines the association between several aspects of social role participation and satisfaction with life (SWL) in patients with ankylosing spondylitis (AS) compared to population controls.METHODS: In a cross-sectional study, participants completed the Social Role Participation Questionnaire (SRPQ) and SWL scale. The SRPQ assesses several dimensions of participation (importance, satisfaction with performance, satisfaction with time and physical difficulty) in 11 roles representing three domains (interpersonal relations, leisure and work). For individuals with AS and controls, the association between role-domains and SWL were examined using linear regression for each participation dimension separately, in the total and the employed population, adjusting for age, gender, education and income.RESULTS: 246 AS patients (age: 51±12 years; 62% males; disease duration: 17±12 years) and 510 controls (age: 42±15 years; 70% males) were included. Patients were more frequently (extremely) dissatisfied with life (17.9% vs 8.6%; p

Objective.Despite advances integrating patient-centered outcomes into rheumatologic studies, concerns remain regarding their representativeness across diverse patient groups and how this affects equity. The Outcome Measures in Rheumatology (OMERACT) Equity Working Group aims to determine whether and how to address equity issues within the core outcome sets of domains and instruments.Methods.We surveyed current and previous OMERACT meeting attendees and members of the Campbell and Cochrane Equity Group regarding whether to address equity issues within the OMERACT Filter 2.0 Core Outcome Sets and how to assess the appropriateness of domains, instruments, and measurement properties among diverse patients. At OMERACT 2016, results of the survey and a narrative review of differential psychosocial effects of rheumatoid arthritis (i.e., on men) were presented to stimulate discussion and develop a research agenda.Results.We proposed 6 moments for which an equity lens could be added to the development, selection, or testing of patient-reported outcome measures (PROM): (1) recruitment, (2) domain selection, (3) feasibility in diverse settings, (4) instrument validity, (5) thresholds of meaning, and (6) consideration of statistical power of subgroup analyses for outcome reporting.Conclusion.There is a need to (1) conduct a systematic review to assess how equity and population characteristics have been considered in PROM development and whether these differences influence the ranking of importance of outcome domains or a patient’s response to questionnaire items, and (2) conduct the same survey described above with patients representing groups experiencing health inequities.

Objective: Gout and rheumatoid arthritis (RA) are the two most common forms of inflammatory arthritis worldwide. As hospitalizations for both conditions lead to substantial health resource use, contemporary inpatient trends and associated costs may provide important benchmarks of disease burden. However, relevant data are limited. Methods: We used PopulationData BC, a population-based administrative dataset from Canada. We examined trends in the annual hospitalization and surgery rate of gout and RA from 2000-2011. We additionally examined annual trends in the inpatient cost burden of both conditions. We assessed annual trends in hospitalization and surgery rates using Poisson regression models and cost trends using linear regression models. Results: From 2000 to 2011, the annual hospitalization rate for RA declined by 49% from 15.4 to 7.9 per 100,000 Canadian adults (p

Background Active self-management is a process where patients are fully engaged in managing their health in daily life by having access to contextualized health data and tailored guidance to support a healthy lifestyle. This study aims to determine whether an e-health intervention that incorporates symptom/disease activity monitoring and physical activity counselling can improve self-management ability in patients with rheumatoid arthritis (RA). Methods The ‘Empowering active self-management of arthritis: Raising the bar with OPERAS (an On-demand Program to EmpoweR Active Self-management)’ project is a randomized controlled trial that uses a delayed control design. One hundred thirty-four participants with RA will be randomly assigned to start the intervention either immediately (immediate group) or 6 months later (delayed group). The intervention involves (1) use of a Fitbit-compatible web app to record and monitor their RA disease activity, symptoms, and time spent on physical activity and a Fitbit; (2) group education and individual counselling by a physiotherapist (PT); and (3) six phone calls with a PT. The primary outcome measure is self-management ability measured by the Patient Activation Measure. Secondary outcome measures include disease status, fatigue, pain, depressive symptoms, and characteristics of habitual behavior and also time spent in physical activity and sedentary activity with a wearable multi-sensor device (SenseWear Mini). After the 6-month intervention, we will interview a sample of participants to examine their experiences with the intervention. Discussion The results of this study will help to determine whether this technology-enhanced self-management intervention improves self-management ability and health outcomes for people living with RA. A limitation of this study is that participants will need to self-report their symptoms, disease status, and treatment use through questionnaires on the OPERAS web app. The user-friendly interface, reminder emails from the research staff, and tailored guidance from PTs will encourage participants to actively engage with the app. Trial registration Date of last update in ClinicalTrials.gov: January 2, 2019. ClinicalTrials.gov Identifier: NCT03404245.

Background: The study evaluates Performance Measures (PMs) for Juvenile Idiopathic Arthritis (JIA): The percentage of patients with new onset JIA with at least one visit to a pediatric rheumatologist in the first year of diagnosis (PM1); and the percentage of patients with JIA under rheumatology care seen in follow-up at least once per year (PM2). Methods: Validated JIA case ascertainment algorithms were used to identify cases from provincial health administrative databases in Manitoba, Canada in patients < 16 years between 01/04/2005 and 31/03/2015. PM1: Using a 3-year washout period, the percentage of incident JIA patients with ≥1 visit to a pediatric rheumatologist in the first year was calculated. For each fiscal year, the proportion of patients expected to be seen in follow-up who had a visit were calculated (PM2). The proportion of patients with gaps in care of > 12 and > 14 months between consecutive visits were also calculated. Results: One hundred ninety-four incident JIA cases were diagnosed between 01/04/2008 and 03/31/2015. The median age at diagnosis was 9.1 years and 71% were female. PM1: Across the years, 51–81% of JIA cases saw a pediatric rheumatologist within 1 year. PM2: Between 58 and 78% of patients were seen in yearly follow-up. Gaps > 12, and > 14, months were observed once during follow-up in 52, and 34%, of cases, and ≥ twice in 11, and 5%, respectively. Conclusions: Suboptimal access to pediatric rheumatologist care was observed which could lead to diagnostic and treatment delays and lack of consistent follow-up, potentially negatively impacting patient outcomes.

Background. Active self-management is a process where patients are fully engaged in managing their health in daily life by having access to contextualized health data and tailored guidance to support a healthy lifestyle. The current study aims to determine whether an e-health intervention which incorporates symptom/disease activity monitoring and physical activity counselling can improve self-management ability in patients with rheumatoid arthritis (RA). Methods. The Empowering active self-management of arthritis: Raising the bar with OPERAS (an On-demand Program to EmpoweR Active Self-management) project is a randomized controlled trial which uses a delayed control design. 134 participants with RA will be randomized to either start the intervention immediately (Immediate Group) or start 6 months later (Delayed Group). The intervention involves: 1) use of a Fitbit-compatible web app to record and monitor their RA disease activity, symptoms and time spent on physical activity and a Fitbit; 2) group education and individual counselling by a physiotherapist (PT), and 3) 6 phone calls with a PT. The primary outcome measure is self-management ability measured by the Patient Activation Measure. Secondary outcome measures include disease status, fatigue, pain, depressive symptoms, and characteristics of habitual behavior. In addition, time spent in physical activity and sedentary activity with a wearable multi-sensor device (SenseWear Mini). Following the 6-month intervention, we will interview a sample of participants to examine their experiences with the intervention. Discussion. The results of this study will help to determine whether this technology-enhanced self-management intervention improves self-management ability and their health outcomes for people living with RA. A limitation of this study is that participants will need to self-report their symptoms, disease status, and treatment use through questionnaires on the OPERAS web app. The user-friendly interface, reminder emails from the research staff, and tailored guidance from PTs will encourage participants to actively engage with the app. Trial Registration. Date of last update in ClinicalTrials.gov: January 2, 2019 ClinicalTrials.gov Identifier: NCT03404245

Background: Recent studies have demonstrated a declining trend in RA mortality relative to the general population (1). This improvement in mortality could be due to improvement in incident risk of cardiovascular events that are the leading cause of excess deaths in RA (2). Objectives: Our objective was to assess secular trends in ten-year incident risk of acute myocardial infarction (AMI) in incident cohorts of RA versus general population controls, using administrative health data. Methods: We conducted a retrospective study of a population-based cohort of incident RA cases who first met previously published RA criteria between 01/01/1997 and 31/12/2004 in British Columbia, followed until 12/2014, with general population controls matched 2:1 on gender, age, and index year. Individuals were excluded if they had a diagnosis of MI prior to index date. Incident AMI was defined as first AMI during follow-up using ICD codes (ICD-9 code 410/ICD-10 code I21) in Hospital Discharge data or death certificate in Vital Statistics data. RA and general population cohorts were stratified according to year of RA incidence, defined according to first RA visit, using a 7-year wash-out period. Incident rates (IRs) of AMI for RA and general population cohorts, as well as incident rate ratios (IRRs), with 95% confidence intervals (CI) were calculated per calendar years of incidence. Multivariable Cox Proportional Hazard models with left truncation were used to estimate risk of AMI in RA relative to general population while controlling for potential confounders, with contribution of person time of follow-up starting from index date (second RA visit) to avoid immortal time bias and censoring at ten years from incident year, or last health care utilization. To examine whether secular trends differed in RA relative to general population, an interaction term was tested between the RA indicator and year of RA incidence. To account for non-linear effect of cohort year, we compared cox regression models with linear, quadratic, and flexible spline forms of the cohort-year effects and the model with the best AIC was used to interpret the data. Results: 23,237 RA individuals (66.4% female; mean [SD] age 58[16.88] years) and 46,474 controls experienced 1,133 and 1,646 incident AMI, respectively. Cox Proportion model with the lowest AIC best fit the data. Risk of AMI was significantly higher in RA vs. general population [aHR (95% CI): 1.21(1.10, 1.32); p Conclusion: Our finding suggests that the risk of AMI has significantly decreased over time in RA and general population cohorts. However, the declining trend was not significantly different in RA compared to the general population. References: [1] Lacaille, D., et al., Improvement in 5-year mortality in incident rheumatoid arthritis compared with the general population—closing the mortality gap. Annals of the Rheumatic Diseases, 2016. [2] Myasoedova, E. and S.E. Gabriel, Overview of rheumatoid arthritis and mortality in relation to cardiovascular disease, in Handbook of Cardiovascular Disease Management in Rheumatoid Arthritis, A.G. Semb, Editor. 2017, Springer International Publishing: Cham. p. 1-17. Disclosure of Interests: Kiana Yazdani: None declared, Hui Xie: None declared, Antonio Avina: None declared, Yufei Zheng: None declared, Michal Abrahamowicz: None declared, Diane Lacaille Grant/research support from: Bristol-Myers Squibb and Eli Lilly Canada

Background The abatacept global post-marketing epidemiology programme consists of observational studies based on biologic disease registries and healthcare claims databases to assess infection and malignancy risks associated with abatacept treatment, as used in routine clinical practice. Objectives To evaluate the risk of infection in patients with RA treated with abatacept versus conventional synthetic (cs)DMARDs and other biologic (b) or targeted synthetic (ts)DMARDs. Methods Data were analysed from five cohorts: two biologic registries (the Anti-Rheumatic Therapy in Sweden register and the Rheumatoid Arthritis Observation of Biologic Therapy German registry), a disease registry (FORWARD, The National Databank for Rheumatic Diseases in the USA) and two healthcare claims databases (the population-based British Columbia Canadian RA Cohort and the US Optum Research Database). Crude incidence rates (per 1000 patient-years of exposure) with 95% CIs were calculated for hospitalised infections and opportunistic infections. Adjusted risk ratios (RRs) with 95% CIs were estimated using multivariate models adjusting for demographics, co-morbidities and other potential cofounders within each database and were subsequently pooled using a random effects model for meta-analyses.1 Results From all cohorts, patients treated with abatacept (∼6400), csDMARDs (∼137K) and other b/tsDMARDs (∼54K) were followed up for a mean of 2.3–3.7, 2.2–6.2 and 2.3–4.7 years, respectively. Patients were mainly female (71–86%), with a mean age ranging from 49–63 years, and 3–18% had a history of prior severe infections across treatment groups/cohorts. A greater number of abatacept-treated patients had a history of ≥2 prior biologics (44–85% vs csDMARDs, 11% [FORWARD] and other b/tsDMARDs, 0–19%). In abatacept-treated patients, incidence rates for hospitalised infections ranged from 16–56 and opportunistic infections from 0.4–7.8 (Table). Adjusted RRs (95% CIs) for abatacept vs csDMARDs (range: 0.3 [0.2, 0.7] to 2.2 [1.3, 3.7]; pooled estimate: 1.2 [0.6, 2.2]) and abatacept vs other b/tsDMARDs (range: 0.5 [0.3, 0.8] to 1.3 [0.8, 2.1]; pooled estimate: 0.9 [0.6, 1.3]) showed no increased risk in hospitalised infections. Conclusion In this large, international post-marketing epidemiology programme, pre-specified infection risks were more frequent with abatacept than csDMARDs and b/tsDMARDs in some, but not all, cohorts. Increased risks for individual outcomes/cohorts may be attributed to prior biologic exposure, study design and practice pattern differences. These data are consistent with the current safety profile of abatacept. References [1] DerSimonian R, Laird N. Control Clin Trials 1986;7:177–188. Acknowledgement Professional Medical writing: Rachel Rankin, PhD, Caudex; funding: Bristol-Myers Squibb Disclosure of Interests Teresa Simon Employee of: Bristol-Myers Squibb, Samy Suissa Grant/research support from: Advisory board meetings, or as speaker, or received research grants from AstraZeneca, Bayer, Boehringer-Ingelheim, Bristol-Myers Squibb, Novartis, Speakers bureau: Advisory board meetings, or as speaker, or received research grants from AstraZeneca, Bayer, Boehringer-Ingelheim, Bristol-Myers Squibb, Novartis, Mary Lou Skovron Shareholder of: Bristol-Myers Squibb, Consultant for: Bristol-Myers Squibb, Thomas Frisell: None declared, Johan Askling Grant/research support from: Karolinska Institutet (JA) has or has had research agreements with the following pharmaceutical companies, mainly in the context of the ATRIS national safety monitoring programme for rheumatology biologicals: Abbvie, BMS, MSD, Eli Lilly, Pfizer, Roche, Samsung Bioepis, and UCB., Consultant for: Karolinska Institutet has received remuneration for JA participating in ad boards arranged by Lilly, Novartis, and Pfizer., Kaleb Michaud Grant/research support from: Research grant funding in the last 2 years from Rheumatology Research Foundation and Pfizer, Sofia Pedro Employee of: FORWARD, The National Data Bank of Rheumatic Diseases, Anja Strangfeld Speakers bureau: Speakers fees from Bristol-Myers Squibb, MSD, Pfizer, Roche, Maarten Boers Consultant for: Bristol-Myers Squibb, Teva, Novartis, Pfizer, GlaxoSmithKline, Diane Lacaille Grant/research support from: Bristol-Myers Squibb and Eli Lilly Canada, Marc Hochberg Shareholder of: BriOri Biotech, Theralogix LLC., Consultant for: Bristol Myers Squibb, Eli Lilly, EMD Serono, Novartis Pharma AG, Pfizer Inc., Samumed LLC, Symic Bio Inc., Theralogix LLC, TissueGene Inc., TLC Biopharmaceuticals, Inc., Zynerba, Galapagos, IQVIA, Hoffman LaRoche., Veena Hoffman Shareholder of: UnitedHealth Group, Inc (parent company of Optum), Employee of: Optum, Andres Gomez Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb

Background Rheumatoid arthritis (RA) patients often complain of “brain fog” as a symptom when their disease activity is greater. The exact areas of cognition that this “brain fog” means are not yet understood. Previous studies have found that people with RA have lower cognitive function (CF) than healthy controls and age based population norms. A study by Shin et al which looked at prevalence of cognitive impairment in persons with RA found that 31% of their 115 person sample was cognitively impaired and stated that further studies should be done to identify the specific domains of cognitive function that are most commonly affected (1). In this project, I will be looking at and summarizing all the data and findings that have been collected and reported on CF in the RA population and seeing which domains of cognition differ and which do not differ when compared to the general population and aged based population norms. Objectives To conduct a systematic review of studies reporting on cognitive function (CF) in rheumatoid arthritis (RA) patients compared to non-RA populations (based on comparison with a control group or age-based population norms). Methods We conducted a comprehensive literature search of MEDLINE, EMBASE, and PUBMED databases using the following search terms: rheumatoid arthritis or arthritis or inflammatory arthritis, and cognitive function or cognition. The search was conducted with no limit for years, and confined to only articles in English or French. After title and abstract screen, relevant articles were selected for review. Only full length articles were considered. Study selection criteria included: 1) must be presenting original data, 2) must contain RA group with confirmed diagnosis, 3) must be reporting on CF in RA, 4) must use a validated measure of CF (self-reported or from conducting CF tests), and 5) must contain a healthy control group or age-based populations norms. Selected articles were critically appraised using the SIGN Methodology Checklist and data extracted using a standardized form. Results Our initial literature search yielded 747 titles, and after screening for irrelevant titles and duplicates, 28 abstracts remained. Upon excluding non-full length articles and articles which did not report on CF, 13 abstracts remained. Of these 13 articles, 8 met our selection criteria. All studies were published after the year 2000, 3 were from the USA, 1 from Canada, 1 from the UK, 1 from Australia, 1 from Egypt, and 1 from Taiwan. Sample sizes for RA and control groups varied from 15 to 120. Of these 8 articles, 6 found a significant difference in cognitive function in the RA group compared to control group or age-based population norms in at least one domain of CF. All articles that found a significant difference in CF used standardized neuropsychological tests. Domains of CF that differed included fluency, attention, visual-spatial learning, memory, decision making time, and simple reaction time. Domains of CF that were not found to differ from general population across all studies included reasoning, comprehension, and intelligence (IQ). Conclusion Overall, 75% of the articles reviewed found a significant difference in at least one domain of CF in RA patients compared to healthy controls or age-based population norms. The domains of CF most commonly affected are those related to processing and speed rather than intellectual ability. Further studies are needed to explore these differences in greater depth and to understand the underlying reasons for these differences. Reference [1] Shin, So Young, Patricia Katz, Margaret Wallhagen, and Laura Julian. 2012. “Cognitive Impairment in Persons with Rheumatoid Arthritis.”Arthritis Care & Research. Disclosure of Interests Teresa Szlachetka: None declared, Linda Li: None declared, Teresa Liu-Ambrose: None declared, Hui Xie: None declared, Kiana Yazdani: None declared, Diane Lacaille Grant/research support from: Bristol-Myers Squibb and Eli Lilly Canada

Background Various studies have found that rheumatoid arthritis (RA) patients perform less physical activity than the general population, likely due to joint pain and impaired physical function. However, recent studies suggest that physical activity may have a beneficial effect on inflammation and could therefore contribute to reducing RA disease activity. A greater understanding of the relationship between physical activity levels and RA disease activity would be valuable for physical activity counselling of RA patients. Objectives The aim of this study was to evaluate the association between baseline physical activity levels and subsequent changes in measures of disease activity in patients with RA using self-reported data. Methods We conducted a longitudinal study using 2015-2017 data from an annual survey administered to an RA cohort derived from a population-based cohort for BC originally assembled using physician billing data and a previously validated algorithm. Subjects were grouped into three levels (Low, Medium and High) of physical activity (PA) at the baseline year (2015) according to the specifications of the International Physical Activity Questionnaire. We examined whether physical activity at baseline was associated with a change over time in RA disease activity outcomes from 2015 to 2017. We fitted linear mixed models for Rheumatoid Arthritis Disease Activity Index (RADAI), Fatigue visual analog scale (VAS), and Pain VAS scores separately without/with adjusting for age, sex, sociodemographic factors, body mass index, RA duration, physical function (Modified Health Assessment Questionnaire [mHAQ]), smoking, depression and other comorbidities at baseline. Models include the outcome at three years (2015-2017) as the dependent variables, an indicator variable representing the year of measurement (2015-17), PA level at baseline, their interactions, and baseline characteristics as covariates. Models include random effects for subjects to account for correlations among within-subject repeated measures. Missing values were imputed using multiple imputation methods. The analyses were conducted using R 3.5. Results Of the 169 patients who responded to the 2015 survey, 29.6%, 42.0%, and 28.4% had low, medium, and high levels of PA in 2015, respectively. There were no significant differences in RADAI (p=0.67), Fatigue (p=0.78), and Pain (p=0.98) at baseline (Figure 1). The low PA group experienced significant worsening of disease activity outcomes over time, including yearly increases of 0.31 in RADAI (p=0.007), 0.41 in Fatigue (p=0.007), and 0.43 in Pain (p=0.007). Those in the medium and high PA groups at baseline experienced either a decrease or no change in their disease activity outcomes over time. The interaction terms for PA level and year show that the low PA group had significantly different time trends for RADAI, Fatigue, and Pain compared to the medium and high PA groups (all p values Conclusion Across RADAI, Fatigue VAS, and Pain VAS scores, RA patients with a low PA level demonstrated a significant increase in disease activity over the span of three years. The trends for both the high and medium PA groups differ significantly from that of the low PA group, showing small, overall decreases in disease activity over time. These results add to the accumulating evidence that physical activity may reduce disease activity and is an essential aspect of RA management. Acknowledgement Funded by the CIHR. Disclosure of Interests Kiera Lee-Pii: None declared, Hui Xie: None declared, Yufei Zheng: None declared, Linda Li: None declared, Diane Lacaille Grant/research support from: Bristol-Myers Squibb and Eli Lilly Canada

Background The abatacept global post-marketing epidemiology programme includes observational studies based on biologic disease registries and healthcare claims database studies to evaluate infection and malignancy risks associated with abatacept treatment, as used in routine clinical practice. Objectives To assess the risk of solid tumour malignancies in patients with RA treated with abatacept vs conventional synthetic (cs)DMARDs and other biologic (b) or targeted synthetic (ts)DMARDs. Methods Data were analysed from four cohorts: two biologic registries (the Anti-Rheumatic Therapy in Sweden [ARTIS] register and the Rheumatoid Arthritis Observation of Biologic Therapy [RABBIT] German registry), a disease registry (FORWARD, The National Databank for Rheumatic Diseases in the USA) and a healthcare claims database (the population-based British Columbia Canadian RA Cohort [BC]). Exposure defined as “ever exposed” unless specified. Crude incidence rates (per 1000 patient-years of exposure) with 95% CIs were calculated for overall malignancy, breast cancer, lung cancer and lymphoma. Adjusted risk ratios (RRs) with 95% CIs were estimated using multivariate models adjusting for demographics, comorbidities and other potential cofounders within each database and were subsequently pooled using a random-effects model for meta-analyses.1 Results Patients treated with abatacept (∼5100), csDMARDs (∼74K) and other b/tsDMARDs (∼37K) were followed up for a mean of 3.0–3.7, 3.0–6.2 and 3.0–4.7 years, respectively. Patients were mainly female (71–86%), with a mean age ranging from 55–63 years, and 4–34% had a history of malignancy. A greater number of abatacept-treated patients had been treated with ≥2 prior biologics (abatacept, 44–85%; csDMARDs, 11% [FORWARD] and other b/tsDMARDs, 0–19%). The incidence rate of overall malignancy in abatacept-treated patients was low (Table). Adjusted RRs (95% CIs) for abatacept vs csDMARDs (range: 0.8 [0.2, 3.4] to 1.3 [0.5, 3.3]; pooled estimate: 1.1 [0.8, 1.5]) and abatacept vs other b/tsDMARDs (range: 1.0 [0.4, 2.6] to 1.2 [0.6, 2.3]; pooled estimate: 1.0 [0.8, 1.3]) showed no increased risk in overall malignancy. Although individual registries showed a slight increase in breast (BC), lung (RABBIT) and lymphoma (ARTIS) cancers in patients treated with abatacept, numbers were too low to make an accurate comparative risk assessment. Conclusion While the development of malignancy is a potential risk associated with the use of immunomodulators, data from this large, international, post-marketing epidemiology programme suggest that the risks of overall malignancy and breast, lung or lymphoma cancers were not significantly increased in patients treated with abatacept. These data are consistent with the established safety profile of abatacept. Reference [1] DerSimonian R, Laird N. Control Clin Trials 1986;7:177–88. Acknowledgement Professional Medical writing: Claire Line, PhD, Caudex; funding: Bristol-Myers Squibb Disclosure of Interests Teresa Simon Employee of: Bristol-Myers Squibb, Samy Suissa Grant/research support from: Advisory board meetings, or as speaker, or received research grants from AstraZeneca, Bayer, Boehringer-Ingelheim, Bristol-Myers Squibb, Novartis, Speakers bureau: Advisory board meetings, or as speaker, or received research grants from AstraZeneca, Bayer, Boehringer-Ingelheim, Bristol-Myers Squibb, Novartis, Mary Lou Skovron Shareholder of: Bristol-Myers Squibb, Consultant for: Bristol-Myers Squibb, Thomas Frisell: None declared, Johan Askling Grant/research support from: Karolinska Institutet (JA) has or has had research agreements with the following pharmaceutical companies, mainly in the context of the ATRIS national safety monitoring programme for rheumatology biologicals: Abbvie, BMS, MSD, Eli Lilly, Pfizer, Roche, Samsung Bioepis, and UCB., Consultant for: Karolinska Institutet has received remuneration for JA participating in ad boards arranged by Lilly, Novartis, and Pfizer., Kaleb Michaud Grant/research support from: Research grant funding in the last 2 years from Rheumatology Research Foundation and Pfizer, Sofia Pedro Employee of: FORWARD, The National Data Bank of Rheumatic Diseases, Anja Strangfeld Speakers bureau: Speakers fees from Bristol-Myers Squibb, MSD, Pfizer, Roche, Maarten Boers Consultant for: Bristol-Myers Squibb, Teva, Novartis, Pfizer, GlaxoSmithKline, Diane Lacaille Grant/research support from: Bristol-Myers Squibb and Eli Lilly Canada, Marc Hochberg Shareholder of: BriOri Biotech, Theralogix LLC., Consultant for: Bristol Myers Squibb, Eli Lilly, EMD Serono, Novartis Pharma AG, Pfizer Inc., Samumed LLC, Symic Bio Inc., Theralogix LLC, TissueGene Inc., TLC Biopharmaceuticals, Inc., Zynerba, Galapagos, IQVIA, Hoffman LaRoche., Andres Gomez Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb

Background Recent studies have demonstrated a declining trend in RA mortality relative to the general population (1). This improvement in mortality could be due to improvement in incident risk of cardiovascular events that are the leading cause of excess deaths in RA (2). Objectives Our objective was to assess secular trends in ten-year incident risk of cerebrovascular accident (CVA) in incident cohorts of RA versus general population controls, using administrative health data. Methods We conducted a retrospective study of a population-based cohort of incident RA cases who first met previously published RA criteria between 01/01/1997 and 31/12/2004 in British Columbia followed until 31/12/2014, with general population controls matched 2:1 on gender, age, and index year. Individuals were excluded if they had a diagnosis of CVA prior to index date. Incident CVA was defined as first CVA during follow-up using ICD codes 9 code 433, 434/ICD-10 code I64, I63) in Hospital Discharge data or death certificate in Vital Statistics data. RA and general population cohorts were stratified according to year of RA incidence, defined according to first RA visit, using a 7-year wash-out period. Incident rates (IRs) of CVA for RA and general population cohorts, as well as incident rate ratios (IRRs), with 95% confidence intervals (CI) were calculated per calendar years of incidence. Multivariable Cox Proportional Hazard models with left truncation were used to estimate risk of CVA in RA relative to general population while controlling for potential confounders, with contribution of person time of follow-up starting from index date (second RA visit) to avoid immortal time bias and censoring at ten years from incident year, or last health care utilization. To examine whether secular trends differed in RA relative to general population, an interaction term was tested between the RA indicator and year of RA incidence. To account for non-linear effect of cohort year, we compared cox regression models with linear, quadratic, and flexible spline forms of the cohort-year effects and the model with the best AIC was used to interpret the data. Results 23,545 RA individuals (65.7% female; mean [SD] age 58.11[16.82] years) and 47,090 controls experienced 658 and 1,220 incident CVA respectively. A linear spline Cox model with a knot at year 1999 was selected to fit the CVA events. The change in CVA risk over time differed significantly in RA vs. general population after 1999 [p=0.0488], but not before 1999 [p=0.06]. A significant decline in risk of CVA was observed over the calendar years of incidence after 1999 in RA [0.91 (0.86, 0.96); p=.0003] but not in the general population [0.97(0.93, 1.01); p=0.1019]. Conclusion Our findings suggest that the risk of CVA has significantly declined over time in people with RA onset from 1999 onwards, but not in the general population. References [1] Lacaille, D., et al., Improvement in 5-year mortality in incident rheumatoid arthritis compared with the general population—closing the mortality gap. Annals of the Rheumatic Diseases, 2016. [2] Myasoedova, E. and S.E. Gabriel, Overview of rheumatoid arthritis and mortality in relation to cardiovascular disease, in Handbook of Cardiovascular Disease Management in Rheumatoid Arthritis, A.G. Semb, Editor. 2017, Springer International Publishing: Cham. p. 1-17. Disclosure of Interests Kiana Yazdani: None declared, Hui Xie: None declared, Antonio Avina: None declared, Yufei Zheng: None declared, Michal Abrahamowicz: None declared, Diane Lacaille Grant/research support from: Bristol-Myers Squibb and Eli Lilly Canada

Background: Work disability (WD) and presenteeism (decreased at-work productivity) are often caused by arthritis, leading to major impact on individuals’ quality of life and cost to society. Objectives: Our study objective was to identify the determinants of presenteeism in workers with inflammatory arthritis. Methods: Baseline data from the randomized controlled trial of an employment intervention, the Making-it-WorkTMprogram, were used. Participants were recruited from British Columbia, Alberta and Ontario. Inclusion criteria: diagnosis of inflammatory arthritis, currently employed, age 18-59, and having concerns about arthritis affecting ability to work. The primary outcome, presenteism, was assessed using the% impaired while at work subscale of the Work Productivity and Activity Impairment scale for Specific Health Problem (WPAI-SHP). First, the association between potential explanatory variables and WPAI was assessed in bivariate analyses. Variables evaluated included: 1) sociodemographic variables: age, gender, ethnicity, marital status, education, children under age 19; 2) disease variables: IA diagnosis, disease duration, number of limiting comorbidities, global assessment of disease activity (VAS), joint pain (VAS), Disease activity [Rheumatoid Arthritis Disease Activity Index (RADAI)], physical function (HAQ II), Fatigue [VAS, Global Fatigue Index from the Multidimensional Assesment of Fatigue (MAF)], Sleep quality [Insomnia Severity Index (ISI), Depression (Patient Health Questionnaire – PHQ-9); 3) work variables: physical demand, job autonomy, difficulty commuting to/from work, job spillover, job strain, psycho-social work characteristics [Job Content Questionnaire (JCQ) decision latitude, physical and psychological job demands, social support at work], self-employment, family support of decision to work, importance of working. Variables correlated with WPAI-SHP at p ≤ 0.20 were selected for inclusion in the multivariable linear regression analysis, using stepwise selection with alpha of 0.15. Results: The sample included 565 participants [49% with RA, 17% PsA, 14% SLE, 20% AS] with median (IQR) arthritis duration of 7(3-15) years; mean (SD) age 45.6 (10) years; 43% were 50 years or older; 78% were females; 76% had completed post secondary education; 17% were self-employed. Multivariable linear regression analyses revealed that age Conclusion: This study identified important sociodemographic, disease and work-related factors associated with reduced productivity at work in people with inflammatotry arthritis. These results provide useful information to health professionals counselling patients on dealing with employment issues. References [1] Carruthers, et al. [2] “Employment and arthritis: making it work” a randomized controlled trial evaluating an online program to help people with inflammatory arthritis maintain employment (study protocol). BMC Medical Informatics and Decision Making 2014 14:59 Disclosure of Interests: Andre Luquini: None declared, Diane Lacaille Grant/research support from: Bristol-Myers Squibb and Eli Lilly Canada, Eric C. Sayre: None declared, Rebecca Schnurr-Howsam: None declared

Objective To estimate the overall risk and the temporal trend of venous thromboembolism (VTE), deep vein thrombosis (DVT), and pulmonary embolism (PE) before and after gout diagnosis in an incident gout cohort compared with the general population. Methods We conducted a matched cohort study using a province-wide population-based administrative health database in Canada. We calculated incidence rates (IRs) and multivariable adjusted hazard ratios (HRs) for the risk of VTE, DVT and PE before and after gout diagnosis. Results Among 130 708 incident individuals with gout (64% male, mean age 59 years), 2071 developed VTE, 1377 developed DVT and 1012 developed PE. IRs per 1000 person-years for gout were 2.63, 1.74 and 1.28 compared with 2.03, 1.28 and 1.06 for non-gout, respectively. The fully adjusted HRs (95% CI) for VTE, DVT and PE were 1.22 (1.13, 1.32), 1.28 (1.17, 1.41) and 1.16 (1.05, 1.29). For the pre-gout period, the fully adjusted HRs (95% CI) were 1.51 (1.38, 1.64), 1.55 (1.40, 1.72) and 1.47 (1.31, 1.66) for VTE, DVT and PE. During the third, second and first years preceding gout, the fully adjusted HRs for VTE were 1.44, 1.56 and 1.62. During the first, second, third, fourth and fifth years after gout, the fully adjusted HRs were 1.63, 1.29, 1.33, 1.28 and 1.22. Similar trends were also seen for DVT and PE. Conclusion Increased risks of VTE, DVT and PE were found both before and after gout diagnosis. The risk increased gradually before gout, peaking in the year prior to diagnosis, and then progressively declined. Gout-associated inflammation may contribute to venous thrombosis risk.

Background:Inflammatory arthritis (IA) predisposes patients to several chronic conditions including cardiovascular diseases (CVD), diabetes (DM), osteoporosis (OP) and infections, likely due to systemic effects of inflammation. Studies have found that patients with IA often receive suboptimal care for screening and managing these conditions.Objectives:This is the first phase of a study which will develop and pilot test automated EMR reminders for family physicians. The reminders will prompt family physicians to screen for and address risk factors for these conditions. We conducted a Delphi process to select care recommendations to be addressed by the EMR reminders.Methods:We conducted a review of current BC, Canadian and international guidelines for screening and addressing risk factors for CVD, DM, OP and infection. A list of 22 care recommendations, including their level of evidence and risks/benefits of implementation, was reviewed by a panel of six family physicians, three rheumatologists and three IA patients, in a three-round online modified Delphi process. Panelists rated each care recommendation, using 9-point scales, on 1) their clinical importance, 2) their likelihood of improving outcomes, and 3) implementation feasibility. Results were discussed in an online forum. Panelists then rated slightly revised care recommendations, modified based on feedback from the discussion. Care recommendations were retained if the median rating was ≥7 with no disagreement as defined by the RAND/UCLA Method handbook.Results:A list of 15 care recommendations was selected by the Delphi process for EMR integration, including recommendations that address CVD risk assessment (1), hypertension screening (1), DM screening (2), fracture risk assessment (1), BMD testing (1), osteoporosis prevention (1) and treatment (1) with bisphosphonates, preventing infections through immunization (2), minimizing steroids (1) and hepatitis screening (1), screening for hydroxychloroquine retinal toxicity (1), and counselling for lifestyle modifications (2). We excluded 7 recommendations which addressed lipid testing (1), BMD testing in steroid users (1), immunizations (2), weight management (1), and DMARD laboratory test monitoring (2). Recommendations were excluded on the basis of importance (1) or feasibility (6).Conclusion:The results of the Delphi process will inform the development of reminders, integrated in EMRs, that will support family physicians in their efforts to engage IA patients in addressing risk factors for chronic diseases related to inflammation. We hope to improve the prevention of these diseases, which represent an important cause of morbidity and mortality for people with inflammatory arthritis.Acknowledgements:Iman Sheriff’s work on this project was funded by the CRA summer studentship programme. Dr. Lacaille is supported by the Mary Pack Chair in Arthritis Research from UBC and The Arthritis Society of Canada. Thank you to all who participated in the Delphi survey.Disclosure of Interests:None declared

Background:According to the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017, over 120,000 individuals currently have rheumatoid arthritis (RA) in Canada, yet a study that evaluates the combined effect of RA on the longevity and quality of life in the country is lacking.Objectives:The objectives of this study are three: 1) to describe burden of RA levels and trends from 1990-2017 using GBD data, 2) to describe age and sex differences, and 3) to compare Canada RA burden to other countries.Methods:We obtained publicly available data from GBD Study 2017 from the Institute for Health Metrics and Evaluation interactive visualization tool (http://vizhub.healthdata.org/gbd-compare). Disease burden indicators include prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs). Estimates were presented as non age-standardized and age-standardized rates per 100,000 population. GBD estimated prevalence using published literature, survey data, patient records, and health insurance claims, and mortality using cause of death ensemble modelling technique. YLLs measure premature death calculated as the sum of each death multiplied by the standard life expectancy at each age. YLDs measure amount of time in a year an individual lives with a short- or long-term health condition, calculated by combining prevalence with disability weights for each age/sex/year. DALYs were calculated as the sum of YLLs and YLDs. DALYs for Canada were compared to DALYs of countries with similar socio-demographic index (SDI) values. SDI combines income per capita, average educational attainment, and fertility rates. Data were analysed by DisMod-MR 2.1, a Bayesian meta-regression tool.Results:In Canada, RA mortality (mortality and YLLs) improved over time, with a steeper decline after the year 2002. However, the population burden of quality of life (YLDs and DALYs) increased due to increasing prevalence. The disease burden was higher in females (prevalence, mortality, YLLs, YLDs, DALYs), and DALY rates were higher among older populations. Compared to other countries, Canada had greater improvement in mortality and YLLs over time and had a lower age-standardized DALYs rate compared to countries of similar SDI values. A weak association was found between global age-standardized DALYs and SDI (R2 = 0.0138).Conclusion:RA is a major public health challenge. Canada fares better than other countries with regards to national RA burden. Early identification and management are critical to reducing the overall burden of RA in Canada, especially in women. More data from multiple provincial RA databases would increase the accuracy of our estimates for Canada.References:[1]Cross M, Smith E, Hoy D, et al. The global burden of rheumatoid arthritis: estimates from the global burden of disease 2010 study. Ann Rheum Dis. 2014;73(7):1316-1322. doi:10.1136/annrheumdis-2013-204627[2]Myasoedova E, Davis JM 3rd, Crowson CS, Gabriel SE. Epidemiology of rheumatoid arthritis: rheumatoid arthritis and mortality. Curr Rheumatol Rep. 2010;12(5):379-385. doi:10.1007/s11926-010-0117-y[3]Safiri S, Kolahi AA, Hoy D, et al. Global, regional and national burden of rheumatoid arthritis 1990-2017: a systematic analysis of the Global Burden of Disease study 2017. Ann Rheum Dis. 2019;78(11):1463-1471. doi:10.1136/annrheumdis-2019-215920Acknowledgements:Nejat Hassen is supported by a grant from the Canadian Institute of Health Research. Dr. Diane Lacaille is supported by the Mary Pack Chair in Arthritis Research from the University of British Columbia and The Arthritis Society of Canada.Disclosure of Interests:None declared

ObjectivesTo obtain stakeholder perspectives to inform the development and implementation of a rheumatoid arthritis (RA) healthcare quality measurement framework.DesignQualitative study using thematic analysis of focus groups and interviews.SettingArthritis stakeholders from across Canada including healthcare providers, persons living with RA, clinic managers and policy leaders were recruited for the focus groups and interviews.ParticipantsFifty-four stakeholders from nine provinces.InterventionsQualitative researchers led each focus group/interview using a semistructured guide; the digitally recorded data were transcribed verbatim. Two teams of two coders independently analysed the transcripts using thematic analysis.ResultsPerspectives on the use of different types of measurement frameworks in healthcare were obtained. In particular, stakeholders advocated for the use of existing healthcare frameworks over frameworks developed in the business world and adapted for healthcare. Persons living with RA were less familiar with specific measurement frameworks, however, they had used existing online public forums for rating their experience and quality of healthcare provided. They viewed a standardised framework as potentially useful for assisting with monitoring the care provided to them individually. Nine guiding principles for framework development and 13 measurement themes were identified. Perceived barriers identified included access to data and concerns about how measures in the framework were developed and used. Effective approaches to framework implementation included having sound knowledge translation strategies and involving stakeholders throughout the measurement development and reporting process. Clinical models of care and health policies conducive to outcome measurement were highlighted as drivers of successful measurement initiatives.ConclusionThese important perspectives will be used to inform a healthcare quality measurement framework for RA.

ObjectiveExcess mortality in rheumatoid arthritis (RA) is expected to have improved over time, due to improved treatment. Our objective was to evaluate secular 5-year mortality trends in RA relative to general population controls in incident RA cohorts diagnosed in 1996–2000 vs 2001–2006.MethodsWe conducted a population-based cohort study, using administrative health data, of all incident RA cases in British Columbia who first met RA criteria between January 1996 and December 2006, with general population controls matched 1:1 on gender, birth and index years. Cohorts were divided into earlier (RA onset 1996–2000) and later (2001–2006) cohorts. Physician visits and vital statistics data were obtained until December 2010. Follow-up was censored at 5 years to ensure equal follow-up in both cohorts. Mortality rates, mortality rate ratios and HRs for mortality (RA vs controls) using proportional hazard models adjusting for age, were calculated. Differences in mortality in RA versus controls between earlier and later incident cohorts were tested via interaction between RA status (case/control) and cohort (earlier/later).Results24 914 RA cases and controls experienced 2747 and 2332 deaths, respectively. Mortality risk in RA versus controls differed across incident cohorts for all-cause, cardiovascular diseases (CVD) and cancer mortality (interactions pConclusionsIn our population-based incident RA cohort, mortality compared with the general population improved over time. Increased mortality in the first 5 years was observed in people with RA onset before, but not after, 2000.

Objective.To characterize the practicing rheumatologist workforce, the Canadian Rheumatology Association (CRA) launched the Stand Up and Be Counted workforce survey in 2015.Methods.The survey was distributed electronically to 695 individuals, of whom 519 were expected to be practicing rheumatologists. Demographic and practice information were elicited. We estimated the number of full-time equivalent rheumatologists per 75,000 population from the median proportion of time devoted to clinical practice multiplied by provincial rheumatologist numbers from the Canadian Medical Association.Results.The response rate was 68% (355/519) of expected practicing rheumatologists (304 were in adult practice, and 51 pediatric). The median age was 50 years, and one-third planned to retire within the next 5–10 years. The majority (81%) were university-affiliated. Rheumatologists spent a median of 70% of their time in clinical practice, holding 6 half-day clinics weekly, with 10 new consultations and 45 followups seen per week. Work characteristics varied by type of rheumatologist (adult or pediatric) and by practice setting (community- or university-based). We estimated between 0 and 0.8 full-time rheumatologists per 75,000 population in each province. This represents a deficit of 1 to 77 full-time rheumatologists per province/territory to meet the CRA recommendation of 1 rheumatologist per 75,000 population, depending on the province/territory.Conclusion.Our results highlight a current shortage of rheumatologists in Canada that may worsen in the next 10 years because one-third of the workforce plans to retire. Efforts to encourage trainees to enter rheumatology and strategies to support retention are critical to address the shortage.

OBJECTIVE: Social role participation of persons with a chronic disease is important for their lives, but interpretation of data on participation is difficult in the absence of a benchmark. This study aimed to compare social role participation in patients with ankylosing spondylitis (AS) to population controls using the social role participation questionnaire (SRPQ). METHODS: 246 AS patients and 510 population controls completed the SRPQ which assesses participation in eleven roles (score range 1-5) across four dimensions (importance, satisfaction with performance, satisfaction with time, and difficulty), and additionally ranked their three most important roles. The ranking of role-importance, the SRPQ dimension scores, and the gap between 'importance' and 'satisfaction with performance' of roles were compared between patients and controls. RESULTS: Patients (62% male; 51±12 year,) and controls (70% male;42±15 year,)ranked 'intimate relationships', 'relationship with (grand/step-) children' and 'employment' as most important roles. Compared to controls, patients gave higher scores on the SRPQ to 'importance' (3.75 vs 3.43), but reported lower 'satisfaction with performance' (3.19 vs 3.58) and greater 'physical difficulty' (3.87 vs 4.67) (all p≤0.05). The largest difference in gaps between 'importance' and 'satisfaction with performance' for patients compared to controls were seen for physical leisure, hobbies, travelling and vacation, where patients conferred a higher importance but especially lower satisfaction. CONCLUSION: As society places increasing emphasize on individual's responsibility to participate fully in social roles, the current data suggest that healthcare providers should pay more attention to participation-restrictions experienced by patients with AS. This article is protected by copyright. All rights reserved.