Rheumatoid arthritis (RA) is a potentially devastating form of chronic arthritis. Methotrexate is the cornerstone of drug therapy of the disorder, and may slow or prevent joint damage. Unfortunately, this agent is not without adverse effects. Furthermore, increasing age has been been invoked as a predictor of greater toxicity and drug discontinuation by some, but not all, investigators.
To assess the effect of age and other covariates on methotrexate discontinuation in a population-based sample of older patients with newly diagnosed RA.
We studied the health administrative databases covering residents of the province of Québec, Canada. In these databases, we identified 246 individuals aged>or=65 years with newly diagnosed RA who had been started on methotrexate. We assessed discontinuation of methotrexate therapy using Cox proportional hazards regression models, with potential predictors of discontinuation being age, sex, co-morbidity, methotrexate dose and route (oral vs intramuscular), folic acid coadministration and disease severity.
Five patients died or were lost to follow-up in the database at 6 months, and there were ten such patients at 1 year. Six months after the initial prescription of methotrexate therapy, about 80% (n=192) of remaining subjects continued to be prescribed the drug. By 1 year, 161 of 236 (68.2%) subjects continued to be prescribed the drug; by 2 years, only 108 of 217 (49.8%) subjects continued to receive the drug. Increasing age was associated with a greater risk of methotrexate discontinuation.
Our population-based data indicate that increasing age is associated with a greater tendency for methotrexate discontinuation in patients with newly diagnosed RA. These results emphasize the need to ensure that older patients with RA are provided with effective therapy to minimize the effects of this chronic, potentially disabling disease.
To assess the effects of disease modifying anti-rheumatic drugs (DMARDs) on lung cancer risk in a large rheumatoid arthritis (RA) cohort.
We assembled a cohort of RA patients (N=23,810) from population-based administrative healthcare databases. We ascertained cases of lung cancer in the cohort using physician billing and hospitalization records. Each lung cancer case was age and sex matched to 10 controls. We used conditional logistic regression to determine the effects of DMARDs on lung cancer risk, calculating the adjusted rate ratio (RR) attributable to each DMARD.
Subjects were followed for a total of 157,204 person-years. During this time, 960 cases of lung cancer were recorded. The frequency of exposures to various DMARDs was similar in cases and controls; our adjusted RR estimates, reflecting the independent effects of each DMARD exposure, did not associate any of the drugs with an increased risk of lung cancer.
Our data do not suggest that DMARD exposures are the primary mediator of lung cancer risk in RA. An increased risk of lung cancer in RA patients may be related to other determinants, including shared risk factors for the development of both RA and lung cancer.
To determine how duration of observation affects estimation of incidence and prevalence of systemic lupus erythematosus (SLE).
SLE incidence and prevalence estimates from data periods as brief as 3 years (2001-2003) were compared to estimates from a 15-year period (1989-2003).
The 15-year period incidence was 5.6/100,000 (95% CI 5.0-6.1) and the prevalence was 59.1/100,000 (95% CI 57.4-60.8). When a 3-year period was used, incidence was overestimated by 238.1% and prevalence underestimated by 66.0%.
SLE incidence and prevalence estimates vary considerably according to the observation period; more than 5 years of data is likely required.
To estimate the effects of biological drugs on the risk of demyelinating events in rheumatoid arthritis (RA).
Case-control analyses nested in an administrative database cohort.
Initially the risk of demyelinating events appeared to be increased after exposure to anakinra and decreased after exposure to antitumour necrosis factor (anti-TNF) agents. However, this apparent differential risk was due to more anakinra use (and avoidance of anti-TNF agents) in persons at high risk for demyelinating events. In individuals not at high risk, the adjusted rate ratio was 1.31 (95% CI 0.68 to 2.50) after exposure to anti-TNF agents and 0.80 (95% CI 0.29 to 2.24) after exposure to anakinra.
When accounting for differential prescription patterns, there was a trend towards more events after exposure to anti-TNF agents. When studying rare but important potential drug associations, pharmacoepidemiological studies are valuable but must be carefully performed.
To examine the validity of case definitions for systemic autoimmune rheumatic diseases [SARD; systemic lupus erythematosus (SLE), systemic sclerosis (SSc), myositis, Sjögren's syndrome, vasculitis, and polymyalgia rheumatica] based on administrative data, compared to rheumatology records.
A list of rheumatic disease diagnoses was generated from population-based administrative billing and hospitalization databases. Subjects who had been seen by an arthritis center rheumatologist were identified, and the medical records reviewed.
We found that 844 Nova Scotia residents had a diagnosis of one of the rheumatic diseases of interest, based on administrative data, and had had = 1 rheumatology assessment at a provincial arthritis center. Charts were available on 824 subjects, some of whom had been identified in the administrative database with > 1 diagnosis. Thus a total of 1136 diagnoses were available for verification against clinical records. Of the 824 subjects, 680 (83%) had their administrative database diagnoses confirmed on chart review. The majority of subjects who were "false-positive" for a given rheumatic disease on administrative data had a true diagnosis of a similar rheumatic disease. Most sensitivity estimates for specific administrative data-based case definitions were > 90%, although for SSc, the sensitivity was 80.5%. The specificity estimates were also > 90%, except for SLE, where the specificity was 72.5%.
Although health administrative data may be a valid resource, there are potential problems regarding the specificity and sensitivity of case definitions, which should be kept in mind for future studies.
To determine the risk of tuberculosis (TB) among a cohort of patients with rheumatoid arthritis (RA) in Quebec and assess whether this risk is associated with exposure to nonbiologic disease-modifying antirheumatic drugs (DMARDs).
We studied a cohort of patients with RA identified from the Quebec provincial physician billing and hospitalization databases for 1980-2003. TB incidence rates were determined for the period 1992-2003 and compared with the general population, standardized for age and sex using the standardized incidence ratio (SIR). Conditional logistic regression was used in a nested case-control analysis to estimate the rate ratio (RR) of TB related to nonbiologic DMARD exposure during the year before the index date.
Of the 24,282 patients with RA in the cohort, 50 cases of TB were identified. The standardized incidence rate was 45.8 cases per 100,000 person-years compared with 4.2 cases per 100,000 person-years in the general population of Quebec (SIR 10.9, 95% confidence interval [95% CI] 7.9-15.0). The adjusted RR of TB was 2.4 (95% CI 1.1-5.4) with corticosteroid use and 3.0 (95% CI 1.6-5.8) with nonbiologic DMARD use.
The age- and sex-standardized incidence rate of TB in RA patients is 10 times that of the general population. At least some of this risk may be related to nonbiologic DMARD and corticosteroid therapies. Our data support the role of TB screening before initiation of any immunosuppressive therapy.
Patients with rheumatoid arthritis (RA) should be seen by a rheumatologist promptly; however, there are no recommendations for patients with osteoarthritis (OA). Our goal was to describe wait times from referral by the primary care provider to rheumatology consultation and to explore whether wait times are associated with type of arthritis diagnosis, geographic area, or type of rheumatology office.
Appointments were requested by telephone using case scenarios that were created by a group of experts and included (1) presumed RA, (2) possible RA, and (3) presumed OA. Wait times were evaluated as the time between the initial request and the appointment date provided. We used descriptive statistics, bivariate analysis, and logistic regression in the analysis.
For all scenarios combined, 34% were given an appointment with a rheumatologist within 3 months of referral, 32% waited longer than 3 months, and 34% were told that the rheumatologist was not accepting new referrals at the time the request was made. Patients with presumed RA were much more likely to be seen within 3 months of referral compared with those with presumed OA (odds ratio, 13; 95% confidence interval, 1.70-99.38).
Rheumatoid arthritis is prioritized over OA for rheumatology appointments. However, most patients with RA are still not receiving an appointment to a rheumatologist in a timely manner. Effective triage tools to decrease these delays should be instituted.
Although cross-sectional studies have identified correlates of dysfunction in fibromyalgia (FM) patients (e.g., psychological distress and pain), predictors of health status have not been previously investigated using a longitudinal research design. We gathered data from 156 women who met American College of Rheumatology criteria for primary FM recruited from both tertiary care and community settings. Stepwise multiple linear regression analysis indicated that poorer health status (p
To describe care partnerships between family physicians and rheumatologists.
A random sample (20%, n = 478) of family physicians was mailed a questionnaire, asking if there was at least 1 particular rheumatologist to whom the physician tended to refer patients. If the answer was affirmative, the physician would be considered as having a "care partnership" with that rheumatologist. The family physician then rated, on a 5-point scale, factors of importance regarding the relationship with that rheumatologist.
The questionnaire was completed by 84/462 (18.2%) of family physicians; 52/84 (61.9%) reported having rheumatology care partnerships according to our definition. Regarding interactions with rheumatologists, most respondents rated the following as important (score = 4): adequate communication and information exchange (44/50, 88.0%); waiting time for new patients (40/50, 80.0%); clear and appropriate balance of responsibilities (39/49, 79.6%); and patient feedback and preferences (34/50, 68%). Male family physicians were more likely than females to accord high importance to personal knowledge of the rheumatologist, and to physical proximity of the rheumatologist's practice. Regarding relationships with rheumatologists, 30/50 (60.0%) of respondents felt communication and information exchange were adequate, and 35/50 (70.0%) felt they had a clear balance of responsibilities.
Almost two-thirds of family physicians have rheumatology care partnerships, according to our definition. In this partnership, establishing adequate communication and shorter waiting time seem of paramount importance to family physicians. A balanced sharing of responsibilities and patients' preferences are also valued. Although many physicians reported adequate communication and clear and appropriate balance of responsibilities in their current interactions with rheumatologists, there appears to be room for improvement.
Optimal care in RA includes early use of DMARDs to prevent joint damage and hopefully decrease the need for costly surgical interventions. Our objective was to determine whether a reduced rate of orthopaedic surgery was evident for persons with RA who saw a rheumatologist early in the disease course.
We studied persons who had a diagnosis of RA based on billing code data in the province of Quebec in 1995, and for whom the initial date of RA diagnosis by a non-rheumatologist could be established before the confirmatory diagnosis by the rheumatologist. We followed these patients until 2007. Patients were classified as early consulters or late consulters depending on whether they were seen by a rheumatologist within or beyond 3 months of being diagnosed with RA by their referring physician. The outcome, orthopaedic surgery, was defined using International Classification of Diseases (ICD) procedure codes ICD9 and ICD10. Multivariate Cox regression with time-dependent covariates estimated the effect of early consultation on the time to orthopaedic surgery.
Our cohort consisted of 1051 persons; mean age at diagnosis was 55.7 years, 68.2% were female and 50.7% were early consulters. Among all patients, 20.5% (215) had an orthopaedic surgery during the observation interval. Early consulters were less likely to undergo orthopaedic surgery during the 12-year follow-up period (adjusted hazard ratio 0.60, 95% CI 0.44, 0.82).
Persons with RA who consult a rheumatologist later in the disease course have a worse outcome in terms of eventual requirement for orthopaedic surgery.