Improving Quality of Care in Chronic Disease

Dr. Sherry RohekarSeptember 10, 2009

OverviewWhat is the program?Your goals

Results of needs assessmentBurden of arthritisApproach to arthritis

Polyarthritis Acute vs. chronic

Monoarthritis Septic vs. crystal

The Arthritis Expert Program: Why?Many communities in SW Ontario are

underserviced in terms of arthritis careArthritis Experts (AEs) will better support

local health teams in their delivery of complex medical care

Comprised of nurses, nurse practitioners and family physicians who frequently refer patients to rheumatologists at St. Joseph’s Health Care (SJHC) in London

The Arthritis Expert Program: What?Will occur over 18 months, with monthly

sessionsParticipants may attend sessions at SJHC or

attend monthly telemedicine conferences via computer

At the end of the program, we expect that participants will able to:Identify and triage rheumatologic complaintsConfidently treat some complaintsCo-manage chronic arthritic complaints in

conjunction with rheumatologists at SJHC

Course CurriculumTeleconferences / Broadcasting from

Telehealth, to be archived for use for those who can’t attend live

Knowledge assessments – at the beginning and throughout the program

Preceptorships and rounds in some regions – also telecast

Case of the month – each month a case related to the learning will be posted with each candidate giving the answers, and then answers are posted and discussion can occur

Course CurriculumInternet discussion boardChart audit –10 MSK patients sometime in

first 6 months, with data extraction tool, to be done 3 times over the course

Attendance at the Education Day (live or via broadcast / DVD) once over the course – offered at various times, usually on a Thursday, scheduled well in advance

Opportunity to do advanced training preceptorship in London (not mandatory)

Needs Assessment30 participants; all were NPs

Top 3 Areas: DiagnosisRA, SLE/CTD, PMR/TA: 86.7%Fibromyalgia: 83.3%Back pain: 70%

Top 3 Areas: TreatmentRA: 86.7%SLE: 83.3%PMR/TA: 80%

Needs AssessmentOther areas of interest:

Comprehensive approach to MSK exam: 93.3%Medications and monitoring of RA: 90%MSK imaging: 90%Approach to lab tests (i.e. RF, ANA): 76.7%

Arthritis Expert Program: Chart Review Data Extraction Form Reviewer: ___________________________ (first name, surname) Date of chart review: ______/_____/________ (day/month/year) Date of last patient visit: ______/_____/________ (day/month/year) Rheumatologic diagnosis (please select all that apply): Rheumatoid arthritis Lupus Osteoarthritis Scleroderma Gout Fibromyalgia Connective Tissue Dz Ankylosing spondylitis Psoriatic arthritis Crohn’s/ulcerative colitis related arthritis Polymyalgia rheumatica/temporal arteritis Vasculitis Sjogren’s syndrome Raynaud’s Other: _____________________ Is this patient being co-managed with a rheumatologist? Yes No Data Collection: Please review the chart and examine if the following have been done. Please check the appropriate box. 1. History of rheumatic condition documented. Yes No Unknown 2. Fatigue level documented. Yes No Unknown 3. Pain level documented. Yes No Unknown 4. Functional impairments documented. Yes N o Unknown 5. Health Assessment Questionnaire completed. Yes No Unknown 6. Renal function documented. Yes No Unknown 7. Hepatic function documented. Yes No Unknown

General Arthritis Statistics in Canada4 million Canadians have some form of

arthritis (1 in 6 people).2/3 are women3 in 5 are <65 years old

By 2026, 6 million Canadians will have arthritis.

One of the top 3 most common chronic conditions (with non-food allergies and back problems).

Health Canada. Arthritis in Canada. An Ongoing Challenge. Ottawa: Health Canada, 2003.Perruccio et al. J Epidemiol Community Health 2007;61:1056-61.

The Burden of ArthritisMajor outcome of arthritis:

chronic pain reduced mobility decreased level of function

Impact on quality of life: mobility, communication, schooling & employment.

Cost of arthritis was over $4 billion (1998) in health care expenses and loss of productivity.

In 1998, medication accounted for $270 million, or 6% of total arthritis cost. This will increase with the use of biologics.

The Arthritis Society of Canada. Arthroscope. An Ongoing Challenge, 2004.

A Chronic and Disabling DiseaseCompared to patients with other chronic

conditions, those with arthritis:Experienced more pain, activity restrictions &

long-term disabilityWere more likely to need help with daily

activitiesReported worse self-rated health, more

disrupted sleep and depressionHave more contacts with healthcare

professionals

Health Canada. Arthritis in Canada. An Ongoing Challenge. Ottawa: Health Canada, 2003.

Common Comorbidities in Rheumatic Disease• CVD & Atherosclerosis

• Metabolic Syndrome

• Fibromyalgia

• Peridontal Disease

• Effects of Smoking

Impact of ComorbiditiesPoorer outcomes (response, remission)Higher morbidityIncreased mortality (e.g., CVD)Potential for drug interactions

Krishnan E, et al. Ann Rheum2005;64:1350-2.Wasko MC. Curr Opin Rheumatol 2004;16:109-13.

Boers M, et al. Arthritis Rheum 2004;50:1734-9.

In the 1986 Canadian population.

% prevalence in the Ontario population.

Degenerative vs. InflammatoryThe problem with inflammatory arthritis is in

the lining (synovium) of the jointThe problem with degenerative arthritis is in

the cartilage

Approach To PolyarthritisWhat is polyarthritis? How is it different

from polyarthralgia?Polyarthritis: swelling, tenderness and warmth

of >4 joints, demonstrated by physical examination

Polyarthralgia: pain in >4 joints without demonstrable inflammation on physical examination

Polyarticular SymptomsPolyarticular Symptoms

Acute (<6 wks)Acute (<6 wks) Chronic (>6 wks)Chronic (>6 wks)

InfectionInfection Not InfectionNot Infection

InflammatoryInflammatory Not InflammatoryNot Inflammatory

Polyarticular SymptomsPolyarticular Symptoms

Acute (<6 wks)Acute (<6 wks)

InfectionInfection Not InfectionNot Infection

Gonoccocal

Meningococcal

Lyme disease

Acute rheumatic fever

Bacterial endocarditis

Viral

Rubella

Hepatitis B or C

Parvovirus B19

EBV

HIV

RA

SLE

Reactive arthritis

Psoriatic arthritis

Polyarticular gout

Sarcoidosis

Serum sickness

Polyarticular SymptomsPolyarticular Symptoms

Chronic (>6 wks)Chronic (>6 wks)

InflammatoryInflammatory Not InflammatoryNot Inflammatory

RA

SLE

SSc

PM

ReA

PsA

Polyarticular crystal

Enteropathic arthritis

Sarcoid

Vasculitis

PMR

OA

CPPD

Paget’s disease

FM

Benign hypermobility syndrome

Hemochromatosis

TimingMigratory Additive Intermittant

Present for few days, remits, then

recurs in other joints

Rheumatic fever

Gonococcal

Lyme disease

Begins in some joints and persists,

then goes on to involve others

RA

PsA

Enteropathic arthritis

SLE

Repeated attacks of polyarthritis with complete

remission between attacks

RA

PsA

ReA

Sarcoid

Polyarthricular gout

Approach To Monoarthritis:Acute Hot, Red Monoarthritis1. Infection2. Infection3. Infection4. Gout5. Pseudogout6. Oh, did I mention …. Infection?

What do you want to do?Aspirate the joint (i.e. take a sample of

fluid from the joint)IF THE JOINT IS RED, THE TUBES GET

FED!

What do you send the fluid for?The 3 C’s

Cell Count: A couple of hoursCulture & Sensitivity: 24-48 hoursCrystals: A couple of hoursGram Stain

Septic Arthritis

Acute Bacterial ArthritisMedical

emergency!!

Importance Of Diagnosis

Failure to recognize and appropriately treat bacterial septic arthritides may lead to significant rates of morbidity and even mortality Specifically, debilitating destruction of

the joint

Importance Of Diagnosis

Failure to recognize and appropriately treat bacterial septic arthritides may lead to significant rates of morbidity and even mortality Specifically, debilitating destruction of

the joint

Historical Features

Acute onset of joint pain (may be superimposed on chronic pain)

History of trauma Remember iatrogenic joint aspiration

Monoarticular vs. polyarticular Extra-articular symptoms IV drug use/presence of intravenous

catheters

Historical Features

Exposure to STDs Conditions that may decrease patient’s

immunity Liver disease, DM, cancer, complement

deficiencies, hypogammaglobulinemia, immunosuppressive medication

Historical Features

Classically, present with complaints of low grade fever (40-60%), pain (75%) and decreased ROM, evolving over days or weeks

Sometimes difficult to distinguish from the presentation of crystal arthropathies Tend to have spiking fevers and chills,

rigors

Historical Features

If prosthetic joint infection, course usually low-grade with gradually increasing pain

Usually no significant swelling or fever S. aureus associated with a fulminant

course Devitalized tissues (i.e. hematomas)

more susceptible to bacterial multiplication

Course usually more muted in case of bacteremic spread

Historical Features

Tuberculous arthritis has indolent features Usually negative PPD, no signs of past

or present pulmonary TB

Physical Findings

Most commonly involved joints: knee (50%), hip (20%), shoulder (8%), ankle (7%), wrists (7%) Elbow, interphalangeal,

sternoclavicular, SI joints 1-4% cases

Physical Findings

Erythema and swelling in 90% of cases Warmth and tenderness also essential for

diagnosis Usually an obvious effusion Marked limitation of PROM and AROM Beware of locations where difficult to find:

spine, hip, shoulders Physical findings muted in elderly,

immunocompromised, IVDU and especially those with RA

Differential Diagnosis

Crystals (gout, pseudogout) RA Seronegative disease (PsA,

enteropathic arthritis) Reactive arthritis Rheumatic fever Drug-induced arthritis

Diagnosis: Acute GoutThe Disease of KingsAcute inflammatory

arthritis caused uric acid crystal deposition in the joint

Who gets Gout?First attack in men between the ages of

35 and 50.In women it starts after menopause as

estrogen has a protective effect on the excretion of uric acid.

Clinical Features of the AttackStarts quickly and very intensely – over a few

hoursVery painful (Can’t stand the bed sheets

touching it)Swollen, warm, and redMay feel unwell and have an associated feveri.e. it can look just like an infected joint!

What Joints does it affect?Usually a single joint in

the lower extremityFirst metatarsophalangeal

(MTP) joint (i.e. the big toe) is affected in 50% of cases

Common Risk Factors for GoutImpaired renal functionDiuretics: Lasix & hydrochlorothiazideExcessive Alcohol IntakeFamily historyMale Sex

Other Disease Associations“A Disease of Plenty”ObesityHypertension (high blood

pressure)DiabetesHyperlipidemia (high lipids)

What “triggers” the Attack?SMARTSSurgeryMechanical InjuryAlcoholRecent IllnessTravel / dehydrationStart/Stop Allopurinol

How to Confirm the DiagnosisMust aspirate the joint and find urate

crystals to prove diagnosis (needle shaped)

Urate crystals negatively birefringent in polarized light

What Blood Tests Should I Order?Complete Blood Count (CBC)

May see elevated WBCMay see reactive thrombocytosis (increased

platelets)

Creatinine (measure renal function)Uric Acid

Levels may be normal during an acute attack

Fasting GlucoseFasting Lipid Levels

Tryglycerides & cholesterol

A Word About Uric AcidThere are lots of people walking around with

elevated uric acid levels (hyperuricemia)Many of these people will not get goutHyperuricemia CANNOT be used to make a

diagnosis of gout!Do not treat isolated hyperuricemia

Treatment: Non-PharmacologicRest, ice, and elevate the JointDietary modification

Meat & seafood are BadVegetables & low-fat dairy are good

Reduce alcohol intakeGood hydration

PharmacologicIntra-articular corticosteroids

Inject the affected jointOral NSAIDs or COXIBs

Indomethacin 50 mg PO TIDOral colchicine

0.6 mg PO q8h Oral prednisone

50 mg po x 7 days

When To Consider Allopurinol1. Recurrent acute episodes of gout affecting

lifestyle; 2. Patients at risk from complications of

treatments required for acute attacks; 3. Patient acceptance of the need for lifelong

medication compliance;4. Uric acid tophaceous deposits

AllopurinolDo not start during an acute attackProphylaxis with an NSAID/ColchicineReduce uric acid to lower limit of laboratory

reference range

Xanthine Uric Acid Xanthine Oxidase

ALLOPURINOL inhibits

Xanthine Uric Acid Xanthine Oxidase

ALLOPURINOL inhibits

Diagnosis: Acute Pseudogout Acute inflammatory

arthritis caused by calcium pyrophosphate crystals

Who gets Pseudogout?Older individualsOften have associated osteoarthritis

Clinical Features of the AttackStarts quickly and very intensely Tends to be less intense than gout and takes

longer to reach peak than acute goutVery painful Swollen, warm, and redMay feel unwell and have an associated feveri.e. it can look just like an infected joint!

What Joints Does it Affect?Usually a single joint in

the lower extremityKnee is the most common

How to Confirm the DiagnosisMust aspirate the joint and find

intracellular calcium pyrophosphate crystals to prove diagnosis (rhomboid shaped)

CPP crystals positively birefringent in polarized light

Non-Pharmacologic TreatmentRest, ice, and elevate the jointGood hydration

PharmacologicIntra-Articular

Corticosteroids Inject the affected joint

Oral NSAIDs or COXIBsIndomethacin 50 mg PO

TID

Oral Prednisone50 mg po od x 7 days

SummaryWe hope to increase teamwork between NPs,

FPs and rheumatologistsCo-management of chronic diseaseContinuing education