Transcript Arthritis Expert Program:

Improving Quality of Care in Chronic Disease
Dr. Sherry Rohekar
September 10, 2009
Overview
 What is the program?
 Your goals
 Results of needs assessment
 Burden of arthritis
 Approach 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 care
 Arthritis 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 sessions
 Participants 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 complaints
 Confidently treat some complaints
 Co-manage chronic arthritic complaints in conjunction
with rheumatologists at SJHC
Course Curriculum
 Teleconferences / 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 Curriculum
 Internet discussion board
 Chart 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 Assessment
 30 participants; all were NPs
 Top 3 Areas: Diagnosis
 RA, SLE/CTD, PMR/TA: 86.7%
 Fibromyalgia: 83.3%
 Back pain: 70%
 Top 3 Areas: Treatment
 RA: 86.7%
 SLE: 83.3%
 PMR/TA: 80%
Needs Assessment
 Other 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%
1
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 
Other: _____________________
Raynaud’s 
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
 No
 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
Canada
 4 million Canadians have some form of arthritis (1 in 6
people).
 2/3 are women
 3 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 Arthritis
 Major 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 Disease
 Compared to patients with other chronic conditions,
those with arthritis:
 Experienced more pain, activity restrictions & long-term
disability
 Were more likely to need help with daily activities
 Reported worse self-rated health, more disrupted sleep
and depression
 Have 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 Comorbidities
 Poorer outcomes (response, remission)
 Higher morbidity
 Increased 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.
Patient Outcomes
Arthritis and Disability
Arthritis And Work Disability
In the 1986 Canadian population.
% prevalence in the Ontario population.
Degenerative vs. Inflammatory
 The problem with inflammatory arthritis is in the
lining (synovium) of the joint
 The problem with degenerative arthritis is in the
cartilage
Approach To Polyarthritis
 What 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 Symptoms
Acute (<6 wks)
Infection
Chronic (>6 wks)
Not Infection
Inflammatory
Not Inflammatory
Polyarticular Symptoms
Acute (<6 wks)
Infection
Not Infection
Gonoccocal
RA
Meningococcal
SLE
Lyme disease
Reactive arthritis
Acute rheumatic fever
Psoriatic arthritis
Bacterial endocarditis
Polyarticular gout
Viral
Sarcoidosis
Rubella
Hepatitis B or C
Parvovirus B19
EBV
HIV
Serum sickness
Polyarticular Symptoms
Chronic (>6 wks)
Inflammatory
Not Inflammatory
RA
SLE
SSc
OA
PM
CPPD
ReA
Paget’s disease
PsA
FM
Polyarticular crystal
Enteropathic arthritis
Sarcoid
Vasculitis
PMR
Benign hypermobility
syndrome
Hemochromatosis
Timing
Migratory
Additive
Intermittant
Present for few
days, remits, then
recurs in other
joints
Begins in some
joints and persists,
then goes on to
involve others
Repeated attacks
of polyarthritis with
complete
remission between
attacks
Rheumatic fever
RA
RA
Gonococcal
PsA
PsA
Lyme disease
Enteropathic
arthritis
SLE
ReA
Sarcoid
Polyarthricular
gout
Approach To Monoarthritis:
Acute Hot, Red Monoarthritis
Infection
2. Infection
3. Infection
4. Gout
5. Pseudogout
6. Oh, did I mention …. Infection?
1.
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 hours
 Culture & Sensitivity: 24-48 hours
 Crystals: A couple of hours
 Gram Stain
Septic Arthritis
Acute Bacterial Arthritis
Medical 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 Gout
 The Disease of Kings
 Acute 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 Attack
 Starts quickly and very intensely – over a few hours
 Very painful (Can’t stand the bed sheets touching it)
 Swollen, warm, and red
 May feel unwell and have an associated fever
 i.e. it can look just like an infected joint!
What Joints does it affect?
 Usually a single joint in the
lower extremity
 First metatarsophalangeal
(MTP) joint (i.e. the big toe) is
affected in 50% of cases
Common Risk Factors for Gout
 Impaired renal function
 Diuretics: Lasix & hydrochlorothiazide
 Excessive Alcohol Intake
 Family history
 Male Sex
Other Disease Associations
“A Disease of Plenty”
 Obesity
 Hypertension (high blood pressure)
 Diabetes
 Hyperlipidemia (high lipids)
What “triggers” the Attack?
SMARTS
 Surgery
 Mechanical Injury
 Alcohol
 Recent Illness
 Travel / dehydration
 Start/Stop Allopurinol
How to Confirm the Diagnosis
 Must 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 WBC
 May see reactive thrombocytosis (increased platelets)
 Creatinine (measure renal function)
 Uric Acid
 Levels may be normal during an acute attack
 Fasting Glucose
 Fasting Lipid Levels
 Tryglycerides & cholesterol
A Word About Uric Acid
 There are lots of people walking around with elevated
uric acid levels (hyperuricemia)
 Many of these people will not get gout
 Hyperuricemia CANNOT be used to make a diagnosis
of gout!
 Do not treat isolated hyperuricemia
Treatment: Non-Pharmacologic
 Rest, ice, and elevate the Joint
 Dietary modification
 Meat & seafood are Bad
 Vegetables & low-fat dairy are good
 Reduce alcohol intake
 Good hydration
Pharmacologic
 Intra-articular corticosteroids
 Inject the affected joint
 Oral NSAIDs or COXIBs
 Indomethacin 50 mg PO TID
 Oral colchicine
 0.6 mg PO q8h
 Oral prednisone
 50 mg po x 7 days
When To Consider Allopurinol
1.
2.
3.
4.
Recurrent acute episodes of gout affecting lifestyle;
Patients at risk from complications of treatments
required for acute attacks;
Patient acceptance of the need for lifelong
medication compliance;
Uric acid tophaceous deposits
Allopurinol
 Do not start during an acute attack
 Prophylaxis with an NSAID/Colchicine
 Reduce uric acid to lower limit of laboratory reference
range
Xanthine
Uric Acid
Xanthine Oxidase
ALLOPURINOL
inhibits
Diagnosis: Acute Pseudogout

Acute inflammatory
arthritis caused by calcium
pyrophosphate crystals
Who gets Pseudogout?
 Older individuals
 Often have associated osteoarthritis
Clinical Features of the Attack
 Starts quickly and very intensely
 Tends to be less intense than gout and takes longer to
reach peak than acute gout
 Very painful
 Swollen, warm, and red
 May feel unwell and have an associated fever
 i.e. it can look just like an infected joint!
What Joints Does it Affect?
 Usually a single joint in the
lower extremity
 Knee is the most common
How to Confirm the Diagnosis
 Must aspirate the joint and find intracellular
calcium pyrophosphate crystals to prove diagnosis
(rhomboid shaped)
 CPP crystals positively birefringent in polarized
light
Non-Pharmacologic Treatment
 Rest, ice, and elevate the joint
 Good hydration
Pharmacologic
 Intra-Articular
Corticosteroids
 Inject the affected joint
 Oral NSAIDs or COXIBs
 Indomethacin 50 mg PO TID
 Oral Prednisone
 50 mg po od x 7 days
Summary
 We hope to increase teamwork between NPs, FPs and
rheumatologists
 Co-management of chronic disease
 Continuing education