Time to Consultation and Disease-modifying Antirheumatic Drug Treatment of Patients with Rheumatoid Arthritis — Northern Alberta Perspective

Objective.To determine the timeliness of consultation and initiation of disease-modifying antirheumatic drugs (DMARD) in patients with rheumatoid arthritis (RA) referred to rheumatologists.Methods.The first part of the study was a review of the charts of 151 patients with RA followed by 3 rheumatologists. The outcome measure was the interval between symptom onset and consultation with a rheumatologist. The second part of the study involved a chart review of 4 family physician practices in a small urban center in order to determine the accuracy of diagnostic coding (International Classification of Diseases; ICD-9) of RA, as well as the proportion of patients with RA seen by a rheumatologist. Finally, a survey was sent to primary care physicians at a group of walk-in clinics to determine what percentage of their patients with RA were referred to a rheumatologist and, concerning referral patterns, how likely it is they would refer a confirmed or suspected RA patient to a rheumatologist.Results.Patients with RA referred to rheumatologists in this sample were seen by a rheumatologist at a mean of 9.8 months (median 5 mo, range 0–129 mo) after symptom onset, and mean 1.2 months (median 4.0 mo, range 0–8 mo) after being referred by their primary care physician. All referred patients with confirmed RA were started on DMARD within 1 week of initial consultation. Primary care physicians would refer suspected RA patients 99.5% of the time (median 100, range 90–100%), and 87.6% (median 90, range 50–100%) of patients with confirmed RA would have seen a rheumatologist at least once. A chart review showed that, in a select group of family physicians, 70.9% (22/31) of patients coded as RA per the ICD-9 did indeed have RA and all had seen a rheumatologist for their condition.Conclusion.In Northern Alberta, patients with RA are seen and started on DMARD therapy in a timely fashion. Most of the delay is at the primary care level, suggesting a need for improved education of patients and primary care physicians rather than a formal triage system.

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SAT0065 TIMING OF PNEUMOCOCCAL VACCINATIONS IN RELATION TO STARTING DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS IN RHEUMATOID ARTHRITIS

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2020-eular.1157 ◽

2020 ◽

Vol 79 (Suppl 1) ◽

pp. 965.1-966

Author(s):

R. E. Costello ◽

J. Humphreys ◽

K. Winthrop ◽

W. Dixon

Keyword(s):

Rheumatoid Arthritis ◽

Primary Care ◽

Primary Care Physicians ◽

Index Date ◽

Pneumococcal Vaccination ◽

British Society ◽

Cross Sectional ◽

Disease Modifying ◽

Sat 1 ◽

Over Time

Background:Pneumococcal vaccinations are recommended for patients with rheumatoid arthritis (RA). There is evidence that pneumococcal vaccinations are less effective when administered after starting conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs). Vaccination guidelines have changed over time, since 1992 UK guidelines recommend pneumococcal vaccination for the immunocompromised, and in 2003 was expanded to all individual’s age ≥65 years. Guidelines from British Society of Rheumatology (2011) and EULAR (2019) advise to vaccinate prior to starting csDMARDs where possible. There is little evidence about whether these guidelines are being followed.Objectives:The aims of this study were to explore the timing of pneumococcal vaccination in patients with RA in relation to starting csDMARDs and examine whether this has changed over time.Methods:This was a cross-sectional study using UK electronic health records from primary care between 1st January 2000 and 31st December 2018. To be included in the study patients needed to 1) have a diagnosis of RA, 2) be prescribed csDMARDs up to 3 months prior to, or after RA diagnosis date and 3) have received a pneumococcal vaccination. Index date was considered the start of csDMARDs and vaccinations were required to be up to 5 years prior to the index date or after index date until leaving the practice, death or the end of the study period. For each patient it was determined if the first vaccination was prior to starting csDMARDs. For those vaccinated up to 3 years prior to, or up to 3 years after starting csDMARDs, the time between vaccination and starting csDMARDs in months was determined and this distribution was plotted in a bar chart. To explore how timing of vaccination has changed over time the proportion (with 95% confidence intervals (CI)) of people vaccinated prior to starting csDMARDs was plotted by year.Results:Of 21461 people with RA identified who were prescribed their first csDMARD on or after 1st January 2000, there were 8205 (38.2%) patients vaccinated and eligible to be included in the study. The cohort had a mean age 62 years, 66.4% were female. There were 2997 (36.5%) patients vaccinated prior to starting csDMARDs. Those vaccinated prior to starting csDMARDs were older, with 72% (n=2168) being aged 65 years or over vs 28% (n=1465) in those vaccinated after starting csDMARDs. 5358 (65.3%) were vaccinated up to 3 years prior to, or up to 3 years after starting csDMARDs. The distribution showed that the most frequent time of vaccination was in the 3 months after starting csDMARDs and the frequency was higher in the months after starting csDMARDs than in the months preceding (Figure 1). Of those vaccinated outside these times, 1000 (12.2%) were vaccinated >3 years prior and 1844 (22.5%) were vaccinated >3 years after starting csDMARDs. The proportion vaccinated prior to starting csDMARDs has increased over time from a minimum of 17.2% in 2001 to a maximum of 55.6% in 2016. The greatest increases were seen between 2003 and 2007 (Figure 2).Figure 1.Time between starting csDMARDs and pneumococcal vaccinationFigure 2.Proportion and 95% confidence interval of those vaccinated prior to starting csDMARDs by year.Conclusion:This study shows that timing of pneumococcal vaccination is improving with a trend towards increasing vaccination prior to starting csDMARDs and a high proportion of patients were vaccinated around the time of csDMARD initiation. However, just over a fifth (22.5%) were vaccinated more than 3 years after starting csDMARDs. Rheumatologists need to continue to work to raise awareness of the importance of vaccinations through better communications to patients and primary care physicians, to ensure best practice is being followed.Disclosure of Interests:Ruth E Costello: None declared, Jenny Humphreys: None declared, Kevin Winthrop Grant/research support from: Bristol-Myers Squibb, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Galapagos, Gilead, GSK, Pfizer Inc, Roche, UCB, William Dixon Consultant of: Bayer and Google

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AB1361-HPR PRIMARY CARE PHARMACOLOGICAL TREATMENT FOR PATIENTS WITH HAND ARTHRALGIA

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2020-eular.4728 ◽

2020 ◽

Vol 79 (Suppl 1) ◽

pp. 1967.1-1968

Author(s):

M. M. Castañeda-Martínez ◽

G. Figueroa-Parra ◽

D. Vega-Morales ◽

J. M. Calderón Espinosa ◽

B. R. Vázquez Fuentes ◽

...

Keyword(s):

Rheumatoid Arthritis ◽

Primary Care ◽

Family Medicine ◽

Early Diagnosis ◽

Pharmacological Treatment ◽

Primary Care Physicians ◽

Therapeutic Window ◽

Care Practice ◽

Inflammatory Rheumatic Diseases ◽

Disease Modifying

Background:Primary care physicians (PCP) are the first point of contact for patients with a new-onset inflammatory rheumatic disease, like rheumatoid arthritis (RA). Consequently, primary care is crucial to the early diagnosis and prompt treatment of such individuals. The first three months following the onset of RA symptoms represent an important therapeutic window. Historically, patients with inflammatory arthritis received first-line treatment with non-steroidal anti-inflammatory drugs (NSAIDs), moving to synthetic disease-modifying anti-rheumatic drugs (DMARDs) relatively late in the disease process. As synthetic DMARDs are usually initiated in secondary care by rheumatologists, PCP focus on alleviation of patient’s discomfort. Documented problems in primary care practice include accuracy of diagnosis, test ordering, medication use and delays in referral.There is no evidence of which is the pharmacological treatment more commonly used for hand arthralgia in Family Medicine patients of a university hospital on their first or second visit.Objectives:To examine the primary care physicians’ pharmacological treatment prescribed for hand arthralgia in a Family Medicine Consultation.Methods:In a period of a year and two months, eligible patients were recruited on their first or second visit to the Family Medicine Consultation of the Hospital Universitario “Dr. José Eleuterio González” in Monterrey, Nuevo León, México. Eligible patients were adults (aged≥18 years) with hand arthralgia as their chief complaint, who had not rheumatologic diagnosis and wasn’t caused by trauma. Ninety patients were recruited, data were collected by capturing the prescription made by PCP.Results:In this cohort of 90 patients, 71 (78.9%) were women. Of the 90 patients, 19 (21.1%) had no pharmacological prescription at all. Forty-nine patients (54.4%) had one prescribed drug, 17 (18.9%) had two drugs and 5 (5.6%) had three drugs. Prescribed drugs and their frequencies are reported in Table 1.Table 1.Prescribed drugs and frequencies.Drugn (%)No treatment19 (21.1)Celecoxib26 (28.9)Oxicams22 (24.4)Propionic acid derivatives6 (6.7)Phenyl Acetic acids5 (5.6)Acetaminophen15 (16.7)Tramadol12 (13.3)Steroids11 (12.2)Methotrexate1 (1.1)Conclusion:The most common group of drugs used for hand arthralgia in this cohort of patients was NSAID, and the most used of this group was celecoxib. Only in one patient, PCP prescribed disease-modifying anti-rheumatic drugs (DMARD) therapy, in this case was methotrexate. Almost 80% of the patients were prescribed with at least one drug without knowing the final diagnosis.References:[1]Warburton L, Hider SL, Mallen CD, Scott IC. Suspected very early inflammatory rheumatic diseases in primary care. Best Pract Res Clin Rheumatol. 2019;33(4):101419[2]Calabrese L. Rheumatoid arthritis and primary care: The case for early diagnosis and treatment. The Journal of the American Osteopathic Association. 1999;99(6):313.Disclosure of Interests:None declared

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An Examination of the Prescription Renewal Process and Implications for Primary Care Physicians and Community Pharmacists

Journal of Pharmacy Practice ◽

10.1177/0897190018799217 ◽

2018 ◽

Vol 33 (2) ◽

pp. 187-191

Author(s):

Anthony J. Pattin ◽

Nathan Devore ◽

Jonathan Fowler ◽

David Weldy

Keyword(s):

Primary Care ◽

Renewal Process ◽

Primary Care Physicians ◽

Care Setting ◽

Primary Care Setting ◽

Community Pharmacists ◽

Effective Management ◽

Physician Practices ◽

Staff Members ◽

Inappropriate Medications

In physician practices and pharmacies, staff members work to process prescription renewals so that patients receive a steady supply of medications. These functions are essential to ensure patients have continuous access to medications and remain adherent to prescribed therapies. Despite the incorporation of e-prescribing software programs to ease management of these processes, barriers to effective management of the prescription renewal process exist. Mismanagement of pharmacy adherence programs can ultimately lead to patients receiving inappropriate medications and excessive use of staff resources. The objective of this article is to examine the prescription renewal process in both the primary care setting and the pharmacy and report challenges associated with the process. A literature review was conducted to find studies that describe pharmacists’ and physicians’ handlings of prescription renewals, use of e-prescribing software, and benefits and barriers to using these technologies. Although studies report e-prescribing software improves efficiency in the prescription renewal process, there is a need to reduce technological problems that create challenges in use. It is recommended that staff within physician practices and pharmacies standardize prescription renewal processes and educate patients about the prescription renewal process.

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Time intervals and routes to diagnosis for lung cancer in 10 jurisdictions: cross-sectional study findings from the International Cancer Benchmarking Partnership (ICBP)

BMJ Open ◽

10.1136/bmjopen-2018-025895 ◽

2019 ◽

Vol 9 (11) ◽

pp. e025895 ◽

Cited By ~ 2

Author(s):

Usha Menon ◽

Peter Vedsted ◽

Alina Zalounina Falborg ◽

Henry Jensen ◽

Samantha Harrison ◽

...

Keyword(s):

Lung Cancer ◽

Primary Care ◽

Northern Ireland ◽

Symptom Onset ◽

Primary Care Physicians ◽

Cancer Registries ◽

Secondary Outcome ◽

Newly Diagnosed ◽

Time Intervals ◽

Cross Sectional

ObjectiveDifferences in time intervals to diagnosis and treatment between jurisdictions may contribute to previously reported differences in stage at diagnosis and survival. The International Cancer Benchmarking Partnership Module 4 reports the first international comparison of routes to diagnosis and time intervals from symptom onset until treatment start for patients with lung cancer.DesignNewly diagnosed patients with lung cancer, their primary care physicians (PCPs) and cancer treatment specialists (CTSs) were surveyed in Victoria (Australia), Manitoba and Ontario (Canada), Northern Ireland, England, Scotland and Wales (UK), Denmark, Norway and Sweden. Using Wales as the reference jurisdiction, the 50th, 75th and 90th percentiles for intervals were compared using quantile regression adjusted for age, gender and comorbidity.ParticipantsConsecutive newly diagnosed patients with lung cancer, aged ≥40 years, diagnosed between October 2012 and March 2015 were identified through cancer registries. Of 10 203 eligible symptomatic patients contacted, 2631 (27.5%) responded and 2143 (21.0%) were included in the analysis. Data were also available from 1211 (56.6%) of their PCPs and 643 (37.0%) of their CTS.Primary and secondary outcome measuresInterval lengths (days; primary), routes to diagnosis and symptoms (secondary).ResultsWith the exception of Denmark (−49 days), in all other jurisdictions, the median adjusted total interval from symptom onset to treatment, for respondents diagnosed in 2012–2015, was similar to that of Wales (116 days). Denmark had shorter median adjusted primary care interval (−11 days) than Wales (20 days); Sweden had shorter (−20) and Manitoba longer (+40) median adjusted diagnostic intervals compared with Wales (45 days). Denmark (−13), Manitoba (−11), England (−9) and Northern Ireland (−4) had shorter median adjusted treatment intervals than Wales (43 days). The differences were greater for the 10% of patients who waited the longest. Based on overall trends, jurisdictions could be grouped into those with trends of reduced, longer and similar intervals to Wales. The proportion of patients diagnosed following presentation to the PCP ranged from 35% to 75%.ConclusionThere are differences between jurisdictions in interval to treatment, which are magnified in patients with lung cancer who wait the longest. The data could help jurisdictions develop more focused lung cancer policy and targeted clinical initiatives. Future analysis will explore if these differences in intervals impact on stage or survival.

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