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Objective: To examine the association between rheumatologist access, early treatment, and ongoing care of older-onset rheumatoid arthritis (RA) and healthcare utilization and costs following diagnosis., Methods: We analyzed data from a population-based inception cohort of individuals aged > 65 years with RA in Ontario, Canada, diagnosed between 2002 and 2014 with follow-up to 2019. We assessed 4 performance measures in the first 4 years following diagnosis, including access to rheumatology care, yearly follow-up, timely treatment, and ongoing treatment with a disease-modifying antirheumatic drug. We examined annual healthcare utilization, mean direct healthcare costs, and whether the performance measures were associated with costs in year 5., Results: A total of 13,293 individuals met inclusion criteria. The mean age was 73.7 (SD 5.7) years and 68% were female. Total mean direct healthcare cost per individual increased annually and was CAD $13,929 in year 5. All 4 performance measures were met for 35% of individuals. In multivariable analyses, costs for not meeting access to rheumatology care and timely treatment performance measures were 20% (95% CI 8-32) and 6% (95% CI 1-12) higher, respectively, than where those measures were met. The main driver of cost savings among individuals meeting all 4 performance measures were from lower complex continuing care, home care, and long-term care costs, as well as fewer hospitalizations and emergency visits., Conclusion: Access to rheumatologists for RA diagnosis, timely treatment, and ongoing care are associated with lower total healthcare costs at 5 years. Investments in improving access to care may be associated with long-term health system savings., (Copyright © 2023 by the Journal of Rheumatology.)

Objective: We evaluated the associations between time-varying methotrexate (MTX) use and risk of cardiovascular events (CVE) in patients with rheumatoid arthritis (RA)., Methods: We studied an inception cohort of 23,994 patients with RA diagnosed after their 65th birthday. Multivariable Cox regression models were fit to evaluate the associations between time-varying MTX use, controlling for other risk factors, and time to CVE. Alternative models assessed the cumulative duration of MTX use over the (1) first year, (2) previous year (recent use), and (3) entire duration of followup. We also assessed whether the strength of the association varied over time., Results: Over 115,453 patient-years (PY), 3294 (13.7%) patients experienced a CVE (28.5 events per 1000 PY; 95% CI 27.6-29.5). In the multivariable analyses, the model assessing time-varying continuous use in the most recent year yielded the best fit. Increasing recent MTX use was associated with lower CVE risks (HR 0.79 for continuous use vs no use in past 12 months, 95% CI 0.70-0.88; p < 0.0001). Greater MTX use in the first year after cohort entry was also protective (HR 0.84, 95% CI 0.72-0.96; p = 0.0048), but this effect decreased with increasing followup. In contrast, longer MTX use during the entire followup was not clearly associated with CVE risk (HR 0.98, 95% CI 0.95-1.01; p = 0.1441)., Conclusion: We observed about a 20% decrease in CVE associated with recent continuous MTX use. Greater MTX use in the first year of cohort entry also appeared to be important in the association between MTX and CVE risk.

Objective: Persistent systemic lupus erythematosus (SLE) disease activity is associated with increased morbidity and mortality. In a multicenter cohort of patients with prevalent SLE, we described persistence, patterns, and predictors of change in disease activity over time., Methods: Based on SLE Disease Activity Index (SLEDAI)-2K scores at cohort entry, patients were classified into 4 groups: low (score < 4; LOW), moderate (4 to < 6; MOD), moderately high (6 to ≤ 10; MHIGH), and very high (> 10; VHIGH). Multivariable linear and longitudinal mixed linear regression models were used to identify predictors of change over time in SLEDAI-2K., Results: There were 2019 participants, with declining followup data over 5 years (1326, 580, 274, 186, and 148 patients, respectively). At cohort entry, mean (± SD) age was 42 (± 17) years, disease duration 11 (± 10) years, and 90% were female. The 4 groups included 44% LOW (n = 891), 20% MOD (n = 400), 22% MHIGH (n = 442), and 14% VHIGH (n = 286); therefore, 36% had clinically important SLE activity. The proportion of patients in the LOW group at entry who moved to a higher activity level varied from 30% (167/557) at 1 year, to 49% (41/83) at 3 years, and 54% (30/56) at 5 years. Among 181 patients with MOD to VHIGH entry activity and 3 years of followup, 116 (64.1%) remained active. In all analyses, only higher SLEDAI-2K at cohort entry remained a significant predictor of higher SLEDAI-2K in subsequent years., Conclusion: Higher SLEDAI-2K at study entry was the single major independent predictor of higher SLEDAI-2K over time, reflecting frequent persistence of active disease, even in patients with longstanding disease. This highlights gaps in the optimal treatment of SLE.

Objective: To evaluate compliance with diabetes screening guidelines for cardiovascular disease (CVD) prevention in rheumatoid arthritis (RA) compared to the general population., Methods: We conducted the first longitudinal study of a population-based RA cohort including all prevalent RA cases in British Columbia between 1996 and 2006 and followed until 2010, with matched general population comparators. Using administrative data, we measured compliance with general population guidelines [i.e., testing plasma glucose (PG) at least once every 3 years after age 45] after excluding individuals with previous diabetes. Followup was divided into 3-year eligibility periods. Compliance was measured as the proportion of periods with ≥ 1 PG test performed. OR (95% CI) of compliance in RA (vs general population) was calculated using generalized estimating equation models, adjusting for age and sex. Mean compliance rate per patient was also calculated and compared using the Mann-Whitney U test., Results: Analysis included 22,624 individuals with RA, contributing 48,724 three-year eligibility periods; and 22,579 people in a general population group, contributing 51,081 three-year eligibility periods. PG was measured in 72.3% (SD 37%) of the eligible time periods in the RA sample and in 70.4% (SD 38%) for the general population (OR 1.05, 95% CI 1.02-1.09, p < 0.0001). RA individuals met recommended screening guidelines in 71.4% of their eligible periods, compared to 70.6% (p < 0.001). Screening improved over time in RA relative to the general population. Family physicians ordered nearly all the PG tests., Conclusion: Compliance with general population guidelines for diabetes screening in RA was suboptimal, with little difference relative to the general population, despite a higher risk of CVD and diabetes.

Objective: Disease-modifying antirheumatic drugs (DMARD) have the greatest effect when initiated early. We evaluated the influence of early exposure to DMARD on time to joint replacement surgery among patients with incident rheumatoid arthritis (RA)., Method: Using a common protocol, we undertook 2 independent population-based cohort studies of patients with incident RA aged 66 years or older in Ontario (ON) and Quebec (QC) covering the period 2000-2013. We used Cox proportional hazards regression with time-dependent variables measuring duration of drug use in the first year, separately for methotrexate (MTX) and other DMARD, adjusting for baseline demographics, clinical factors, and other potentially confounding drug exposures. Our outcome measure was any joint replacement derived from standardized procedure codes. Adjusted HR and 95% CI were estimated., Results: Among 20,918 ON and 6754 QC patients with RA followed for a median of 4.5 years, 2201 and 494 patients underwent joint replacement surgery for crude event rates of 2.0 and 1.4 per 100 person-years, respectively. Greater cumulative exposure to MTX (HR 0.97, 95% CI 0.95-0.98) and other DMARD (HR 0.98, 95% CI 0.97-0.99) in the first year after diagnosis was associated with longer times to joint replacement in ON, corresponding to a 2-3% decrease in the hazard of surgery with each additional month of early use. Similar results were observed in QC., Conclusion: Greater duration of exposure to DMARD soon after RA diagnosis was associated with delays to joint replacement surgery in both provinces. Early intensive treatment of RA may ultimately reduce demand for joint replacement surgery.

Objective: To produce evidence on the longitudinal evolution of risk factors for coronary heart disease (CHD) in patients with systemic lupus erythematosus (SLE)., Methods: Based on data for 115 patients from the Montreal General Hospital Lupus Clinic (1971-2003) and for 4367 control subjects from the Framingham Offspring Study (1971-1994), we investigated the temporal evolution of total serum cholesterol, systolic blood pressure (SBP), body mass index (BMI), blood glucose, and estimated risk for CHD (reflecting the balance of changes in different risk factors). In analyses limited to patients with SLE, we assessed the effect of SLE duration on each risk factor, adjusting for age, calendar time, sex, baseline level of the risk factor, and medication use. Next, we assessed how the adjusted difference in the values of the risk factors between SLE and controls changes over time., Results: Among patients with SLE, longer disease duration was independently associated with higher SBP and blood glucose levels. Compared with controls, these patients appeared to have accelerated rates of increase in total cholesterol, blood glucose, and overall estimated CHD risk. The rate of increase in BMI was lower in patients with SLE than in controls., Conclusion: Elevated CHD risk in patients with SLE appears to be at least partially mediated by accelerated increases in some CHD risk factors, longitudinal trajectories of which increasingly diverge over time from those of population controls.

Objective: To describe treatment adherence to a multimodal integrated program for patients with fibromyalgia (FM), identify predictors of adherence to treatment recommendations, and examine the relationship between adherence and patient outcomes., Methods: Sixty-three patients with FM were followed while participating in a 3-month outpatient program including physiotherapy, occupational therapy, nursing, and cognitive-behavior therapy. Patients completed a battery of psychosocial questionnaires pre- and post-treatment. At the end of each month of the treatment, patients completed 2 adherence questionnaires (for general and specific adherence) and 1 questionnaire about barriers to adherence to treatment. Generalized estimating equations extension of multivariable linear regression analyses for repeated measures examined predictors of general and specific adherence. Conventional linear regression analyses examined the relationships of general adherence with post-treatment FM disability and pain intensity., Results: In general, adherence to treatment recommendations was good (mean general adherence score of 62 points, on a 0 to 100 scale), with no significant changes in mean level of general or specific adherence over the 3-month period. The main predictor for both general and specific adherence was barriers to adherence to treatment. Increased general adherence was significantly associated with lower pain at post-treatment., Conclusion: The items described in the questionnaire for barriers to treatment are the main problem when it comes to adhering to a multimodal treatment program for FM. Healthcare professionals are advised to discuss these barriers directly with patients and assist in overcoming them.

Objective: Treatment recommendations for fibromyalgia (FM) include regular physical exercise. In this prospective study we examined predictors for adherence to stretching and aerobic exercises in women provided with an individualized home based program., Methods: Thirty-nine women kept exercise diaries for 12 weeks., Results: For both types of exercise, women who were less physically fit at baseline engaged in more exercise during the program. Yet for stretching, more lower body pain at baseline predicted engaging in less stretching exercise over time, whereas for aerobic exercise, more baseline upper body pain predicted more exercise over time. As time passed, participants with higher baseline physical fitness and/or older age were reducing their aerobic exercise practice at significantly faster rates, as were those women with higher baseline stress., Conclusion: Given that adequate levels of adherence were limited to about half of the participants for both types of exercise, steps to reduce barriers to exercise (e.g., stress) need to be taken when prescribing exercise in the treatment of FM.

Objective: To evaluate the comparability of prospective and retrospective evaluations of the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC/ACR DI)., Methods: Consecutive patients meeting ACR criteria for SLE were enrolled prospectively in our cohort. Prospective SLICC/ACR DI scores were collected on the 134 cohort members who were observed in the cohort between 1993-1999. The last available prospective SLICC/ACR DI scores were compared to scores that were retrospectively assigned (for the corresponding time point) from chart review by a research nurse blinded to the prospective values. Intra- and inter-observer agreement was assessed. Kappa coefficients with 95% confidence intervals (CI) were determined., Results: The kappa correlation coefficient for agreement between prospective versus retrospective total damage scores was 0.68 (95% CI 0.54-0.81). Moderate to very good agreement was also observed with respect to the 12 individual organ systems itemized in this damage index. Substantial agreement was found between assessments done by different research nurses and for repeat assessments done by the same research nurse., Conclusion: These data suggest good agreement between prospective and retrospective evaluations of the SLICC/ACR DI scores.

Objective: We evaluated different methods for quantifying patient-physician discordance and identified factors associated with discordance in the assessment of lupus disease activity., Methods: Data from 208 female patients who had a comprehensive annual examination were extracted from the Montreal General Hospital Lupus Registry. Discordance was measured by the difference between the patient self-reported 10 cm visual analog scale (VAS) and the physician VAS for global disease activity (VASDIFF). Multiple linear regression was used to identify the correlates of discordance, e.g., SF-36TM scales, Systemic Lupus Activity Measure (SLAM) components, etc. Four regression models were estimated using: (1) all patients; (2) only patients who evaluated disease activity higher than their physician's assessment; (3) only patients who evaluated disease activity lower than their physician's assessment; and (4) all patients, with the absolute value of VASDIFF as the dependent variable., Results: Of the 208 observations, 150 (72%) of the VASDIFF scores were within +/- 2.5 cm on a 10 cm scale, indicating absence of marked discordance; 43 (20.7%) were from patients overscoring and 15 (7.2%) from patients underscoring their physician by at least 2.5 cm. Higher SF-36 role physical score, more bodily pain, and lower role emotional score in addition to the SLAM-skin component were independently associated with higher discordance. SF-36 social function and mental health scores as well as SLAM-neurological and kidney components were correlated with discordance in some subanalyses. Bodily pain was the most important variable for predicting "clinically relevant" discordance, followed by SLAM-skin and kidney components., Conclusion: Discordance between patients and physicians may result from patients scoring their disease activity based on their psychological and physical well-being, whereas physicians score disease activity based on the clinical and physical signs and symptoms of lupus.

Objective: Discordance between patients' and physicians' health perceptions and satisfaction with the office visit in fibromyalgia (FM) has not been examined. We investigated this phenomenon to identify demographic, clinical, and psychosocial factors associated with patient-physician discordance on physical functioning, well being, and satisfaction with the office visit., Methods: A sample of 182 women were examined by a rheumatologist to confirm the FM diagnosis. Patients and physicians independently completed the Patient-Physician Discordance Scale to assess perceptions of health and satisfaction with the office visit. Patients also completed questionnaires pertaining to sociodemographics, social support, disability, perceived stress, and psychological distress following the office visit. Separate generalized estimating equations with forward selection, controlling for the possible dependence of outcomes among patients of same physician, were modeled for each measure of discordance., Results: The highest discordance score was on satisfaction with the office visit; physicians systematically underestimated patients' level of satisfaction. Higher levels of satisfaction with social support (p < 0.02) and more psychological distress (p < 0.03) were marginally associated with greater discordance on physical functioning. Higher levels of satisfaction with social support (p < 0.003), younger age (p < 0.02), and lower disability (p < 0.03) were associated with greater discordance on well being. More sexual abuse (p < 0.01) was significantly associated with more discordance on satisfaction with the office visit., Conclusion: There is a gap between what patients with FM and rheumatologists examining them experience during the office visit. Psychosocial factors contribute to our understanding of discordance on physical functioning, well being, and satisfaction.

Objective: To determine (1) which organ system manifestations contribute to the overall responsiveness of the Systemic Lupus Activity Measure (SLAM, revised 1991 with minor modifications as SLAM-R) and the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI); and (2) whether responsive items differ for physicians and patients., Methods: Blinded data were obtained from repeated visits of 76 patients in the Study of Methotrexate in Lupus Erythematosus. At each visit, physicians and patients reported improvement, no change, or deterioration, and physicians then completed SLAM-R and SLEDAI. Items in SLAM-R and SLEDAI were grouped by organ system. The generalized estimating equations approach was used to measure associations between change in organ system activity and physician or patient perception of change in overall disease activity. The outcomes assessed, in separate analyses, were improvement and deterioration from the previous visit., Results: Seventy-six patients contributed a total of 471 observations. The strongest correlates of physician-reported improvement were decreased constitutional, gastrointestinal (GI), and musculoskeletal involvement (components of SLAM-R), and decreased musculoskeletal (MSK) and central nervous system involvement (SLEDAI). Improvement reported by patients was most strongly associated with decreases in erythrocyte sedimentation rate and MSK and reticuloendothelial activity (SLAM-R), and in MSK activity (SLEDAI). Increased integument and MSK subscores (SLAM-R) and serosal and MSK subscores (SLEDAI) were associated with overall deterioration reported by physicians. Patient-reported deterioration was associated with increased GI subscores (SLAM-R) and with no changes in organ system involvement in SLEDAI., Conclusion: Organ systems associated with reported change in overall SLE activity differed between SLAM-R and SLEDAI, between patients and physicians, and between each direction of change.

Objective: New scales for the clinical assessment of patients with systemic lupus erythematosus (SLE) are valid and reliable, and quantitate disease activity. We assessed the responsiveness to change of 2 widely used standardized multi-item lupus activity measures, the revised Systemic Lupus Activity Measure (SLAM-R) and the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), and their ability to detect clinically relevant changes., Methods: Ninety-six (96) patients with definite SLE participated in this study. The group mean age was 45.0 (13.7) years, 91% were female, and the mean disease duration was 14.9 (7.5) years. Sociodemographic information, lupus activity (SLAM-R, SLEDAI), and damage were recorded at baseline. At each of the 5 monthly followup visits, the activity measures were repeated and a transition scale asked the physician if their patient's lupus activity had changed. Five different methods were used to compare the responsiveness of the activity measures studied: 1. the effect size; 2. the standardized response mean; 3. the control standardized response mean; 4. the area under the curve of a receiver operating characteristic (ROC) curve; and 5. a new multiple response modeling approach., Results: Both SLAM-R and SLEDAI are responsive. SLAM-R is consistently, although moderately, more responsive than SLEDAI. All 5 methods of evaluating responsiveness yielded a consistent ranking of disease activity measures., Conclusion: SLAM-R and SLEDAI are responsive measures of lupus activity. SLAM-R appears to be more responsive than SLEDAI.

Objective: To explore the relationship between patients' systemic lupus erythematosus (SLE) activity and physicians' decision to treat with steroids or alternative medication., Methods: Baseline information and clinical status was extracted from case histories of 30 patients with lupus and represented in clinical vignettes. These vignettes were then mailed to 60 physicians (rheumatologists and immunologists with experience in the treatment of lupus), asking them in each case whether they would initiate treatment or not. The relationship between the 38 complete responses and the SLE Activity Measure (SLAM-R) and SLE Disease Activity Index (SLEDAI) lupus activity scores was analyzed using a general additive model., Results: SLE disease activity measured by SLAM-R or SLEDAI is a significant predictor (p < 0.0001) of physicians' decision to initiate treatment for patients with lupus. Variation between physicians was observed but was mostly due to a few outliers. Some other variations remained unexplained by patients' SLE disease activity, damage, or by specific organ involvement., Conclusion: We present reference tables and curves for research that may be used as a basis to derive standardized quantitative criteria for entry in clinical trials. More research is needed on how these tools can be used by clinicians to guide them in their decision to treat or not.

Objective: To evaluate the sensitivity, specificity, and likelihood ratios of anti-dsDNA, C3, C4, and Clq binding tests for predicting flares in systemic lupus erythematosus (SLE) and to evaluate the conflicting results reported in the recent literature., Methods: Test results from 9 to 3 months preceding 83 flares among 53 patients from a cohort study of 202 patients with SLE were assessed for their ability to predict renal and nonrenal flares and all flares combined. A flare was defined as a 6 point rise in a modified SLE Disease Activity Index., Results: For all 4 tests, sensitivity approximated 50% and specificity was less than 75%. For anti-dsDNA, Clq binding, and C4, both positive and negative likelihood ratios were close to 1.0, suggesting little clinical value for routine testing. For C3, likelihood ratios for a positive test approximated 2.0, meeting the minimal level for clinical significance. Review of previous studies suggested that sample size, the use of a standardized disease activity measure to define a flare, the severity of the flare, and the study duration could not explain the discrepant results among studies. The 2 studies with testing every 4 to 6 weeks found that a rising anti-dsDNA predicted flares, while those with less frequent testing did not., Conclusion: While our study provided no major support for routine testing with anti-dsDNA, C3, C4, or Clq binding, additional longitudinal studies are needed to assess monthly testing of anti-dsDNA as a predictor of flare in SLE.

Objective: To evaluate and compare responsiveness of laboratory and clinical measures over 4 months in outpatient systemic lupus erythematosus (SLE)., Methods: We studied 23 patients with SLE at monthly intervals during 4 mo and collected demographic data, prednisone dose, global patient and physician assessment of disease activity on 10 cm visual analog scales (VAS), scores on 3 clinical measures of lupus disease activity [SLE disease activity index (SLEDAI), SLE activity measure (SLAM), lupus activity index (LAI)], and results of 5 routine laboratory tests [erythrocyte sedimentation rate (ESR), anti-dsDNA, C3, C4, circulating immune complexes]. We calculated correlations between a particular measure and our gold standard (physician's VAS) for individual patients and pooled this information using a novel application of the meta-analytic approach., Results: The range of disease activity by patient and physician VAS varied from inactive to moderately active> Change in patient global assessment and all 3 clinical measures showed significant positive correlations with change in physician VAS (p < 0.05). Change in ESR, anti-dsDNA, or level of C3, C4, or circulating immune complexes did not correlate with change in physician VAS., Conclusion: Clinical measures of disease activity in SLE are more responsive to small changes than traditional laboratory tests. All 3 clinical measures appeared to perform equally well. At least one SLE disease activity measure should be used in SLE trials. The new analytic method will likely be of value in similar evaluations of responsiveness in other diseases.