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Objective To investigate the incidence of and factors associated with SARS-CoV-2 testing and infection in immune mediated inflammatory diseases (IMIDs) versus matched non-IMIDs comparators from the general population. Methods We conducted a population-based, matched cohort study among adult residents from Ontario, Canada, from January to December 2020. We created cohorts for the following IMIDs: rheumatoid arthritis (RA), psoriasis, psoriatic arthritis, ankylosing spondylitis, systemic autoimmune rheumatic diseases, multiple sclerosis (MS), iritis, inflammatory bowel disease (IBD), polymyalgia rheumatica and vasculitis. Each patient was matched with five patients without IMIDs based on socio-demographic factors. We estimated the incidence of SARS-CoV-2 testing and infection in IMIDs and non-IMIDs patients. Multivariable logistic regressions assessed odds of SARS-CoV-2 infection. Results We studied 493,499 patients with IMIDs and 2,466,946 patients without IMIDs. Patients with IMIDs were more likely to have at least one SARS-CoV-2 test, versus patients without IMIDs (27.4% vs. 22.7%), but the proportion testing positive for SARS-CoV-2 was identical (0.9% in both groups). Overall, IMIDs patients had 20% higher odds of being tested for SARS-CoV-2 (odds ratio (OR) 1.20, 95% CI 1.19, 1.21). The odds of SARS-CoV-2 infection varied across IMIDs groups but was not significantly elevated for most IMID groups compared with non-IMIDs. The odds of SARS-CoV-2 infection was lower in IBD and MS and marginally higher in RA and iritis. Conclusions Patients across all IMIDs were more likely to be tested for SARS-CoV-2 versus those without IMIDs. The risk of SARS-CoV-2 infection varied across disease sub-groups.

Patients with inflammatory arthritis (IA) are at high risk for atherosclerotic cardiovascular disease (ASCVD), yet management of dyslipidemia is infrequently prioritized. We applied Canadian dyslipidemia guidelines to determine how many patients with IA would be eligible for primary prevention with statins.We conducted a cross-sectional study of patients with IA in a cardio-rheumatology clinic, with no known CVD and without statin therapy at cohort entry. We stratified patients by Framingham Risk Score (FRS) and summarized the proportion meeting guideline statin-indicated criteria. Multivariable logistic regression analyses determined the association of variables with statin indication after adjustment for age, sex, traditional ASCVD risk factors, and arthritis characteristics.Among 302 patients, most had rheumatoid arthritis (59%). Mean age was 58 years, and 71% were female. Overall, 50% of the cohort was eligible for statin therapy. The majority was low FRS risk category (68%), and the most frequent qualifier for statins was elevated apolipoprotein B (ApoB) levels or low-density lipoprotein cholesterol (LDL-c) levels. In the intermediate FRS group, 91% met criteria for statin therapy based on the presence of a coronary artery calcification (CAC) score0 or an elevated high-sensitivity C-reactive protein. Male sex, hypertension, elevated ApoB, and a CAC score0 were the factors most strongly associated with indication for statin therapy.Statin therapy is suboptimal in IA despite a significant number of patients meeting indication based on lipoprotein thresholds or CAC scores. Understanding the barriers and potential facilitators of implementing and interpreting these CVD screening tools in IA is needed.

Aims To assess differences in estimated cardiovascular disease (CVD) risk among rheumatoid arthritis (RA) patients from different world regions and to evaluate the management and goal attainment of lipids and blood pressure (BP). Methods and results The survey of CVD risk factors in patients with RA was conducted in 14 503 patients from 19 countries during 2014–19. The treatment goal for BP was Conclusion We revealed considerable geographical differences in estimated CVD risk and preventive treatment. Low goal attainment for LLT was observed, and only half the patients obtained BP goal. Despite a high focus on the increased CVD risk in RA patients over the last decade, there is still substantial potential for improvement in CVD preventive measures.

Objective The coronavirus disease 2019 (COVID-19) pandemic created challenges for patients with RA. We examined the potential impact of the pandemic on patient-reported outcomes (PROs), disease activity and medication profiles, comparing the periods pre-pandemic and during the pandemic. Methods Patients enrolled in the Ontario Best Practices Research Initiative were included if they had at least one visit to a physician or study interviewer within 12 months before and after the start of pandemic-related closures in Ontario (15 March 2020). Baseline characteristics, disease activity, PROs [i.e. health assessment questionnaire disability index, RA disease activity index (RADAI), European quality of life five-dimension questionnaire], medication use and changes were included. Student’s paired two-sample t-tests and McNamar’s tests were performed for continuous and categorical variables between time periods. Results The sample for analysis consisted of 1508 patients, with a mean (s.d.) age of 62.7 (12.5) years, and 79% were female. Despite decreases in the number of in-person visits during the pandemic, there was no significant negative impact on disease activity or PRO scores. The DASs in both periods remained low, with either no clinically significant differences or slight improvement. Scores for mental, social and physical health were either stable or improved. There were statistically significant decreases in conventional synthetic DMARD use (P Conclusion In this cohort, disease activity and PROs of RA patients remained stable during the COVID-19 pandemic. The longer-term outcomes of the pandemic warrant investigation.

ObjectiveTo investigate coronavirus disease 2019 (COVID-19) hospitalization risk in patients with immune-mediated inflammatory diseases (IMIDs) compared with matched non-IMID comparators from the general population.MethodsWe conducted a population-based, matched cohort study using health administrative data from January to July 2020 in Ontario, Canada. Cohorts for each of the following IMIDs were assembled: rheumatoid arthritis (RA), psoriasis, psoriatic arthritis (PsA), ankylosing spondylitis, systemic autoimmune rheumatic diseases (SARDs), multiple sclerosis (MS), iritis, inflammatory bowel disease, polymyalgia rheumatica, and vasculitis. Each patient was matched with 5 non-IMID comparators based on sociodemographic factors. We compared the cumulative incidence of hospitalizations for COVID-19 and their outcomes between IMID and non-IMID patients.ResultsA total of 493,499 patients with IMID (417 hospitalizations) and 2,466,946 non-IMID comparators (1519 hospitalizations) were assessed. The odds of being hospitalized for COVID-19 were significantly higher in patients with IMIDs compared with their matched non-IMID comparators (matched unadjusted odds ratio [OR] 1.37, adjusted OR 1.23). Significantly higher risk of hospitalizations was found in patients with iritis (OR 1.46), MS (OR 1.83), PsA (OR 2.20), RA (OR 1.42), SARDs (OR 1.47), and vasculitis (OR 2.07). COVID-19 hospitalizations were associated with older age, male sex, long-term care residence, multimorbidity, and lower income. The odds of complicated hospitalizations were 21% higher among all IMID vs matched non-IMID patients, but this association was attenuated after adjusting for demographic factors and comorbidities.ConclusionPatients with IMIDs were at higher risk of being hospitalized with COVID-19. This risk was explained in part by their comorbidities.

Objective: To describe the prevalence of atrial fibrillation (AF) in patients with rheumatoid arthritis (RA), and to evaluate the proportion of patients with AF receiving guideline-recommended anticoagulation for prevention of stroke, based on data from a large international audit. Methods: The cohort was derived from the international audit SUrvey of cardiovascular disease Risk Factors in patients with Rheumatoid Arthritis (SURF-RA) which collected data from 17 countries during 2014-2019. We evaluated the prevalence of AF across world regions and explored factors associated with the presence of AF with multivariable logistic regression models. The proportion of AF patients at high risk of stroke (CHA(2)DS(2)-VASc & GE; 2 in males and & GE; 3 in females) receiving anticoagulation was examined. Results: Of the total SURF-RA cohort (n = 14,503), we included RA cases with data on whether the diagnosis of AF was present or not (n = 7,665, 75.1% women, mean (SD) age 58.7 (14.1) years). A total of 288 (3.8%) patients had a history of AF (4.4% in North America, 3.4% in Western Europe, 2.8% in Central and Eastern Europe and 1.5% in Asia). Factors associated with the presence of AF were older age, male sex, atherosclerotic cardiovascular disease, heart failure and hypertension. Two-hundred and fifty-five (88.5%) RA patients had a CHA(2)DS(2)-VASc score indicating recommendation for oral anticoagulant treatment, and of them, 164 (64.3%) were anticoagulated. Conclusion: Guideline-recommended anticoagulant therapy for prevention of stroke due to AF may not be optimally implemented among RA patients, and requires special attention.

ObjectiveTo describe changes in service delivery and access to rheumatologists before and during the coronavirus disease 2019 (COVID-19) pandemic periods.MethodsWe conducted a population-based study in Ontario, Canada. Patient visits with rheumatologists were ascertained using billing claims data. Contact with rheumatologists was defined separately by the type of patient encounter (including office visits, telemedicine visits, and new patient consultations). Changes in the total weekly volume of encounters and monthly rates after COVID-19 public health measures were imposed were compared to expected baseline rates determined before pandemic onset (March 17, 2020).ResultsIn the year prior to the pandemic, there were 289,202 patients (of which 96,955 were new consults) seen by 239 rheumatologists. In the 1 year following the pandemic onset, there were 276,686 patients (of which 86,553 were new consults) seen by 247 rheumatologists. In March 2020, there was an immediate 75.9% decrease in outpatient office visits and a rapid rise in telemedicine visits. By September 2021, 49.7% of patient encounters remained telemedicine visits. For new patient consultations, there was an immediate 50% decrease in visits at the pandemic onset, with 54.8% diverted to telemedicine visits in the first year of the pandemic versus 37.4% by September 2021. New rheumatology consultation rates continued decreasing over the study period.ConclusionRheumatology care delivery has shifted due to the pandemic, with telemedicine increasing sharply early in the pandemic and persisting over time. The pandemic also negatively affected access to rheumatologists, resulting in fewer new consultations and raising concerns for potential delays to diagnosis.

Objective.To compare differences in clinical activity and remuneration between male and female rheumatologists and to evaluate associations between physician gender and practice sizes and patient volume, accounting for rheumatologists’ age, and calendar year effects.Methods.We conducted a population-based study in Ontario, Canada, between 2000 to 2015 identifying all rheumatologists practicing as full-time equivalents (FTEs) or above and assessed differences in practice sizes (number of unique patients), practice volumes (number of patient visits), and remuneration (total fee-for-service billings) between male and female rheumatologists. Multivariable linear regression was used to evaluate the effects of gender on practice size and volume separately, accounting for age and year.Results.The number of rheumatologists practicing at ≥ 1 FTE increased from 89 to 120 from 2000 to 2015, with the percentage of females increasing from 27.0% to 41.7%. Males had larger practice sizes and practice volumes. Remuneration was consistently higher for males (median difference of CAD $46,000–102,000 annually). Our adjusted analyses estimated that in a given year, males saw a mean of 606 (95% CI 107–1105) more patients than females did, and had 1059 (95% CI 345–1773) more patient visits. Among males and females combined, there was a small but statistically significant reduction in mean annual number of patient visits, and middle-aged rheumatologists had greater practice sizes and volumes than their younger/older counterparts.Conclusion.On average, female rheumatologists saw fewer patients and had fewer patient visits annually relative to males, resulting in lower earnings. Increasing feminization necessitates workforce planning to ensure that populations’ needs are met.

Supplemental material, Supplementary for Acute mental health service use is increased in rheumatoid arthritis and ankylosing spondylitis: a population-based cohort study by Bindee Kuriya, Vivian Tia, Jin Luo, Jessica Widdifield, Simone Vigod and Nigil Haroon in Therapeutic Advances in Musculoskeletal Disease

Objective.To quantify population-level and practice-level encounters with rheumatologists over time.Methods.We conducted a population-based study from 2000 to 2015 in Ontario, Canada, where all residents are covered by a single-payer healthcare system. Annual total number of unique patients seen by rheumatologists, the number of new patients seen, and total number of encounters with rheumatologists were identified.Results.From 2000 to 2015, the percentage of the population seen by rheumatologists was constant over time (2.7%). During this time, Ontario had a stable supply of rheumatologists (0.8 full-time equivalents/75,000). From 2000 to 2015, the number of annual rheumatology encounters increased from 561,452 to 786,061, but the adjusted encounter rates remained stable over time (at 62 encounters per 1000 population). New patient assessment rates declined over time from 10 new outpatient assessments per 1000 in 2000 to 6 per 1000 in 2015. The crude volume of new patients seen annually decreased and an increasing proportion of rheumatology encounters were with established patients. We observed a shift in patient case mix over time, with more assessments for systemic inflammatory conditions. Rheumatologists’ practice volumes, practice sizes, and the annual number of days providing clinical care decreased over time.Conclusion.Over a 15-year period, the annual percentage of the population seen by a rheumatologist remained constant and the volume of new patients decreased, while followup patient encounters increased. Patient encounters per rheumatologist decreased over time. Our findings provide novel information for rheumatology workforce planning. Factors affecting clinical activity warrant further research.

Background Rheumatoid arthritis increases the risk of cardiovascular disease (CVD). Less is known about the direct influence of CVD and CVD risk factors (RF) on RA outcomes, but higher comorbidity burden has been suggested to adversely affect RA treatment response1-2. Objectives We tested our hypothesis that CVD risk factors (RFs) alone, in the absence of CVD, are associated with higher disease activity and disability in RA. Methods The Ontario Best Practices Research Initiative (OBRI) is a clinical registry of RA patients followed in routine care. RA subjects with complete data to calculate disease activity according to the Disease Activity Score-28 (DAS28), Clinical Disease Activity Index (CDAI), 28 swollen joint count (SJC28) and functional status (Health Assessment Questionnaire Disability Index [HAQ-DI]) at cohort entry were selected. Patients were divided into mutually exclusive groups by baseline CVD status as: (1) no CVD/no CVD RFs; (2) CVD including coronary artery disease, myocardial infarction, cerebral vascular accidents, and peripheral arterial disease; (3) no CVD but CVD RFs including hypertension (HTN), dyslipidemia (DLD), diabetes (DM), or smoking. We performed separate linear regression analyses for each outcome, adjusted for baseline clinical and demographic variables, to determine the independent effect of CVD status on disease outcomes at baseline and one year follow-up. Results Of 2033 patients examined, 49.5% had no CVD, 5.4% had CVD and 45.1% had CVD RFs alone. The most common RF was HTN (33%) followed by DLD (19.7%), current smoking (17%), and DM (8.1%). At cohort entry, having a CVD RF was associated with significantly higher DAS28 (β 0.13, 95%CI 0.002-0.26, p 0.04) and HAQ-DI (β 0.16, 95%CI 0.10-0.23, p Conclusion Even in the absence of CVD, traditional CVD RF are associated with greater RA disease severity and disability both at baseline and one year. Self-perceived impact of comorbidity (patient global assessment of health) may be driving this relationship. Moreover, patients with CVD RF maybe more treatment-resistant, suggesting that co-management of CVD RF in RA patients may be beneficial on both fronts. References [1] Avina-Zubieta, J. A., Thomas, J., Sadatsafavi, M., Lehman, A. J. & Lacaille, D. Risk of incident cardiovascular events in patients with rheumatoid arthritis: a meta-analysis of observational studies. Ann. Rheum. Dis. 71, 1524–1529 (2012). [2] Crepaldi, G. et al. Cardiovascular Comorbidities Relate More than Others with Disease Activity in Rheumatoid Arthritis. PLoS One11, (2016). Acknowledgement OBRI investigators Disclosure of Interests Kangping Cui: None declared, Mohammad Movahedi Employee of: ONTARIO BEST PRACTICE RESEARCH INITIATIVE (OBRI), Claire Bombardier Grant/research support from: Abbvie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Pfizer Inc, Roche, Sanofi, UCB, Consultant for: AbbVie, Hospira, Janssen, Merck, Novartis, Pfizer Inc, Sanofi, Speakers bureau: Roche, Bindee Kuriya Consultant for: Advisory Board Member: Abbvie, Sanofi Genzyme, Eli Lilly, Pfizer Canada, Roche

Background Prevalence studies of metabolic syndrome (MetS) in early rheumatoid arthritis (ERA) are sparse and estimates are variable. Differences by sex and menopausal status have not been formally assessed. Objectives We estimated prevalence and factors associated with MetS in ERA patients treated in routine practice settings. Variations by sex, and by menopausal status were also examined. Methods Cross-sectional data were analyzed from patients meeting 1987 or 2010 ACR/EULAR RA criteria enrolled in the Canadian Early Arthritis Cohort (CATCH) from January 2007-March 2017. CATCH is a prospective multicenter observational study of patients diagnosed and treated for early inflammatory arthritis (symptoms Results The sample included 1543 participants; 71% were female and mean(SD) age was 54 (15) years. 476 (31%) of the total sample met criteria for MetS. Participants with MetS were older, more frequently past smokers and reported more comorbid conditions, including cardiovascular disease (CVD) (p Conclusion Approximately 1 in 3 ERA patients met crietria for MetS. Though men had a higher prevalence of MetS and individual MetS components, post-menopausal women had a similar MetS profile as men, and should equally be considered high risk for CVD development. Characteristics and associations with MetS differed in men and women suggesting sex-specific variations are important considerations for comorbidity screening and surveillance of CVD outcomes in ERA. Reference [1] Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med. 1998;15(7):539-53. Acknowledgement Sponsors: Amgen & Pfizer-Founding sponsors 2007+; AbbVie 2011+; Medexus 2013+;EliLilly2016+, Merck Canada 2017+, Hoffmann-LaRoche & Janssen Biotect 2011-2016, UCB & BMS 2011-2018, Sanofi-Genzyme 2016-2017. Disclosure of Interests Bindee Kuriya Consultant for: Advisory Board Member: Abbvie, Sanofi Genzyme, Eli Lilly, Pfizer Canada, Roche, Orit Schieir: None declared, Marie-France Valois: None declared, Janet Pope Consultant for: Eli Lilly and Company, Gilles Boire Grant/research support from: Investigator-initiated studies: Amgen, Abbvie, BMS, Eli Lilly, Merck, Novartis, Pfizer, Consultant for: Advisory boards: Amgen, BMS, Celgene, Eli Lilly, Pfizer, Speakers bureau: Merck, BMS, Pfizer, Louis Bessette Grant/research support from: Amgen, BMS, Janssen, Roche, UCB, AbbVie, Pfizer, Merck, Celgene, Sanofi, Lilly, Novartis, Consultant for: Amgen, BMS, Janssen, Roche, UCB, AbbVie, Pfizer, Merck, Celgene, Sanofi, Lilly, Novartis, Speakers bureau: Amgen, BMS, Janssen, Roche, UCB, AbbVie, Pfizer, Merck, Celgene, Sanofi, Lilly, Novartis, Glen Hazlewood : None declared, Carter Thorne Grant/research support from: Investigator-initiated studies: Amgen, Pfizer. RCTs: Abbvie, Celgene, CaREBiodam, Novartis, Pfizer, Consultant for: Advisory board: Abbvie, Amgen, Celgene, Lilly, Medexus/Medac, Merck, Novartis, Pfizer, Sanofi. Consultant: Abbvie, Centocor, Janssen, Lilly, Medexus/Medac, Pfizer, Speakers bureau: Medexus/Medac, Diane Tin: None declared, CArol Hitchon Grant/research support from: Pfizer, UCB (unrelated studies), Susan J. Bartlett Consultant for: Pfizer, UCB, Lilly, Novartis, Merck, Jansen, Abbvie, Edward Keystone Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, F. Hoffmann-La Roche Inc, Gilead, Janssen Inc, Lilly Pharmaceuticals, Pfizer Pharmaceuticals, Sanofi-Aventis, Consultant for: AbbVie, Amgen, AstraZeneca Pharma, Biotest, Bristol-Myers Squibb Company, Celltrion, Crescendo Bioscience, F. Hoffmann-La Roche Inc, Genentech Inc, Gilead, Janssen Inc, Lilly Pharmaceuticals, Merck, Pfizer Pharmaceuticals, Sandoz, UCB., Speakers bureau: Amgen, AbbVie, Bristol-Myers Squibb Canada, F. Hoffmann-La Roche Inc., Janssen Inc., Merck, Pfizer Pharmaceuticals, Sanofi Genzyme, UCB, Vivian Bykerk Grant/research support from: Mallinckrodt, BMS, Crescendo Biosciences, Sanofi/Regeneron., Consultant for: Amgen, Pfizer, UCB, Scipher, Sanofi/Genzyme/Regeneron, Lillian Barra: None declared

Appendix. Search strategy used for systematic review record retrieval. Figure S1. Flow diagram of the search strategy and study selection for inclusion in the systematic review. (DOCX 67 kb)

Aims: Rheumatoid arthritis (RA) is associated with cardiovascular disease (CVD), but the influence of CVD risk factors on RA outcomes is limited. We examined if CVD risk factors alone are associated with RA disease activity and disability. Methods: We performed a cross-sectional analysis of participants in the Ontario Best Practices Research Initiative, RA registry. Patients were categorized into mutually exclusive CVD categories: (1) No established CVD and no CVD risk factors; (2) CVD risk factors only including ⩾1 of hypertension, dyslipidemia, diabetes, or smoking; or (3) history of established CVD event. Multivariable regression analyses examined the effect of CVD status on Disease Activity Score 28 (DAS28-ESR), Clinical Disease Activity Index (CDAI), and Health Assessment Questionnaire Disability Index (HAQ-DI) scores at baseline. Results: Of 2033 patients, 50% had at least 1 CVD risk factor, even in the absence of established CVD. The presence of ⩾1 CVD risk factor was independently associated with higher CDAI [β coefficient 1.59, 95% confidence interval (CI) 0.29–2.90, p = 0.02], DAS28-ESR (β coefficient 0.20, 95% CI 0.06–0.34, p = 0.01) and HAQ-DI scores (β coefficient 0.15, 95% CI 0.08–0.22, p 1 CVD risk factor was associated with higher disease activity and disability, compared with having one or no CVD risk factors. Conclusion: CVD risk factors alone, or in combination, are associated with higher disease activity and disability in RA. This emphasizes the importance of risk factor recognition and management, not only to prevent CVD, but also to improve potential RA outcomes.

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.

Background: Rheumatology workforces are challenged by too few physicians, increasing incidence and prevalence of MSK diseases (and complexity of co-morbid conditions) in aging populations, and expanding therapeutic options that increase demand for service. Understanding trends in rates of rheumatology encounters with new and existing patients will help to identify why patients have delays to rheumatology care and mobilize efforts to help meet patients’ needs. Objectives: To describe trends in patient encounters with rheumatologists over time in Ontario, Canada. Methods: We analyzed administrative health data from 2000 to 2013 in Ontario, Canada, where all 13 million residents are covered by a publicly-funded healthcare system and access to rheumatologists is dependent upon referrals. During this time, Ontario had a stable rheumatology supply of 1 rheumatologist per 75,000 population (0.7 FTEs/75,000). We determined annual incident, follow-up and total patient encounters seen by rheumatologists. Rates were calculated using the total population of Ontario residents 18 and older, each year. Diagnosis codes assigned at each encounter were used to assess changes in the case-mix of patients under rheumatology care over time. Results: From 2000 to 2013, the proportion of all Ontario residents seen by rheumatologists was constant over time (2.7%). The total number of rheumatology encounters increased from 561,452 to 742,952 but the total encounter rate remained relatively stable over time (table 1). The annual new consultation rate significantly declined over time from 1.6 to 0.8 new patients per 100 population. Both the annual proportion of incident patients and the ratios of incident to established patients and incident to total patient encounters declined significantly over time. We observed a shift in the diagnostic case-mix over time: encounter rates for systemic inflammatory conditions significantly increased over time and encounter rates for non-systemic conditions (OA, regional MSK conditions) decreased. The volume of rheumatoid arthritis (RA) encounters increased the most, with 17% of all rheumatology encounters related to RA in 2000 versus 32% in 2013. Conclusions: The significant decline in new patient consultation rates over time helps illustrate the growing supply-demand mismatch in rheumatology care. An increasing fraction of rheumatology encounters in Ontario are with established patients, which may be limiting access for new consultations and increasing wait times. We also observed a shift in the patient case-mix over time with rheumatologists seeing/prioritizing more systemic inflammatory conditions. Our findings provide new inputs for rheumatology workforce planning models. Disclosure of Interest: None declared

Background The global shortage of rheumatologists is an increasing concern. Statistics from physician surveys have projected changes in the workforce composition (ageing, feminization, and generational trends), which have implications for the workforce clinical activity. In order to adequately document the issues and potential solutions, more detailed information is needed regarding clinical activity, demographic changes and the implications of these, in a population-based sample. Objectives To describe changes in the number, demographics and clinical activity of Ontario rheumatologists over the past decade. Methods We analysed administrative health data from 2000 to 2013 in Ontario, Canada, where all 13 million residents are covered by a publicly funded healthcare system. Rheumatologists, and their characteristics, were identified using a validated physician registry. We used fee-for-service billing claims to quantify clinical activity levels expressed as full-time equivalents (FTE). Physicians below the 40th percentile of total billings were classified as providing less clinical activity ( 60 th percentile as >1 FTE (i.e. high volume community practice). Results In 2000, there were 146 rheumatologists in Ontario (88 of whom worked ≥1 FTEs); this increased to 187 rheumatologists (114≥1 FTEs) in 2013. Despite the increase, due to an increase in the Ontario population over this time, the proportion of Ontarians seen by a rheumatologist annually remained constant (2.7%) as was the overall provincial per capita supply (1.2 rheumatologists per 75 000 population, 0.7 FTEs/75,000). In 2000, 34% of rheumatologists were female compared to 48% in 2013. During this time, the proportion of rheumatologists aged >60 + years increased (16% to 26%). The annual median (IQR) number of days of clinical service decreased from 220 178–243 days in 2000 to 176 138–213 days in 2013. The percentage of rheumatologists with patient encounters on at least 209 days/year (an alternative FTE benchmark) showed a downward trend from 46% in 2000 to 22% in 2013. Male rheumatologists had more patient encounters each year, and a higher proportion of male rheumatologists worked as ≥1 FTE. Average practice sizes declined over time (figure 1A), as did the median number of patient encounters per rheumatologist per year (figure 1B). Conclusions Although there has been an increase in the number of rheumatologists, the per capita supply and access to rheumatologists have remained unchanged. We observed changing workforce demographics and declining clinical activity over time. Factors affecting clinical activity (including an ageing and greater feminization of the workforce, clinic saturation, increasing care complexity, models of care, greater demands for continuing medical education and research activity) warrants further study. Disclosure of Interest None declared

Different strategies to implement the eular guideline for cardiovascular risk management in daily practice

Background Inflammatory arthritis is associated with the development of mental health disorders. However, there is limited data on the risk of serious mental health outcomes following a rheumatoid arthritis (RA) or ankylosing spondylitis (AS) diagnosis. Objectives To estimate the risk of deliberate self-harm in patients with ankylosing spondylitis or rheumatoid arthritis compared with the general population. Methods We evaluated population-based cohorts of RA (n=53,240) and AS (n=13,964), each matched 1:4 by age, sex, and calendar year (at diagnosis) with non-IA comparator cohorts in Ontario, Canada. Individuals with a history of mental illness or prior episode of deliberate self-harm were excluded. The outcome was a first emergency room presentation for deliberate self-harm, subsequent to RA or AS diagnosis, between April 1, 2002 and March 31, 2016. We estimated hazard ratios (HR) and 95% confidence intervals (95% CI) for RA and AS, separately, versus the comparator groups, adjusting for demographic, clinical and health service utilisation variables. Results Individuals with AS were more likely to deliberately self-harm (incidence rate [IR] of 6.79/10,000 person years [PY] compared to 3.19/10,000 PY in comparators, with an adjusted HR 1.82 (95% CI: 1.26 to 2.62). Deliberate self-harm was also increased for individuals with RA (IR 3.51/10,000 PY) compared to comparators (IR 2.45/10,000 PY) only before (HR 1.43, 95% CI: 1.16 to 1.75), but not after covariate adjustment (HR 1.09, 95% CI: 0.88 to 1.36). The most frequent method of self-harm was poisoning (64% of attempts in AS, 81% in RA) or self-mutilation (36% in AS, 18% in RA). Conclusions There is a significantly increased rate of self-harm attempt in inflammatory arthritis and the risk is particularly elevated following a diagnosis of AS. These findings highlight the need for routine evaluation of self-harm behaviour as part of the management of chronic inflammatory arthritis. Understanding the mechanisms contributing to deliberate self-harm attempts will help tailor preventive strategies to reduce morbidity associated with this serious mental health outcome. Acknowledgements This work was funded by the Division of Rheumatology Pfizer Research Chair, University of Toronto Disclosure of Interest None declared

Objective.We sought to determine if initial high disease activity or changes in disease activity contribute to persistent depression in early rheumatoid arthritis (ERA). We also determined if disease activity and depression is modified by sex.Methods.Depression was ascertained by self-report among patients enrolled in the Ontario Best Practices Research Initiative. The association between baseline disease activity, measured by the Clinical Disease Activity Index (CDAI), and persistent depression was evaluated with multivariate regression models, and effect modification by sex was tested. A general estimating equation assessed the association between change in CDAI over time and risk of depression.Results.The sample of 469 ERA subjects was predominantly female (73%). At baseline, the prevalence of depression was 26%, and 23% reported persistent depression. After adjusting for potential confounders, higher baseline CDAI was associated with both baseline and persistent depression (OR 1.03, 95% CI 1.01–1.05). Female sex was an effect modifier of this relationship (OR 1.04, 95% CI 1.01–1.06). Maintaining a moderate or high CDAI score over 2 years also increased the risk of future depression.Conclusion.Depression in ERA is common and initial high disease activity is associated with the probability of depression and its persistence. This risk seems particularly modified in women with active disease and represents an area for targeted focus and screening. Future studies in ERA are needed to determine if intervening during the “window of opportunity” to control disease activity has the potential to mitigate the development and maintenance of adverse mental health outcomes, including depression.

This study aims to compare characteristics between late-onset rheumatoid arthritis (RA) and young-onset RA and determine the association between age at disease onset and disease severity. We cross-sectionally studied 971 patients at the time of entry into the Ontario Best Practices Research Initiative, a registry of RA patients followed up in routine care. We restricted patients to ≤5 years of disease duration. Late-onset RA was defined as an onset ≥60 years of age and young-onset RA

Objective To evaluate excess mortality over time, comparing rheumatoid arthritis (RA) patients with the general population. Methods We computed all-cause mortality rates among Ontario residents age ≥15 years with RA versus without RA from 1996 to 2009. Age- and sex-standardized mortality rates were expressed as the number of deaths per 1,000 population. Excess mortality rates were calculated as the difference between death rates among RA patients and those in the general population. We estimated standardized mortality ratios (SMRs) and mortality rate ratios (MRRs) to assess relative excess mortality over time. Results From 1996 to 2009, SMRs in RA ranged from 13.0 (95% confidence interval [95% CI] 12.2, 13.9) to 9.2 deaths per 1,000 RA patients (95% CI 8.4, 10.0); and for those without RA from 8.7 (95% CI 8.6, 8.7) to 6.0 deaths (95% CI 5.9, 6.0) per 1,000 general population. Over the study period, the excess mortality rate among RA patients was approximately 3 excess deaths per 1,000 population. Relative reductions in standardized mortality rates occurred over time for those with and without RA (−21.4% versus −13.4%). The SMRs for RA patients in 1996–1997, 2000–2001, 2004–2005, and 2008–2009 were 1.51 (95% CI 1.43, 1.59), 1.50 (95% CI 1.43, 1.57), 1.43 (95% CI 1.37, 1.50), and 1.41 (95% CI 1.35, 1.47), respectively. We did not find a significant change in the MRR by calendar time. Conclusion Mortality for RA patients has decreased over time but remains elevated compared to the general population, with 40–50% more deaths among RA patients. The relative excess mortality over time (mortality gap) remains unchanged in our sample.

Objective.To evaluate the prevalence and predictive factors of sustained remission in an early rheumatoid arthritis (ERA) population. Predictive factors of sustained remission in ERA are unknown. We hypothesized that a short time to remission is an important predictor of sustained clinical remission.Methods.Patients in the Canadian Early Arthritis Cohort were included. Remission was defined by Boolean-based American College of Rheumatology/European League Against Rheumatism clinical trial and clinical practice definitions and Simplified Disease Activity Index (SDAI). Logistic regression analysis identified predictors of sustained remission and influence of time to remission.Results.Of 1840 patients, 633 (34%) achieved clinical trial remission, 759 (41%) clinical practice remission, and 727 (39%) SDAI remission. Over half of those meeting remission criteria achieved sustained remission based on clinical trial (55%), clinical practice (60%), and/or SDAI (58%). Corticosteroid use and lack of initial disease-modifying antirheumatic drug (DMARD) were associated with decreased probability of sustained remission, while initial combination DMARD increased this probability. Female sex, greater pain, and longer time to first remission made sustained remission less likely.Conclusion.Female sex, greater pain, and lack of initial DMARD therapy reduced the probability of sustained remission. A shorter time to remission is related to sustainability and supports striving for early remission.

Objective Epidemiologic assessments of sufficiently large populations are required in order to obtain robust estimates of disease prevalence and incidence, particularly when exploring the influence of various factors (age, sex, calendar time). We undertook this study to describe the epidemiology of rheumatoid arthritis (RA) over the past 15 years. Methods We used the Ontario Rheumatoid Arthritis administrative Database (ORAD), a validated population-based research database of all Ontarians with RA. The ORAD records were linked with census data to calculate crude and age and sex–standardized prevalence and incidence rates from 1996 to 2010. Vital statistics were used to estimate annual all-cause mortality during the study period. Results As of 2010, there were 97,499 Ontarians with RA, corresponding to a cumulative prevalence of 0.9%. Age and sex–standardized RA prevalence increased steadily over time from 473 (95% confidence interval [95% CI] 469–478) per 100,000 population (0.49%) in 1996 to 784 (95% CI 779–789) per 100,000 population (0.9%) in 2010. Age and sex–standardized incidence per 100,000 population ranged from 62 (95% CI 60–63) in 1996 to 54 (95% CI 52–55) in 2010. All-cause mortality decreased by a relative 21.4% since 1996. Conclusion Over a 15-year period, we observed an increase in RA prevalence over time. This rise may be attributed to the increasing time to ascertain cases (which may have been latent in the population during earlier years of the study), increasing survival, and/or an increase in the aging background population. Incidence appears to be stable.

Objective To determine the rate of induced abortions in women with rheumatoid arthritis (RA) exposed to methotrexate (MTX) compared with women with RA unexposed to this medication. Methods We performed a nested case–control study using administrative databases from Quebec. All women with RA ages 15–45 years were identified and cases were defined as women having an induced abortion. Each case was matched to ≥1 controls for age, calendar time, and cohort entry. Exposure was defined as having filled ≥1 prescriptions of MTX ≤16 weeks prior to the index date. Results We identified 112 cases of induced abortions in women with RA and 5,855 RA controls. Exposure to MTX occurred in 10.7% of cases and 21.7% of controls. Women exposed to MTX had a lower rate of induced abortions compared with unexposed women (rate ratio [RR] 0.47 [95% confidence interval (95% CI) 0.25–0.89]). In the multivariate analysis, there was a trend toward an increased rate of induced abortions among women exposed to anti–tumor necrosis factor (anti-TNF) agents (RR 2.07 [95% CI 0.81–5.27]). Conclusion Women with RA exposed to MTX have a lower rate of induced abortions than unexposed women. Women with RA exposed to anti-TNF agents may have an increased rate of induced abortions compared to unexposed women.

The 28-Joint Disease Activity Score (DAS28) using C-reactive protein (CRP) and DAS28 using erythrocyte sedimentation rate (DAS28-ESR) may not be interchangeable. We sought to compare and estimate optimal thresholds for the DA28-CRP for use in early rheumatoid arthritis (ERA).Patients from the Canadian Early Arthritis Cohort with baseline and 12 months' data for both DAS28-ESR and DAS28-CRP were examined for correlations and differences between DAS28-CRP and DAS28-ESR across their range of values. Receiver operating characteristic analysis identified thresholds for DAS28-CRP that best corresponded to established thresholds for the DAS28-ESR using the total sample, then stratified by age and sex. Agreement between DAS28-CRP and DAS28-ESR thresholds was assessed with the kappa statistic.The sample included 995 patients with mean (SD) age of 53.7 (14.5) years, 5.8 (2.9) months of symptom duration and 74% were female. DAS28-CRP and DAS28-ESR scores were highly correlated (r= 0.92, p0.0001), however DAS28-CRP values were consistently lower than DAS28-ESR values. Calculated thresholds for DAS28-CRP were lower with 2.5 for remission, 2.9 for low disease activity, and 4.6 for high disease activity but showed moderate agreement with the DAS28-ESR thresholds (kappa=0.70).In this large sample of ERA patients, newly estimated thresholds for DAS28-CRP were consistently lower than DAS28-ESR thresholds across the spectrum of disease activity. This may have important clinical implications if inflammatory markers are used interchangeably. Additional external validation of our findings is needed.

Objective.To describe the frequency of remission in an early rheumatoid arthritis (ERA) cohort.Methods.The frequency of remission was evaluated, based on 8 definitions including the Boolean-based American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria.Results.Of 369 patients, remission at 12 months ranged from 18% according to the ACR/EULAR clinical trial criteria to 40% according to the 28-joint Disease Activity Score (DAS28) < 2.6. Higher tender joint count, swollen joint count, and physician global scores were seen for DAS28-based definitions, and patient global assessment (PtGA) scores were almost 5-fold higher for DAS28 remission.Conclusion.Remission is achievable in ERA but its frequency differs according to the remission definition applied. Adoption of the new ACR/EULAR definition will limit the number classified as in remission, especially if the PtGA criteria are rated high for reasons other than inflammatory arthritis.

Background Although biologic treatments have excellent efficacy for many autoimmune diseases, safety concerns persist. Understanding the absolute and comparative risks of adverse events in patient and disease subpopulations is critical for optimal prescribing of biologics. Purpose The Safety Assessment of Biologic Therapy collaborative was federally funded to provide robust estimates of rates and relative risks of adverse events among biologics users using data from national Medicaid and Medicare plus Medicaid dual-eligible programs, Tennessee Medicaid, Kaiser Permanente, and state pharmaceutical assistance programs supplementing New Jersey and Pennsylvania Medicare programs. This report describes the organizational structure of the collaborative and the study population and methods. Methods This retrospective cohort study (1998–2007) examined risks of seven classes of adverse events in relation to biologic treatments prescribed for seven autoimmune diseases. Propensity scores were used to control for confounding and enabled pooling of individual-level data across data systems while concealing personal health information. Cox proportional hazard modeling was used to analyze study hypotheses. Results The cohort was composed of 159 000 subjects with rheumatic diseases, 33 000 with psoriasis, and 46 000 with inflammatory bowel disease. This report summarizes demographic characteristics and drug exposures. Separate reports will provide outcome definitions and estimated hazard ratios for adverse events. Conclusion This comprehensive research will improve understanding of the safety of these treatments. The methods described may be useful to others planning similar evaluations. Copyright © 2011 John Wiley & Sons, Ltd.

Objective.We aimed to systematically review rheumatoid arthritis (RA) disease severity indices for use in administrative healthcare databases. We also provide an overview of alternative methods to control for RA disease severity in administrative database research.Methods.We conducted a systematic review of studies that developed/validated an index for RA disease severity using variables in administrative databases, and compared the convergent validity/reliability of the index with a standard measure of RA severity.Results.After reviewing 539 articles, 2 studies were included. The claims-based index for RA severity (CIRAS) was developed in one study. Components of the CIRAS included tests for inflammatory markers, number of chemistry panels/platelet counts ordered, rheumatoid factor test, number of rehabilitation and rheumatology visits, and Felty’s syndrome. The CIRAS correlated moderately well with a previously validated RA medical records-based index of severity. The second study assessed whether current and lifetime treatment with disease-modifying antirheumatic drugs and/or biologics accurately predicted RA severity, as measured by the patient-reported Patient Activity Scale (PAS). Treatment variables did not fully distinguish patients in the highest and lowest quartiles of PAS scores (67.2% correctly classified).Conclusion.Two claims-based indices of RA severity were identified but have some limitations for routine use. A concerted effort from experts in the field is needed to define, develop, and validate a widely applicable measure of RA disease severity for administrative database research.

Objective To characterize therapies prescribed during pregnancy to women with rheumatoid arthritis (RA). Methods We conducted a cohort study of women with RA with pregnancies using health care utilization data from 2002–2008. We examined the distribution of RA drugs by therapeutic classes, including nonsteroidal antiinflammatory drugs (NSAIDs)/coxibs, glucocorticoids, nonbiologic disease-modifying antirheumatic drugs (DMARDs), and biologic DMARDs, during 90-day pregnancy trimesters and the 180 days prior to pregnancy. Drugs were characterized according to the Food and Drug Administration risk classification system. Differences in exposure by period were determined by chi-square tests. Results A total of 393 pregnancies were identified among 34,169 women with RA. Seventy-two percent of pregnancies ended in a delivery. Approximately 24% of women with RA received a DMARD during preconception. At any point during pregnancy, 23% of women with deliveries were dispensed ≥1 DMARD and the proportion of use declined from the first to the third trimester (P = 0.03). Similar to DMARD therapy, use of NSAIDs/coxibs and exposure to category D/X medications were significantly lower compared to prepregnancy use (P < 0.05). In contrast, more women were prescribed glucocorticoids during pregnancy than before pregnancy. Use of biologics occurred in 12.5% of pregnancies. Compared to women with deliveries, women who experienced abortions were more frequently exposed to NSAIDs/coxibs (P < 0.05). Dispensing of category D/X medications was also higher in women with spontaneous abortions and primarily involved methotrexate (P < 0.05). Conclusion Approximately 24% of women with RA received a DMARD in the 180 days before conception, and the proportion dropped during pregnancy. Glucocorticoid use remained high throughout pregnancy. Our results suggest that continued efforts directed at counseling women and their physicians about the potential risks/benefits of RA therapies during pregnancy are warranted.

Objective. To systematically review the differential diagnosis and minimal clinical investigation used prior to making a diagnosis of undifferentiated peripheral inflammatory arthritis (UPIA). Methods. A systematic literature search was performed for articles published between January 1950 and December 2008 in Medline and Embase, and for abstracts presented at the 2007 and 2008 meetings of the American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR). Studies including defined cohorts of patients with UPIA were retrieved according to predefined inclusion/exclusion criteria. Selected studies were systematically reviewed and relevant data extracted. Baseline characteristics were also recorded to obtain a clinical picture of patients classified as UPIA. Results. Seventy-four articles were included. Of those, 52 reported baseline characteristics. Tremendous variation existed among studies, reflecting the different inclusion/exclusion criteria used. Rheumatoid arthritis, spondyloarthropathies, osteoarthritis, crystal arthritis, connective tissue diseases, and infections were the most common diagnoses of exclusion for UPIA and made up the other subsets of patients in cohorts with mixed populations. The baseline investigation undertaken prior to diagnosis of UPIA was reported in 7 articles. History, physical examination, tender and swollen joint count, rheumatoid factor, HLA-B27, erythrocyte sedimentation rate, C-reactive protein, and radiographs of hands and feet were the only items mentioned in at least 50% of the reports. Conclusion. Studies of UPIA are heterogeneous. Few studies reported on the minimal clinical investigation necessary to arrive at a diagnosis of UPIA. Differential diagnosis usually consisted of the most common rheumatologic conditions but could be vast.

Objective. To review the diagnostic and prognostic value of history/physical examination among patients with undifferentiated peripheral inflammatory arthritis (UPIA). Methods. We conducted a systematic review evaluating the association between history/physical examination features and a diagnostic or prognostic outcome. Results. Nineteen publications were included. Advanced age, female sex, and morning stiffness were predictive of a diagnosis of rheumatoid arthritis (RA) from UPIA. A higher number of tender and swollen joints, small/large joint involvement in the upper/lower extremities, and symmetrical involvement were associated with progression to RA. Similar features were associated with persistent disease and erosions, while disability at baseline and extraarticular features were predictive of future disability. Conclusion. History/physical examination features are heterogeneously reported. Several features predict progression from UPIA to RA or a poor prognosis. Continued measurements in the UPIA population are needed to determine if these features are valid and reliable predictors of outcomes, especially as new definitions for RA and disease states emerge.

Objective:To validate a model which predicts progression from undifferentiated arthritis (UA) to RA, in a Canadian UA cohort.Methods:The prediction rule, comprising variables which are scored from 0 to 13, with higher scores reflecting an increased risk of RA, was applied to baseline characteristics of all patients with UA. Progression to RA was determined at 6 months.Results:105 patients were identified. By 6 months, 80 (76%) had developed RA while 25 (24%) had developed another diagnosis. Number of tender and swollen joints, rheumatoid factor positivity, anti-cyclic citrullinated peptide positivity, poor functional status and high disease activity were associated with development of RA (pConclusions:High scores in our cohort predicted those who progressed to RA by 6 months. Baseline scores ⩾8 corresponded with higher rates of progression.

Biologics have changed expectation and outcomes for rheumatoid arthritis (RA). However, the optimal duration and sequence of therapy for this disease has yet to be determined. Also, a significant number of patients do not satisfactorily respond to currently available therapies. The Janus kinase (JAK) inhibitors represent a new class of therapies for RA. These drugs work uniquely by inhibiting intracellular pathways thought to be important in the pathogenesis of RA. They are available as oral agents, which is also different from the currently available biologics. Baricitinib has now been evaluated in four phase III clinical trials, and although safety concerns cannot fully be answered until the drug is studied over longer periods of time, the data to date suggest that this drug with its once daily dosing, rapid onset of action and efficacy as monotherapy represents an important addition to the RA therapeutic armamentarium. Further study and experience will better define how baricitinib will be used and by which patients.

A 61-year-old woman of Italian descent with a history of hypertension and gastroesophageal reflux disease presented to the emergency department with a two-week history of pain, erythema, swelling and restricted range of motion of her left ankle. The patient was prescribed cephalexin for possible

This conference report describes six presentations that were given during a Canadian Institutes for Health Research-funded workshop. The goal of the workshop was to discuss key knowledge gaps in the study of outcomes in mothers with rheumatic diseases and their offspring. Presentations focused on epidemiological and methodological issues associated with the reproductive and perinatal health of women with rheumatic diseases. Discussions of relevant recent research allowed for discovery of potential data sources that could facilitate interdisciplinary research and created the opportunity for future collaborations.

Objective.To develop a list of 5 tests or treatments used in rheumatology that have evidence indicating that they may be unnecessary and thus should be reevaluated by rheumatology healthcare providers and patients.Methods.Using the Delphi method, a committee of 16 rheumatologists from across Canada and an allied health professional generated a list of tests, procedures, or treatments in rheumatology that may be unnecessary, nonspecific, or insensitive. Items with high content agreement and perceived relevance advanced to a survey of Canadian Rheumatology Association (CRA) members. CRA members ranked these top items based on content agreement, effect, and item ranking. A methodology subcommittee discussed the items in light of their relevance to rheumatology, potential effect on patients, and the member survey results. Five candidate items selected were then subjected to a literature review. A group of patient collaborators with rheumatic diseases also reviewed these items.Results.Sixty-four unique items were proposed and after 3 Delphi rounds, this list was narrowed down to 13 items. In the member-wide survey, 172 rheumatologists responded (36% of those contacted). The respondent characteristics were similar to the membership at large in terms of sex and geographical distribution. Five topics (antinuclear antibodies testing, HLA-B27 testing, bone density testing, bone scans, and bisphosphonate use) with high ratings on agreement and effect were chosen for literature review.Conclusion.The list of 5 items has identified starting points to promote discussion about practices that should be questioned to assist rheumatology healthcare providers in delivering high-quality care.

To evaluate excess mortality over time, comparing rheumatoid arthritis (RA) patients with the general population.We computed all-cause mortality rates among Ontario residents age ≥15 years with RA versus without RA from 1996 to 2009. Age- and sex-standardized mortality rates were expressed as the number of deaths per 1,000 population. Excess mortality rates were calculated as the difference between death rates among RA patients and those in the general population. We estimated standardized mortality ratios (SMRs) and mortality rate ratios (MRRs) to assess relative excess mortality over time.From 1996 to 2009, SMRs in RA ranged from 13.0 (95% confidence interval [95% CI] 12.2, 13.9) to 9.2 deaths per 1,000 RA patients (95% CI 8.4, 10.0); and for those without RA from 8.7 (95% CI 8.6, 8.7) to 6.0 deaths (95% CI 5.9, 6.0) per 1,000 general population. Over the study period, the excess mortality rate among RA patients was approximately 3 excess deaths per 1,000 population. Relative reductions in standardized mortality rates occurred over time for those with and without RA (-21.4% versus -13.4%). The SMRs for RA patients in 1996-1997, 2000-2001, 2004-2005, and 2008-2009 were 1.51 (95% CI 1.43, 1.59), 1.50 (95% CI 1.43, 1.57), 1.43 (95% CI 1.37, 1.50), and 1.41 (95% CI 1.35, 1.47), respectively. We did not find a significant change in the MRR by calendar time.Mortality for RA patients has decreased over time but remains elevated compared to the general population, with 40-50% more deaths among RA patients. The relative excess mortality over time (mortality gap) remains unchanged in our sample.

Epidemiologic assessments of sufficiently large populations are required in order to obtain robust estimates of disease prevalence and incidence, particularly when exploring the influence of various factors (age, sex, calendar time). We undertook this study to describe the epidemiology of rheumatoid arthritis (RA) over the past 15 years.We used the Ontario Rheumatoid Arthritis administrative Database (ORAD), a validated population-based research database of all Ontarians with RA. The ORAD records were linked with census data to calculate crude and age and sex-standardized prevalence and incidence rates from 1996 to 2010. Vital statistics were used to estimate annual all-cause mortality during the study period.As of 2010, there were 97,499 Ontarians with RA, corresponding to a cumulative prevalence of 0.9%. Age and sex-standardized RA prevalence increased steadily over time from 473 (95% confidence interval [95% CI] 469-478) per 100,000 population (0.49%) in 1996 to 784 (95% CI 779-789) per 100,000 population (0.9%) in 2010. Age and sex-standardized incidence per 100,000 population ranged from 62 (95% CI 60-63) in 1996 to 54 (95% CI 52-55) in 2010. All-cause mortality decreased by a relative 21.4% since 1996.Over a 15-year period, we observed an increase in RA prevalence over time. This rise may be attributed to the increasing time to ascertain cases (which may have been latent in the population during earlier years of the study), increasing survival, and/or an increase in the aging background population. Incidence appears to be stable.

Background The interchangeability of Disease Activity Score 28 joints (DAS28) calculated using the erythrocyte sedimentation rate (ESR) versus C-reactive protein (CRP) has been questioned (1). Objectives To compare the 28-Joint Disease Activity Score (DAS28) calculated using C-reactive protein (CRP) with that using erythrocyte sedimentation rate (DAS28-ESR) in a multi-centre, usual care, early rheumatoid arthritis (ERA) cohort. Methods The present study analyzed baseline and 12-month follow up data from the Canadian Early Arthritis Cohort. The study sample included patients with RA with symptom duration less than 12 months and complete data on DAS28-ESR and DAS28-CRP at both time points. The linear association between continuous DAS28-ESR and DAS28-CRP scores was estimated using Pearson9s correlation coefficient and differences across the range of DAS28 scores were examined with Bland-Altman Plots. Receiver operating characteristic (ROC) analysis was used to identify optimal thresholds for disease activity for DAS28-CRP scores that would best correspond with established DAS28-ESR thresholds in the total sample as well as in stratified samples by age and sex. Agreement between newly calculated DAS28-CRP and established DAS28-ESR thresholds was examined (kappa statistic). Results The study sample included 995 ERA patients. Sample baseline mean (SD) age was 53.7 (14.5) with 5.8 (2.9) months of symptom duration and 738 (74%) were female. Though continuous DAS28-CRP and DAS28-ESR scores were highly correlated (r=0.92, p Conclusions Results from this large observational study of “real-world” ERA patients showed that DAS28-CRP and DAS28-ESR scores were strongly correlated but that DAS28-CRP scores were consistently lower than DAS28-ESR scores. Differences between DAS28-CRP and DAS28-ESR were greater at lower ranges of the DAS28 and were most pronounced in women and older patients. This suggests that substituting one continuous score for the other is likely reasonable for research purposes in data analysis and that interpreting the DAS28-CRP using established DAS28-ESR thresholds may be acceptable for higher levels of disease activity, but not for lower levels, particularly not for remission. References Siemons L, Vonkeman HE, ten Klooster PM, van Riel PL, van de Laar MA. Interchangeability of 28-joint disease activity scores using the erythrocyte sedimentation rate or the C-reactive protein as inflammatory marker. Clin Rheumatol. 2014 Jun;33(6):783–9. Disclosure of Interest B. Kuriya: None declared, O. Schieir: None declared, D. Lin: None declared, J. Pope: None declared, G. Boire: None declared, B. Haraoui: None declared, C. Thorne: None declared, D. Tin: None declared, C. Hitchon: None declared, E. Keystone: None declared, V. Bykerk Grant/research support from: The CATCH study was designed and implemented by the investigators. The authors have received unrestricted grants from: Amgen Canada Inc and Pfizer Canada Inc - Founding sponsor since 2007, Hoffmann-La Roche Ltd, UCB Canada Inc, Bristol-Myers Squibb Canada, AbbVie Corporation and Janssen Inc since 2011, Medexus Inc since 2014 and Eli Lilly Canada Inc since 2015.

Preeclampsia is a serious complication of pregnancy that can compromise the health of pregnant women and neonates1. Studies have consistently shown that women with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) have an increased risk for preeclampsia; SLE is associated with a 2 to 6-fold increase in risk and RA is associated with a 1.4 to 2-fold increase in risk2–6. Limited data exist on the association of other autoimmune diseases, such as multiple sclerosis and inflammatory bowel disease, and preeclampsia7–8. Disease-Modifying Antirheumatic Drugs (DMARD) are a part of standard treatments for autoimmune disease, and their use during pregnancy may be necessary to avoid flares of disease that may compromise the health of the expectant mother and fetus9–10. It is possible that DMARDs may decrease the risk of preeclampsia by diminishing the maternal immune response to the placenta, which may play a role in the development of preeclampsia11. However, it is critical to account for underlying autoimmune disease when assessing the relation between DMARD use and preeclampsia given the well-reported association between various autoimmune diseases and preeclampsia2–6. Corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed for pregnant women with autoimmune disease9–10, 12. Corticosteroids may mitigate the systemic inflammatory response associated with preeclampsia13 and aspirin, a non-selective NSAID, modestly decreases the risk for preeclampsia14. In the study, we first described DMARD, oral corticosteroid, and NSAID use during pregnancy in a population-based cohort. We then assessed the impact of DMARDs, oral corticosteroids and NSAIDs on the risk for preeclampsia adjusting for autoimmune diseases and factors related to autoimmune disease severity.

This review examines the literature on the frequency of remission associated with different treatment approaches in early rheumatoid arthritis (ERA). Trials reporting remission outcomes were identified through searches of the CINAHL, EMBASE, and Medline (PubMed) databases from 2000 through August 2012. Additional literature was identified through hand searching. The proportion of patients achieving remission and/or radiographic non-progression was extracted from each study. Evidence was examined in the context of unified remission criteria and practical considerations for achieving and maintaining remission are discussed. The literature highlights the benefits of early treatment with disease-modifying anti-rheumatic drug (DMARD) combination therapy, combination therapy with a biologic, and tight control with a pre-specified treatment target in achieving remission in ERA. The added stringency of the 2011 remission criteria may increase the proportion of patients achieving true remission, while identifying predictors of sustained remission may also help patients achieve better radiographic and functional outcomes.

Although biologic treatments have excellent efficacy for many autoimmune diseases, safety concerns persist. Understanding the absolute and comparative risks of adverse events in patient and disease subpopulations is critical for optimal prescribing of biologics.The Safety Assessment of Biologic Therapy collaborative was federally funded to provide robust estimates of rates and relative risks of adverse events among biologics users using data from national Medicaid and Medicare plus Medicaid dual-eligible programs, Tennessee Medicaid, Kaiser Permanente, and state pharmaceutical assistance programs supplementing New Jersey and Pennsylvania Medicare programs. This report describes the organizational structure of the collaborative and the study population and methods.This retrospective cohort study (1998-2007) examined risks of seven classes of adverse events in relation to biologic treatments prescribed for seven autoimmune diseases. Propensity scores were used to control for confounding and enabled pooling of individual-level data across data systems while concealing personal health information. Cox proportional hazard modeling was used to analyze study hypotheses.The cohort was composed of 159,000 subjects with rheumatic diseases, 33,000 with psoriasis, and 46,000 with inflammatory bowel disease. This report summarizes demographic characteristics and drug exposures. Separate reports will provide outcome definitions and estimated hazard ratios for adverse events.This comprehensive research will improve understanding of the safety of these treatments. The methods described may be useful to others planning similar evaluations.

Objective The target outcome in early rheumatoid arthritis (ERA) is now remission. This meta-analysis compared the effi cacy of initial methotrexate monotherapy versus combination therapy (methotrexate plus biological agent) for clinical remission and radiographic non-progression among ERA patients with minimal or no previous methotrexate exposure. Methods A systematic search was performed for randomised controlled trials of ERA using predefi ned criteria. A random effects model was used to pool the risk ratio (RR) for clinical and radiographic remission at 52–56 weeks of follow-up. Results Seven trials of combination therapy with infl iximab, adalimumab, etanercept or abatacept were included. The majority of studies defi ned clinical remission as a 28-joint disease activity score (DAS28) of 2.6 or less. Radiographic non-progression was primarily defi ned as a modifi ed total Sharp score change of less than 0.5 units. All trials demonstrated risk estimates in favour of combination therapy: the pooled RR for achieving clinical remission was 1.74 (95% CI 1.54 to 1.98) and for radiographic non-progression was 1.30 (95% CI 1.01 to 1.68). Signifi cant heterogeneity among studies for the latter outcome was detected (p

Objective To determine whether quality of life in patients with systemic lupus erythematosus (SLE) measured by the Short Form 36 (SF-36) changes over time and which patient- and disease-related factors influence such change. Methods SLE patients who had ≥6 SF-36 evaluations during followup were identified from a database. Outcomes were slopes of scores of the 8 SF-36 domains as well as the physical and mental component scores. Based on the direction of the slope, patients were designated as unchanged, improved, or worsened. Linear regression models were used to test the contribution of risk factors to slopes. Nonparametric tests were used to evaluate risk factors between patterns of clinical change. Results A total of 146 patients had ≥6 SF-36 evaluations in 1,047 visits over a mean ± SD period of 8.2 ± 1.1 years. During the interval, the majority of patients showed no change in the SF-36 domains and only a small minority demonstrated improvement. Physical and mental component scores were unchanged in 84.3% and 87.7% of patients whereas 4.1% and 7.5% improved, respectively. According to slopes of the domains and summary scores, only physical functioning demonstrated a significant decrease over time. There were no lupus disease features associated with decline in physical functioning except for the presence of fibromyalgia. Conclusion The SF-36 in SLE patients with established disease changed little over an 8-year period. Changes in the SF-36 were not affected by disease activity, steroids, or damage accumulation during the interval, but were affected by the presence of fibromyalgia.

Background Disease progression in longitudinal studies of rheumatoid arthritis (RA) is usually assessed by examining a measure of disease over fixed time intervals; results can be presented as the mean of the whole group or, for subgroups sharing common underlying characteristics. These approaches do not addresses individual within-patient changes over time. In contrast, a multi-state model classifies each patient into one of several pre-defined disease states at patient visit and examines moves between disease states over time. Objectives The objectives were: (1) to provide a descriptive analysis of patients9 disease states defined by the DAS-28 throughout the first three years of treatment; (2) to determine the time spent in each disease state; and (3) to estimate the probabilities of changing between disease states. Methods From a large ongoing prospective study of RA in Ontario, Canada (OBRI), patients who met the following inclusion criteria were selected: 1) incident RA, 2) active disease (≥1 swollen or tender joint) and 3) at least 2 follow-up visits to their rheumatologist. The DAS-28 disease score was collected at each visit and patients were classified in one of four DAS-28 categories, from remission to high disease activity. A multi-state (in this case 4-state) Markov model was fitted to describe patient progression through disease states over time. Traditional assumptions of Markov models are equal intervals between visits, which do not reflect the clinical reality of irregular visits. We fitted a novel Markov model to account for the irregular time intervals considering time as a continuous variable allowing us to examine real-world disease course over time. Results There were 3014 visits in 586 patients over the 3-year follow-up window (see figure). At baseline, 43% of patients were in DAS-28 high disease activity, but patients, moved out of this health state rapidly on average 0.17 years, 95% CI (0.19, 0.23). At baseline 9% of patients were in DAS-28 remission, increasing to 30% at 6 months and 45% at 1 year. Once a patient achieved remission, the mean duration before moving to another disease state was 0.81 years, 95% CI (0.67, 0.97). By 1.5 years after initiation of treatment, patients in each disease state remained relatively constant indicating no net movement between health states. Conclusions We identified that individual patients transition between disease states rapidly in the first 3 years of treatment when observed in usual care. Our analysis indicates the critical first year of treatment before a steady disease state with no net movement will be reached. Major changes in the first year of treatment especially in the first 6 months could be a result of treat-to target strategy but do not occur as quickly as specified by treat-to-target guidelines indicating possible gaps in care. Future research will adjust for covariates including drug history and demographic factors while also examining between physician differences. Disclosure of Interest None declared

Background Patients with rheumatoid arthritis (RA) have an increased mortality compared with the general population. 1 Established risk factors for premature mortality include active inflammation/disease activity, comorbidity and extra-articular disease manifestations. Thus, early and greater exposure to disease-modifying anti-rheumatic drugs (DMARDs) may mitigate these risk factors and improve survival in RA. Objectives Our aim was to evaluate the associations between RA drug exposures and survival in seniors with incident RA. Methods This retrospective cohort study investigated all incident cases of RA diagnosed from 2000 to 2013. We studied a subset of patients within the Ontario RA Database (ORAD) - a validated population-based cohort of all Ontarians with RA - who were aged 66 years and older who have comprehensive public drug insurance. We used Cox proportional hazards regression to investigate mortality, defined as death from any cause, exploring time-dependent cumulative drug exposures during the entire duration of follow-up, while adjusting for baseline age, sex, urban vs. rural residence, socioeconomic status, pre-existing comorbidities (e.g. hypertension, COPD, diabetes, coronary artery disease, cancer), past drug exposures, time-dependent number of physician visits, and extra-articular manifestations of RA (as proxies for RA severity). Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated. Results Among 25,416 senior RA patients, 67.8% were female, the mean (SD) age was 75.2 (6.5) years, and 85.4% lived in urban areas. During median and maximum follow-up times of 4.4 and 13.2 years, respectively, 7,956 patients died (31.3%) for a mortality rate of 6.2 per 100 person-years. In multivariable analyses, we observed no association between greater cumulative exposure to methotrexate, other DMARDs, or anti-TNF agents and survival. Greater exposure to corticosteroids was associated with greater risk of mortality [HR 1.15 (95% CI 1.14-1.17)], as were greater baseline comorbidity [Charlson HR 1.36 (95% CI 1.34-1.38)] and extra articular disease [HR 1.53 (95% CI 1.47, 1.61)]. Females and residents living in urban areas had lower mortality risk [HR 0.78 (95% CI 0.75-0.82) and HR 0.92 (95% CI 0.86-0.98), respectively]. Conclusions Though we could not demonstrate an association between exposure to DMARDs and over-all survival in seniors with RA, cause-specific mortality warrants further investigation. Greater exposure to corticosteroids, comorbidity and extra articular RA was associated with pre-mature mortality in our sample. References Widdifield et al, Trends in Excess Mortality among Patients with Rheumatoid Arthritis in Ontario, Canada. Arthritis Care & Research 2015 [in press]. Disclosure of Interest None declared