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Objectives: To assess physicians' preferences on diagnostic pathways and treatment priorities for systemic lupus erythematosus (SLE) using a discrete choice experiment (DCE)., Methods: A board of 11 SLE experts and a DCE expert statistician defined informative profiles of diagnostic pathways, pharmacological therapies, and two distinct profiles of mild-moderate and severe SLE. An independent panel of 115 clinicians involved in SLE management was invited to participate. Parameter estimates from the model were interpreted as relative preference weights (PWs). The mean PWs were used to calculate each attribute's relative importance (RI)., Results: 95 clinicians (57% females, 71% rheumatologists) completed the DCEs. The DCEs could not identify a hierarchy of importance among diagnostic pathway attributes. Nevertheless, "referral time to a rheumatologist" was considered more important for mild-moderate (RI=25%) and severe (RI=20%) SLE. Among the therapeutic attributes, the effect on organ damage progression after 12 months showed the highest preference for mild-moderate (RI=35%) and severe (RI=41%) SLE patients, followed by reduction in disease activity levels (max RI=19%) and glucocorticoid dose (max RI=13%) after six months. Reducing prednisone dose below 5 mg/day scored higher utility levels for mild-moderate (PW=66.1) than severe (PW=14.2) SLE. Administration route, action rapidity, patient-global assessment, and serious infection risk showed lesser relevance (RI 7-8%). No distinctions were found among subgroups categorised by the clinicians' areas of expertise., Conclusions: These DCEs highlight a high degree of awareness among lupus-treating physicians, with no differences across medical specialties, of the unmet need for early diagnosis and prevention of damage accrual in SLE management.

Introduction: To investigate current practices, changes, and perceptions of rheumatologists regarding GC use in RA patients., Methods: A cross-sectional survey was conducted using a structured questionnaire between April and August 2023. Rheumatologists from 31 province-level regions of Mainland China were invited to participate. Chi-squared tests were adopted to investigate the differences by sociodemographic characteristics., Results: 1,717 rheumatologists from 598 hospitals completed the survey with a response rate of 92%. Up to 60% of participants expressed currently infrequent initiation of GC co-therapy with csDMARDs (hardly ever 7.0%; occasionally 24.6%; sometimes 29.1%), accompanied by a decline of frequency over time reported in 64.2%. Regarding attitudes towards bridging therapy with GC, 604 (35.2%) participants supported this approach, 468 (27.3%) opposed it, and 645 (37.6%) remained inconclusive. Time to GC discontinuation in context of csDMARDs was commonly reported within 6 months in current practice which has been narrowed over time. Reasons for chronic GC use were mostly reported due to suboptimal disease control, followed by the need of RA complications, and pre-existing comorbidities. After failure of GC cessation, majority of respondents (84.4%) would escalate RA therapy (commonly by addition of JAK inhibitors, TNF inhibitors), which usually or often facilitated the GC cessation. The most frequently reported advantages and weaknesses of GC were rapid and strong efficacy, adverse events, respectively. Regarding long-term low-dose GC use for RA, the percentage of respondents who supported, opposed, or depended on the situation were 15.9%, 17.2%, and 66.9%, respectively., Conclusions: The current data demonstrate that GC initiation for RA treatment is not as frequent as before and the awareness of GC discontinuation is growing in current practice. Attitudes towards GC co-therapy with csDMARDs vary considerably and long-term low-dose GC use remain situation dependent., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: Vigorous cardiorespiratory training (CRT) in patients with axial spondyloarthritis (SpA) is effective, safe. and feasible; however, it has not yet been adopted in axial SpA exercise programs. Therefore, the aim of this study was to explore the barriers and facilitators for vigorous CRT among patients, physiotherapists, and rheumatologists., Methods: Stakeholder-specific surveys were used to examine perceptions of barriers and facilitators to vigorous CRT, with categories organized according to the recommendations proposed by Grol and Wensing. Respondents chose the 3 most important barrier and facilitator categories and rated individual items on a 4-point scale. Frequencies and proportions were calculated, and ratings between active and inactive patients were compared., Results: Among all patients (n = 575 [response rate 34%]), the top 3 barrier categories were "low motivation" (n = 317 [59%]), "unsuccessful timing in daily routine" (n = 292 [55%]), and "hindering disease symptoms" (n = 272 [51%]). The top 3 facilitator categories were "high motivation" (n = 248 [47%]), "good organizational conditions" (n = 217 [41%]), and "facilitating disease symptoms" (n = 209 [40%]). More inactive patients than active patients chose "low motivation" as a barrier (P = 0.01). Among physiotherapists (n = 40 [response rate 48%]), the top 3 barrier categories were "heterogeneous groups" (n = 26 [70%]), "difficult organizational conditions" (n = 19 [51%]), and "low perceived motivation" (n = 19 [51%]). Among physiotherapists, the top 3 facilitator categories were "knowledge" (n = 20 [54%]), "homogeneous group composition," and "high perceived motivation" (both n = 17 [46%]). For rheumatologists (n = 73 [response rate 17%], with 54 [74%] answering barrier items and 68 [93%] answering facilitator items), the strongest barriers included "not enough information" (n = 25 [47%]) and "anticipated or perceived disinterest of patient" (n = 27 [50%]). The strongest facilitators reported by rheumatologists included "exercise important topic even in limited consultation time" (n = 65 [96%]) and "clear evidence for effectiveness of flexibility exercises" (n = 62 [91%])., Conclusion: The identified facilitators and barriers will guide the development of stakeholder-specific implementation strategies., (© 2018, American College of Rheumatology.)

Objective: To evaluate the diagnosis, monitoring, and treatment of systemic lupus erythematosus (SLE) in Canada., Methods: A 63-question electronic survey was developed with the Canadian Rheumatology Association and others. Descriptive analyses of responses were performed., Results: Survey respondents (n = 175) reported varying practices in the diagnosis, monitoring, and treatment of SLE. Performance of laboratory investigations for diagnosis and monitoring varied, with 78% of responders performing them at least every 6 months. Validated measures of SLE disease activity and damage were not commonly used. Most common first-line agents besides steroids for induction therapy for class III or IV lupus nephritis included intravenous cyclophosphamide and mycophenolate mofetil. Antimalarial use was common, with 96% of respondents using these in active skin disease. Over 60% of respondents indicated that 80-100% of their patients were taking antimalarials, while another 25% indicated they used these drugs in up to 80% of their patients. There were 71% of responders who reported completing frequent (6-12 mos) ophthalmology screening in patients taking antimalarials. Biologics were infrequently used. Responders were more likely to stop azathioprine and chloroquine than hydroxychloroquine in pregnant patients with SLE. Other aspects of routine care including vaccination and cardiovascular risk management varied considerably. The majority (80%) agreed that a dedicated multidisciplinary care team would improve SLE care., Conclusion: Considerable practice variation in SLE management was noted. This may help inform future recommendations for the diagnosis, monitoring, and treatment of SLE in Canada.

Objective: To compare practice patterns and prescribing differences for juvenile idiopathic arthritis (JIA) between adult rheumatologists (ARs) and pediatric rheumatologists (PRs), the perceived educational needs, and factors that enhance or impede co-management., Methods: Two parallel, cross-sectional surveys focusing on JIA were administered in 2009 to a random sample of 193 PRs and 500 ARs using the American College of Rheumatology membership file. Bivariate analysis was conducted for common items., Results: The response rate was 62.1% for ARs (n = 306) and 72.3% for PRs (n = 138). Only 23% of responding ARs (n = 69) reported caring for children with JIA. Of these, 94% strongly agreed/agreed feeling comfortable diagnosing JIA; however, only 76% felt comfortable treating JIA. Clinical vignettes highlighted several prescribing differences. Forty-eight percent of ARs and 31% of PRs felt medications to treat JIA did not have clear dosing guidelines. Though PRs initiated disease-modifying antirheumatic drugs and biologic agents earlier, treatments were similar after 3 months. To enhance co-management, 74% of pediatric respondents endorsed shared medical records., Conclusion: Nearly one-quarter of surveyed ARs care for children with JIA, with most limiting their practice to older children. There was more discomfort in treating JIA than diagnosing it, and there were significant prescribing differences. Both provider types identified the need for better dosing and treatment resources. Updated management guidelines along with exposure to pediatric rheumatology in fellowship could reduce treatment differences and enhance the care of children with JIA. Shared medical records and improvement in reimbursement may optimize co-management., (© 2017, American College of Rheumatology.)

Objectives: To explore the relationship between antinuclear antibody (ANA) overuse and rheumatologist-related factors before and after an intervention aimed at reducing ANA overuse., Method: In this mixed methods study we performed surveys among rheumatologists (n = 20) before and after the ANA intervention (education and feedback). We identified clinician-related determinants of ANA overuse (demographic characteristics, cognitive bias, numeracy, personality, thinking styles, and knowledge) by multivariate analysis. Two focus group meetings with rheumatologists were held 6 months after the intervention to explore self-reported determinants., Results: Questionnaires were completed by all rheumatologists and eight participated in the focus groups. Rheumatologists with more work experience and a less extravert personality ordered more ANA tests before the intervention [β = 0.01, 95% confidence interval (CI) 0.003 to 0.02, p = 0.01 and β = -0.11, 95% CI -0.21 to -0.01, p = 0.04, respectively; R 2 = 47%]. After the intervention, female rheumatologists changed less than their male colleagues with regard to the number of ANA tests ordered (β = 0.15, 95% CI 0.03-0.26, p = 0.02; R 2 = 25%). During the focus groups, seven themes were identified that influenced improvement in ANA overuse: determinants related to the intervention and the study, individual health professionals, patients, professional interactions, incentives and resources, capacity for organizational change, and social, political, and legal factors., Conclusions: We identified several determinants that together explained a sizable part of the variance observed in the ANA outcomes at baseline and in the change in ANA outcomes afterwards. Furthermore, the focus groups yielded additional factors suggesting a complex interplay of determinants influencing rheumatologists' ANA ordering behaviour.

Objectives: Accurate diagnosis and appropriate management of psoriatic arthritis (PsA) is essential to avoid unnecessary morbidity. Our aim in this study was to evaluate the current approach to the management of PsA among rheumatologists., Methods: A 16-item online questionnaire, produced using the Delphi method, was submitted to a panel of rheumatologists who anonymously expressed their opinions on a scale from 1 (maximum disagreement) to 5 (maximum agreement). Positive consensus was defined by ≥66% of the respondents scoring an item 3, 4 or 5. Negative consensus was defined by ≥66% of the respondents scoring an item 1 or 2., Results: The surveyed rheumatologists agreed that in its early stage, PsA is characterised by the involvement of few joints and/or entheses and that psoriasis, although possibly absent, will be present in a patient's past personal or family history. There was no consensus among the rheumatologists regarding normalisation of C-reactive protein levels and erythrocyte sedimentation rates defining remission. The specialists believed that clinical remission was achieved more frequently and for longer among patients with PsA than rheumatoid arthritis. The participants believed that neutralising antibodies altered the efficacy of anti-tumour necrosis factor agents and that monoclonal antibodies induced greater production of neutralising antibodies than receptor proteins. However, knowledge was somewhat lacking in relation to the prophylaxis of latent tuberculosis., Conclusions: The data collected showed that the surveyed rheumatologists had a good knowledge of the diagnosis of early-stage PsA and a good understanding of its management in relation to its clinical phenotype, with the exception of the form having predominantly axial involvement.

Background: The use of biologic agents has become an important option in treating patients with rheumatoid arthritis. However, these drugs have been associated with an increased risk of tuberculosis (TB) reactivation. Local guidelines for TB screening prior to the use of biologic agents were developed to address this issue., Aim: This study is a survey describing the compliance of Filipino rheumatologists to these guidelines., Method: Eighty-seven rheumatologists in the Philippines were given the questionnaire and responses from 61 rheumatologists were included in the analysis., Results: All respondents agree that patients should be screened prior to giving the biologic agents. Local guidelines recommend screening with tuberculin skin test (TST) and chest radiograph. However, cut-off values considered for a positive TST and timing of initiation of biologic agents after starting TB prophylaxis and treatment varied among respondents. In addition, screening of close household contacts were only performed by 41 (69.5%) respondents. There were 11 respondents who reported 16 patients developing TB during or after receiving biologic agents, despite adherence to the guidelines., Conclusion: This survey describes the compliance rate of Filipino rheumatologists in applying current local recommendations for TB screening prior to initiating biologic agents. The incidence of new TB cases despite the current guidelines emphasizes the importance of compliance and the need to revise the guidelines based on updated existing literature., (© 2015 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd.)

Objectives: The evidence base for treatment of the idiopathic inflammatory myopathies is extremely limited. The rarity and heterogeneity of these diseases has hampered the development of good quality clinical trials and while a range of immunomodulatory treatments are commonly used in clinical practice, as yet there are no clear guidelines directing their use. We aimed to establish current prescribing regimens used to treat adults with myositis internationally., Methods: An electronic survey based on different clinical scenarios was distributed internationally to clinicians involved in the treatment of patients with myositis. Participants were asked to select their first-line treatment preferences in each situation. A multinomial regression analysis was used to assess the influence of clinical scenario, respondent expertise and country of origin on first-line treatment choice., Results: 107 survey responses were received. 57% of respondents considered themselves an expert in myositis and the majority of respondents were rheumatologists although responses from other specialities were also received. Pharmacological treatment with steroids and additional immunotherapy was the preference in most scenarios. First-line immunosuppressant choice was significantly influenced by the clinical scenario, the expertise of the treating physician and country of practice. Azathioprine, methotrexate and mycophenolate mofetil were the most commonly chosen agents., Conclusions: In the absence of available evidence, clinical experience and expert consensus often forms the basis of treatment guidelines. These results suggest that an international consensus approach would be possible in myositis and would overcome an urgent, yet unmet need for patients suffering with this difficult disease.