NP/FP Rheumatology Outreach Program

1. NP/FP Rheumatology Outreach Program Improving Quality of Care in Chronic Disease Dr. Sherry Rohekar September 10, 2009

2. Overview • What is the program? • Your goals • Results of needs assessment • Burden of arthritis • Approach to arthritis • Polyarthritis • Acute vs. chronic • Monoarthritis • Septic vs. crystal

3. The Arthritis Expert Program: Why? • Many communities in SW Ontario are underserviced in terms of arthritis care • Arthritis Experts (AEs) will better support local health teams in their delivery of complex medical care • Comprised of nurses, nurse practitioners and family physicians who frequently refer patients to rheumatologists at St. Joseph’s Health Care (SJHC) in London

4. The Arthritis Expert Program: What? • Will occur over 18 months, with monthly sessions • Participants may attend sessions at SJHC or attend monthly telemedicine conferences via computer • At the end of the program, we expect that participants will able to: • Identify and triage rheumatologic complaints • Confidently treat some complaints • Co-manage chronic arthritic complaints in conjunction with rheumatologists at SJHC

5. Course Curriculum • Teleconferences / Broadcasting from Telehealth, to be archived for use for those who can’t attend live • Knowledge assessments – at the beginning and throughout the program • Preceptorships and rounds in some regions – also telecast • Case of the month – each month a case related to the learning will be posted with each candidate giving the answers, and then answers are posted and discussion can occur

6. Course Curriculum • Internet discussion board • Chart audit –10 MSK patients sometime in first 6 months, with data extraction tool, to be done 3 times over the course • Attendance at the Education Day (live or via broadcast / DVD) once over the course – offered at various times, usually on a Thursday, scheduled well in advance • Opportunity to do advanced training preceptorship in London (not mandatory)

7. Needs Assessment • 30 participants; all were NPs • Top 3 Areas: Diagnosis • RA, SLE/CTD, PMR/TA: 86.7% • Fibromyalgia: 83.3% • Back pain: 70% • Top 3 Areas: Treatment • RA: 86.7% • SLE: 83.3% • PMR/TA: 80%

8. Needs Assessment • Other areas of interest: • Comprehensive approach to MSK exam: 93.3% • Medications and monitoring of RA: 90% • MSK imaging: 90% • Approach to lab tests (i.e. RF, ANA): 76.7%

10. General Arthritis Statistics in Canada • 4 million Canadians have some form of arthritis (1 in 6 people). • 2/3 are women • 3 in 5 are <65 years old • By 2026, 6 million Canadians will have arthritis. • One of the top 3 most common chronic conditions (with non-food allergies and back problems). Health Canada. Arthritis in Canada. An Ongoing Challenge. Ottawa: Health Canada, 2003. Perruccio et al. J Epidemiol Community Health 2007;61:1056-61.

11. The Burden of Arthritis • Major outcome of arthritis: • chronic pain • reduced mobility • decreased level of function • Impact on quality of life: mobility, communication, schooling & employment. • Cost of arthritis was over $4 billion (1998) in health care expenses and loss of productivity. • In 1998, medication accounted for $270 million, or 6% of total arthritis cost. This will increase with the use of biologics. The Arthritis Society of Canada. Arthroscope. An Ongoing Challenge, 2004.

12. A Chronic and Disabling Disease • Compared to patients with other chronic conditions, those with arthritis: • Experienced more pain, activity restrictions & long-term disability • Were more likely to need help with daily activities • Reported worse self-rated health, more disrupted sleep and depression • Have more contacts with healthcare professionals Health Canada. Arthritis in Canada. An Ongoing Challenge. Ottawa: Health Canada, 2003.

13. Common Comorbidities in Rheumatic Disease • CVD & Atherosclerosis • Metabolic Syndrome • Fibromyalgia • Peridontal Disease • Effects of Smoking

14. Impact of Comorbidities • Poorer outcomes (response, remission) • Higher morbidity • Increased mortality (e.g., CVD) • Potential for drug interactions Krishnan E, et al. Ann Rheum2005;64:1350-2. Wasko MC. Curr Opin Rheumatol 2004;16:109-13. Boers M, et al. Arthritis Rheum 2004;50:1734-9.

15. Patient Outcomes

16. Arthritis and Disability

17. Arthritis And Work Disability

18. In the 1986 Canadian population.

19. % prevalence in the Ontario population.

23. Approach To Arthritis

24. Degenerative vs. Inflammatory • The problem with inflammatory arthritis is in the lining (synovium) of the joint • The problem with degenerative arthritis is in the cartilage

26. Approach To Polyarthritis • What is polyarthritis? How is it different from polyarthralgia? • Polyarthritis: swelling, tenderness and warmth of >4 joints, demonstrated by physical examination • Polyarthralgia: pain in >4 joints without demonstrable inflammation on physical examination

27. Polyarticular Symptoms Acute (<6 wks) Chronic (>6 wks) Infection Not Infection Not Inflammatory Inflammatory

28. Polyarticular Symptoms Acute (<6 wks) Infection Not Infection • Gonoccocal • Meningococcal • Lyme disease • Acute rheumatic fever • Bacterial endocarditis • Viral • Rubella • Hepatitis B or C • Parvovirus B19 • EBV • HIV RA SLE Reactive arthritis Psoriatic arthritis Polyarticular gout Sarcoidosis Serum sickness

29. Polyarticular Symptoms Chronic (>6 wks) Inflammatory Not Inflammatory RA SLE SSc PM ReA PsA Polyarticular crystal Enteropathic arthritis Sarcoid Vasculitis PMR OA CPPD Paget’s disease FM Benign hypermobility syndrome Hemochromatosis

30. Timing Migratory Additive Intermittant Present for few days, remits, then recurs in other joints Begins in some joints and persists, then goes on to involve others Repeated attacks of polyarthritis with complete remission between attacks RA PsA ReA Sarcoid Polyarthricular gout Rheumatic fever Gonococcal Lyme disease RA PsA Enteropathic arthritis SLE

31. Approach To Monoarthritis:Acute Hot, Red Monoarthritis • Infection • Infection • Infection • Gout • Pseudogout • Oh, did I mention …. Infection?

32. What do you want to do? • Aspirate the joint (i.e. take a sample of fluid from the joint) • IF THE JOINT IS RED, THE TUBES GET FED!

33. What do you send the fluid for? • The 3 C’s • Cell Count: A couple of hours • Culture & Sensitivity: 24-48 hours • Crystals: A couple of hours • Gram Stain

34. Septic Arthritis Acute Bacterial Arthritis Medical emergency!!

35. Importance Of Diagnosis • Failure to recognize and appropriately treat bacterial septic arthritides may lead to significant rates of morbidity and even mortality • Specifically, debilitating destruction of the joint

36. Importance Of Diagnosis • Failure to recognize and appropriately treat bacterial septic arthritides may lead to significant rates of morbidity and even mortality • Specifically, debilitating destruction of the joint

37. Historical Features • Acute onset of joint pain (may be superimposed on chronic pain) • History of trauma • Remember iatrogenic  joint aspiration • Monoarticular vs. polyarticular • Extra-articular symptoms • IV drug use/presence of intravenous catheters

38. Historical Features • Exposure to STDs • Conditions that may decrease patient’s immunity • Liver disease, DM, cancer, complement deficiencies, hypogammaglobulinemia, immunosuppressive medication

39. Historical Features • Classically, present with complaints of low grade fever (40-60%), pain (75%) and decreased ROM, evolving over days or weeks • Sometimes difficult to distinguish from the presentation of crystal arthropathies • Tend to have spiking fevers and chills, rigors

40. Historical Features • If prosthetic joint infection, course usually low-grade with gradually increasing pain • Usually no significant swelling or fever • S. aureusassociated with a fulminant course • Devitalized tissues (i.e. hematomas) more susceptible to bacterial multiplication • Course usually more muted in case of bacteremic spread

41. Historical Features • Tuberculous arthritis has indolent features • Usually negative PPD, no signs of past or present pulmonary TB

42. Physical Findings • Most commonly involved joints: knee (50%), hip (20%), shoulder (8%), ankle (7%), wrists (7%) • Elbow, interphalangeal, sternoclavicular, SI joints 1-4% cases

43. Physical Findings • Erythema and swelling in 90% of cases • Warmth and tenderness also essential for diagnosis • Usually an obvious effusion • Marked limitation of PROM and AROM • Beware of locations where difficult to find: spine, hip, shoulders • Physical findings muted in elderly, immunocompromised, IVDU and especially those with RA

44. Differential Diagnosis • Crystals (gout, pseudogout) • RA • Seronegative disease (PsA, enteropathic arthritis) • Reactive arthritis • Rheumatic fever • Drug-induced arthritis

45. Diagnosis: Acute Gout • The Disease of Kings • Acute inflammatory arthritis caused uric acid crystal deposition in the joint

46. Who gets Gout? • First attack in men between the ages of 35 and 50. • In women it starts after menopause as estrogen has a protective effect on the excretion of uric acid.

47. Clinical Features of the Attack • Starts quickly and very intensely – over a few hours • Very painful (Can’t stand the bed sheets touching it) • Swollen, warm, and red • May feel unwell and have an associated fever • i.e. it can look just like an infected joint!

48. What Joints does it affect? • Usually a single joint in the lower extremity • First metatarsophalangeal (MTP) joint (i.e. the big toe) is affected in 50% of cases

49. Common Risk Factors for Gout • Impaired renal function • Diuretics: Lasix & hydrochlorothiazide • Excessive Alcohol Intake • Family history • Male Sex

50. Other Disease Associations “A Disease of Plenty” • Obesity • Hypertension (high blood pressure) • Diabetes • Hyperlipidemia (high lipids)