Bridging the rural-urban divide for patients with rheumatoid arthritis

1. Bridging the rural-urban divide for patients with rheumatoid arthritis Brenna Bath School of Physical Therapy University of Saskatchewan

2. Research Team/ Co-authors • Dr. Regina Taylor-Gjevre, Professor, Rheumatologist (PI); • Dr. Bindu Nair, Associate Professor, Rheumatologist; • Dr. Samuel Stewart, Research Associate, Biostatistician; • Dr. Regan Arendse, Clinical Assistant Professor, Rheumatologist; • Dr. LathaNaik, Clinical Assistant Professor, Rheumatologist; • Dr. Catherine Trask, Assistant Professor; • Dr. Erika Penz, Assistant Professor; • MeenuSharma, Research Assistant; • Katie Crockett, Clinical Research Associate

3. Outline • Background • Research objectives • Design and measures • Significance/ relevance • What have we learned so far? • Questions/ Discussion

4. Background • Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting approximately 1% of the Canadian population. • Current standard of care includes use of disease modifying anti-rheumatic drugs and often biological agents, which require ongoing monitoring for toxicity and efficacy.

5. Background • People with RA often require regular rheumatology follow-up to ensure their disease is well-controlled and optimally treated. • Up to a frequency of every 3 months • Includes history and physical examination. • This may lead to substantial travelling for RA patients who live in rural/remote regions.

6. Background • 30% of Saskatchewan’s (SK) population lives in rural and remote regions • over 50% of RA patients attending a Saskatoon rheumatology clinic reside in health regions other than Saskatoon Health Region • 36% of rheumatoid arthritis (RA) patients in SK consider location of their place of residence negatively impact ability to access health care

7. *ALL SK Rheumatologists and 90% of PTs practice in urban centres

8. Our Challenge:How can we improve access to follow-up rheumatology care in rural SK communities? • Teams PTs travelling to rural communities to complete history/ “hands on” physical examination with rural RA patients • Technology Telehealth/ Videoconferencing to link to urban-based rheumatologist

9. Health Care Team • 3 Rheumatologists • 1 Nurse Educator • 3 PTs travelling to clinics in 5 rural SK communities

10. Rural Communities: Prince Albert North Battleford Rosetown Wynyard Arborfield

11. Technology: VIDYO (Secure VC)

12. Research Objectives • To determine whether disease-specific activity measures are equivalent for patients evaluated longitudinally by telehealth/VC compared to those seen in traditional rheumatology clinics over a nine-month period. • To evaluate quality-of-life and health-status measures as well as patient/healthcare provider levels of satisfaction for each care model.

13. Research Objectives • To determine incremental costs (direct and indirect) associated with distance telehealth/VC compared with traditional in-person rheumatology clinics. • To determine the validity/ accuracy of Rheumatologist/ PT team RA assessment through VC versus Rheumatologist in person.

14. Participants: RCT • 160 patients living outside 100 km or more outside of Saskatoon, age over 18 years, and rheumatologist established diagnosis of RA will be recruited • Participants will be randomly assigned to one of two arms: 1) followed by telehealth/VC in or near their home community 2) continue travelling to Saskatoon rheumatology clinic.

15. RCT Design

16. RCT measures: Primary • DAS-28 CRP (at 9 months) • Physical examination (swollen and tender joint count) • Examiner global score (100mm VAS) • C-reactive Protein (CRP)

17. RCT measures: Secondary • Provider categorical assessment related to disease activity (inactive/stable;mildly active; very active) • Modified health assessment questionnaire (mHAQ) • RA disease activity index (RADAI) • Quality of life (EQ5D) • Cost diaries • Patient satisfaction (VSQ-9) • Patient and provider experience with VC/ telehealth (survey and interviews)

18. Validation study • Purpose to demonstrate that there is not a greater difference between disciplines than there is within disciplines for appendicular joint examination accuracy or for assessment of disease activity status. • 50 participants with RA from Saskatoon region

19. Validation study • Each will be undergo physical examination (joint count) by 3 Rheumatologists and 3 PTs • The comparison groups will be:1. Rheumatologist A. to Rheumatologist B.2. Physiotherapist A. to Physiotherapist B.3. Rheumatologist A/B to Physiotherapist C/teleconferenced Rheumatologist C.

20. Significance/ Relevance • No previous reported studies of telehealth/VC based care for longitudinal rheumatologic follow up in RA patients • No reported studies utilizing interdisciplinary care teams in the telehealth/VC assessment process for this population.

21. Where is the project at? • Recruited approximately 50 patients for RCT • First VC team visits started in March 2015 • Anticipate recruiting until September, 2015, with 9 month completion by June 2016 • Validation study (Fall 2015)

22. What have we learned so far? • Technology: hardware, software, connectivity, support • Team: • scope and collaborative practice • scheduling • Recruitment: • “near” home community • “Costco” effect

23. Where to from here? • Combined experience and learning from this project and PT/ NP models for chronic low back pain • Mapping of primary care service (PT/ GP/ NP) to identify geographical care gaps • Rural and Remote musculoskeletal clinic • Primary/ secondary interface care • Multidisciplinary & Interprofessional • Combination of in-person and VC triage or follow-up care

24. Acknowledgements

25. Questions/ Discussion