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Improving Quality of Care in Chronic Disease Dr. Sherry Rohekar September 10, 2009.

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Presentation on theme: "Improving Quality of Care in Chronic Disease Dr. Sherry Rohekar September 10, 2009."— Presentation transcript:

1 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%

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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, Perruccio et al. J Epidemiol Community Health 2007;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: Wasko MC. Curr Opin Rheumatol 2004;16: Boers M, et al. Arthritis Rheum 2004;50:

15 Patient Outcomes

16 Arthritis and Disability

17 Arthritis And Work Disability

18 In the 1986 Canadian population.

19 % prevalence in the Ontario population.

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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

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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 Inflammatory Not 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 MigratoryAdditiveIntermittant Present for few days, remits, then recurs in other joints Rheumatic fever Gonococcal Lyme disease Begins in some joints and persists, then goes on to involve others RA PsA Enteropathic arthritis SLE Repeated attacks of polyarthritis with complete remission between attacks RA PsA ReA Sarcoid Polyarthricular gout

31 Approach To Monoarthritis: Acute Hot, Red Monoarthritis 1. Infection 2. Infection 3. Infection 4. Gout 5. Pseudogout 6. 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: 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. aureus associated 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)

51 What “triggers” the Attack? SMARTS Surgery Mechanical Injury Alcohol Recent Illness Travel / dehydration Start/Stop Allopurinol

52 How to Confirm the Diagnosis Must aspirate the joint and find urate crystals to prove diagnosis (needle shaped) Urate crystals negatively birefringent in polarized light

53 What Blood Tests Should I Order? Complete Blood Count (CBC) May see elevated WBC May see reactive thrombocytosis (increased platelets) Creatinine (measure renal function) Uric Acid Levels may be normal during an acute attack Fasting Glucose Fasting Lipid Levels Tryglycerides & cholesterol

54 A Word About Uric Acid There are lots of people walking around with elevated uric acid levels (hyperuricemia) Many of these people will not get gout Hyperuricemia CANNOT be used to make a diagnosis of gout! Do not treat isolated hyperuricemia

55 Treatment: Non-Pharmacologic Rest, ice, and elevate the Joint Dietary modification Meat & seafood are Bad Vegetables & low-fat dairy are good Reduce alcohol intake Good hydration

56 Pharmacologic Intra-articular corticosteroids Inject the affected joint Oral NSAIDs or COXIBs Indomethacin 50 mg PO TID Oral colchicine 0.6 mg PO q8h Oral prednisone 50 mg po x 7 days

57 When To Consider Allopurinol 1. Recurrent acute episodes of gout affecting lifestyle; 2. Patients at risk from complications of treatments required for acute attacks; 3. Patient acceptance of the need for lifelong medication compliance; 4. Uric acid tophaceous deposits

58 Allopurinol Do not start during an acute attack Prophylaxis with an NSAID/Colchicine Reduce uric acid to lower limit of laboratory reference range Xanthine Uric Acid Xanthine Oxidase ALLOPURINOL inhibits Xanthine Uric Acid Xanthine Oxidase ALLOPURINOL inhibits

59 Diagnosis: Acute Pseudogout Acute inflammatory arthritis caused by calcium pyrophosphate crystals

60 Who gets Pseudogout? Older individuals Often have associated osteoarthritis

61 Clinical Features of the Attack Starts quickly and very intensely Tends to be less intense than gout and takes longer to reach peak than acute gout Very painful Swollen, warm, and red May feel unwell and have an associated fever i.e. it can look just like an infected joint!

62 What Joints Does it Affect? Usually a single joint in the lower extremity Knee is the most common

63 How to Confirm the Diagnosis Must aspirate the joint and find intracellular calcium pyrophosphate crystals to prove diagnosis (rhomboid shaped) CPP crystals positively birefringent in polarized light

64 Non-Pharmacologic Treatment Rest, ice, and elevate the joint Good hydration

65 Pharmacologic Intra-Articular Corticosteroids Inject the affected joint Oral NSAIDs or COXIBs Indomethacin 50 mg PO TID Oral Prednisone 50 mg po od x 7 days

66 Summary We hope to increase teamwork between NPs, FPs and rheumatologists Co-management of chronic disease Continuing education


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