Nienke Lesuis

Gender and the treatment of immune-mediated chronic inflammatory diseases: rheumatoid arthritis, inflammatory bowel disease and psoriasis: an observational study

BackgroundRheumatoid arthritis (RA), inflammatory bowel disease (IBD), and psoriasis are immune-mediated inflammatory diseases with similarities in pathophysiology, and all can be treated with similar biological agents. Previous studies have shown that there are gender differences with regard to disease characteristics in RA and IBD, with women generally having worse scores on pain and quality of life measurements. The relationship is less clear for psoriasis. Because treatment differences between men and women could explain the dissimilarities, we investigated gender differences in the disease characteristics before treatment initiation and in the biologic treatment prescribed.MethodsData on patients with RA or IBD were collected from two registries in which patients treated with biologic medication were enrolled. Basic demographic data and disease activity parameters were collected from a time point just before the initiation of the biologic treatment. For patients with psoriasis, the data were taken from the 2010 annual report of the Swedish Psoriasis Register for systemic treatment, which included also non-biologic treatment. For all three diseases, the prescribed treatment and disease characteristics were compared between men and women.ResultsIn total, 4493 adult patients were included in the study (1912 with RA, 131 with IBD, and 2450 with psoriasis). Most of the treated patients with RA were women, whereas most of the patients with IBD or psoriasis were men. There were no significant differences between men and women in the choice of biologics. At treatment start, significant gender differences were seen in the subjective disease measurements for both RA and psoriasis, with women having higher (that is, worse) scores than men. No differences in objective measurements were found for RA, but for psoriasis men had higher (that is, worse) scores for objective disease activity measures. A similar trend to RA was seen in IBD.ConclusionsWomen with RA or psoriasis scored significantly higher on subjective, but not on objective, disease activity measures than men, and the same trend was seen in IBD. This indicates that at the same level of treatment, the disease has a greater effect in women. These findings might suggest that in all three diseases, subjective measures are discounted to some extent in the therapeutic decision-making process, which could indicate undertreatment in female patients.

Choosing Wisely in daily practice: An intervention study on Antinuclear Antibody testing by rheumatologists

To assess the effect of a simple intervention on antinuclear antibody (ANA) test overuse by rheumatologists.

Implementation of protocolized tight control and biological dose optimization in daily clinical practice: results of a pilot study

Objectives: To assess the effects of education, guideline development, and individualized treatment advice on rheumatologist adherence to tight control-based treatment and biological dose optimization in rheumatoid arthritis (RA), psoriatic arthritis (PsA), and spondyloarthropathy (SpA) patients. Method: This pilot study, among two rheumatologists and two specialized nurses in a general hospital, combined education, feedback, local guideline development, and individualized treatment advice. Outcomes (baseline and 1 year post-intervention) were the percentage of patients with a Disease Activity Score in 28 joints (DAS28) or Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) measured during the visit, mean DAS28/BASDAI, and the percentage of patients using a reduced biological dose. DAS28 outcomes only applied to RA and PsA patients, BASDAI outcomes only applied to SpA patients whereas outcomes on biological dose applied to all patients. Results: A total of 232 patients (67% RA, 15% PsA, 18% SpA; 58% female, mean age 56 ± 15 years) were included in the study. The percentage of DAS28 and BASDAI measurements performed increased after the intervention [DAS28 15–51%, odds ratio (OR) 3.3, 95% confidence interval (CI) 2.1–5.5; BASDAI 23–50%, OR 2.2, 95% CI 1.0–5.5], with mean DAS28 and BASDAI scores remaining similar (DAS28: mean difference 0.1, 95% CI −0.3 to 0.5; BASDAI: mean difference 0.03, 95% CI −1.8 to 1.9). Use of a reduced biological dose increased from 10% to 61% (OR 3.9, 95% CI 2.4–6.5). Conclusions: A multicomponent intervention strategy aimed at rheumatologists can lead to improved adherence to tight control-based treatment and a reduction in the use of biologicals in RA, SpA, and PsA patients.

Choosing wisely in daily practice: a mixed methods study on determinants of antinuclear antibody testing by rheumatologists

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; R2 = 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; R2 = 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.

FRI0586 The Effects of An Educational Meeting and Subsequent Computer Reminders on The Ordering of Laboratory Tests by Rheumatologists: An Interrupted Time Series Analysis

Background Excessive use of diagnostic laboratory does not only constitute a waste of resources, it may also result in an increased rate of false positives which may lead to further unnecessary testing, unnecessary treatment, and increased anxiety in both patients and physicians. Still, many clinicians order irrelevant laboratory tests despite the available information about unnecessary test utilization. Objectives To examine the effects of an educational meeting and subsequent computer reminders on the number of ordered laboratory tests. Methods Using interrupted time series analysis we assessed whether trends in the number of laboratory tests ordered by rheumatologists between September 2012 and September 2015 at the Sint Maartenskliniek (the Netherlands) changed following an educational meeting (September 2013) and introduction of computer reminders into the Computerized Physician Order Entry System (July 2014). The reminders functioned as follows: whenever a clinician tried to order one of the intervention tests a pop-up message appeared explaining in which specific rheumatology-related situation the test was indicated or not, and asked for a reason for ordering the test. The analyses were done for the set of tests on which both interventions had focussed (intervention tests; complement, cryoglobulins, immunoglobins, M protein) and for a set of tests unrelated to the interventions, included as a control (alanine transferase, anti-cyclic citrullinated peptide, C-reactive protein, creatine, haemoglobin, leukocytes, mean corpuscular volume, rheumatoid factor and thrombocytes). Secondary outcomes were the percentage of abnormal intervention test results and the percentage of valid reasons provided with the intervention test orders, as judged by two experts. Results At study start 101 intervention tests and 7660 control tests were ordered per month by the rheumatologists. After the educational meeting both the level and trend of ordered intervention and control tests did not change significantly. After implementation of the reminders, the level of ordered intervention tests decreased with 85 tests (95%>CI -133 to -37, p<0.01), though the trend did not change significantly (1.06, 95%>CI -6.2 to 8.3, p=0.77). The level and trend of control tests did not change following the introduction of reminders. Of the reasons given for ordering the intervention tests after the introduction of reminders, only 34% was deemed valid by two experts. Interestingly, the percentage of abnormal results in the intervention tests did not change significantly after the introduction of the reminders (17.4% before introduction of reminders compared 18.4% after introduction (p=0.73)), nor was it different in those cases were the reason for ordering the test was judged as valid (18.8%). Conclusions The educational meeting alone was not effective in decreasing the number of ordered intervention tests, but subsequent introduction of computer reminders did result in a large decrease of those tests. Therefore, we recommend using computer reminders additionally to education if reduction of inappropriate test use is aimed for. Disclosure of Interest None declared

Comment on “Choosing Wisely in daily practice: an intervention study on Antinuclear Antibody testing by rheumatologists”: Reply

neurologic disorders, and specific rashes (4). Having at least 4 positives from these categories signifies a high likelihood of correctly classifying a patient as having SLE. Using this knowledge, one could develop a serology ordering form that asks the ordering physician to consider that for an ANA test to be completed, at least 2 of the following criteria must be met: 1) lupus rash; 2) oral ulcers; 3) physicianobserved swelling of 2 or more joints OR tender joints with morning stiffness; 4) serositis, pleuritis, or pericarditis; 5) evidence of renal disease; 6) evidence of neurologic disease; 7) cytopenia; 8) antiphospholipid antibody positive; 9) nonscarring alopecia; and 10) low complement levels. That is, if a patient does not have at least 2 of the above criteria present, positive ANA testing will certainly not be helpful. It has recently been shown in an Alberta practice setting that using these a priori minimum criteria before ordering ANA tests can greatly reduce the number of tests ordered without missing important diagnoses (3).