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Abstract Number: 296

Does Care By a Multidisciplinary Team Improve Outcomes in Rheumatoid Arthritis? a Randomized Controlled Study

Manjari Lahiri1,2, Peter P.M. Cheung1,2, Preeti Dhanasekaran2, Su Ren Wong3, Ai Yap3, Daphne Tan3, Amelia Santosa1,2 and Phillip HC Phan2, 1Division of Rheumatology, University Medicine Cluster, National University Hospital, Singapore, Singapore, Singapore, 2Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore, 3Department of Rehabilitation, National University Hospital, Singapore, Singapore, Singapore

Meeting: 2018 ACR/ARHP Annual Meeting

Keywords: Multidisciplinary pain team, outcomes, quality of life and rheumatoid arthritis (RA)

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Session Information

Date: Sunday, October 21, 2018

Session Title: Health Services Research Poster I – ACR/ARHP

Session Type: ACR/ARHP Combined Abstract Session

Session Time: 9:00AM-11:00AM

Background/Purpose: Quality standards recommend an annual review by a multidisciplinary team (MDT) for all patients with rheumatoid arthritis (RA); however, this is based on expert opinion.

Methods: Single centre randomised single-blind controlled trial of MDT vs. routine rheumatologist review in established RA.

Primary outcome: Minimal clinically important difference (MCID) in quality of life (QOL) (increase in European QOL-5-Dimension-3-Level Singapore (EQ5D-SG) index by 0.1) at 6 months.

Secondary outcomes: Change in EQ5D-SG, pain, disease activity score in 28 joints (DAS28), physical function (modified Health Assessment Questionnaire, mHAQ), coping, self-efficacy (Rheumatoid Arthritis Self-Efficacy scale, RASE), Medication Adherence Report Scale (MARS), Disease Specific Knowledge (DSK) and physical activity.

Adult patients with RA were randomly assigned to a single visit to a 6-member MDT (rheumatologist, nurse, medical social worker, physiotherapist, occupational therapist and podiatrist) or usual care. MDT providers prescribed disease modifying anti-rheumatic drugs (DMARD) and counselled patients with respect to managing flares, medication adherence, coping, joint protection, exercise, footwear. Data were collected by face-to-face questionnaires, review of medical records and joint counts by a standardised blinded assessor at 0, 3 and 6 months. Paired and between-group t test with Bonferroni-Holm correction for multiple testing and logistic regression were used.

Results: 140 (power 95%, 10% attrition) patients (86.3% female, 53.4% Chinese, age 54.4±12.7 years) were recruited. There were fewer females and seropositive patients in MDT (Table 1). The median (IQR) disease duration was 5.5 (2.4, 11.0) years and DAS28 was 2.87 (2.08, 3.66). There was more DMARD escalation in MDT (34.4% vs. 19.4%), and the mean patient experience score (1-10) was higher (8.9±1.0 vs. 8.4±1.0, p=0.009).

123 patients completed the study. 40.6% (MDT) vs. 34.3% patients achieved an MCID in EQ5D-SG, OR 1.3 (0.6, 2.7). Among the secondary outcomes, there were significant within group improvements in RASE and coping in the MDT arm, but not in the control arm (Table 2).

Conclusion: A single visit to a MDT in stable patients with established RA and low disease activity failed to achieve a MCID in EQ5D-SG index but did achieve small but significant improvements in coping and self-efficacy. Patients valued the MDT experience. Recommendation of MDT care needs to balance resource use with marginally improved outcomes.

Table 1: Baseline Characteristics

 

Usual Care, n = 67

Multidisciplinary team care, n = 64

EQ5D Index (SG), mean (SD)

0.76 (0.29)

0.72 (0.27)

Age (years), median (IQR)

56.6 (46.7, 61.3)

56.5 (45.9, 62.6)

Gender, female (%)

61 (91.0)

52 (81.2)

Race

 

 

Chinese

34 (50.7)

36 (56.2)

Malay

9 (13.4)

6 (9.4)

Indian

19 (28.4)

18 (28.1)

Other

5 (7.5)

4 (6.2)

Education level

 

 

None/ Primary / Secondary

41 (61.2)

44 (68.7)

Vocational / Diploma

10 (14.9)

8 (12.5)

Degree

16 (23.9)

12 (18.7)

Socioeconomic status: Occupation

 

 

Unpaid work/ unemployed

28 (41.8)

37 (57.8)

Manual

7 (10.4)

4 (6.2)

Technical/ Admin/ Manager

27 (40.3)

19 (29.7)

Professional

5 (7.5)

4 (6.2)

Language, English speaking (%)

59 (88.1)

55 (85.9)

BMI, median (IQR)

25.4 (20.9, 29.2)

24.9 (21.9, 29.2)

Ever-smoker (%)

10 (14.9)

12 (18.7)

Disease duration, years, median (IQR)

5.7 (2.4, 9.4)

5.3 (2.4, 13.0)

Seropositive (RF+ or ACPA+) (%)

51 (85.0)

41 (66.1)

Physical activity (minutes/ week), median (IQR)

52.5 (0, 210)

85 (0, 210)

Comorbidity

 

 

Diabetes (%)

9 (13.4)

12 (19.0)

Charlson’s comorbidity score, median (IQR)

3 (2, 4)

3 (2, 4)

DAS28-ESR, median (IQR)

2.9 (2.4, 3.4)

2.9 (2.1, 3.9)

mHAQ, median (IQR)

0.12 (0, 0.37)

0 (0, 0.12)

Pain, VAS (0-10)

2 (1, 5)

3 (0.5, 5)

Prednisolone dose (mg), median (IQR)

4 (2, 5)

3.8 (2, 5)

Proportion on methotrexate (%)

54 (81.8)

50 (79.4)

Proportion on biologics (%)

5 (7.8)

2 (3.4)

Medication adherence, MARS (5, worst – 25, best), median (IQR)

23 (21, 25)

24 (21, 25)

Self-Efficacy, RASE (28, worst – 140, best), median (IQR)

104 (98, 108)

103.5 (98, 109)

Coping, VAS (0, very well – 100, very poorly), median (IQR))

20 (0, 40)

30 (10, 50)

DSK (0-12), median (IQR)

6 (5, 7)

5 (4, 7.5)


Table 2: Secondary outcomes

 

 

Baseline

6 months

Change

within group paired t test for change, p value

Between group t test for change, p value

EQ5D Index (SG) (-0.59, worse than death – 1, perfect)

Usual care

0.76 (0.69, 0.83)

0.73 (0.66, 0.81)

-0.03 (-0.09, 0.03)

0.36

0.04

MDT care

0.72 (0.65, 0.79)

0.79 (0.72, 0.86)

0.07 (0.00, 0.15)

0.06

DAS28-ESR (0-10)

Usual care

2.80 (2.56, 3.04)

2.90 (2.63, 3.17)

0.10 (-0.18, 0.38)

0.49

0.03

MDT care

3.13 (2.84, 3.42)

2.79 (2.53, 3.06)

-0.34 (-0.61, -0.06)

0.02

mHAQ (0, no disability – 3, fully disabled)

Usual care

0.22 (0.14, 0.30)

0.24 (0.15, 0.33)

0.02 (-0.05, 0.09)

0.60

0.27

MDT care

0.12 (0.05, 0.18)

0.20 (0.12, 0.28)

0.08 (0.00, 0.17)

0.06

Pain, VAS (0, no pain – 10, worst pain)

Usual care

3.1 (2.4, 3.8)

2.5 (1.9, 3.1)

-0.6 (-1.5, 0.3)

0.19

0.62

MDT care

2.9 (2.2, 3.6)

2.1 (1.5, 2.7)

-0.9 (-1.6, -0.1)

0.02

Medication Adherence, MARS (5, worst – 25, best)

Usual care

22.3 (21.5, 23.0)

22.7 (21.7, 23.6)

0.4 (-0.6, 1.4)

0.42

0.72

MDT care

22.6 (21.8, 23.5)

23.3 (22.4, 24.2)

0.6 (-0.2, 1.5)

0.16

Self-Efficacy, RASE (28, worst – 140, best)

Usual care

102.1 (99.6, 104.5)

103.8 (101.4, 106.2)

1.8 (-0.6, 4.1)

0.13

0.10

MDT care

104.0 (101.2, 106.8)

108.3 (106.0, 110.7)

4.3 (2.3, 6.4)

<0.001*

Coping, VAS (0, very well -100, very poorly)

Usual care

25.1 (19.8, 30.5)

25.7 (20.9, 30.5)

0.5 (-5.7, 6.8)

0.86

0.02

MDT care

31.2 (25.0, 37.5)

22.4 (17.4, 27.4)

-8.8 (-13.7, -4.0)

<0.001*

DSK (0, none – 12, all)

Usual care

6.1 (5.5, 6.6)

6.4 (5.7, 7.1)

0.3 (-0.2, 0.8)

0.21

0.54

MDT care

5.8 (5.1, 6.5)

6.4 (5.7, 7.2)

0.6 (-0.1, 1.4)

0.11

Physical activity (min/ week)

Usual care

119.7 (77.5, 161.9)

100.3 (63.3, 137.4)

-19.4 (-56.8, 18.0)

0.30

0.35

MDT care

186.3 (101.8, 270.8)

135.5 (82.7, 188.3)

-50.8 (-107.5, 5.9)

0.08

All values are mean (95% CI)

*significant after Bonferroni-Holm correction


Disclosure: M. Lahiri, None; P. P. M. Cheung, None; P. Dhanasekaran, None; S. R. Wong, None; A. Yap, None; D. Tan, None; A. Santosa, None; P. H. Phan, None.

To cite this abstract in AMA style:

Lahiri M, Cheung PPM, Dhanasekaran P, Wong SR, Yap A, Tan D, Santosa A, Phan PH. Does Care By a Multidisciplinary Team Improve Outcomes in Rheumatoid Arthritis? a Randomized Controlled Study [abstract]. Arthritis Rheumatol. 2018; 70 (suppl 10). https://acrabstracts.org/abstract/does-care-by-a-multidisciplinary-team-improve-outcomes-in-rheumatoid-arthritis-a-randomized-controlled-study/. Accessed December 6, 2019.
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