Background/Purpose: Inflammatory arthritis (IA) disproportionately affects Canada’s First Nations population. A Model of Care (MoC) consisting of rheumatology specialty services embedded in the primary care context on-reserve was instituted to reduce barriers to care and improve treatment outcomes. This study assessed the system-level performance of the MoC as well as its effectiveness on disease activity measures and patient-reported outcomes over 7 years (2011 – 2017) at one centre.

Methods: Patients with incident and prevalent IA were enrolled in a longitudinal cohort. Clinical characteristics, disease activity measures, and treatment recommendations were systematically recorded over follow-up. System-level performance was evaluated according to established measures including: wait times for new referral, proportion of patients seen in yearly follow-up, proportion of patients prescribed DMARD treatment, and time to DMARD initiation. Treatment escalation (new DMARD or biologic prescribed) was characterized in relation to disease activity state at each visit. Mixed-model regression was performed to determine rates of change for disease activity measures over time, with adjustment for baseline demographics and disease activity measures.

Results: 59 participants (78% female, mean age 47 (SD 13)) with IA (n=39 RA, n=7 PsA, n=7 SLE and related CTD, n=3 JIA, n=1 SpA, n=2 crystal arthritis; 29 with incident and 30 with prevalent disease, mean 16 (SD 13) years duration) were followed for a mean of 29 (SD 23) months with a mean of 6 (SD 5) visits per participant.

At the system-level, the 50th and 90th percentile wait times were 69 and 695 days, respectively. Only 33% of patients were seen in the benchmark waiting time of 4 weeks but 83% of patients were followed up in each measurement year. Nearly all (96%) of patients received a DMARD in each measurement year and 90% were prescribed a DMARD within 2 weeks of diagnosis.

At the baseline visit, 70% of participants were in DAS28 moderate or high disease activity. Treatment was escalated at 60% of visits where the individual was in moderate or high disease activity. Swollen and tender joint counts significantly improved during follow-up (SJC28 adjusted slope -0.16, 95%CI -0.27 to -0.05, p=0.004; TJC28 adjusted slope -0.16, 95%CI -0.32 to -0.0057, p=0.04.). Pain (adjusted slope -0.014, 95%CI -0.70 to -0.04, p=0.62), MD Global (adjusted slope -0.028, 95%CI -0.095 to 0.040, p=0.42), HAQ (adjusted slope 0.0028, 95%CI -0.0088 to 0.014, p=0.64), and DAS28 (adjusted slope -0.038, 95% CI -0.078 to 0.0016, p=0.060) did not significantly improve over time. Patient global continued to increase over time (adjusted slope 0.081, 95%CI 0.025 to 0.137, p=0.005). No significant differences were found in a sensitivity analysis comparing outcomes for incident and prevalent patients.

Conclusion: Evaluation of the MoC highlighted areas for further improvement. The program met several system-level performance measure targets however patients still experience long wait times. Despite improvement in swollen and tender joint counts, disease activity measures and patient-reported outcomes did not significantly improve during follow-up. This suggests that there are still gaps in meeting relevant outcomes.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/effectiveness-of-the-outreach-model-for-rheumatology-specialty-clinics-to-on-reserve-first-nations-in-canada-system-level-and-individual-measures-of-performance-and-outcomes/