ORADE Grant Recipient – Angelo Papachristos

ORADE Report – Angelo Papachristos, EULAR 2018 AMSTERDAM

I would like to thank the ORA for supporting my attendance at the EULAR 2018 European Congress of Rheumatology that was held in Amsterdam June 13-16, 2018. Without the generous support of this grant, attendance at international congress events and opportunities for allied health professionals would not be possible. In addition to submission of this report for the ORA, I have presented locally at two journal club events specifically for advance practice clinicians.

There were a few general themes that I noted. There was a trend away from rheumatoid arthritis with the focus of many of the talks and posters on management of co-morbidities, seronegative arthritis, osteoarthritis and sustainable models of care /practice issues. I will summaries a few sessions that were of interest from an ACP perspective.

Pettersson presented on ‘Physical Capacity Contributes Marginally in Explaining Variations of Fatigue in Persons Moderately Affected by Rheumatoid Arthritis.’ Fatigue is a common problem in people with RA. Physical activity is often utilized as an important non-pharmacological intervention that positively affects fatigue. Capacity including aerobic, muscle strength and lower limb function thought to be modifiable. The study included 269 people with RA and looked at disease related variables [disease duration, activity, dmards, biologics, comorbidities], physical capacity tests [time stands tests, grip strength, aerobic capacity, bmi ect.] as well as perceived disease impact [fatigue, activity limitation, perceived health, pain, axiety/depression].   Logistic regression for severe fatigue [defined as greater that 5/10 scale] was significantly significantly associated with heath perception, pain and anxiety/depression.  None of the physical capacity measures demonstrated any significance.

Karin Niedermann presented on the EULAR exercise recommendations for physical activity in people with inflammatory arthritis and osteoarthritis.   Discussed the importance of PA [physical activity] in people with inflammatory and osteoarthritis. Existing EULAR recommendations in management of RA, SpA or HOA/KOA not specific for type or dosage of PA. Discussed the 4 overarching principles and 10 recommendations. I will not discuss all of these in this brief but to summarize: General PA recommendations should include all four domains [cardiorespiratory, muscle strength, flexibility, and neuromotor performance] and all deemed to be feasible and safe in people with RA/SpA/OA. No evidence of specific screening tools to use. Recommended general and specific CI before starting physical activity.  Health care providers should consider different modes of delivery [supervised/ individual, group, in person, online, booster strategies] that are in line with peoples preferences. See link to 2018 EULAR recommendation: https://ard.bmj.com/content/early/2018/07/11/annrheumdis-2018-213585?papetoc

There was a focus on ‘Sustainability in Healthcare in Rheumatology” and the role of health professionals. This included integrated healthcare models, outpatient on demand models, role of nursing, sustainability with multidisciplinary co-management.

Bert Vrijhoef from the Netherlands went into in-depth discussion on sustainability of healthcare. He discussed the World Health Organization 2016 framework on integrated people-centered health services and the five pillars. He discussed IHI developed that value based healthcare and movement from ‘Triple Aim’ to ‘Quadruple Aim’.  The primary goal is to improve health of populations, improving patient experience and reducing costs. The forth or Quadruple Aim was to include improving work life of the healthcare providers. He discussed physician and nursing burnout and overuse of resources that increase cost of care. Some basic strategies and definitions were discussed such as use of implementation of team documentation, pre-visit planning and pre-appointment lab testing, use of expanded role practitioners, standardization of workflows and prescription refills, co-location of teams so physicians work in same space as team members and ensuring staff are well trained to assume new responsibilities and that unnecessary work is reengineered out of the practice.

Anne-Marie Seeney from Denmark presented an interesting concept of ‘On Demand” outpatient follow-up for patients with RA –two year randomized controlled trial. Studied patients with stable illness. Arthritis flare was typically between scheduled medical visits and difficult to get acute appointments. 289 patients were included. They studies clinical and psychological parameters including patient satisfaction. Clinical evaluation completed by staff rheumatologist. The control group was scheduled appointments as per routine procedure and access to acute appointments according to availability. The intervention ‘On Demand’ group got information and education about disease, symptoms and when to contact clinic, no scheduled appointments but had nurse led consultations without booked appointments and a hotline. They had access to acute appointments with rheumatologist within 5 days or less. The results demonstrated that disease activity and PROM outcome from On Demand group was comparable to those from traditional scheduled routine procedures. No radiological progression detected at year 1 or 2. The on demand group made more phone calls to clinic but had fewer visits.

The sustainability in healthcare presentations raised interesting points about the roles of expanded role practitioners internationally. The ORA has completed a previous white paper and presented work on Models of Care in Ontario to address supply-demand constraints and delivery of arthritis care. Ongoing collaboration between allied health professionals and the ORA is important to address improved health care delivery and achieving Quadruple Aim principle.


Angelo Papachristos

Advance Practice Physiotherapist, ACPAC

St. Michaels Hospital