Diane Lacaille

The full abstract for this thesis is available in the body of the thesis, and will be available when the embargo expires.

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Background: Recent evidence suggests a significant decline in all-cause and cardiovascular mortality over time in rheumatoid arthritis (RA) relative to the general population. This improvement in mortality could be due to improvement in risk of cardiovascular events that are the leading cause of excess deaths in RA. Our objective was to evaluate secular trends in ten-year risk of incident a. Acute Myocardial Infarction (AMI), and b. Cerebrovascular Accidents (CVA), in incident RA cohorts, according to their year of RA incidence, relative to the general population. Methods: We conducted two retrospective studies of a population-based cohorts of incident RA with RA onset from 01.01.1997 to 31.12.2004, in British Columbia, with matched general population. RA and general population cohorts were divided according to the year of RA incidence, defined based on the first RA visit, using a 7-year wash-out period. Chapter 2 and 3 describe the risk of incident a. AMI, and b. CVA respectively, using Cox delayed entry models to avoid immortal bias. To determine non-linear effect of years of incidence, Cox regressions, with linear, quadratic and spline functions of years of incidence were compared, and the model with the lowest AIC was selected to interpret the data. To assess whether the risk of AMI/CVA in RA differed from the general population, an interaction term between the indicator of RA vs general population and years of incidence was tested in the Cox models. Results: The decline in risk of AMI incidence did not differ significantly in RA vs. general population [interaction p=0.498]. The change in risk of incident CVA over time, differed significantly in RA vs. general population after 1999 [p=0.0393], but not before 1999 [p=0.0564]. Conclusion: There was a significant decline in10-year risk of AMI in RA, and this decline did not differ in RA vs. general population. There was a significant decline in 10-year risk of CVA in RA with onset from 1999 onwards, and this decline was to a greater extent in RA than it was in the general population.

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Background: Previous research suggest that individuals with Rheumatoid Arthritis (RA) may have an increased risk of Diabetes Mellitus (DM). Furthermore, RA individuals may receive sub-optimal care for their non-RA health related complications. Aims: 1) evaluate the risk of DM in RA compared to the general population; 2) evaluate quality of care for cardiovascular disease (CVD) prevention in RA by measuring compliance with general population screening guidelines.Methods: We conducted three studies using a population-based cohort of RA patients from 1996 to 2006, with follow-up until 2010, in British Columbia, identified using previously described criteria (N=36,438). Controls were selected from the general population and matched 1:1 to RA individuals on age, sex, and calendar year. Different inclusion and exclusion criteria were used in each study. Chapter 2 describes the risk of DM during follow-up in an incident RA cohort, and the risk associated with RA medications, using a Cox proportional hazard model. Chapter 3 and 4 describe the compliance with general population screening guidelines for DM and hyperlipidemia in RA compared to the general population, using predefined eligible periods. A generalized estimating equation model was used to compare RA compliance to controls.Results: Incidence of DM was 8.37 and 7.41 per 1,000P/Y in RA and controls, respectively. RA individuals had a 9% increase in the risk of developing DM compared to controls (aHR [95%CI]:1.09[1.02,1.18]). Glucocorticosteroid use was associated with a doubling in the risk of DM, while hydroxychloroquine and methotrexate use were associated with a reduction in the risk of DM. Compliance with the DM screening guideline was 71.4% and 70.6% in RA and controls, respectively. Compliance with the lipid screening guideline was 56% and 59% in RA and controls, respectively. RA individuals had a 5% greater odds of receiving a plasma glucose test and no difference in receiving a lipid test compared to controls.Conclusion: Risk of DM was higher in RA compared to controls, and screening for DM and hyperlipidemia in RA was similar to controls, but are still considered sub-optimal.

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Rheumatoid arthritis (RA) is a chronic inflammatory polyarthritis, affecting 1% of the adult population, which left untreated can lead to progressive physical disability, joint damage, and premature mortality. In the last decade, there has been a paradigm shift in the treatment of RA, with its goal being eradication of inflammation. This message of paradigm shift in the treatment to early, aggressive and sustained use of Disease Modifying Anti-Rheumatic Drugs, has not yet reached all Family Physicians (FPs). Academic Detailing (AD) involving visits by trained health care professionals, like pharmacists, to physicians in their offices to provide evidence based information on a selected topic, seems to be a promising technique to influence the behaviour of FPs. To our knowledge, there are no publications of use of AD for RA. Our study, through a mixed methods approach, aims to fill this knowledge gap for understanding FPs perceptions of AD for RA management. Before investing in implementation of AD for RA as a health service strategy, it is necessary to know if FPs perceive AD as a useful, acceptable and feasible technique to receive information about RA management. Our systematic review showed the effectiveness of AD at optimizing prescription behaviour of FPs, with a modest effect size in majority of studies reviewed. Survey findings suggested that most FPs rated AD as a useful and convenient CME technique and is well accepted. FPs appreciated AD for its educational value, convenience, one-on-one interaction, short duration; subject expert review of content, and practical, evidence based and focused content. Some FPs mentioned disadvantages like difficulty incorporating AD during work days, lack of dedicated CME time, lack of time for detailed discussions, lack of time to consult information provided by AD, and delivery of standardised messages. AD was acceptable to most FPs as demonstrated by the outcomes of this visit, including improved confidence, anticipation of changes in RA management and willingness to receive AD in future.Overall, AD was perceived as a useful, acceptable and feasible CME technique, by FPs, to receive information about RA management and hence to optimize care.

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