1506 TheJournalofRheumatology2008;35:8 Personal non-commercial use only. The Journal of Rheumatology Copyright © 2008. All rights reserved. Smoldering Rheumatoid Arthritis: Is the Canadian Healthcare System Neglecting a Significant Disease Population? STEVEN EDWORTHY, MICHEL ZUMMER, STEPHANIE GARNER, GILLES BOIRE, SHARON LeCLERCQ, VIVIAN BYKERK, GUNNER KRAAG, JANET MARKLAND, DIANE THOMAS, JOHN THOMSON, and JAMIE HENDERSON ABSTRACT. Objective. To investigate rheumatology practice in Canada with regard to evaluating disease activity status and treatment regimens in patients with rheumatoid arthritis (RA). It was hypothesized that patients with “smoldering” disease activity were not being adequately treated. Methods. Rheumatologists were invited to participate by the Canadian Rheumatology Association in an audit entitled the Assessment in Rheumatology (AIR) program. From across Canada, 65 rheumatologists participated. One thousand five hundred ninety-six consecutive patients with RA seen in regular clinics were classified according to 4 states of disease activity: remission, controlled adequately, smoldering, and uncontrolled. Demographics (age, sex, geographic region), therapy (nonsteroidal antiinflammatory drugs, disease modifying antirheumatic drugs, biologicals, steroids), joint counts (tender/swollen), comorbidity, and treatment decisions at the time of the visit were recorded. Data were collected at the time of the visit with personal digital assistants (PDA) and aggregated, without personal identifiers, for analysis in SPSS. Results. The majority of patients had “smoldering” (29%) or “uncontrolled” disease (23%), with the remainder in “remission” (15%) or “controlled adequately” (33%) at the time of their visit. Following the appointment, the uncontrolled group had a 100% increase (from 10.4% to 23.4%) in the addition of biological agents; however, there was no significant increase in the rates for those with smoldering disease (19.4% to 20.5%). Conclusion. Despite Canada’s universal healthcare system, current treatment regimens may not be optimized on the basis of disease activity. A large proportion of patients with RA (29%) seen in Canadian rheumatology practices may be experiencing unnecessary disease for a variety of reasons. (First Release June 15 2008; J Rheumatol 2008;35:1506–12) KeyIndexingTerms: RHEUMATOIDARTHRITIS THERAPEUTICS PROSPECTIVE STUDIES BIOLOGICAL THERAPY CLINICAL PRACTICE PATTERN HEALTH POLICY FromtheUniversityofCalgary,Calgary,Alberta;UniversitédeMontréal, Montreal;UniversitédeSherbrooke,Sherbrooke,Quebec;Universityof Toronto,Toronto;UniversityofOttawa,Ottawa,Ontario;Universityof Saskatchewan,Saskatoon,Saskatchewan;andtheUniversityofNew Brunswick,Fredericton,NewBrunswick,Canada. SponsoredbytheCanadianRheumatologyAssociation(CRA)throughan unrestrictededucationalgrantfromAmgen-Wyeth. S.Edworthy,MD;S.Garner,BSc;S.LeClercq,MD;D.Thomas,MD, UniversityofCalgary;M.Zummer,MD,UniversitédeMontréal; G.Boire,MD,UniversitédeSherbrooke;V.Bykerk,MD,Universityof Toronto;G.Kraag,MD;J.Thomson,MD,UniversityofOttawa; J.Markland,UniversityofSaskatchewan;J.Henderson,MD,University ofNewBrunswick. AddressreprintrequeststoDr.S.Edworthy,UniversityofCalgary, 3330HospitalDr.NW,Calgary,AlbertaT2N4N1,Canada. E-mail:sedworth@ucalgary.ca AcceptedforpublicationMarch12,2008. Rheumatoid arthritis (RA) is an autoimmune disease affect- ing 1% of Canadians 1 . RA causes joint inflammation lead- ing to deformity and disability 2 . Patients with RA are chal- lenged with increased functional disability and mortality 3,4 . If inadequately controlled, the disease puts a high economic burden on the patient and the healthcare system 5-7 . Over the past 15 years, there have been significant advances in the field of rheumatology with the introduction of more effec- tive treatments, including biological agents, and of more aggressive objectives for therapy. RA disease control and even remission are becoming more realistic treatment goals. In the spring of 2005, a group of Canadian rheumatolo- gists raised the question: How well were they managing their patients with RA? They were concerned they were not adequately treating a significant number of their RA patients with “smoldering” disease activity. An audit, the Assessment in Rheumatology (AIR) program, was initiated with the goal of evaluating disease activity status and treat- ment regimens of patients with RA followed in rheumatol- ogy clinics across Canada. Patients were classified into 4 disease states: remission, controlled, smoldering, and active. The classification was based on the number of joint areas with swollen and tender joints, duration of morning stiff- ness, energy level, and erythrocyte sedimentation rate (ESR). Rheumatologists recorded treatment decisions, joint www.jrheum.org Downloaded on January 10, 2022 from