1. + Bridging the rural-urban divide for patients with rheumatoid arthritis Brenna Bath School of Physical Therapy University of Saskatchewan

2. + Research Team/ Co-authors Dr. Regina Taylor-Gjevre, Professor, Rheumatologist (PI); Dr. Bindu Nair, Associate Professor, Rheumatologist; Dr. Samuel Stewart, Research Associate, Biostatistician; Dr. Regan Arendse, Clinical Assistant Professor, Rheumatologist; Dr. Latha Naik, Clinical Assistant Professor, Rheumatologist; Dr. Catherine Trask, Assistant Professor; Dr. Erika Penz, Assistant Professor; Meenu Sharma, Research Assistant; Katie Crockett, Clinical Research Associate

3. + Outline Background Research objectives Design and measures Significance/ relevance What have we learned so far? Questions/ Discussion

4. + Background Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting approximately 1% of the Canadian population. Current standard of care includes use of disease modifying anti-rheumatic drugs and often biological agents, which require ongoing monitoring for toxicity and efficacy.

5. + Background People with RA often require regular rheumatology follow-up to ensure their disease is well-controlled and optimally treated. Up to a frequency of every 3 months Includes history and physical examination. This may lead to substantial travelling for RA patients who live in rural/remote regions.

6. + Background 30% of Saskatchewan’s (SK) population lives in rural and remote regions over 50% of RA patients attending a Saskatoon rheumatology clinic reside in health regions other than Saskatoon Health Region 36% of rheumatoid arthritis (RA) patients in SK consider location of their place of residence negatively impact ability to access health care

7. + *ALL SK Rheumatologists and 90% of PTs practice in urban centres

8. + Our Challenge: How can we improve access to follow-up rheumatology care in rural SK communities? 1. Teams  PTs travelling to rural communities to complete history/ “hands on” physical examination with rural RA patients 2. Technology  Telehealth/ Videoconferencing to link to urban- based rheumatologist

9. + Health Care Team 3 Rheumatologists 1 Nurse Educator 3 PTs travelling to clinics in 5 rural SK communities

10. + Rural Communities: Prince Albert North Battleford Rosetown Wynyard Arborfield

11. + Technology: VIDYO (Secure VC)

12. + Research Objectives 1) To determine whether disease-specific activity measures are equivalent for patients evaluated longitudinally by telehealth/VC compared to those seen in traditional rheumatology clinics over a nine-month period. 2) To evaluate quality-of-life and health- status measures as well as patient/healthcare provider levels of satisfaction for each care model.

13. + Research Objectives 3) To determine incremental costs (direct and indirect) associated with distance telehealth/VC compared with traditional in-person rheumatology clinics. 4) To determine the validity/ accuracy of Rheumatologist/ PT team RA assessment through VC versus Rheumatologist in person.

14. + Participants: RCT 160 patients living outside 100 km or more outside of Saskatoon, age over 18 years, and rheumatologist established diagnosis of RA will be recruited Participants will be randomly assigned to one of two arms: 1) followed by telehealth/VC in or near their home community 2) continue travelling to Saskatoon rheumatology clinic.

15. RCT Design

16. + RCT measures: Primary DAS-28 CRP (at 9 months) Physical examination (swollen and tender joint count) Examiner global score (100mm VAS) C-reactive Protein (CRP)

17. + RCT measures: Secondary Provider categorical assessment related to disease activity (inactive/stable; mildly active; very active) Modified health assessment questionnaire (mHAQ) RA disease activity index (RADAI) Quality of life (EQ5D) Cost diaries Patient satisfaction (VSQ-9) Patient and provider experience with VC/ telehealth (survey and interviews)

18. + Validation study Purpose to demonstrate that there is not a greater difference between disciplines than there is within disciplines for appendicular joint examination accuracy or for assessment of disease activity status. 50 participants with RA from Saskatoon region

19. + Validation study Each will be undergo physical examination (joint count) by 3 Rheumatologists and 3 PTs The comparison groups will be: 1. Rheumatologist A. to Rheumatologist B. 2. Physiotherapist A. to Physiotherapist B. 3. Rheumatologist A/B to Physiotherapist C/teleconferenced Rheumatologist C.

20. + Significance/ Relevance No previous reported studies of telehealth/VC based care for longitudinal rheumatologic follow up in RA patients No reported studies utilizing interdisciplinary care teams in the telehealth/VC assessment process for this population.

21. + Where is the project at? Recruited approximately 50 patients for RCT First VC team visits started in March 2015 Anticipate recruiting until September, 2015, with 9 month completion by June 2016 Validation study (Fall 2015)

22. + What have we learned so far? Technology: hardware, software, connectivity, support Team: scope and collaborative practice scheduling Recruitment: “near” home community “Costco” effect

23. + Where to from here? Combined experience and learning from this project and PT/ NP models for chronic low back pain Mapping of primary care service (PT/ GP/ NP) to identify geographical care gaps Rural and Remote musculoskeletal clinic Primary/ secondary interface care Multidisciplinary & Interprofessional Combination of in-person and VC triage or follow-up care

24. + Acknowledgements

25. + Questions/ Discussion