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Improving
arthritis treatment in rural Newfoundland
By
Sharon Gray
Photo
by HSIMS
Research nurse Susan Burlock (R) and Dr. Majed Kraishi at
the Arthritis Research Centre.
Like
most medical specialists, rheumatologists are centred in St.
John’s. In rural Newfoundland and Labrador, one of the many
problems in managing patients with arthritis is delayed referrals
to rheumatologists, which leads to delay in initiating appropriate
therapy. In a disease like rheumatoid arthritis, early intervention
may prevent the start of joint damage and consequent long-term
disability.
At the Arthritis Research Centre, located at St. Clare’s
Hospital, three members of the Faculty of Medicine have just
finished the first part of a pilot project aimed at improving
the outcomes of arthritis patients in Newfoundland. Rheumatologists
Dr. Majed Khraishi and Dr. Proton Rahman teamed up with medical
educator Dr. Vernon Curran to deliver problem-based education
to rural doctors, with the emphasis on clinical skills (including
laboratory utilization) and treatment decision-making.
“Our primary goal is to provide rural physicians with the
tools to enable them to make early and correct diagnosis, and
use the available resources effectively,” explained Dr.
Khraishi. “When I’m travelling around the province
to see patients and do clinics, it always strikes me that the
real deficiency is that rural physicians don’t have the
chance to access continuing medical education in the same way
that physicians in St. John’s do.”
The pilot project was made possible by a $40,000 grant from Merck
Frosst, a pharmaceutical company. “To be fair to the company,
this was a non-pharmaceutical study, so it was very generous
of them to give us an unrestricted grant to cover the costs of
a study co-ordinator and some travel.”
The first part of the study used three centres in Goose Bay,
Twillingate and Stephenville. “We want to find the best
intervention that will help improve the physician’s confidence
and knowledge about managing arthritis,” said Dr. Khraishi.
“It’s not just a matter of improving knowledge, but
we want to see if it actually translates into better management
of patients with arthritis living in those areas.”
Three interventions were tested from February to June. At Twillingate,
three doctors had random e-mail contact with the rheumatologists.
At Lake Melville Hospital in Goose Bay, eight doctors participated
in a videoconference every two weeks at which Dr. Khraishi, alternating
with Dr. Rahman, spent 1.5 hours discussing cases. Stephenville
was used as a control centre, where the two rheumatologists continued
to make personal visits and do clinics.
“We wanted to see if providing timely and relevant arthritis
education to rural doctors would lead to better, or as good management,
as our presence, “ said Dr. Kraishi. “We were hoping
physicians would enforce their knowledge or add new dimensions
to their ability to manage their own patients with our support.”
Dr. Kraishi said that preliminary results suggest that the videoconferencing
technique used at the Goose Bay site is the best. “Of course
we have to take into account that there are superb physicians
in all three centres. But we do think that videoconferencing
combined with a Web site in a future phase of the project, where
physicians can ask questions afterwards, shows great promise.
We hope to expand on that in the second stage of the project
and involve more than one centre in the province.”
While using telemedicine to offer medical support is not a new
technique, Dr. Khraishi said this study went the extra step of
having a control site in order to compare results.
“It seems to me from our short experience that physicians
were very interactive with us and the patients benefited. Of
course there are issues like MCP fees and medico-legal aspects
where there may be concerns if I, as a specialist, haven’t
actually physically examined the patient. So far, in the pilot
study, we’ve been getting the consent of patients who participated
in the videoconferencing.”
The next phase of the project is to implement the most effective
intervention or interventions in other communities in the province
in partnership with the Family Medicine Program at Memorial,
the Professional Development Office, and the Division of Community
Health. New centres will be chosen and other rheumatologists,
physiotherapists, occupational therapists and community nurses
will be involved as well as patient advocates from the Arthritis
Society, locally and nationally, and the Department of Health
and Community Services.