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(July 12, 2001, Gazette)

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.

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.

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