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2016 Bernard Connor Medal Award
Dr Fraser also praised the 2016 Bernard Connor Medal Award winner, medical student Ms Anca Smyth, Queen’s University Belfast, for her “excellent presentation” at the ISR 2016 Autumn Meeting, which was an observation of current RA treatment, specifically in regards to flares.
Ms Smyth opened her presentation by pointing out that unlike the ACR/EULAR classification criteria for RA, there has been no standard definition of what constitutes an RA flare or how it can be objectively assessed and classified according to severity.
Apart from measuring the efficacy and safety of novel pharmacological agents used in the treatment of RA by means of randomised, controlled clinical trials, a valid definition and classification of a flare would prove to be an invaluable tool in guiding clinical care and monitoring disease outcome, Ms Smyth said.
When a patient is experiencing a flare, there is often discrepancy in the interpretation of the severity of signs and symptoms between the doctor and the patient, she commented.
This may lead to inappropriate treatment, patient dissatisfaction and non-adherence to therapeutic interventions, Ms Smyth noted.
Such discordance is due to the heterogeneous nature of the patient experience during this acute episode, which not only affects objectively-measured clinical parameters, but also generates self-reported symptoms such as pain, weakness, sleeplessness or fatigue. From the patient’s perspective, the experience of a flare is also about functional impairment, disability and social participation, which interfere with the patient’s quality of life and psychological wellbeing.
There is also variation between RA sufferers regarding what constitutes a significant disease flare, according to Ms Smyth. Reasons for this include the fact that patients report the severity of a flare according to their baseline disease activity and previous experiences with the disease. Additional factors in defining a significant flare include the level of a patient’s tolerance to worsening of signs and symptoms, health beliefs and coping skills.
Current methods of assessing RA patients include the DAS28 score, Health Assessment Questionnaire (HAQ28) and Visual Analogue Scale (VAS). However, none of these approaches are without flaws, she maintained. Two of the main determinants of the patient’s global health are pain and fatigue, subjective symptoms that cannot be measured accurately and which are influenced by many factors.
Given the complexity of patient experiences and the heterogeneity of assessment tools that affect the interpretation of a significant disease flare, there is thus no ‘one size fits all’ approach to monitoring a flare, Ms Smyth contended.
Nowadays, there is an emphasis on treating the individual in the community, with medical care providers offering evidence-based patient education and counselling regarding management of flares or side-effects of medication in the form of leaflets, telephone consultation with various members of the multidisciplinary team or telemedicine services for people to report to and be advised on their flares, she noted.
Such a model of care not only promotes self-efficacy and helps achieve an internal locus of control, but it also increases accessibility and reduces travelling time for patients in the rural communities, she said.
Since RA is a chronic condition, the patient may be the expert in monitoring their condition, and self-management of a flare by means of non-pharmacological or pharmacological interventions seems to be the approach employed by most RA patients experiencing flares, Ms Smyth explained. There are times, however, when self-management of a flare is ineffective and the patient decides to seek medical help.
Concluding, Ms Smyth said the concept of a significant disease flare in RA is complex, non-standardised and its interpretation depends on interplay between a patient’s physical and psychological parameters, previous disease experience and health beliefs. Monitoring of this acute episode should occur in the community, with health professionals providing ongoing patient education and counselling and facilitating timely review by the clinician when the patient seeks medical help, she said. “Shared decision-making is key in caring for these patients,” she told the Medical Independent.