Letter to the Editor
How do Spanish Rheumatologists handle referral? Survey of knowledge and approach before and after a training workshop
¿Cómo manejan la remisión los reumatólogos españoles? Encuesta de conocimientos y abordaje antes y después de un taller formativo
Alejandro Balsaa,
, Isidoro González-Álvarob, Raimon Sanmartíc, Hector Corominasd
Corresponding author
a Servicio de Reumatología, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
b Servicio de Reumatología, Hospital Universitario La Princesa, IIS-IP, Madrid, Spain
c Servicio de Reumatología, Hospital Universitari Clínic, IDIBAPS, Barcelona, Spain
d Servicio de Reumatología, Hospital de la Santa Creu i Sant Pau, Hospital Dos de Maig, Barcelona, Spain
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Encuesta de conocimientos y abordaje antes y después de un taller formativo" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The aim of rheumatoid arthritis (RA) treatment is to achieve remission, but the criteria by which to establish remission are varied, complex, and unequally stringent<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>, with the consequent complication of management. The main criteria are the cut-off points of composite indices (DAS28, SDAI, or CDAI), Boolean ACR/EULAR criteria, remission without treatment, or ultrasound remission<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. Once remission is achieved, guidelines recommend dose reduction without discontinuing any drug (ACR<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>), tapering glucocorticoids initially and then biologic therapy (EULAR<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>), or tapering glucocorticoids (not classic DMARDs) and establishing a biologic therapy dose reduction plan (SER<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>).</p><p id="par0010" class="elsevierStylePara elsevierViewall">Two years ago, we set out to analyse rheumatologists’ knowledge regarding RA remission and its influence on therapeutic management in the outpatient setting. The rheumatologists completed a two-fold survey (<a class="elsevierStyleCrossRef" href="#sec0020">Appendix B</a>. Supplementary Material) before and 3 months after attending four scientific workshops on remission and management of patients in remission (including the RedoSER tool)<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>. Respondents were deemed to have elevated knowledge when ≥70% answered correctly; a 10-point increase or decrease in correct answers before and after the workshop implied variation.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The results indicated that Spanish rheumatologists possess adequate knowledge of remission (prior to the workshop, at least 70% answered 67% of the questions correctly) and that a very high percentage of these specialists consider that the assessment of remission should include imaging, patient perspective, and biomarkers. Remission is largely evaluated by means of the DAS28 or its components and very little using imaging or PRO (patient-dependent variables). Especially noteworthy is the similarity of the responses and the scant change of opinion following the workshops. The only two remission questions that changed were the inclusion of seroconversion in the definition (change from 14% to 29%) and the use of the CDAI (change from 22% to 38%) (<a class="elsevierStyleCrossRef" href="#sec0020">Appendix B</a>. Supplementary material).</p><p id="par0020" class="elsevierStylePara elsevierViewall">As regards management once remission is attained, the factors the rheumatologists valued most to decide whether or not to lower the dose of biologic therapy in patients in remission are: previous failure of biologics, poor prognostic factors, presence of Power Doppler signal, monotherapy, and being on glucocorticoids. Some Spanish rheumatologists use ultrasound in certain cases to reduce biologics, but do not generally use drug levels or the RedoSER tool. The only remission management questions that changed after the workshops had to do with the importance given to low-dose glucocorticoids, the presence of high activity at the time of biologic initiation, and disease duration <1–2 years.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The main changes in decision-making following the workshops were an increase in the use of ultrasound to determine a downward titration of biologic dose, and increased use of the RedoSER tool (unknown to 54%). According to rheumatologists’ comments, this should include, among others, the risk of infection, drug or antibody levels, and calprotectin, a biomarker that correlates positively with inflammatory activity and increased radiographic progression<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> (<a class="elsevierStyleCrossRef" href="#sec0020">Appendix B</a>. Supplementary material).</p><p id="par0030" class="elsevierStylePara elsevierViewall">Despite its limitations, this work provides interesting new insights into rheumatologists' doubts surrounding remission, its influence on therapeutic decision-making, and the need to individualise the therapeutic target during remission<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>. Finally, the workshops have contributed to increased the use of ultrasound and RedoSER for decision-making and brought about changes in motivation for lowering doses.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">AbbVie was involved in the design and development of the study, as well as providing funding for the study. AbbVie was involved in the interpretation of the results, review, and approval for publication.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">AB has received research support grants, consulting or speaking fees from Abbvie, Amgen, Gebro, Pfizer, Novartis, BMS, Nordic, Sanofi, Sandoz, MSD, Lilly, UCB, and Roche.</p><p id="par0045" class="elsevierStylePara elsevierViewall">IG-A has received grants from the Instituto de Salud Carlos III during the course of the study. He has also received personal fees from Lilly and Sanofi, personal fees, and non-financial support from BMS and Abbvie; research support, personal fees, and non-financial support from Roche, and non-financial support from MSD, Pfizer, and Novartis, which may be related to the work presented.</p><p id="par0050" class="elsevierStylePara elsevierViewall">RS is a permanent member of the advisory board of the outpatient hospital medication assessment committee (MHDA). Cat-Salut. Generalitat de Catalunya. He has received funding for conferences and projects from Abbvie, BMS, MSD, Roche, UCB, Pfizer, Gebro, Lilly, and Sanofi.</p><p id="par0055" class="elsevierStylePara elsevierViewall">HC has received speaker’s fees from MSD, Roche, Lilly, Abbvie, Pfizer, Gebro, BMS, and Sanofi, and has participated in consultancies for Celgene, Abbvie, Amgen, Pfizer, Biogen, and Sanofi.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 2 => array:2 [ "identificador" => "xack632964" "titulo" => "Acknowledgements" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Balsa A, González-Álvaro I, Sanmartí R, Corominas H. ¿Cómo manejan la remisión los reumatólogos españoles? Encuesta de conocimientos y abordaje antes y después de un taller formativo. Reumatol Clin. 2022;18:564–566.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:2 [ 0 => array:3 [ "apendice" => "<p id="par0065" class="elsevierStylePara elsevierViewall">Miriam Almirall Bernabé (Hospital Vall d’Hebrón, Barcelona). Tomás Almorza Hidalgo (Hospital 12 de Octubre, Madrid). Isabel Añon Oñate (Hospital Virgen de las Nieves, Granada). Carmen Barbadillo Mateos (Hospital Puerta Hierro-Majadahonda, Madrid). Julia Bernárdez Moreno (Hospital Mutua de Terrassa). Noemí Busquets Pérez (Hospital General de Granollers). Yolanda Cabello Fernandez (Hospital SAS de Jerez de la Frontera). Rafael Cáliz Cáliz (Hospital Virgen de las Nieves, Granada). Santos Castañeda Sanz (Hospital de la Princesa, Madrid). Sonia Castell Quiñones (Parc de Salut del Mar, Barcelona). Meritxell Castellanos Duarte (Hospital de Badalona). Raul Antonio Castellanos Moreira (Hospital Clínico i Provincial, Barcelona). Miguel Ángel Doña Naranjo (Hospital Torrecárdenas, Almería). Alejandro Escudero Contreras (Hospital Reina Sofía, Córdoba). Miguel Ángel Ferrer González (Hospital Virgen de las Nieves, Granada). Noelia García Castañeda (Hospital de la Princesa, Madrid). Isabel García Hernández (Hospital Universitario Virgen Macarena, Sevilla). María José González Fernández (Instituto Universitario Dexeus, Barcelona). Eduardo Graell Martín (Hospital Parc Taulí, Sabadell). Blanca Hernández Cruz (Hospital Universitario Virgen Macarena, Sevilla). Stanislava Mandelikova (Hospital Clínico i Provincial, Barcelona). Melania Martínez Morillo (Hospital Germans Trias i Pujol, Badalona). Lourdes Mateo Soria (Hospital Germans Trias i Pujol, Badalona). Natalia Mena Vázquez (Hospital Regional Universitario de Málaga). Sonia Mínguez Blasco (Hospitalde Manresa). Rafaela Ortega Castro (Hospital Reina Sofía, Córdoba). José Luis Pablos Álvarez (Hospital 12 octubre, Madrid). Blanca Panero Lamothe (Hospital Regional Universitario, Málaga). M. José Pérez Galán (Complejo Hospitalario, Jaén). Carolina Pérez García (Parc de Salut Mar, Barcelona). Manuel Pujol Busquets (Hospital Mutua de Terrassa). Delia Reina Sanz (Consorci Sanitari Integral Moises Broggi, Sant Joan Despí). José Rey Rey (Hospital Virgen de la Salud, Toledo). Elena Riera Alonso (Hospital Mutua de Terrassa). Carlos Rodríguez Escalera (Complejo Hospitalario, Jaén). Sebastián Cruz Rodríguez García (Hospital Clínico i Provicial, Barcelona). Pablo Rodríguez Merlos (Hospital La Paz, Madrid). Montserrat Romera Baures (Hospital Bellvitge-Príncipes de España, L’Hospitalet de Llobregat). Montserrat Romero Gómez (Hospital Reina Sofia, Córdoba). Virginia Ruiz-Esquide Torino (Hospital Clínico i Provincial, Barcelona). Georgina Salvador Alarcon (Hospital Mutua de Terrassa). Clara Pilar Sangüesa Gómez (Hospital Germans Trias i Pujol, Badalona). Nuria Segales Plana (Consorci Sanitari del Maresme, Mataró). Elena Leonor Sirvent Alierta (Parc Sanitari Sant Joan de Deu, Sant Boi). José Luis Tandaipan Jaime (Hospital Mutua de Terrassa). Eva Tomero Muriel (Hospital de la Princesa, Madrid). Julia Uceda Montañés (Hospital de Valme, Sevilla). M. Carmen Vargas Lebrón (Hospital Univ. Virgen Macarena, Sevilla). Cristina Vergara Dangond (Hospital Madrid, Sanchinarro), and Beatriz Yoldi Muñoz (Instituto Univ. Dexeu, Barcelona).</p>" "titulo" => "Appendix A. Grupo de trabajo Destino Remisión (Destination Referral Working Group)" "identificador" => "sec0015" ] 1 => array:4 [ "apendice" => "<p id="par0075" class="elsevierStylePara elsevierViewall">The following is Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix B" "titulo" => "Supplementary data" "identificador" => "sec0025" ] ] ] ] "multimedia" => array:1 [ 0 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 367658 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.S. 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"fecha" => "2015" "volumen" => "42" "paginaInicial" => "760" "paginaFinal" => "770" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25729036" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Exploring the remission concept in rheumatoid arthritis with patients and rheumatologists: time for a new approach?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Acebes" 1 => "J.L. Andreu" 2 => "A. Balsa" 3 => "E. Batlle" 4 => "J. de Toro-Santos" 5 => "F. García Llorente" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Exp Rheumatol." "fecha" => "2017" "volumen" => "35" "paginaInicial" => "816" "paginaFinal" => "822" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28516881" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack632964" "titulo" => "Acknowledgements" "texto" => "<p id="par0060" class="elsevierStylePara elsevierViewall">Loreto Carmona, InMusc, for conducting the surveys, data collection, and medical writing. This service was funded by AbbVie. The authors would like to thank all members of the Destination Referral working group.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000001800000009/v2_202210290545/S2173574321002203/v2_202210290545/en/main.assets" "Apartado" => array:4 [ "identificador" => "8400" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000001800000009/v2_202210290545/S2173574321002203/v2_202210290545/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574321002203?idApp=UINPBA00004M" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 12 | 22 |
| 2024 October | 41 | 39 | 80 |
| 2024 September | 60 | 21 | 81 |
| 2024 August | 76 | 38 | 114 |
| 2024 July | 62 | 33 | 95 |
| 2024 June | 53 | 37 | 90 |
| 2024 May | 65 | 37 | 102 |
| 2024 April | 55 | 43 | 98 |
| 2024 March | 49 | 24 | 73 |
| 2024 February | 68 | 32 | 100 |
| 2024 January | 83 | 28 | 111 |
| 2023 December | 34 | 36 | 70 |
| 2023 November | 86 | 36 | 122 |
| 2023 October | 80 | 36 | 116 |
| 2023 September | 113 | 38 | 151 |
| 2023 August | 56 | 21 | 77 |
| 2023 July | 38 | 23 | 61 |
| 2023 June | 54 | 42 | 96 |
| 2023 May | 37 | 30 | 67 |
| 2023 March | 11 | 6 | 17 |
| 2022 May | 1 | 0 | 1 |
| 2022 March | 1 | 0 | 1 |
| 2022 January | 1 | 2 | 3 |
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