Arthritis & Rheumatism, Volume 62,
November 2010 Abstract Supplement

Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Atlanta, Georgia November 6-11, 2010.


Are SSc Experts Doing What They Should Do? An Analysis of Practice Variability in Large SSc Centers within the Canadian Scleroderma Research Group (CSRG) Shows Practice Differences.

Harding4,  Sarah, Khimdas4,  Sarit, Bonner2,  A., Baron1,  Murray, Pope3,  Janet E.

Jewish General Hospital, Montreal, QC, Canada
McMaster University
St Joseph Health Care London, London, ON, Canada
University of Western Ontario

Objective:

There is currently no consensus on best practice in SSc. To determine if variability in treatment and investigations exists, practices among Canadian Scleroderma Research Group (CSRG) centers were compared.

Methods:

Prospective clinical and demographic data from adult SSc patients are collected annually from 15 CSRG treatment centers. Laboratory parameters, self-reported socio-demographic questionnaires, current and past medications and disease outcome measures are recorded. For centers with >50 patients enrolled, treatment practices were analyzed to determine practice variability.

Results:

Data from 640 of 938 patients within the CSRG database met inclusion criteria, where 87% were female, the mean ± SEM age was 55.3 ± 0.5; 49% had limited SSc and 48% had diffuse SSc (and 3% uncharacterized). Several investigation and treatment practices were inconsistent among 6 centers including proportion receiving PDE5 inhibitors for Raynaud's phenomenon (p=0.036); cyclophosphamide (p=0.037) and azathioprine (p=0.037) for treatment of ILD; hydroxychloroquine (p=0.023), D-penicillamine (p=0.008), and steroids (p=0.039) for inflammatory arthritis; hyperalimentation (p=0.000) and esophageal dilatations (p=0.000) among centers analyzed. Where negative trails exists, there were differences in use of D-penicillamine (although infrequent) for MRSS >10 (p=0.004), Between site performing of: chest X-rays (72–98%,p=0.000), HRCTs (11–41%,p=0.000) and ECGs (75–98%p=0.000) were different. Annual echocardiograms (91–100%, p=0.2) and PFTs (85–97%, p=0.17) were usually performed annually and did not vary among sites.

 Center 
 A N=52B N=65C N=86D N=98E N=154F N=185 
N=640Frequency (%)Frequency (%)Frequency (%)Frequency (%)Frequency (%)Frequency (%)P-value
Raynaud's phenomenon       
N (%) with RP52 (100)65 (100)86 (100)91 (94.8)152 (100)183 (98.9)0.002
Calcium Channel Blocker25 (48.1)25 (38.5)41 (47.7)50 (54.9)62 (40.8)85 (46.4).280
Iloprost0 (0)0 (0)0 (0)0 (0)1 (0.7)0 (0).678
PDE5 Inhibitors5 (9.6)2 (3.1)1 (1.2)0 (0)8 (5.3)6 (3.3).036
Digital ulcers (DU) (ever)       
N (%) with DU ever28 (53.8)31 (47.7)56 (65.1)47 (48.0)56 (36.4)60 (32.4)0.000
Calcium Channel Blocker15 (53.6)11 (35.5)28 (50)28 (59.6)28 (50.0)39 (65.0).131
Bosentan2 (7.1)3 (9.7)2 (3.6)1 (2.1)2 (3.6)4 (6.7).650
Skin involvement (MRSS>10)       
N (%) with MRSS>1021 (40.4)42 (64.6)54 (62.8)47 (48.0)76 (49.4)88 (47.6)0.020
Corticosteroids3 (14.3)8 (19.0)8 (14.8)15 (31.9)16 (21.3)23 (26.1)0.299
D-penicillamine0 (0)1 (2.4)6 (11.1)0 (0)1 (1.3)1 (1.1)0.004
Methotrexate2 (9.5)9 (21.4)8 (14.8)8 (17.0)6 (8.0)15 (17.0)0.387
Cyclophosphamide3 (14.3)0 (0)1 (1.9)5 (10.6)3 (4.0)8 (9.1)0.062 Dysphagia
N (%) with dysphagia31 (59.6)41 (63.1)55 (64.0)54 (55.1)94 (61.0)94 (50.8)0.236
Esophageal Dilatation7 (22.6)11 (26.8)8 (14.5)12 (22.6)35 (37.2)4 (4.3)0.000
Inflammatory arthritis       
N (%) with inflammatory arthritis19 (37.3)23 (35.4)71 (83.5)42 (44.7)32 (21.2)39 (21.1)0.000
Methotrexate1 (5.3)7 (30.4)10 (14.1)9 (21.4)4 (12.5)8 (20.5)0.259
Hydroxychloroquine5 (26.3)0 (0)10 (14.1)11 (26.2)7 (21.9)13 (33.3)0.023
D-penicillamine0 (0)0 (0)7 (9.9)0 (0)0 (0)0 (0)0.008
NSAIDs9 (47.4)5 (21.7)26 (36.6)21 (50.0)15 (46.9)12 (30.8)0.174
Corticosteroids4 (21.1)8 (34.8)10 (14.1)16 (38.1)6 (18.8)13 (33.3)0.039
Renal crisis ever       
N (%) with renal crisis ever3 (5.8)3 (4.6)6 (7.0)5 (5.2)12 (7.9)8 (4.3)0.787
ACE inhibitor2 (66.7)2 (66.7)5 (83.3)5 (100.0)7 (58.3)7 (87.5)0.463
PAH       
N (%) with PAH1 (2.2)2 (3.3)1 (1.3)4 (4.2)10 (7.4)24 (14.4)0.001
Bosentan1 (100.0)1 (50.0)0 (0)1 (25.0)2 (20.0)4 (16.7)0.383
Sitaxentan0 (0)1 (50.0)0 (0)0 (0)1 (10.0)7 (29.2)0.516
Warfarin1 (100.0)0 (0)0 (0)1 (25.0)2 (20.0)5 (20.8)0.476
PDE5 Inhibitors1 (100.0)1 (50.0)0 (0)0 (0)3 (30.0)3 (12.5)0.150
ILD with FVC<70%       
* P-values measure variation among centres

Treatment and investigation practice frequency and variation among centers with n>50

Conclusions:

There is site variation in SSc with respect to investigations and management among CSRG centers suggesting a need for a standardized approach to the investigation and treatment of SSc. One would speculate that more variability would occur between rheumatologists who did not have a critical mass of SSc and were not given reminders of annual tests to be performed (ex. echocardiograms) as we looked only at practices within a database.

To cite this abstract, please use the following information:
Harding, Sarah, Khimdas, Sarit, Bonner, A., Baron, Murray, Pope, Janet E.; Are SSc Experts Doing What They Should Do? An Analysis of Practice Variability in Large SSc Centers within the Canadian Scleroderma Research Group (CSRG) Shows Practice Differences. [abstract]. Arthritis Rheum 2010;62 Suppl 10 :1203
DOI: 10.1002/art.28969

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