OP0155-HPR REMOTE MANAGEMENT OF RHEUMATOID ARTHRITIS VS ROUTINE OUTPATIENT FOLLOW-UP: A PROSPECTIVE, LONGITUDINAL REAL-WORLD STUDY

Background:Remote management of rheumatoid arthritis (RA) using patient self-assessment of disease and patient-reported outcomes has potential to inform timely clinical decisions on disease management, reduce burden on busy rheumatology services and promote effective self-management. However, it is unclear how patients’ self-reporting relates to treatment decisions.Objectives:To determine the agreement between remote treatment decisions based on patient self-assessment questionnaire assessed blindly by a health professional and treatment decisions based on routine outpatient monitoring appointments.Methods:This was a prospective real-world study including patients (who gave informed consent) enrolled in an observational study of RA patients starting a new biologic therapy.Enrolled patients continued with their usual care and usual clinic monitoring. In addition, they completed at home, self-assessment questionnaires at monthly intervals, including: two self-reported components which are collected as part of routine clinical practice (joint stiffness and flare), visual analogue scales for pain, global health and fatigue; and HAQ-DI and self-efficacy scales (Arthritis Self-Efficacy Pain and Other Symptoms subscales) at inclusion visits, 12 and 24 months.Remote treatment decisions were made by an independent (blinded) health professional, based on the self-assessment questionnaires and information collected in the study: medical history, ongoing therapies for RA, clinical outcomes, adverse events and toxicity. In this analysis, the independent blinded clinician did not have the same information as the routine hospital visit clinician (blood results and joints assessment).The remote decisions were matched with the hospital visit decisions (within 2 weeks) and the measure of agreement between the 2 raters (independent blinded health professional and clinician at outpatient appointment) were evaluated using kappa coefficient: <0.2, 0.21-0.40, 0.41-0.60, 0.61-0.80 and 0.81-0.99 representing poor, fair, moderate, substantial and almost perfect agreement respectively.Results:A total of 72 RA patients were recruited into the sub-study: mean (SD) age 57.8 (11.6), disease duration 11.7 (10.3) and 52 (87%) were female. The pre-categorised remote decisions were: no change to biologic, stop biologic, add concomitant DMARD, reduction/removal of a concomitant DMARD and bring in for review. There were 57 matched decisions between the independent health professional and the outpatient clinicians. The outpatient clinician made 7 changes to biologic and 18 non-biologic therapy changes, while the remote health professional made 1 change to biologic and 17 changes to a non-biologic DMARD including bringing in for review. The self-assessment questionnaires reported 34 RA flares of which 21 had resolved. In the matched decisions, there was only one adverse event that needed stopping treatment, identified by both the remote and the outpatient treatment. The independent health professional and the outpatient clinician had a ‘fair’ agreement on changes to biologic therapy (Kappa = 0.226, p = 0.007) and overall changes to RA therapy (Kappa = 0.24, p = 0.07).Conclusion:Remote RA monitoring using patient self-assessment and outcome measures was feasible with fair agreement on treatment decisions. Further work is required on understanding the importance of adding blood test monitoring to remote decision-making.Disclosure of Interests:None declared

Patient Self-Assessment and Acoustic Voice Analysis in Screening of Postoperative Vocal Fold Paresis and Paralysis

Background and Aims: The aim of this study was to evaluate the utility of two items in vocal fold paresis and paralysis screening after thyroid and parathyroid surgery: patient self-assessment of voice using the Voice Handicap Index and computer-based acoustic voice analysis using the Multi-Dimensional Voice Program. Materials and Methods: This was a prospective study of 181 patients who underwent thyroid or parathyroid surgery over a 1-year study period (2017). Preoperatively, all patients underwent laryngoscopic vocal fold inspection and acoustic voice analysis, and they completed the Voice Handicap Index questionnaire. Postoperatively, all patients underwent laryngoscopy prior to hospital discharge; 2 weeks after the surgery, they completed the Voice Handicap Index questionnaire a second time. Two weeks postoperatively, patients with vocal fold paresis or paralysis and 20 randomly selected controls without vocal fold paresis or paralysis underwent a follow-up acoustic voice analysis. Results: Fourteen patients had a new postoperative vocal fold paresis or paralysis. Postoperatively, the total Voice Handicap Index score was significantly higher (p = 0.040) and the change between preoperative and postoperative scores was greater (p = 0.028) in vocal fold paresis or paralysis patients. A total postoperative Voice Handicap Index score > 30 had 55% sensitivity, and 90% specificity, for vocal fold paresis or paralysis. In the postoperative Multi-Dimensional Voice Program analysis, vocal fold paresis or paralysis patients had significantly more jitter (p = 0.044). Postoperative jitter > 1.33 corresponded to 55% sensitivity, and 95% specificity, for vocal fold paresis or paralysis. Conclusion: In identifying postoperative vocal fold paresis or paralysis, patient self-assessment and jitter in acoustic voice analysis have high specificity but poor sensitivity. Without routine laryngoscopy, approximately half of the patients with postoperative vocal fold paresis or paralysis could be overlooked. However, if the patient has no complaints of voice disturbance 2 weeks after thyroid or parathyroid surgery, the likelihood of vocal fold paresis or paralysis is low.

Voice disorders after total thyroidectomy: Prospective patient self-assessment in comparison with traditional and alternative methods of examining the vocal folds

Background Voice alterations after thyroidectomy with mobile vocal folds are common. Ultrasonography has been used to assess the mobility of the vocal folds after thyroidectomy. Methods 54 patients underwent thyroidectomy. Indirect laryngoscopy, ultrasonography and GRBAS scoring were performed preoperatively,3 days, 2 and 6 months postoperatively. Results On the third postoperative day, the mobility of the vocal folds was preserved in 52 patients and paresis were recorded in 2 patients. All patients after total thyroidectomy noted the presence of voice alteration in the absence of the postoperative paresis of the vocal folds. On the third postoperative day, the voice was impaired by all criteria of the GRBAS scale, but mainly due to roughness (85%). Sixth month postoperatively 62% of the subjects considered the voice to be altered. Asthenia was observed in 39%. On the third postoperative day indirect laryngoscopy revealed the unchanged vocal folds, the symmetrical edema and the shortening of one of the vocal folds in 56%,42% and 1.9%. Six months postoperatively, the vocal folds returned to their original form. Ultrasonography was well correlated to the results of indirect laryngoscopy. Patients with edema of the vocal folds had a significantly higher mean GRBAS grade than patients without edema. The mean GRBAS score decreased from 3.36 to 0.90, 3 days and 6 months postoperatively. Conclusion Voice alteration after total thyroidectomy is always present. Postoperative edema represents a likely main cause of voice alteration and resolves within 6 months. Ultrasonography is recommended as alternative to indirect laryngoscopy in assessing of the vocal folds in thyroid surgery patients.

Measuring Patient’s Orofacial Estheticsin in Prosthodontics: A Scoping Review of a Current Instrument

Objective: Although prosthodontic treatment is aimed at improving oral function, esthetics has become the most common motivation for treatment. To ensure successful outcomes, valid and reliable instruments for comprehensively evaluating the esthetic aspects of prosthodontic treatment from both clinician perspective and patient self-assessment are needed. The literature on measurement tools used in prosthodontics to evaluate orofacial esthetic aspects was also studied. Methods: A scoping review was conducted to map existing instruments such as a questionnaire, index, or scale designed to evaluate orofacial esthetics by clinician and patient for prosthodontic treatment. Results: Of the 27 studies evaluated, the Orofacial Esthetic Scale (OES) was used mostly for evaluating a patient’s esthetic perception. The ‘Dental Esthetic Screening Index’ (DESI) was found as the most currently developed instrument with objective quantification for the clinical situation having good reliability and validity. The Prosthetic Esthetic Index (PEI) also has sufficient psychometric properties as an objective assessment tool for clinicians. But the PEI and the DESI are still rarely used in research and practice. Teeth color and position were determined to be the most important factors in recognizing esthetic impairment. Following tooth analysis (appearance, color, alignment, space, proportion, and wear), gingival appearance, smile analysis, facial analysis, and unaesthetic restoration or prosthesis were the most important esthetic factors identified. Conclusion: Esthetics is subjective and is influenced by many factors. Instruments for subjective and objective evaluation are needed to determine the esthetic perceptions of clinicians and patients. OES, PEI and DESI were found to be relevant instruments for this.

Acceptability of older patients’ self-assessment in the Emergency Department (ACCEPTED)—a randomised cross-over pilot trial

Background patient self-assessment using electronic tablet could improve the quality of assessment of older Emergency Department(ED) patients. However, the acceptability of this practice remains unknown. Objective to compare the acceptability of self-assessment using a tablet in the ED to a standard assessment by a research assistant (RA), according to seniors and their caregivers. Design randomised crossover pilot study. Setting The Hôpital de l’Enfant-Jésus (CHU de Québec–Université Laval) (2018/05–2018/07). Subjects (1) ED patients aged ≥65, (2) their caregiver, if present. Methods participants’ frailty, cognitive and functional status were assessed with the Clinical Frailty scale, Montreal Cognitive Assessment, and Older American Resources and Services scale and patients self-assessed using a tablet. Test administration order was randomised. The primary outcome, acceptability, was measured using the Treatment Acceptability and Preferences (TAP) scale. Descriptive analyses were performed for sociodemographic variables. TAP scores were adjusted using multivariate linear regression. Thematic content analysis was performed for qualitative data. Results sixty-seven patients were included. Mean age was 75.5 ± 8.0 and 55.2% were women. Adjusted TAP scores for RA evaluation and patient self-assessment were 2.36 and 2.20, respectively (P = 0.08). Patients aged ≥85 showed a difference between the TAP scores (P < 0.05). Qualitative data indicates that this might be attributed to the use of technology. Data from nine caregivers showed a 2.42 mean TAP score for RA evaluation and 2.44 for self-assessment. Conclusions our results show that older patients believe self-assessment in the ED using an electronic tablet as acceptable as a standard evaluation by a research assistant. Patients aged ≥85 find this practice less acceptable.