Multimorbidity Screening Program Enhances Management of Chronic Inflammatory Rheumatism Patients

doi:10.21203/rs.3.rs-4842308/v1

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Research Article

Multimorbidity Screening Program Enhances Management of Chronic Inflammatory Rheumatism Patients

https://doi.org/10.21203/rs.3.rs-4842308/v1

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Background

A program was established at Montpellier University Hospital to screen and prevent multimorbidities in chronic inflammatory rheumatism. To evaluate the impact of this program, we conducted a systematic follow-up reassessment. The study aimed to assess the application of initial assessment recommendations and variations in clinico-biological parameters.

Methods

The application of the initial recommendations was evaluated during a systematic standardized visit with the first 198 patients reassessed.

Results

The median time from initial screening to the follow-up visit was 24 months (interquartile range = [12; 36]). At the initial workup, a mean of 3.69 ± 1.72 recommendations (/11) were issued per patient (n = 192). The mean number of recommendations implemented was 2.53 ± 1.46 per patient. Initial recommendations were applied in 60/110 (54.5%) patients with lipid levels above the target, in 30/34 (88.2%) with high blood pressure, and in 18/22 (81.8%) with hyperglycemia. In addition, 79/128 (61.7%) of patients followed vaccination recommendations and 64/103 (62.1%) updated their cancer screening. Overall, 19/60 (31.6%) patients stopped smoking. Levels of low-density lipoprotein and total cholesterol decreased significantly for patients with an initial cholesterol recommendation (-0.23 ± 0.38 g/l, p = 0.01, n = 26; -0.25 ± 0.47 g/l, p = 0.03, n = 21).

Conclusion

The medium-term evaluation of the screening and prevention program demonstrates the good application of recommendations and objective improvement of several multimorbidity criteria.

Chronic inflammatory rheumatism

multimorbidity

screening

primary prevention

rheumatoid arthritis

spondyloarthritis

- The multimorbidity screening and prevention program in chronic inflammatory rheumatism demonstrates effective adherence to recommendations in the medium term.

- The implementation of recommendations resulted in a reduction in smoking rates, increased vaccination coverage, improved cancer screening rates, and a significant decrease in cholesterol levels.

The therapeutic management of chronic inflammatory rheumatic diseases such as rheumatoid arthritis (RA), psoriatic arthritis or spondyloarthritis has improved over time, especially with the advent of new treatments. However, morbimortality remains high, especially related to the increased risk of cardiovascular (CV) diseases (1–3). Patients with chronic inflammatory rheumatic diseases also have a high risk of infection, cancer, and osteoporosis due to the disease itself or the treatments used (4–9). These different chronic diseases may be associated in the same patient, and the term "multimorbidity" is used to define them.

Identifying and treating multimorbidities is an important issue in the management of chronic inflammatory rheumatic diseases. Since 2014, Montpellier University Hospital has implemented a program to screen, treat and/or prevent these multimorbidities. This program is carried out in a daily clinic. It includes clinical assessment (questionnaire for obstructive sleep apnea syndrome, CV risk estimation, inventory of vaccinations, cancer screening status, food frequency questionnaires, etc.), biological data (glycemia and levels of lipids, vitamin D, calcium, etc.), ultrasonography (transthoracic echocardiography and supra-aortic trunk ultrasonography [SAT-US] to search for atheromatous plaque), evaluation and management of osteoporosis risk (bone densitometry ± fracture risk assessment tool [FRAX] calculation), and screening for pulmonary abnormalities (questionnaires, clinical examination and spirometry).

To evaluate our program, we previously analyzed the initial screening data for the first 200 patients and conducted a phone reassessment at 3 months (10). Our program was considered helpful in screening and advocating preventive measures. Nevertheless, we still needed to evaluate the real impact of screening in the medium term by evaluating the application of the recommendations issued as well as variations in objective clinico-biological criteria and morbidity. The aim of this present work was to evaluate these two last points. A re-evaluation consultation was set up in Montpellier from 2017 to evaluate the impact of the recommendations.

Screening procedures

The modalities of the screening and prevention check-up were detailed previously (10). In this single-center prospective observational study, we included any individual who participated in the screening and prevention program at Montpellier University Hospital between 2014 and 2019 and who had a systematic follow-up visit. Recall modalities changed between 2014 and 2020. Between 2014 and 2017, the systematic follow-up visit was performed in the daily clinic. The delay from the initial assessment depended on the individual’s initial CV risk level (Systematic Coronary risk Evaluation [SCORE] score): reassessment was proposed at 1 year with high CV risk, at 2 years with moderate risk and at 5 years with low risk. From September 2017, a systematic 1-year out-patient consultation was implemented. This visit was also offered to patients whose initial screening occurred between 2014 and September 2017 who had not been reassessed. This 30-min consultation included a reassessment of disease activity, CV risk, anthropometric measurements (weight, height, Body Mass Index [BMI], waist circumference), lipid and glycemic assessment and evaluation of the application of the recommendations issued from the initial assessment. Supplementary Table S1 summarizes the parameters assessed in the daily clinic and out-patient consultation.

Data collection

A standardized electronic questionnaire was completed by the clinician during the follow-up assessment in daily practice. This questionnaire included the different initial recommendations, their realization or not and the current recommendations. These data were centralized in the computerized patient file (DxCare software) at Montpellier University Hospital.

Objectives and endpoints

The primary objective of the study was to evaluate the implementation of the recommendations issued at the initial assessment. The primary endpoint was the mean number of recommendations applied during the initial assessment.

The secondary objectives were to analyze the impact of the screening and prevention assessment (CV, pulmonary, vaccinations, cancer screening, osteoporosis) on the individual. Secondary endpoints were the number of recommendations issued at the time of hospitalization and the follow-up visit; the proportion of patients who followed the recommendations issued for each domain at the time of hospitalization and the follow-up visit; the proportion of recommendations issued with the discovery of abnormal values; the initiation of treatment or the continuation of explorations; the change in clinico-biological parameters (BMI, waist circumference, blood pressure, glycemia and levels of low-density lipoprotein [LDL] cholesterol, total cholesterol, HbA1c) for all patients and those with recommendations issued; the proportion of recommendations issued at follow-up for patients who did not have recommendations issued initially; and the proportion of patients with an intercurrent event at follow-up.

Recommendation application

Clinicians had to complete the following boxes for each domain: initial recommendation applied (yes/no); if yes, detail whether monitoring was normal or treatment was initiated or explorations were continued; if no, select the reason among on-going, patient refusal, practitioner refusal, forgetfulness or not aware of the recommendation; recommendation at the time of the second evaluation (yes/no). The following domains were assessed: blood pressure, glycemia, lipid levels, cardiologist consultation, smoking cessation, respiratory function tests, polysomnography, cancer screening (at least one), vaccine update (at least one), and bones (recommendation concerned at least one of the following items: bone densitometry, vitamin D supplementation or anti-osteoporotic drug).

Recommendations were considered applied if the recommended monitoring was performed and/or the recommended treatment was taken. If the recommendation was applied, the clinician had to note whether the monitoring gave normal values or led to treatment, device prescription or exploration continuation. Exploration continuation included deeper CV risk assessment (myocardial scintigraphy, stress echocardiography, angio-tomodensitometry) for lipid monitoring, cardiological consultation and SAT-US control; 24-hr ambulatory blood pressure monitoring for hypertension; blood control surveillance or glucose tolerance test for abnormal blood glucose level; thoracic scan or pneumological consultation for pulmonary recommendations and fracture screening for osteoporotic risk recommendation.

Finally, clinician had to note whether the following intercurrent event occurred since the initial assessment: CV events, infections/use of antibiotics, fractures or cancer.

Of note, the policy of our program was to give recommendations to the patients and their general practitioner rather than to directly prescribe CV-related drugs because the general practitioner and not the rheumatologist will oversee efficacy and tolerance assessment. However, because low statin prescription was noted, rheumatologists were encouraged to prescribe CV-related-treatment at the second assessment if required.

Statistical analysis

Clinical characteristics of patients and multimorbidities for patients who benefited from the first screening and prevention assessment and those who benefited from the follow-up assessment were described using numbers and frequencies for categorical variables and median and interquartile range (Q25;Q75) for continuous variables unless noted otherwise. Missing data were not imputed. The implementation of initial recommendations, need for new recommendations, and occurrence of intercurrent events during follow-up as well as clinico-biological measures are described similarly.

The association between the presence or not of initial recommendations and the need to give new recommendations to patients was assessed using Chi square or Fisher exact test depending on the conditions for chi-square test validity. MacNemar tests were used to test the clinico-biological evolution of patients after the implementation of initial recommendations for categorical variables, while Wilcoxon or Student t test for paired series were applied for quantitative variables. The significance level was set at p < 0.05, 2-sided for the tests used.

The resulting data were extracted from the computerized patient record (DxCare), then analyzed by the team of the Clinical Research and Epidemiology Unit (Public Health Department) of Montpellier University Hospital by using SAS Enterprise Guide v8.2 (SAS Institute, Cary, NC).

Ethics

The present study was approved by the ethics committee of Montpellier University Hospital in accordance with the 1975 Declaration of Helsinski and with article R.1121-3 of the French public health law (April 26, 2006) (no. CPPQ2016.11.01).

Participants

A total of 198 patients were included in this analysis. Reasons for not completing a follow-up evaluation were: no initial referral, living far from the screening center, unable to contact the patient, no interest in the program, or planned evaluation not yet completed. The exact rates for the various reasons for non-return could not be collected. Of the patients included, 95 were reassessed in the daily clinic and 103 in out-patient consultation.

Patient characteristics

Supplementary Table S2 reports the characteristics of the patients included in the present study and those of the first analysis previously published (10). The median time to follow-up reassessment was 24 (range = [12 ; 36]) months.

Implementation of recommendations in the overall sample

At the time of the initial assessment, a mean of 3.69 ± 1.72 recommendations (/11) were issued per patient (n = 192). The mean number of recommendations implemented was 2.53 ± 1.46 per patient. Details are summarized in Table 1. The initial recommendations issued were applied in 60/104 (57.7%) patients with recommendations for lipid levels above the target, 30/34 (88.3%) for hypertension, 17/21 (80.9%) for hyperglycemia, 65/87 (74.7%) for cardiological consultation, 25/33 (75.8%) for pulmonary explorations, 8/20 (40%) for polysomnography and 61/85 (71.8%) for osteoporosis. In addition, 78/114 (68.4%) of patients followed vaccine recommendations and 59/99 (59.6%) updated their cancer screenings. Of the tests performed, results for 4 screening tests were abnormal: one breast cancer case was detected and 3 fecal occult blood tests were positive but without abnormalities found on colonoscopy. In total, 19/58 (32.8%) patients stopped smoking. Among the patients who did not stop smoking, 9 were in the process of quitting (smoking reduction strategy).

Table 1

Initial recommendations application and outcomes
Recommendations	Initial recommendations (n/N, (%))	Applied recommendations (n/N, (% of initial recommendations))	Patients who started a drug or continued explorations (n/N, (% of applied recommendations))
Cardiovascular
Blood pressure	34/188 (18.1)	30/34 (88.2)	9/30 (30.0)
Glycemia	22/188 (11.7)	18/22 (81.8)	5/18 (27.7)
Lipid levels	110/195 (56.4)	60/110 (54.5)	8/60 (13.3)
Cardiologist consultation	89/190 (46.8)	65/89 (73.0)	10/65 (15.4)
SAT-US	21/189 (11.1)	9/21 (42.8)	3/9 (33.3)
Lungs
Smoking cessation	60/180 (33.3)	19/60(31.6)	-
Respiratory function tests	33/174 (19.0)	26/33 (78.8)	12/26 (48.0)
Polysomnography	20/183 (10.9)	10/20 (50)	3/10 (30.0)
Cancer screening
At least 1 screening	103/189 (54.5)	64/103(62.1)	4/64 (6.2)
Vaccination
At least 1 vaccination	128/192 (66.7)	79/128 (61.7)	-
Bone
Bone densitometry, vitamin D supplementation or anti-osteoporotic drugs	88/189 (46.6)	61/88 (69.3)	9/61 (14.8%)
SAT-US: supra-aortic trunk ultrasonography

Details of outcomes from recommendations application for patients who followed the recommendations

Lipid monitoring at 3 months was above the target for 28/60 patients for whom lipid monitoring or statin therapy was recommended. Statin therapy was started in 4 patients, and 4 patients continued explorations. Blood pressure control was abnormal for 11/30 patients for whom blood pressure control or antihypertensive drugs was recommended. Antihypertensive drugs were started in 6 patients, and 3 patients continued explorations. Blood glucose control was abnormal for 9/18 patients for whom glucose monitoring was recommended. Anti-diabetic drugs were started in 3 patients, and 2 patients continued explorations. Cardiological consultation results were abnormal for 10/65 patients for whom cardiological consultations were recommended, leading to antiplatelet therapy in 4 patients and continuation of explorations in 6. SAT-US results were abnormal for 3/9 patients for whom monitoring of SAT-US was recommended, leading to treatment for 2 patients and continued explorations for 1 patient. Pneumological explorations were abnormal for 13/33 patients for whom respiratory function tests were recommended, leading to treatment for 3 patients and continued explorations for 9. Polysomnography results were abnormal for 3/20 patients for whom polysomnography was recommended, leading to night-time device use (2 continued; 1 did not tolerate the device). Bone densitometry results were abnormal for 12 patients. Anti-osteoporotic drugs were started in 7 patients, and explorations were continued in 2.

Reasons for non-application of the initial recommendations

The reasons for non-application of the initial recommendations are summarized in Supplementary table S3. Patient refusal mainly concerned vaccinations (refusal of influenza vaccination: 10 of the 14 vaccination refusals), smoking cessation (77.5%; 9 were in the process of quitting smoking [smoking reduction strategy]) and cancer screening (38.1%). General practitioner’s refusal (n = 4) was mentioned in 9.1% of the refusals for dyslipidemia management. Patients frequently cited forgetfulness as a reason for not following the recommendations.

Anthropometric variations between assessments (Table 2)

Table 2

Change in clinical and biological parameters between initial and follow-up assessments
Parameters	n	Initial assessment	n	Initial assessment (1)	N	Follow-up	n	Change in the entire sample	p	n	Change in the sample with initial abnormalities	p
Clinical parameters
BMI	192	25.0 (22.1 ; 29.0)	142	25.4 (22.0 ;29.0)	142	25.4 (22.1 ; 29.1)	142	0.0 (-0.6 ; 0.8)	0.52	73	0.0 (-1.0 ; 0.9)	0.83
Waist circumference (cm)	183	95 (84 ; 103)	128	95.5 (84.0 ;103.5)	134	95 (85 ; 106)	128	+ 2 (-3.0 ; 6.5)	0.01	92	1.5 (-3.5 ; 5)	0.18
Systolic BP (mmHg)	185	127 (116 ;138)	123	126 (116 ;138)	130	131(120 ;145)	123	+ 6.0(-6.0 ;19.0)	0.0001	16	-5.0 (-15 ;28.5)	0.89
Diastolic BP (mmHg)	185	77 (70 ; 85)	123	78 (69 ; 86)	130	78.0 (69 ; 84)	123	-1.0 (-10.0 ; 9.0)	0.86	16	-4.0 (-11.5 ; 2)	0.22
Biologic parameters
Fasting blood glucose (mmol/l)	91	5.20 (4.70 ; 5.60)	50	5.09(4.50 ;5.32)	110	5.19 (4.67 ; 5.55)	50	+ 0.01 (-0.29 ; 0.40)	0.58	17	-0.10 (-0.39 ; 0.04)	0.46
HbA1c (%)	64	5.50 (5.30 ; 5.90)	33	5.60 (5.40 ;6.00)	113	5.60 (5.40 ; 5.90)	33	+ 0.05 (-0.20 ; 0.30)	0.33	11	0.20 (0.00 ; 0.30)	0.05
Total cholesterol (g/l)	107	2.17 (1.93 ; 2.35)	66	2.15(2.00 ;2.34)	130	2.15 (1.80 ; 2.34)	66	-0.06 (-0.19 ; 0.19)	0.47	21	-0.19 (-0.50 ; 0.11)	0.03
LDL cholesterol (g/l)	111	1.31 (1.11 ; 1.49)	76	1.33(1.15 ;1.50)	144	1.26 (1.01 ; 1.47)	76	-0.07 (-0.22 ; 0.14)	0.07	26	-0.25 (-0.35 ; 0.07)	0.01
HDL cholesterol (g/l)	110	0.58 (0.46 ; 0.71)	68	0.58(0.47 ;0.73)	132	0.57 (0.47 ; 0.74)	68	+ 0.02 (-0.08 ; 0.07)	0.95	22	+ 0.02 (-0.06 ; 0.07)	0.65
Total/HDL cholesterol	106	3.58 (2.94 ; 4.60)	59	3.62(2.89 ;4.31)	121	3.60 (2.93 ; 4.24)	59	+ 0.06 (-0.58 ; 0.57)	0.60	18	0.03 (-0.67 ; 0.51)	0.93
Triglycerides (g/l)	109	1.03 (0.79 ; 1.39)	69	1.04(0.89 ;1.48)	132	1.07 (0.79 ; 1.51)	69	+ 0.02 (-0.19 ; 0.22)	0.54	-	-	-
25 OH vitamin D (ng/ml)	66	27.0 (18.1 ; 37.0)	33	26.40(17.70 ;32.00)	119	27.0 (20.0 ; 36.0)	33	+ 3.00 (-6.40 ; 9.20)	0.58	-	-	-
Data are median (interquartile range). BMI: body mass index. BP: blood pressure. LDL: low-density lipoprotein; HDL: high-density lipoprotein
(1) Initial assessment in patients with data at baseline and follow-up

The median BMI did not significantly differ between the two assessments for the overall population (final–initial change: 0.0 [-0.6 ; 0.8], p = 0.52) or for patients with an initial BMI > 25 kg/m² (final–initial change: 0.0 [-1.0 ; 0.9], p = 0.83, n = 73) or > 30 kg/m² (final–initial change: 0. 15 [-1.45; 1.08], p = 0.82, n = 28). Among patients with a BMI ≤ 25 kg/m², 6 (8.7%) were overweight (BMI 25–30 kg/m²). Among patients who were initially overweight, at follow-up, the BMI was ≤ 25 kg/m² for 3 (6.7%) and ≥ 30 kg/m² for 5 (11.1%). Among patients with initial obesity, the BMI was ≤ 30 kg/m² for 5 (17.9%) at follow-up. Waist circumference increased by + 2 cm (-3.0 ; 6.5, p = 0.01, n = 128) at follow-up as compared with the initial value in the total population, but this increase was not significant for patients with an initial abnormal waist circumference (+ 1.5 cm [-3.5 ; 5], p = 0.18, n = 92, Table 2). Overall, 12 (33.33%) patients without initial abdominal obesity exhibited abdominal obesity at follow-up (< 94 cm in men or < 80 cm in women). Conversely, 12 (13.04%) patients with initial abdominal obesity showed a decrease in waist circumference < 94 cm (men) or < 80 cm (women) during follow-up.

Blood pressure variations (Table 2)

Change in systolic blood pressure (+ 6 mmHg [-6; 19], p = 0.0001, n = 123) was significant whereas no significant change for diastolic blood pressure (-1 mmHg [-10 ; 9], p = 0.86, n = 123, Table 2) was found during follow-up. Among those with initial blood pressure abnormality (n = 16), blood pressure changes were not significant in terms of value (-5 mmHg [-15 ; 28.5], p = 0.89, for systolic and − 4 mmHg [-11.5 ; 2], p = 0.22, for diastolic; Table 2).

Biological parameters (Table 2)

Lipid status did not significantly change at follow-up in the entire population (LDL level: -0.07 g/l [-0.22 ; 0.14],p = 0.07, n = 76); total cholesterol: -0.06 g/l [-0.19; 0.19], p = 0.47, n = 66, and HDL: +0.02[-0.08; 0.07], p = 0.95, n = 68). For patients with abnormal lipid levels at baseline, LDL cholesterol and total cholesterol levels decreased significantly (-0.25 g/l [-0.35 ; 0.07], p = 0.01, n = 26, and − 0.19 g/l [-0.50 ; 0.11], p = 0.03, n = 21, respectively). Glycemic control did not change significantly (change in fasting blood glucose level: 0.01 [-0.29; 0.40], p = 0.58, n = 50; change in HbA1c level: 0.05 [-0.20; 0.30], p = 0.33, n = 33) for the total population or for patients with an initial recommendation for glycemic control. The change in vitamin D level was not significant (+ 3.00 ng/ml [-6.40 ; 9.20], p = 0.58, n = 33).

Description of intercurrent events (Supplementary table S4)

During follow-up, 4 cardiovascular events occurred (1 myocardial infarction, 2 strokes, and 1 heart failure). One case of breast cancer was diagnosed; 8 new severe fractures and 1 minor fracture were recorded. Infectious events were the most frequent: 23.7% of patients received at least one antibiotics therapy during follow-up. These infections were mainly pulmonary (22 bronchitis, 13 respiratory infections, 5 influenza) and urinary (10 cystitis, 1 prostatitis but no pyelonephritis).

New recommendations issued (Table 3)

Table 3

Recommendations issued at the second assessment
Type of recommendation		Patients with recommendations (n, % )
Cardiovascular
Blood pressure
BP monitoring	91	34 (37.3)
Anti-hypertensive drug initiation	71	6 (8.5)
Anti-hypertensive drug increase	57	4 (7)
Glycemia
Glycemia monitoring	122	14 (11.5)
Anti-diabetic drug initiation	64	1 (1.6)
Anti-diabetic drug increase	51	3 (5.9)
Lipid levels
Dietary recommendations	105	85 (81.0)
Dietician consultation	83	55 (66.3)
Statins recommended	38	21 (55.3)
Statins prescribed	38	17 (44.7)
Statin dosage increased	28	5 (17.8)
Cardiologist consultation	121	64 (52.9)
SAT-US control	91	13 (14.3)
Anti-platelet therapy to start	75	3 (4.0)
Vascular surgeon consultation	80	0 (0)
Lungs
Smoking cessation	119	38 (31.9)
Respiratory function tests	105	22 (21.0)
Polysomnography	110	20 (18.2)
Cancer screening
At least one	168	68(40.4)
Cervix	68	21
Breast	68	45
Colorectal	68	23
Prostate	68	6
Vaccinations
At least one	143	76 (53.2)
Pneumococcal	76	50
Tetanus	76	32
Influenza	76	53
Bone
Vitamin D supplementation	109	60 (55.1)
Anti-osteoporotic drug initiation	96	22 (22.9)
Anti-osteoporotic drug change	58	5 (8.6)
BP: blood pressure. SAT-US: supra-aortic trunk ultrasonography

A mean of 3.08 ± 1.85 recommendations (/11) per patient were issued during the follow-up visit (n = 168). Table 3 summarizes the recommendations issued at the follow-up visit. Statin therapy was recommended for 21 patients, prescribed for 17, and reinforced for 22. Overall, 40 patients had systolic blood pressure ≥ 140 mmHg, and 6 (8.4%) received a prescription/recommendation for anti-hypertensive therapy. Overall, 14 (11.5%) patients had high blood glucose and/or HbA1c level, leading to glycemic control after dietary changes or anti-diabetic drug recommendation. Of the 14 patients, 10 had no initial recommendations; 4 had an initial recommendation that had led to introduction of an oral anti-diabetic drug in 1 patient and an increase of anti-diabetic drug dose in 3 patients. Cardiology consultation was indicated for 64 (52.9%) patients at follow-up. At follow-up, 22 patients had indications for respiratory function tests and 20 for polysomnography. At least one vaccination was recommended for 76 (53.2%) patients and at least one cancer screening for 68 (40.4%). Dietary (20 patients) and pneumological (11 patients) consultations were recommended during the follow-up consultation for patients with no initial indication(s) for a consultation; 21 (34.4%) patients without an initial recommendation had a recommendation for a cardiological consultation during follow-up. During the follow-up consultation, patients with no initial indication(s) for these treatments received prescriptions for anti-hypertensive medication (3 patients), statins (3 patients), anti-osteoporotic medication (6 patients), and vitamin-calcium treatment (3 patients). No anti-platelet therapy or oral anti-diabetic therapy was prescribed in the absence of an initial indication. A total of 17 patients had a statin indication at the initial workup and at the follow-up visit.

The present work highlights the value at medium term of our program for screening and preventing multimorbidities in chronic inflammatory rheumatism and its follow-up. The initial recommendations were generally well implemented, led to the prescription of various therapies, increased vaccination coverage and cancer screening, and led to significant decreased cholesterol levels in patients with initial abnormalities. These results confirm those of the COMEDRA program, whose mid-term evaluation showed an improvement in screening and management of multimorbidities in patients with chronic inflammatory rheumatic diseases (11, 12).

A significant proportion of patients in this population quit smoking after screening. The initial screening revealed active smoking in 60 (33.3%) patients; 19 (31.6%) had quit smoking at the follow-up visit. Of the patients who had not quit smoking, 9 (22.5%) were in the process of quitting, with a reported reduction in smoking. This smoking cessation rate seems much higher than that with other smoking cessation programs (13, 14). This success may be explained by the information and awareness of the increased cardiovascular risk in chronic inflammatory rheumatic diseases and the concrete visualization by patients of the consequences of smoking on their vessels during the SAT-US. A connection with doctor specializing in tobacco addiction during the day could further increase the smoking cessation rate.

Among patients with an initial recommendation, LDL and total cholesterol levels decreased significantly. Similar results are found in the literature, including in the I-CARE program (15). In our program, management of dyslipidemia seems to be effective but still insufficient because only half of the patients followed the dietary rules, with a low proportion of statin prescriptions (13.3%). Hence, cooperation with the general practitioner could be strengthened. The follow-up visit improved this management with statin prescriptions for 17 patients and dosage reinforcement for 22.

BMI did not significantly differ between the two assessments, nor did waist circumference improve in any patient (+ 2 cm). These results are also comparable to those of the I-CARE program (16). Thus, the management of obesity must be individualized and requires long-term follow-up. Since 2018, patients are now systematically offered care in the Metabolic Diseases Department of Montpellier University Hospital.

The follow-up visit allowed for a reminder of the initial recommendations and motivated the patient to apply recommendations that had not been applied. It also allowed for a re-evaluation of patients and issuing new recommendations for some. The pace of re-evaluation, particularly in the cardiovascular field, remains uncertain. It depends above all on the individual risk score for cardiovascular events at 10 years. Our initial strategy, developed with our cardiologists, was to reassess whether the risk was high at 1 year, moderate at 2 years, and low at 5 years, with a complete assessment identical to the initial assessment. We have adapted this follow-up with a systematic clinico-biological re-evaluation of patients at 1 year in out-patient consultation and a daily-clinic complete assessment at 5 years. For high- and very high-risk patients, an exercise test or a myocardial scan was systematically proposed at the end of the evaluation.

This work has several limitations. The main one is the absence of a control group to compare the clinico-biological follow-up. Some clinico-biological data were missing or not completed during the initial assessment or during the follow-up because the questionnaire was completed in daily practice (< 10%). The reasons for missing or incomplete clinical and biological data were consultations without nursing intervention at the beginning of the program, omission of the patient's biological workup, or lack of understanding by the patient. A number of follow-up questionnaires were completed manually at a later date from the medical file. Most patients had not yet been seen during follow-up consultations. The objective of this work was to assess our practices to optimize them. Patients without an initial referral and those who refused to attend were not re-assessed, which may induce a selection bias limiting the generalization of results to all screened patients. Patients who agreed to return were likely those who were motivated by the initial screenings and who completed them. The rates of referrals made or completed may have been overestimated relative to the overall screened population. The characteristics of the patients re-assessed in terms of multimorbidities were nevertheless close to those of patients in the first analysis. Finally, drug prescription was assessed, but we were not able to analyze compliance.

This study is one of the few to evaluate the concrete remote impact of a screening program. The COMEDRA program evaluated patients at 2 to 4 years but mainly described the number of abnormalities found or recommendations made during screening and follow-up (12). There was no indication of changes in clinical or biological parameters. A significant number of patients could be re-evaluated, which allows for a fairly accurate estimate.

In conclusion, the medium-term evaluation of the screening and prevention assessment program at Montpellier University Hospital demonstrates the interest of the initial program and its follow-up with good application of the initial recommendations and an objective improvement of several multimorbidity criteria. The follow-up consultation allows for re-assessing the patients and issuing new recommendations and thus optimizes the therapeutic management.

Ethics

Consent for publication

Not applicable

Conflicts of interest

GD received honoraria from Galapagos, Abbvie, BMS, UCB, viatris, Pfizer.

AJ has no conflicts of interest

GM received honoraria from Abbvie, Amgen, BMS, Galapagos, Janssen, Lilly, MSD, Nordic Pharma, Novartis, Pfizer, Roche-Chugai, UCB, Viatris

CL received honoraria from Abbvie, BMS, Celgene, Janssen, Medac, MSD, Novartis, Pfizer, Sanofi, Schering, Roche- Chugai, UCB.

CG-V received honoraria from Abbvie, BMS, Celgene, Janssen, Lilly, Medac, MSD, Nordic Pharma, Novartis, Pfizer, Roche-Chugai, Sanofi, Schering, UCB.

BC received honoraria from Abbvie, BMS, Gilead, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, Sanofi, UCB.

JM received honoraria from Abbvie, BMS, Celgene, Janssen, MSD, Novartis, Pfizer, Sanofi, Schering, Roche- Chugai, UCB.

CD received honoraria from Abbvie, BMS, Lilly, Novartis, Pfizer, Roche-Chugai, Sanofi, UCB.

Funding:

No specific funding was received from any bodies in the public, commercial or not-for-profit sectors to carry out the work described in this article.

Author’s contributions:

Conception or design of the work: CD, GD, GM, CL, CG-V, BC, JM ; acquisition and analysis of data for the work: AJ, GD; interpretation of data for the work: CD, GD, AJ; drafting the work: CD, AJ, JM; revising it critically: GM, CL, CG-V, BC, JM; final approval of the version to be published: CD, GD, GM, CL, CG-V, BC, JM; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Acknowledgement:

We would like to thank the healthcare team, especially in the rheumatology day hospitalization, without whom this screening could not be implemented in practice.

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No competing interests reported.

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Multimorbidity Screening Program Enhances Management of Chronic Inflammatory Rheumatism Patients

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Abstract

Background

Methods

Results

Conclusion

Key messages

Background

Methods

Screening procedures

Data collection

Objectives and endpoints

Recommendation application

Statistical analysis

Ethics

Results

Participants

Patient characteristics

Implementation of recommendations in the overall sample

Details of outcomes from recommendations application for patients who followed the recommendations

Reasons for non-application of the initial recommendations

Anthropometric variations between assessments (Table 2)

Blood pressure variations (Table 2)

Biological parameters (Table 2)

Description of intercurrent events (Supplementary table S4)

New recommendations issued (Table 3)

Discussion

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References

Additional Declarations

Supplementary Files

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