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1. R E S E A R C H A R T I C L E
Addressing rural and remote access disparities for patients with
inflammatory arthritis through video‐conferencing and
innovative inter‐professional care models
Regina Taylor‐Gjevre1 | Bindu Nair1 | Brenna Bath3,5 | Udoka Okpalauwaekwe1 |
Meenu Sharma1 | Erika Penz4 | Catherine Trask5 | Samuel Alan Stewart2
1
Division of Rheumatology, College of
Medicine, University of Saskatchewan,
Saskatoon, SK, Canada
2
Medical Informatics, Department of
Community Health & Epidemiology, Dalhousie
University, Halifax, NS, Canada
3
School of Physical Therapy, University of
Saskatchewan, Saskatoon, SK, Canada
4
Division of Respirology, College of Medicine,
University of Saskatchewan, Saskatoon, SK,
Canada
5
Canadian Centre for Health and Safety in
Agriculture, University of Saskatchewan,
Saskatoon, SK, Canada
Correspondence
Dr Regina M. Taylor‐Gjevre, Division of
Rheumatology, Department of Medicine,
University of Saskatchewan, Royal University
Hospital, 103 Hospital Drive, Saskatoon, SK,
S7N0W8, Canada.
Email: r.gjevre@usask.ca
Funding information
Canadian Initiative for Outcomes in Rheuma-
tology cAre (CIORA)
Abstract
Objective: The aim of the present study was to evaluate whether rheumatoid arthritis (RA)
patients followed longitudinally using video‐conferencing and inter‐professional care support
have comparable disease control to those followed in traditional in‐person rheumatology clinics.
Methods: This was a randomized controlled trial for 85 RA patients allocated to either
traditional in‐person rheumatology follow‐up or video‐conferenced follow‐up with urban‐based
rheumatologists and rural in‐person physical therapist examiners. Follow‐up was every 3 months
for 9 months. Outcome measures included disease activity metrics (disease activity in 28 joints
with CRP measure score [DAS28‐CRP], and RA disease activity index [RADAI]), modified health
assessment questionnaire (mHAQ), quality of life (EuroQOL five dimensions questionnaire
[EQ5D]) and patient satisfaction (nine‐item visit‐specific satisfaction questionnaire [VSQ9]).
Results: Of 85 participants, 54 were randomized to the video‐conferencing team model and
31 to the traditional clinic (control group). Dropout rates were high, with only 31 (57%) from
the video‐conferencing and 23 (74%) from the control group completing the study. The mean
age for study participants was 56 years; 20% were male. Mean RA disease duration was
13.9 years. There were no significant between‐group differences in DAS28‐CRP, RADAI, mHAQ
or EQ5D scores at baseline or over the study period. Satisfaction rates were high in both groups.
Conclusions: We found no evidence of a difference in effectiveness between inter‐
professional video‐conferencing and traditional rheumatology clinic for both the provision of
effective follow‐up care and patient satisfaction for established RA patients. High dropout rates
reinforce the need for consultation with patients' needs and preferences in developing models of
care. While use of video‐conferencing/telehealth technologies may be a distinct advantage for
some patients, there may be loss of travel‐related auxiliary benefits for others.
KEYWORDS
access, interdisciplinary, Rheumatoid Arthritis
1 | INTRODUCTION
Rheumatoid arthritis (RA) affects approximately 1% of Canadians
(Widdifield et al., 2014). Optimal management of this chronic disease
includes some regularity of rheumatological follow up, with frequency
dependent on disease activity and severity. In the Canadian province
of Saskatchewan all rheumatologists serving the Northern two‐thirds
of the province are located in the city of Saskatoon. However, over
half of Northern Saskatchewan's population resides in smaller commu-
nities or rural areas. Some of these communities are fairly isolated and,
depending on season, may not be road accessible. The travelling
required for accessing rheumatology follow‐up and care can be
problematic for some people with RA living in these regions. In
congruence with the 2002 Commission on Future of Health Care in
Canada, which recognized geographic location as a determinant of
health, people with RA in Northern Saskatchewan have identified
Received: 10 July 2017 Revised: 7 August 2017 Accepted: 11 August 2017
DOI: 10.1002/msc.1215
Musculoskeletal Care. 2017;1–6. Copyright © 2017 John Wiley & Sons, Ltd.
wileyonlinelibrary.com/journal/msc 1

2. barriers to healthcare access based on the location of residence (Nair,
Schuler, Stewart, & Taylor‐Gjevre, 2016; Romanow, 2002). Key chal-
lenges identified include arranging transportation, environmental fac-
tors and road conditions. One‐third of people surveyed living in
Northern Saskatchewan and outside of the major urban centre
reported that they felt that their location of residence had a negative
impact on their ability to access healthcare for RA (Nair et al., 2016).
Telehealth distance technologies have been considered as an
option to mitigate healthcare challenges or obstacles for people
living in more remote locations. These technologies have been used
in the field of rheumatology, including by Davis, Howard, and
Brockway (2001), who reported a Canadian feasibility study
assessing user satisfaction and cost‐effectiveness in an Alberta clinic
with 52 new consultations. In the latter study, physical examination
was performed by referring family physicians and discussed with the
rheumatologist using telehealth technology. For this heterogeneous
patient population, no subsequent rheumatology consultation was
determined to be required. Leggett et al. (2001) reported on a pro-
spective study of 100 new rheumatology consultations initially seen
via telehealth, and later in person. The accuracy of diagnosis was
97%; however, only 5% of this population carried a diagnosis of
RA. A screening and consultation study in rural Canadian communi-
ties indicated positive physician satisfaction and cost‐effectiveness
with the video‐conference clinic service (Jong & Kraishi, 2004).
There has been positive experience with telehealth as a delivery
method for a patient self‐management program in Ontario, Canada
(Guilcher, Bereket, Voth, Haroun, & Jaglal, 2013).
Despite these reported positive experiences with telehealth
technologies, longitudinal follow‐up via video‐conferencing/telehealth
has not been assessed as a service delivery tool in terms of patient
outcomes in RA populations. The objective of the present study
was to evaluate whether RA patients followed longitudinally over a
9‐month period using video‐conferencing and inter‐professional care
support with physical therapists would have comparable disease con-
trol with those followed in traditional in‐person rheumatology clinics
over a 9‐month time frame.
2 | METHODS
The study was approved by the University of Saskatchewan Bio‐
medical Research Ethics Board (Bio 14–176) and was registered with
ClinicalTrials.gov PRS, (identification number NCT02371915).
2.1 | Study design
This randomized controlled intervention trial was supported by three
urban‐based rheumatologists, who either followed up RA patients in
their rheumatology traditional clinics, or via video‐conferencing, and
by three physical therapists travelling to rural communities who
attended RA follow‐up clinics in five communities in rural
Saskatchewan: Prince Albert, North Battleford, Rosetown, Wynyard
and Arborfield. These sites were identified and selected over other
rural sites in Saskatchewan based on geographical proximity to
eligible patient population densities.
The study rheumatologists and physical therapists participated in an
orientation and education session around RA and the study protocol.
Each physical therapist also spent in‐person time in Saskatoon outpa-
tient clinics with the study rheumatologists, to have a concentrated clin-
ical exposure to people with RA and to facilitate subsequent inter‐
professional communication. The inclusion criteria for participants in
the study were: residence 100 km or more outside Saskatoon or Regina
with a rheumatologist‐established diagnosis of RA. Eligible patients were
identified through Saskatoon rheumatology clinic databases and were
invited to participate either during a clinic visit or through telephone con-
tact. A total of 318 people with RA were invited to participate, of whom
85 agreed and completed the informed consent process.
Following the consent process, participants were randomized
using a stratified block randomization algorithm. Clinicians were not
involved in or aware of the outcome of the randomization allocation,
which was overseen by the research coordinator. Initially, the partici-
pants were stratified to the closest geographical regional location to
their residence; they were then randomized using a block strategy to
either the video‐conferencing arm or the control arm. The block sizes
were pre‐determined by the relative population density per stratifica-
tion. Prince Albert and North Battleford were assigned blocks of seven,
Rosetown and Wynyard, blocks of four and Arborfield blocks of two.
This strategy permitted temporal proximity of follow‐up appointments
to be logistically clustered for the rural physical therapist clinics.
The intervention group was followed by video‐conferencing at
one of the five rural clinic sites. The control group participants were
followed in a traditional in‐person rheumatology clinic in Saskatoon.
Video‐conferencing participants were examined in person by an on‐
site physical therapist, travelling from Saskatoon, who subsequently
reported findings during the video‐conferencing session with their
urban‐based rheumatologist. The physical therapists' participation in
patient care was limited to this role for the purposes of the present
study. The physical therapists set up the video‐conferencing link with
the urban‐based rheumatologist using video‐conferencing software
(VidyoDesktop software, Vidyo Inc., Hackensack, NJ, USA) installed
on laptop computers. A detachable external web camera with remote
pan, tilt and zoom functions was attached to the laptop to provide
additional visualization opportunities for the rheumatologist. All of
the rheumatologists and physical therapists participating in the study
underwent a training session with the software and camera.
Follow‐up visits were conducted approximately every 3 months
over a 9‐month period for both groups (Smolen et al., 2010). This dura-
tion of study was selected by the study team as representing a sufficient
time to detect a change in clinical status. At the 10th month time point,
patients in the video‐conferencing group were evaluated in‐person with
their respective rheumatologists. Continuity in the physical therapist
examiner for each visit for each individual video‐conferenced patient
was maintained. Provision was made for patients in whom urgent con-
cerns arose in the interval between scheduled follow‐up visits, to have
an “urgent” visit in‐person in the rheumatology clinic in Saskatoon.
For in‐person rheumatology clinics in Saskatoon, the rheumatol-
ogy nurse educator was often available as a resource for patients. In
order to maintain ease of access to this resource for study participants,
the rheumatology education nurse contacted each individual 3–
6 months after study entry. This was an in‐person visit for the
2 TAYLOR‐GJEVRE ET AL.

3. participants in the control arm and a telephone visit for the participants
in the intervention arm.
2.2 | Data collection
Demographic data were collected for each patient, including age, gen-
der and body mass index (BMI). Other measures included the following.
Disease activity: This was measured using the disease activity in 28
joints with CRP measure score (DAS28‐CRP), which is calculated from
four components including tender joint count, swollen joint count,
visual analogue scale (VAS) score of the patient's global health and
CRP level. DAS28‐CRP cut‐off scores of 4.09, 2.67 and 2.32 have been
proposed to be indicative of high disease activity, low disease activity
and clinical remission, respectively (Inoue, Yamanaka, Hara, Tomatsu,
& Kamatani, 2007). The rheumatoid arthritis disease activity index
(RADAI), which has a possible range of 0–10, for which higher scores
reflect greater disease activity (Fransen, Langenegger, Michel, & Stucki,
2000), and the modified health assessment questionnaire (mHAQ), with
an average score range of 0–3, increasing with greater impairment
(Pincus, Summey, Soraci, Wallston, & Hummon, 1983) were also used.
Quality of Life: This was evaluated through the EuroQol five
dimensions questionnaire (EQ5D), which is a self‐reported question-
naire with a VAS for state of health and a descriptive component which
includes five dimensions. These dimensions reflect mobility, self‐care,
usual activities, pain/discomfort and anxiety/depression. An EQ5D
maximum score of 1.0 is reflective of full health (Luo et al., 2003).
Satisfaction: This was measured through use of the nine‐item visit‐
specific satisfaction questionnaire (VSQ9), which includes a set of nine
items evaluated to measure visit‐specific satisfaction. The mean from
these nine scale measurements is calculated to provide the individual
VSQ9 score. The possible scores range from 0 to 100, with higher
scores reflecting greater levels of satisfaction (Rubin et al., 1993).
Participants were requested to complete these questionnaire
packages at study entry and at each follow‐up visit for the duration
of the study.
Physical examination data on joint findings (swollen and tender
joint counts) were collected from the rheumatologists for all baseline
visits, all follow‐up visits for the control group and the final 10‐month
visit for the video‐conferencing group. These data were collected from
the on‐site physical therapists for the follow‐up visits for the video‐
conferencing group. The patient's global function score (100 mm VAS
for global function) was collected at baseline and at each follow‐up
visit. Patients were provided with laboratory requisitions to undergo
measurements, including C‐reactive protein levels drawn at baseline
and at each follow‐up visit. These various data contributed to the cal-
culation of the outcome measure for disease activity, the DAS28‐CRP.
2.3 | Statistical analysis
A change in the DAS28‐CRP was identified as the primary outcome
measure, with a minimally clinically significant change being identified
as 1.0 (Ward, Guthrie, & Alba, 2017), with a standard deviation in this
population of 1.3 (Ward et al., 2017). For an alpha value of 0.05 and a
beta value of 0.80, the required minimal sample size for each arm of
the study was 27 individuals. We had aimed for recruitment of
approximately 40–50 individuals per arm, to allow for a dropout rate
of over 30%, anticipating the potential both for participant‐related per-
sonal reasons for withdrawal from the study and potential technical
difficulties with the video‐conferencing tool.
The quality of life, disease status and satisfaction questionnaires
were analysed and presented as means and standard deviations.
Differences between intervention (video‐conferencing) and control
groups were analysed using t‐tests and chi‐square tests where appro-
priate. Changes in disease severity over the course of the study were
tested using linear mixed‐effects models, controlling for time using
an exponential correlation structure (Pinheiro & Bates, 2000). All
analyses employed R version 3.2.2 (R Development Core Team, 2015).
3 | RESULTS
3.1 | Patient participation
Of the 85 patients who consented to participate in this study, 54 were
randomized to the video‐conferencing follow‐up arm and 31 to the
control arm. Subsequent dropout rates at various points in the study
were high (Figure 1). Over the course of the study, 23 participants
(43%) left from the videoconferencing arm and eight (26%) from the
control group. Thirty‐one (57%) participants from the video‐confer-
encing group and 23 participants (74%) from the control group com-
pleted the study. The reasons provided for leaving the study related
primarily to a preference to travel to the city for their rheumatology
appointment, for various reasons, and, to a lesser extent, a disinclina-
tion to continue with the study and complete the study questionnaires.
During the study, technical difficulties arose during 10 video‐con-
ferencing patient visits, resulting in only an audio‐link being available.
Six patients required “urgent” visits outside of the scheduled follow‐
up visits – three from the video‐conferencing group and three from
the control group. Reasons for the “rescue” visits included only one
case where inflammatory arthritis treatment efficacy was at issue;
other reasons provided included medication reactions, abnormality in
laboratory monitoring bloodwork results, inter‐current non‐articular
symptomatology and perioperative requirement.
3.2 | Patient characteristics
The demographic categorical characteristics of the study population
are detailed in Table 1. The mean age of the population overall was
56.4 (standard deviation [SD] = 11.5) years; the control group had a
mean age of 53.1 (SD = 12.2) years, while the intervention group had
a mean age of 58.4 (SD = 10.7) years. The mean duration of RA was
13.9 (SD = 11.8) years, with the control group having a mean RA dura-
tion of 15.5 (SD = 14.4) years, and the intervention group 13.2
(SD = 10.5) years. The mean BMI was overall 32.2 (SD = 7.1 kg/m2
).
The mean BMI for the control and intervention groups were 32.2
(SD = 7.1) kg/m2
and 32.1 (SD = 7.1) kg/m2
, respectively.
3.3 | Outcome measures
Data collection included measures of disease activity (DAS28‐CRP,
RADAI and mHAQ scores) and quality of life (EQ5D). Figure 2
TAYLOR‐GJEVRE ET AL. 3

4. illustrates the changes in these four measurements over the course of
the study period, and Table 2 compares the changes in each measure
over the study period between the two study groups. No statistically
significant differences were observed in these outcome measures
between the study groups at baseline or over the time period studied.
Of further note, when comparing baseline values for these outcome
measures between those who dropped out of the study and those
who continued, no statistically significant differences were observed.
Satisfaction for participants in both groups was evaluated using
the VSQ9 survey tool. Figure 3 illustrates the patient satisfaction
scores for each of the three follow‐up visits for the two groups. There
were no statistically significant differences in reported satisfaction
between the two groups at any time point. Both groups had high
satisfaction scores overall; however, the intervention group rated their
care as “excellent” more often (76%) than the control group (59%). This
difference was offset by ratings of “very good” (17% for intervention
group versus 32% for control group), but explains the difference in
average scores seen in the boxplot (Figure 3).
4 | DISCUSSION
In the present study of RA patients from Northern and rural
Saskatchewan, we compared care provided through traditional rheu-
matology clinics in an urban centre to distance care through an inter‐
professional care model via video‐conferencing with physical therapist
on‐site examiners. Using the DAS28‐CRP as the primary outcome
measure, we did not find any statistically significant difference
between the two follow‐up clinic models. Similarly, there were no sig-
nificant differences in RADAI, mHAQ or EQ5D scores over the course
of the study period. These results provide no evidence to suggest a
difference between effectiveness of video‐conferencing compared
TABLE 1 Patient demographic characteristics
Variable Levels N Control (%) Intervention (%)
All 85 31 54
Gender Male 17 6 (19%) 11 (20%)
Female 68 25 (81%) 43 (80%)
Marital status Married 58 19 (68%) 39 (76%)
Not married 21 9 (32%) 12 (24%)
Education High school or less 30 10 (36%) 20 (39%)
Trade school 17 6 (21%) 11 (22%)
Some university 12 5 (18%) 7 (14%)
University degree 20 7 (25%) 13 (25%)
Income <$30,000 19 5 (19%) 14 (29%)
$30,000–59,999 19 8 (31%) 11 (22%)
$60,000–99,999 21 6 (23%) 15 (31%)
>$100,000 16 7 (27%) 9 (18%)
Work Paid work 40 15 (54%) 25 (49%)
Unemployed 17 5 (18%) 12 (24%)
Retired 22 8 (29%) 14 (27%)
Smoker Smoker 18 9 (33%) 9 (18%)
Former smoker 39 10 (37%) 29 (57%)
Non‐smoker 21 8 (30%) 13 (25%)
FIGURE 1 Participant recruitment flow chart [Colour figure can be viewed at wileyonlinelibrary.com]
4 TAYLOR‐GJEVRE ET AL.

5. with traditional clinics in the provision of longitudinal follow‐up care
for patients with established RA.
There were also no statistically significant differences in satisfaction
scores between groups. It should beclearly noted that patient satisfaction
scores were not lower for those who participated in the video‐conferenc-
ing clinics. These findings are in keeping with the results reported in other
RA patients in a similar population and rural setting (Jong & Kraishi, 2004).
The focus of the present study was towards the comparability of the two
follow‐up clinic strategies from a disease outcome perspective. Economic
comparison data were not available to evaluate the models from a health‐
economic advantage perspective.
The individuals who participated in the present study were longer‐-
duration, relatively stable RA patients. The findings could have been dif-
ferent for patients with earlier‐stage disease or higher baseline activity
levels. Similarly, the duration of study follow‐up over 9–10 months may
not have been long enough to demonstrate differences between the
groups over time. It is possible that significant differences in outcomes
would have become evident over a longer follow‐up period.
Due to recruitment challenges within this study, the strategy of
initially filling the intervention block in the site‐specific recruitment
resulted in a higher number of participants for that arm of the study.
This ultimately unequal allocation made the control (traditional clinic)
group more vulnerable to the impact of study withdrawal. Although
the initial patient sample size was adequately powered for the study,
the unexpectedly high study dropout rate resulted in the control group
falling slightly below the estimated required sample size. Accordingly,
the study results should be interpreted with caution.
One observation from the present study relates to the challenges
that were experienced around the recruitment process. Research coor-
dinators were repeatedly informed that for some patients and their
families, the trip to the urban centre for the rheumatology follow‐up
appointment was welcomed for a variety of reasons, including: the
opportunity to complete errands, have other appointments and visit
family in the city. By contrast, there were some patients who were
pleased to have the opportunity to stay closer to home and avoid
travel or time away from work or their families. A more formal qualita-
tive evaluation may help to elucidate these factors more clearly and
ultimately lead to improved design and tailoring of the intervention
to match individual patient preferences or needs.
FIGURE 2 Disease activity (mHAQ, DAS28‐CRP and RADAI) and quality of life (EQ5D) measures over time for both study groups [Colour figure
can be viewed at wileyonlinelibrary.com]
TABLE 2 Changes in disease activity and quality of life measures from
baseline to 9 months
Measure Control Intervention Difference 95% Ci p‐value
RADAI −1.4 −0.4 0.9 [−2.4, 0.5] 0.1926
EQ‐5D 0.1 0.0 −0.1 [−0.1, 0.4] 0.2942
mHAQ −0.2 0.1 0.2 [−0.5, 0.1] 0.1358
DAS28‐CRP 0.2 1.1 0.9 [−3.1, 1.2] 0.3338
CI, confidence interval; DAS28‐CRP, disease activity in 28 joints with CRP
measure score; EQ5D, EuroQol five dimensions questionnaire; mHAQ,
modified health assessment questionnaire; RADAI, rheumatoid arthritis dis-
ease activity index
FIGURE 3 Patient satisfaction (VSQ9 scores) over time [Colour figure
can be viewed at wileyonlinelibrary.com]
TAYLOR‐GJEVRE ET AL. 5

6. One contributing factor to patient disinclination to participate in
or continue with the video‐conferencing arm of the study may have
been related to the specific site locations for the distance clinic. As it
was not possible within the available resources for the study to have
the physical therapists travel to every rural community, we elected to
identify and utilize several regional sites with capacity for such an
inter‐professional video‐conference clinic. Patients residing in that
geographical region who were assigned to the video‐conferencing
arm of the study were requested to attend the regional rural site clinic.
In some cases, patients had to travel a distance from their rural resi-
dences to reach the regional site clinic. For some, this travel, albeit
shorter in duration, was a disincentive. It would appear that the travel
savings did not meet a threshold for convenience; for example, some
patients described that if they had to travel for an hour to go to the
regional video‐conferencing clinic, they would prefer to travel the 3 h
to come to the city, with the auxiliary benefits of a visit to the city.
In conclusion, based on the results from the current study,
there was no evidence of a difference in effectiveness between
video‐conferencing follow‐up and traditional in‐clinic follow‐up in
terms of disease activity measures (DAS28‐CRP, RADAI, mHAQ), qual-
ity of life (EQ5D) or patient satisfaction (VSQ9) over the study period
of 9–10 months; however, given the relatively high dropout rate, these
results should be interpreted with caution. Video‐conferencing in an
inter‐professional collaborative care model appears to be a feasible
method for follow‐up of stable long‐term RA patients who live in
rural/remote parts of the province.
As the patient recruitment and retention data indicate, it is clear
that strategies for the development of models of care need to involve
consultation with the people they are being developed to serve. While
distance technology may be a distinct improvement and advantage for
some patients, there may be loss of auxiliary benefits for others which
the travel facilitates/supports.
ACKNOWLEDGEMENTS
We would like to thank Dr. Regan Arendse, Dr. Latha Naik, Mr. Richard
Bourassa, Ms. Anne‐Marie Graham, Ms. Denise Cherkas, Ms. Karen
Hardy, Ms. Zoe Arnold and Ms. Katie Crockett for their contributions
to this project. We thank all the patients who participated in this study,
for their time and effort. This study was funded by the Canadian Initia-
tive for Outcomes in Rheumatology cAre (CIORA), a granting organiza-
tion committed to improving the care of Canadians living with all
rheumatic diseases. Dr. Trask was supported through funding from
the Canada Research Chairs program.
ORCID
Regina Taylor‐Gjevre http://orcid.org/0000-0003-2930-7607
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How to cite this article: Taylor‐Gjevre R, Nair B, Bath B, et al.
Addressing rural and remote access disparities for patients with
inflammatory arthritis through video‐conferencing and innova-
tive inter‐professional care models. Musculoskeletal Care.
2017;1–6. https://doi.org/10.1002/msc.1215
6 TAYLOR‐GJEVRE ET AL.