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Summer 2019 (Volume 29, Number 2)

Distinguished Investigator:
Dr. Diane Lacaille

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You are credited as a pioneer in the use of administrative data for quality of care and pharmacoepidemiologic research. What led you to focus on these areas of interest?
The research questions I pursue in my research program are usually inspired by my clinical practice. I started my practice in 2000, at a time when new treatments and approaches completely changed the landscape for rheumatoid arthritis (RA) and opened the door to new possibilities of controlling this terrible disease and preventing joint damage, in ways that had never been possible before. But what struck me early on, was that some patients were completely left out of the game. They were accessing care too late. Having the most effective medications available is of no use, if patients are not accessing care. This is what got me interested in evaluating quality of care at the population level, having the ability to look at everyone across the province, not just the people that we see regularly in our practices.

I expected that care would not be perfect, but I was shocked when I got the results of my first study showing that only half of the patients in British Columbia labelled as having RA by family physicians were being referred to rheumatologists, or started on disease-modifying antirheumatic drugs (DMARDs). At first, I didn't believe my results. But then I remember, shortly after getting those results, seeing a patient in clinic from a rural area, with advanced RA deformities, who had never been on a disease-modifying agent. I knew I was onto something real. Since then, others have noted similar findings in other provinces. Things are better now, but they're still not as good as they should be. The problem is that we don't know what we don't see. We have to design ways of systematically measuring the quality of care received by everyone, if we want to understand care gaps and improve things.

How has your work impacted the local Canadian RA landscape?
I think these results were an eye-opener for many people. In British Columbia, the Ministry of Health and arthritis stakeholders embarked on a chronic disease management strategy for arthritis. Local RA guidelines for family physicians were developed. These results were instrumental in having RA selected as a target for a provincial Practice Support Program, which integrates practical tools in physicians’ practices to support the management of RA by family physicians. Nationally, our research and that of others, identifying similar gaps in care, sparked interest in developing alternative models of care and in developing systems to evaluate the impact of those models of care. The Arthritis Alliance of Canada has done a lot of work in that regard.

You have explored the impact of community-based research, for example with First Nations communities, to develop and evaluate arthritis programs consistent with Indigenous approaches to health. Why is “community-based” research important in the field of rheumatoid arthritis?
When working in partnership with Indigenous communities, a community-based approach to research is absolutely essential. For research to have a real impact and properly address the needs of the community, there has to be buy-in for the research conducted. For this to happen, the community has to be actively involved throughout the process: Setting the research priorities, identifying the needs, providing input, and ensuring that the arthritis services created are consistent with their values and priorities. These relationships take time to develop and have to be built on trust and respect. Having arthritis services that are consistent with Indigenous approaches to health will, hopefully, help reduce the health inequalities observed in First Nations communities.

Why did you focus on employment and developing Making it WorkTM, the first comprehensive program to prevent work disability in people with inflammatory arthritis?
As a rheumatologist, I see how people with arthritis often struggle to continue working, and I recognize how much work means to our patients. It is much more than a source of finances. It is an important part of their self-identity, their sense of contribution to society, their social interactions, and so much more! I am constantly amazed by people's ability to continue forging ahead despite the challenges they encounter at work. People are so resourceful! Their resilience is what inspires me to continue on with my research, to find ways to allow them to continue working, because it matters so much to them.

What future directions do you wish to pursue in your own research? What general developments would you like to see in the field of rheumatology and arthritis care?
I want to continue to design and evaluate strategies to improve the delivery of care for arthritis and for the other diseases that occur as complications of inflammation. I think that we need to leverage technology to improve care, at an individual level, using eHealth technologies so people can be more engaged in their care, like the app we have designed to allow people to self-monitor their RA disease activity; as well as at a system level, by taking advantage of electronic medical records and other sources of data, so we can measure and provide feedback in real time, for continuous quality improvement. I think eHealth technology is going to transform how we provide care in ways we can’t even imagine right now.

What advice would you give to someone looking to pursue a career as an academic rheumatologist?
I would say that it is a very rewarding career. Yes, it requires hard work and perseverance, there are many challenges along the way, especially in the current funding environment. One has to learn to let things roll off your back: the grants that get rejected, the manuscripts that need to be resubmitted. You learn what you can from it, and then move on, and try again. It is also crucial to have a good mentor, someone that can help you navigate the system, give you wise counsel, have your best interest at heart and open doors for you. It is also very important to not get overcommitted in clinical work. Patients always come first, but one needs protected research time to succeed.

But despite all the challenges, it is all well worth it! I find my work continuously stimulating and intellectually challenging. I love the diversity of my days. When projects finally come to fruition, it is very satisfying to see or feel the impact of the work done. Some of my most memorable moments have been hearing participants from the Making it Work program describe how much this program has changed their lives and how much it has meant to them.

What is your guilty pleasure television show?
I don’t watch any TV at all! Only the Olympics and the news.

What is your favourite place to travel to?
My favourite travelling is taking off on our sailboat and heading north along the coast to places where only boats can go, away from the roads, where you can’t hear any cars. I cherish the moment we turn off the engine, let the wind fill the sails and feel at one with the ocean. It doesn’t matter where we are, I just love being at anchor at night in a quiet bay, watching the night fall and the stars appear in the sky.

Drs. John Esdaile and Kam Shojania presented a hilarious video at the CRA Gala introducing your award. What are they like to work with?
They are extremely smart, as quick and witty as in the video, and incredibly supportive! I could not have asked for a better mentor and a more supportive Division Head.

Dr. Diane Lacaille receiving her award from Dr. Vandana Ahluwalia.

Diane Lacaille, MD, FRCPC, MHSc
Mary Pack Chair in Rheumatology Research
Professor of Rheumatology,
University of British Columbia
Senior Research Scientist,
Associate Scientific Director,
Arthritis Research Canada
Richmond, British Columbia

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