Urgent care and tight control of rheumatoid arthritis as in diabetes and hypertension: better treatments but a shortage of rheumatologists

[Manpower of rheumatology in catalonia (Spain)]

OBJECTIVE

To determine the changes in Rheumatology provision and working practice that have occurred on the basis of the 1990, 1996 surveys carried out to update the Catalan Society for Rheumatology register

METHODS

The register includes all rheumatologists in Catalonia (Spain) who are registered and who do clinical work. Questionnaires were sent to all rheumatologists on the register. The questionnaires asked about location and clinical commitments.

RESULTS

One hundred twenty-four rheumatologists work at the public system in Catalonia, 80 (65%) work at hospitals. The majority of rheumatologists (105; 84,6%) are located in the province of Barcelona. One fith of the rheumatologists have a temporal work. Ten general hospitals are still lacking of rheumatologists.

CONCLUSION

Although the number of rheumatologists in Catalonia has increased there are ongoing inequalities in the provision of Rheumatology, especially between Barcelona and the rest of provinces.

Justice and health care in the rheumatic diseases

Coping with a chronic disease is a formidable challenge. Owing to the disabling consequences of their underlying conditions, individuals who suffer with a chronic rheumatic disease have especially daunting lives with their existence often dominated by their health-related needs. Due to the high prevalence, the demographic distribution, indeed the very nature of the rheumatic diseases, too many sufferers of these conditions in our society remain disenfranchised with respect to their access to health care. Those who come from already disadvantaged socioeconomic circumstances face particularly difficult challenges. Rheumatologists and their allied health professionals, therefore, have a moral obligation to ensure greater fairness to their patients--those already compromised by the natural lottery that gave them their disease. To enhance the appreciation of this problem and to motivate the rheumatic disease community, we attempt to identify those variables that create the need for and imperil access to medical care for the rheumatic diseases. The implications of these observations are then explored from the ethical perspective of justice. We conclude with suggestions as to how to change the health care system to address these problems.

Cardiovascular death in rheumatoid arthritis: a population-based study

OBJECTIVE

To determine whether systemic inflammation confers any additional risk for cardiovascular death among patients with rheumatoid arthritis (RA), after adjusting for traditional cardiovascular risk factors and comorbidities.

METHODS

Using the population-based data resources of the Rochester Epidemiology Project, we assembled an incidence cohort of all Rochester, Minnesota residents ages >or=18 years who first fulfilled the American College of Rheumatology 1987 criteria for RA between January 1, 1955 and January 1, 1995. All subjects were followed up longitudinally through their complete (inpatient, outpatient) medical records, beginning at age 18 years and continuing until death, migration, or January 1, 2001. Detailed information on the occurrence of various cardiovascular risk factors (personal history of coronary heart disease [CHD], congestive heart failure, smoking, hypertension, dyslipidemia, body mass index [BMI], diabetes mellitus, menopausal status) as well as indicators of systemic inflammation and RA disease severity (rheumatoid factor [RF] seropositivity, erythrocyte sedimentation rate [ESR], joint swelling, radiographic changes, RA nodules, RA complications, RA treatments, disease duration) and comorbidities were collected on all subjects. Causes of death were ascertained from death certificates and medical records. Cox regression models were used to estimate the independent predictors of cardiovascular death.

RESULTS

This inception cohort comprised a total of 603 RA patients whose mean age was 58 years, of whom 73% were women. During a mean followup of 15 years, 354 patients died and cardiovascular disease was the primary cause of death in 176 patients. Personal history of CHD, smoking, hypertension, low BMI, and diabetes mellitus, as well as comorbidities, including peripheral vascular disease, cerebrovascular disease, chronic pulmonary disease, dementia, ulcers, malignancies, renal disease, liver disease, and history of alcoholism, were all significant risk factors for cardiovascular death (P < 0.01 for each). Multivariable Cox regression analyses, controlled for cardiovascular risk factors and comorbidities, revealed that the risk of cardiovascular death was significantly higher among RA patients with at least 3 ESR values of >or=60 mm/hour (hazard ratio [HR] 2.03, 95% confidence interval [95% CI] 1.45-2.83), RA vasculitis (HR 2.41, 95% CI 1.00-5.81), and RA lung disease (HR 2.32, 95% CI 1.11-4.84).

CONCLUSION

These results indicate that markers of systemic inflammation confer a statistically significant additional risk for cardiovascular death among patients with RA, even after controlling for traditional cardiovascular risk factors and comorbidities.

Clinical trials in rheumatic diseases: designs and limitations

Randomized controlled clinical trials provide the best method to distinguish a drug from placebo without the inevitable selection biases that are seen in standard clinical care. This article reviews designs and limitations of clinical trials that are used in rheumatic diseases. The primary design in clinical trials is a parallel, in which patients are randomized in parallel to different therapies at different dosages or placebo. In recent years, other designs have been used increasingly, including "step-up," "step-down," and "cross-over" designs. Limitations of clinical trials in chronic diseases include a short time frame versus the long duration of disease, inclusion and exclusion criteria, use of surrogate markers that may not represent clinically relevant markers, statistical significance does not necessarily indicate clinical significance necessarily, and the fact that a control group does not assure the absence of bias. Therefore, long-term databases are needed to supplement clinical trials in analyzing results of therapy for rheumatoid arthritis.

"The rheumatologist can see you now": Successful implementation of an advanced access model in a rheumatology practice

OBJECTIVE

To provide rheumatologic care to patients in a timely and patient-centered manner.

METHODS

We developed and implemented processes to measure and help eliminate backlog, created access time for same-day patients, and retooled the appointments process to be more efficient and patient focused. In addition, we developed a protocol to be used by our primary care colleagues to care for osteoarthritis of the knee in a standardized manner.

RESULTS

The third available rheumatology appointment fell from about 60 days to <2 days. Cancellations fell from 40% to <20%. Patient satisfaction measures (composite score, physician score, and accessibility score) improved significantly. The number of new patients seen for knee osteoarthritis decreased by 6.7%, whereas the number of new rheumatoid arthritis referrals increased by 50.4%. Financial performance improved as well.

CONCLUSIONS

This advanced access model in a busy academic rheumatology practice demonstrated considerable improvement in access, patient satisfaction, and finances. Using a team approach, we are now able to give the patient the rheumatologic care they want and need at a time they want and need it.

Quantitative measures for assessing rheumatoid arthritis in clinical trials and clinical care

There is no single 'gold standard' quantitative measure to assess and monitor the clinical status in patients with rheumatoid arthritis (RA). Therefore, a variety of measures have been used in clinical research and clinical care, including laboratory tests, radiographic scores, formal joint counts, physical measures of functional status, global measures and patient self-report questionnaires. These measures may address disease activity, joint damage, both activity and damage, or long-term outcomes. Measures of disease activity, such as joint swelling, are reversible and are emphasized in clinical trials. However, activity measures may be improved over 5 years while measures of damage, such as radiographic score, indicate disease progression. Two quantitative indices which are widely used in clinical trials are the (1) American College of Rheumatology (ACR) Core Data Set, which includes swollen joint count, tender joint count, physician assessment of global status, acute-phase reactant-erythrocyte sedimentation rate or C-reactive protein, functional status, pain, patient estimate of global status, a radiograph in studies over 1 year or longer, and (2) the disease activity score(DAs), which includes a swollen joint count, tender joint count, acute-phase reactant, and patient assessment of global status. Randomized controlled clinical trials provide the optimal method to evaluate new therapies, by comparing a therapy with a placebo or another therapy without selecting patients for specific therapies. However, randomized trials in chronic diseases have important limitations, including a relatively short observation period, patient selection for inclusion and exclusion criteria, inflexible dosage schedules, influence of the design on results despite a control group, emphasis on group data while ignoring individual variation in treatment responses, non-standardized interpretation of adverse effects, and others. Therefore, clinical trials in RA must be supplemented by long-term observational studies to assess results of therapy in regard to long-term outcomes such as work disability, joint replacement surgery and premature mortality. The most simple and effective method of collecting important long-term data from patients in routine clinical care is through patient self-report questionnaires.