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

Authors


When there was little effective long-term therapy for most chronic diseases, such as diabetes, hypertension, or rheumatoid arthritis (RA), no urgency existed for treatment. At this time, by contrast, there are excellent therapies for these chronic diseases, which render treatment a relatively urgent matter, particularly with recognition of early damage without treatment. However, while urgency and “tight control” are widely accepted for diabetes and hypertension, treatment of RA unfortunately remains relatively indolent in many settings.

Recognition of the similarities to diabetes and hypertension (Table 1) may enhance understanding of the need for urgent care and tight control in RA (1). All are disorders of cellular dysregulation, possibly even involving similar cytokines and other mediators, resulting in joint swelling in RA, hyperglycemia in diabetes, and elevated blood pressure in hypertension, as well as systemic effects. Unchecked dysregulation leads to inexorable long-term organ damage in most people, such as joint destruction, retinopathy, and/or cardiomegaly. Development of damage usually is insidious, particularly in early disease, but the untreated “natural history” frequently leads to disability and shortening of life span by up to 10–15 years. No “cure” for these chronic diseases is available, since the dysregulation itself is poorly understood. However, effective therapies are now available to control the consequences of dysregulation, and these therapies will prevent or slow organ damage when instituted prior to this damage.

Table 1. Similarities and differences among rheumatoid arthritis (RA), diabetes, and hypertension*
  • *

    ACR = American College of Rheumatology.

Similarities
 Disorders of cellular dysregulation, possibly involving similar cytokines
 Unchecked dysregulation may lead to long-term organ damage
 Development of damage usually insidious
 Untreated “natural history” includes disability and shortening of life span
 “Cure” not available
 Effective “control” now available, preventing or slowing organ damage
Differences
 Diabetes and hypertension more common than RA
 Diabetes and hypertension may be acutely life threatening
 Diagnoses of early diabetes and hypertension are established through a simple laboratory test or a simple clinical measure; recognition of early RA is complex
 Most physicians recognize high blood pressure value or high glucose level as urgent medical matter, but are often uncertain about urgency of musculoskeletal symptoms
 Hyperglycemia and hypertension likely to be persistent, while many people who meet ACR criteria for RA over <6 months have a self-limited process
 Evidence that “tight control” limits organ damage available in diabetes and hypertension, but not yet in RA

Although similarities of RA to diabetes and hypertension are instructive regarding modern approaches to chronic dysregulatory diseases, important differences are also seen (Table 1). Diabetes and hypertension are more common than RA, and nonspecialist physicians have considerably greater experience in their diagnosis and treatment. Hyperglycemia and hypertension are more likely to be persistent markers of unquestioned severity, while many people who meet the American College of Rheumatology (ACR; formerly, the American Rheumatism Association) 1987 revised criteria for RA (2) for <6 months have a self-limited process rather than a progressive disease (3) and do not require urgent intervention. Indeed, self-limited musculoskeletal problems and fibromyalgia are at least 5–10-fold more common than RA (not to mention other less common inflammatory rheumatic diseases) (4–6).

Perhaps the most prominent difference between RA and diabetes or hypertension is that the diagnoses of early diabetes and hypertension are relatively easily established through a laboratory test or a simple clinical assessment which can be taught to any health professional in a matter of minutes, while recognition of early RA often requires specialized knowledge of physical examination of the joints, with which most physicians are unfamiliar. Therefore, many physicians often rely on radiographs and laboratory tests, the results of which are often normal at times when therapy might be most effective. Furthermore, diabetes and hypertension may be acutely life threatening and listed as attributable causes of death, leading to ready acceptance of a need for urgent care and possible hospitalization. By contrast, premature mortality in RA is largely attributable to cardiovascular and other comorbidities (7), and few people are admitted to a US hospital for musculoskeletal problems, other than for surgery. Finally, it is well established that tight control results in lesser vascular damage in diabetes (8) and in increased survival in hypertension (9), and while there is suggestive evidence that tight control of RA changes long-term outcomes, definitive documentation is not yet available (10).

These differences between RA and other dysregulatory diseases may limit the capacity to provide urgent care for RA. Most new patient appointments with a rheumatologist are for conditions in which a wait of a few months is not likely to make a long-term difference, rather than for conditions in which urgent intervention is essential. Therefore, at this time, a call to see a rheumatologist for definitive diagnosis and therapy generally results in an appointment from weeks to months later.

Evidence that a delay of several months is deleterious to optimal care for a person with RA is reported in this issue of Arthritis & Rheumatism by Möttönen et al (11). Their report of decreased capacity of single drugs to control symptoms of RA after a delay of a few months from onset of symptoms to institution of therapy echoes many suggestions in the rheumatology literature from as early as 1977 (12), that early intervention leads to improved outcomes (13, 14). Therefore, a “standard” 3-month wait (or longer), as seen in much current US rheumatology practice, appears undesirable if not unacceptable, particularly with the availability of excellent new therapies at this time, including methotrexate, leflunomide, etanercept, infliximab, and anakinra.

The observations of Möttönen et al (11) and others suggest that substantial changes in rheumatology practice may be needed to provide optimal patient care, at least in the US. Following are several approaches to allow for possible urgent rheumatologic care:

  • 1Preappointment telephone management. Telephone screening of new patient referrals has been effective (15), although many clinics now use a depersonalized “telephone center,” rendering intelligent screening impossible.
  • 2Flexible scheduling. The rheumatologist can hold one or two “slots” for urgent care, although these openings often are filled by demand for appointments.
  • 3Physician extenders. Nurse clinicians and physician's assistants may be very effective screeners and triage practitioners. An extender may be needed by a rheumatologist as a surgeon needs a trained scrub nurse or a radiologist needs a trained technologist, but reimbursement is often not possible in many clinical settings (including many academic settings).
  • 4Specialized clinics. The “early arthritis clinic” has proven to be an excellent model in many European settings (16, 17) and may address the diagnostic uncertainty which may inhibit early treatment for early RA. However, such centers generally require funding from research sources. Mechanisms for reimbursement for patient visits to an early arthritis clinic might be sought in the US and elsewhere.
  • 5Improved nonrheumatologist training. Better training of nonrheumatologists in rheumatic diseases might be addressed. If medical schools were organized on a rational basis, rheumatology would constitute a major component of the curriculum, since rheumatic diseases are the most common diseases in the US general population, even before age 65 (18) and much more after age 65 (6), and musculoskeletal conditions may account for medical care expenditures equivalent to 2.5% of the US Gross Domestic Product (19). However, teaching of rheumatology is often relegated to a few hours, leaving many if not most physicians poorly equipped to deal with musculoskeletal problems and overly reliant on laboratory tests and radiographs to guide decisions.
  • 6Prioritization. A possible “priority” urgent visit, with a higher level of reimbursement, might be a logical approach in a free market, which does not exist in medical care; however, such priority urgent visits might be worth pursuing.
  • 7Innovative programs for patients with noninflammatory syndromes. Strategies such as all-day group programs for 25 patients with syndromes such as fibromyalgia, rather than one-on-one visits with a rheumatologist (20, 21), could lead to more effective care for these patients while leaving more openings for new RA patients and those returning with disease flares.
  • 8Internet use. Many rheumatologists, including the authors, are using the Internet for patient communications, including those involving possible flares of RA; however, this attractive strategy is necessarily limited to certain patients and is not invariably cost-effective.

We must recognize, however, that a primary reason for delay in providing rheumatologic care is a relative shortage of rheumatologists—certainly relative to the prevalence of rheumatic diseases. The number of residents entering rheumatology fellowships has declined over the last decade, and the mean age of US rheumatologists is 51 years, which is among the oldest among clinical specialists. Therefore, with anticipated retirements and fewer trainees, the ACR has projected that there may be a 20% decrease in the number of US rheumatologists between 2016 and 2026 (Figure 1), despite an aging population's need for more rheumatologists.

Figure 1.

Rise and projected decline of US American College of Rheumatology (ACR) membership, as projected at the ACR Strategic Planning Session, July 2000. In 2000, there were ∼3,800 US Fellow members, a number that is projected to increase steadily until 2006. After 2006, the number leaving due to retirement will be greater than the number entering the specialty, and membership will return to 3,800 by 2016. After 2016, the number of US Fellow members will begin to decline, until ∼10 years later, when the number of members leaving will equal the number entering, resulting in a net decline of 20%.

We must increase the number of residents entering our specialty, with more rheumatology in medical school curricula, greater visibility of clinical rheumatology in-house staff training programs, and improved compensation. Academic rheumatology training programs in the US are asked to be fiscally solvent, but are presented with severe handicaps in meeting this requirement. For example, clinical activities of academic rheumatologists generally result in more revenues for training pathologists, radiologists, orthopedists, and other specialists than for training rheumatologists. Academic clinical rheumatologists are often not provided with dedicated clinic space (in contrast to dedicated laboratory space) to conduct clinical trials and other clinical research, which may be an effective source of revenues to help support other clinical activities such as fellowship training. A US clinical researcher often must pay facility fees in addition to “overhead” for use of an examination room to see a patient whose visit may not be reimbursed by insurance, but may provide support for a training program.

The Arthritis Foundation motto, “It's time we took arthritis seriously,” has been further augmented by commentaries suggesting “Rheumatoid arthritis: a medical emergency?” (22), “treat now, not later!” (23), “time to aim for remission?” (24), and “Does partial control of inflammation prevent long-term joint damage [?]” (25). The reports by Möttönen et al (11) and others indicate that these are no longer slogans or academic issues, but urgent exhortations to address the paradox of a rapidly increasing number of vastly improved therapies coupled with a decreasing number of physicians being trained to use these therapies.

Positive trends include provision of support for first-year fellowships, clinical investigator fellowships, and clinician scholar educator awards; discussions of loan repayment programs by the ACR Research and Education Foundation; and support for rheumatology fellows through pharmaceutical companies (which might be in the companies' best economic interests). The success of these efforts not only may improve the welfare of people with RA and other inflammatory rheumatic diseases, but also may be required to ensure the very survival of rheumatology as a subspecialty. Further dialogue concerning these matters is needed among rheumatologists, arthritis organizations, and people with rheumatic diseases, and would appear to be one of the major medical, intellectual, and ethical responsibilities of the rheumatology community at this time.

Acknowledgements

We thank Audrey Nelson, MD, and Mark Andrejeski for the figure concerning projections of US rheumatologists, and Joseph D. Croft, MD, Leslie J. Crofford, MD, Roger M. Reynolds, James W. Thomas, MD, Terry D. Weiss, MD, and Edward Yelin, PhD for helpful editorial suggestions.

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