Title: Obstacles To The Early Diagnosis And Treatment Of Rheumatoid Arthritis
1Obstacles To The Early Diagnosis And Treatment Of
Rheumatoid Arthritis
- Martin Jan Bergman, MD, FACR, FACP
- Clinical Assistant ProfDUCoM
- Philadelphia, PA
2The Natural History of RA
- Rheumatoid Arthritis (RA) is a lifelong, chronic
inflammatory disease of unknown etiology that
affects 1 of the population - RA is classically characterized by
- Symmetric joint inflammation
- Progressive joint erosion and destruction
- 75 of patients have erosions within 1st two
years of disease1 - Median lag time to make diagnosis18 weeks1
1Emery P AnnRheumDis 61(4) 290-7, 2002
3What is the Reality of Living With RA?
- Damage to the joints coupled with extra-articular
manifestations and complications means - Disability
- Reduced work capacity
- Forced early retirement due to disability
- Reduced quality of life (QoL)
- Risk of earlier death
49-10 Year Survival According to Quantitative
Markers in Three Chronic Diseases
Rheumatoid Arthritis -
Rheumatoid Arthritis -
Active With Ease
C
Hodgkins Disease - Anatomic Stage
100
Stage I
80
Stage II
60
Survival ()
All Stages, All Causes
Stage III
40
Stage IV
20
(Data from Kaplan, 1972)
Years
0
2
4
6
8
10
5Morbidity in RA patients
- Increased morbidity for RA patients
- Twice as likely to develop a myocardial
infarction (MI) - Similar to Type 2 Diabetes
- 70 more likely to suffer a stroke
- 70 more likely to develop an infection
- Up to 26-fold higher risk of lymphoma
Brown SL, et al. Arthritis Rheum.
200246315158 Bjornadal L, et al. J Rheumatol.
20022990612 Wolfe F, et al. J Rheumatol.
2003303640 Doran MF, et al. Arthritis Rheum.
200246228793 Asten P, et al. J Rheumatol.
199926170514 Jones M, et al. Br J Rheumatol.
19963573845 Baecklund E, et al. BMJ.
199831718081 Isomaki HA, et al. J Chronic
Dis. 19783169196 Solomon DH, et al.
Circulation. 2003107130307.
6Does Early Treatment Matter?
7Early RA A Therapeutic Window of Opportunity
- Earlier use of traditional DMARDs results in
better clinical outcomes - Disease Duration Prior Good Clinical
to Use of DMARDs Response ( of
patients) - 1 year 53
- 1 to 2 years 43
- 2 to 5 years 44
- 5 to 10 years 38
- gt 10 years 35
-
P 0.001
Defined by the ACR core criteria meta analyses
including 1,435 patients with RA. Anderson JJ, et
al. Arthritis Rheum. 2000432229.
8Early Treatment of RA (N384) Reduces Disability
5 Years Later - Norfolk Arthritis Register
3.0
2.4
2.5
2.3
2.0
Degree of Disability after 5 Years
1.5
0.9
1.0
0.5
0.0
lt 6 mos (n60)
6-12 mos (n47)
gt 12 mos (n76)
Delay to Start of DMARD/Steroid Treatment
Odds ratio of HAQ ³ 1
Wiles NJ, et al. Arthritis Rheum.
2001441033-1042
9Best of Times, Worst of TimesPresidential Address
- Limited access to meds
- Cost
- Prior authorization
- Follow-up reporting
- non-reimbursed practice expense
- Inadequate reimbursement for EM coding
- Reduction in the number of trainees
- 18 reduction 1995-2001
- Aging of workforce
- Mean age51 (in 2001)
- Therapeutic advancements in treatment
- Public awareness of arthritis treatments
Weinblatt ME ArthritisRheum 46(3), 567-573, 2002
10System-related Delays
11Prior Authorization/Pre-Certification
- Multiple forms for multiple diagnoses and
treatments - Varies by carrier
- Multiple formularies
- Varies by carrier
12(No Transcript)
13(No Transcript)
14(No Transcript)
15Prior Authorization/Pre-Certification
- Recertification
- Includes Medicare Part D recertification for
methotrexate and prednisone - Often by phone
- Staffing to satisfy faxing/reporting requirements
- All are non-reimbursed practice expenses
16Reimbursement Issues
A procedure taking approx. 10 minutes
(ultrasound guided large joint injection) is
reimbursed at a higher rate than a cognitive
skill requiring gt 1 hour (comprehensive patient
consultation).
CMS fee schedule PA region 01 -2008
17Manpower-related Delays
18The number of rheumatologists is declining
- Lack of supply
- Majority of rheumatologists are over the age of
55 - Aging general population
- Decreased funding for training programs
Deal CL ArthritisRheum, 56(3) 722-729, 2005
19- As early as 2010 there will be a projected
shortage of rheumatologists - In 2005 mean time to schedule a new patient 38
days - There will be a need to use rheumatologic
services more efficiently and appropriately
Deal CL ArthritisRheum, 56(3) 722-729, 2005
20Patient And Physician Referral Delays
21Need for early arthritis clinics??
- Patient reluctance to seek early treatment
- Its just arthritis.
- Delay in referral to rheumatologist
- Inaccurate diagnosis
- Over-reliance on lab testing
- Lack of access to rheumatologist
- Shortage of rheumatologists
- Distance to referral
- Time to schedule new visit
- Inappropriate referrals for non-essential
services
Cush J JRheumatol 32(2), 203-7, 2005
22Guidelines for early Referral
- 3 swollen joints
- Positive metacarpalphalangeal or
metatarsal-phalangel squeeze test - Morning stiffness 30 minutes
- Joint symptoms gt 6 weeks
- should be reason enough for referral
- RA even more likely if symptoms gt 12 weeks
- Abnormal ESR, CRP, RF or CCP ab
Adapted from Emery P AnnRheumDis 61 290-7, 2002
and Kim JM ArthritisRheum 43 473-84, 2000
23Cush J JRheumatol 32(2), 203-7, 2005
24- Rheumatoid Arthritis is a chronic and potentially
lethal disease - Early diagnosis and more aggressive treatment
will lead to better outcomes - Delays in diagnosis are due to multiple issues
- System-related delays
- Obstacles to treatment (referrals,
precert/recert) - Practice expense and reimbursement issues
25- Manpower related issues
- Aging workforce and aging population resulting in
decreased access - Long waiting time for consultation
- Inadequate reimbursement
- Patient and referral issues
- Delay in seeking care
- Delay in diagnosis
- Inadequate training in differentiating types of
arthropathies - Better education of patients and PCPs and more
efficient use of rheumatologists may help to
decrease these issues