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Obstacles To The Early Diagnosis And Treatment Of Rheumatoid Arthritis

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Brown SL, et al. Arthritis Rheum. 2002;46:3151 58; Bjornadal L, et al. J Rheumatol. ... Anderson JJ, et al. Arthritis Rheum. 2000;43:22 29. P = 0.001 ... – PowerPoint PPT presentation

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Title: Obstacles To The Early Diagnosis And Treatment Of Rheumatoid Arthritis


1
Obstacles To The Early Diagnosis And Treatment Of
Rheumatoid Arthritis
  • Martin Jan Bergman, MD, FACR, FACP
  • Clinical Assistant ProfDUCoM
  • Philadelphia, PA

2
The 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
3
What 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

4
9-10 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
5
Morbidity 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.
6
Does Early Treatment Matter?
7
Early 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.
8
Early 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
9
Best 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
10
System-related Delays
11
Prior Authorization/Pre-Certification
  • Multiple forms for multiple diagnoses and
    treatments
  • Varies by carrier
  • Multiple formularies
  • Varies by carrier

12
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13
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14
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15
Prior 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

16
Reimbursement 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
17
Manpower-related Delays
18
The 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
20
Patient And Physician Referral Delays
21
Need 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
22
Guidelines 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
23
Cush 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
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