Investment in multidisciplinary care for rheumatoid arthritis patients

My daring idea for health care in Alberta

May 31, 2017

Steven J. Katz, MD, FRCPC

Contributed by: Steven J. Katz, MD, FRCPC

Rheumatology is an exciting field of medicine to be a part of right now. This is particularly true when talking about rheumatoid arthritis management. Twenty years ago, the goals of care for the nearly 30,000 Albertans with rheumatoid arthritis were limited. Mangled and deformed joints were typical outcomes for those with this disease. Half of our patients were disabled within 10 years of disease onset, unable to work and contribute to society. Extra-articular manifestations were common and studies show many patients were dying 10 years earlier than age-matched populations, often due to higher rates of cardiovascular disease.

Much has changed. Biologic medications have made a significant impact on rheumatoid arthritis treatment. Goals of care now include no pain, no swelling, normal function and joint damage prevention. While biologics have played a key role, they are expensive. In fact, biologics are consistently the most expensive drug cost in Alberta each year. Fortunately, the way we use other traditional disease modifying medications such as methotrexate has also changed. Twenty years ago, a typical starting dose of methotrexate would be 7.5 mg weekly, slowly titrated up over time and slowly combined with other medication options. Today we treat aggressively – but safely – intervening early with higher doses of methotrexate, almost always in combination with other disease-modifying antirheumatic drugs (DMARDs) using dual or triple therapy. Data show this strategy is as effective as expensive biologics for many patients.

The thing is, we can still do so much better for our patients, while reducing costs for our health care system, the province and all Albertans. What would I like to see?

Treat-to-target goals

We need to work on achieving remission by employing treat-to-target goals for every patient with rheumatoid arthritis. One solution might be more rheumatologists to see patients regularly and adjust drug therapy for those with active disease. But this fix is too simple for a problem that is much more complex. What we need is dollars invested in multidisciplinary care for rheumatoid arthritis patients, where a holistic and comprehensive approach becomes the norm with advanced care nurses, physical and occupational therapists and/or pharmacists providing evidence-based care strategies (treat-to-target) for every patient.

Early investment in these human resources today will save dollars by delaying or preventing the need for biologics tomorrow. Adding a dozen allied health professionals to the arthritis team in a collaborative care model will improve access to and quality of care as well – if not better – than hiring a dozen more rheumatologists.

Therapy adherence

Adherence is an important issue in all of medicine and we should help ensure DMARD therapy is readily obtainable and as easy to administer as possible for our patients. Subcutaneous methotrexate injections are more effective and better tolerated than oral methotrexate, yet we provide these injections like we live in the dark ages, asking patients to use a needle and syringe to draw up their own drug. We stopped asking diabetics to do this years ago. The technology exists, but because methotrexate has been around for decades, the pharmaceutical industry appears to incorrectly perceive little economic value to take the lead on this common-sense innovation. Why can’t rheumatoid arthritis patients buy their methotrexate in cartridges just like insulin and dial up their dose in a methotrexate pen?

The data show this method improves adherence in patients with diabetes. Can you imagine the impact a methotrexate pen would have for patients with rheumatoid arthritis who may have painful joints and impaired fine motor skills? Improved adherence will likely lead to better results, again delaying or perhaps preventing expensive biologic use and ensuring patients remain tax-paying, contributing members of society.

Better data

Rheumatology and inflammatory arthritis care need to be demystified. Rheumatoid arthritis is a serious medical condition. It kills, full stop. Despite this, we still don’t fully understand the burden of disease in the population. Data from Alberta suggest a population prevalence of 1%, although the number treated with disease-modifying agents or biologics is less clear. It is imperative to resolve this public health issue; we need to determine if this treatment gap is real, and if so, how we can work with the public, patients and physicians to close this gap.

While these are lofty goals, I have to believe they are not just pie in the sky. These are real targets we can achieve. As we celebrate 50 years of rheumatology in Edmonton this year, I invite you to contact me through the Alberta Medical Association if you can help to make these things happen.

How can we convince government and big pharma that we can do better for our patients in a financially prudent way? Seemingly small changes can have a profound impact on the arthritis sufferers in our province, across the country and around the world.

The Alberta Medical Association stands as an advocate for its physician members, providing leadership & support for their role in the provision of quality health care.