Friday, 23 Aug 2019

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War on RA - Part 2: It's All About You

Part II of this series is a direct message to rheumatologists.

Rheumatologists are amazingly facile in diagnosing and managing the complexity of RA.  They live and breathe the “diagnose early and treat aggressively” mantra.  

If you analyze clinical trial data you’ll see that the formal physician global assessment performs very well compared to other variables in accurately depicting RA activity and progression. 

While our joint examination skills are only surpassed by MRI and experienced ultrasonography, the latter expensive imaging techniques do little to the overall successful management of the RA patient. Our skills are not to be outdone by technology.

Yet we seek new tools that can enhance our diagnostic and monitoring skills in RA. The biomarker for RA remains elusive and/or prohibitive. Thus our clinical skills sustain us, improving with training, time and experience.

So, if we’re doing such a great job in RA, then why do we need a war on RA? 

Why is this conflict being laid at the feet of good soldier rheumatologists, those who toil daily at winning therapeutic battles one patient at a time?

The reasons are blunt and true: 

  • “60/40/20” responses - too many patients are not achieving remission; 80 % or more fail to achieve this superlative in clinical trials and practice.
  • RA patients have a much higher mortality –largely driven by inflammation and pain.
  • Comorbidities are not improved by you or your therapies.
  • RA will not get better by itself.   
  • Each of these challenges is anchored in what you – the rheumatologist – will do daily and in the future.  If not you, then who?

We scoreboard our successes often by linking them to hallmark advances in RA therapeutics.  Thus we have:

  • Aspirin era (circa 1900)
  • Steroid era (1950’s)
  • MTX era (1984)
  • Combination Therapy era (1990s)
  • Biologic era (1999). 

It remains to be seen if the introduction of JAK inhibitors will take us to a new level in RA outcomes. 

Studies suggest that RA is getting milder.  This is certainly clear when looking at radiographic and erosive outcomes (much milder these days), arthroplasty rates, TJC, SJC and HAQ scores; all of these benefiting from earlier diagnosis and more DMARD use.

Less clear is whether the same major improvements have been realized in referral times, pain scores, comorbidities and survival statistics.

There are many other reasons to rejoice what has evolved in RA care (even if there are contrarian facts):

  • Better Rheumatologists – they are more experienced and have more tools and drugs to play with. (BUT, I’m still only achieving remission in practice 10-30%, and that’s a generous exaggeration. I cannot explain why, in my past surveys, rheumatologists believe they achieve remission in 60% and an ACR20 of 80% in the RA patients they treat. Sorry but those are crank-head self-aggrandizing stats.)
  • Better Drugs – We have certainly enjoyed a “bull market” in therapeutics (BUT many of my best new drugs are me-too copycats; of the 19 biologics approved for RA in the last 20 years 15 are copies or biosimilars.  We currently have 2 Jak inhibitors and may have 3 or 4 by year end. You can’t always believe the Lying Eyes of a shiny new drug.) 
  • Better Guidelines,algorithms and plans (But we refuse to abide by evidence based practice yet cling to “flare management” rooted in our most dangerous drugs – corticosteroids!) 
  • Better patients - patients are informed, more inquisitive, and more involved. (BUT, why are nonadherence rates so high and why do >90% of my RA patients appear solo at visits? Where is the spouse, concerned friend or sister? Why is there a quizzical equipoise between my words and that learnt from the internet, friends or hairdresser?)

The problem may be that we’ve gotten too good;  Life in the Fast Lane has become easy street in RA management and you’ve grown accustom to writing “doing good” in charts of patients who will progress in front of you and on paper in the years to come.  Stability is great outcome for your patients but may sublimate any ideal quest for remission

What can physicians do if they want to win the War on RA?

  1. Like all wars, win all battles; especially the critical ones (Early RA, Erosive RA, preclinical RA, etc.)
  2. Change your standards – having higher standards for your clinic, RA drug management, outcome assessments will likely yield better outcomes and happier patients. For example, everyone is interested in early diagnosis and seeing early RA patients – but no one has an early RA clinic or a facilitated access plan for early inflammatory arthritis patients. In the USA, each practicing rheumatologist should see 22-25 new early, DMARD-naïve, RA patients.  I believe most of us see only a fraction of that number. 
  3. We should MANDATE that all RA be treated (if not diagnosed) by rheumatologists. There is tremendous inconsistency in overall RA care, mostly by non-rheumatologist providers. Less than 50% of RA patients will ever see a rheumatologist.  That’s a true unmet need, if not tragedy. 
  4. Stop waiting for RA to appear on your door step. Go get them and market your expertise and career commitment to managing RA.
  5. Get involved in research, trials, translational work, biobanks, and registrations. I think that many of us think that the next great discovery in RA will come from another branch of medicine and science.  Instead it is much more likely that systems thinking will create opportunities for the innovators and translational researchers to shed light where it was previously unable to understand. Or we will benefit with incremental advances from big data, artificial intelligence and predictive analytics, and you can be one of thousands who will contribute to this possibility. 
  6. Establish local “think tanks” with rheumatology colleagues and put your collective insights and experience to work for all in your community
  7. Most of all – you must change yourself.  This is should be all about you. Remember the original Grigor et al, T2T trial showed that when rheumatologists changed how they managed RA, using simple DMARDs, they had 4 fold higher remissions and ACR70 rates (increasing from 16% with “routine” care to 70% with “intensive” or T2T care. YOU may be the most pivotal factor in winning this the war.  Mahatma Gandhi said “Be the change you wish to see in the world.” 

URGENCY is what’s lacking from the current state of RA. 

Adversity can breed ingenuity, excellence and good will. You need to recognize and believe that this is a truly adverse disorder we are managing. We manage it well enough to win the battles, but not well enough to win the war.

“If you keep doing what you’re doing, you’re going to keep getting what you’ve got.”  

This is the second in a four part series outlining the need, challenge and tactics needed to win the war on rheumatoid arthritis. Your comments, suggestions, pleas and enlistment are passionately needed!

Read War on RA - Part 1: Walk on the Moon

Read War on RA - Part 3: Useless Drugs

Disclosures: 
The author has no conflicts of interest to disclose related to this subject

Rheumatologists' Comments

This is a great insightful and provocative video Jack. Another change I would advocate for is that rheumatologists be more quantitative in their assessements of patients with RA, SLE and other rhuematic diseases. Whatever problems we may have with EMRs, they do allow for better tracking of quantitative clinical and lab data- important in T2T strategies. Also we need to be more selectively quantitative in our assessment of patient adherence to therapies by measuring blood levels when indicated. For instance in a patient not doing as well as one would like on MTX 15 mg weekly, rather than jumping immediately to a biologic why not measure MTX polyglutamate level? If low then check if the patient is really taking it appropriately and consider switching to SC at the same or a higher dose. In some instances, this would help the patient and would reduce the use of expensive and possibly unnecessary biologic therapies. Just my opinion.
Art I agree...this is what I was asking for when asking rheums to change their standards of practice - that may mean different types of changes for different rheums, but using practice metrics, using labs more wisely, Changing FUV intervals, changing the time needed to detect a meaningful response (eg, from 12 weeks ot 6 or 8 weeks?), etc. If the rheumatologist does not change and improve the standards then you keep getting more of what you got before and have NOT moved the needle on achieving excellence. Vince Lombardi said .. "there is no "perfection", but the quest for perfection is where we find excellence"!
Jack-I appreciate and agree with your impassioned presentation in RA2. The word idealistic comes to mind (we all can't be a Ghandi), Your entreaties remind me of the Old Testament Judges and Prophets warning the royal and clerical leadership of the consequences for not following Mosaic law and covenants and their unwise political choices. I do not not think much will change as long as the current "one-on-one" patient care approach characteristic of a small business prevails. A team approach to patient care directed by the physician that fully engages and empowers the patient to participate is needed to meet the clinical demands of healthcare and address many of the issues you raise regarding evidence based disease measurement, management and outcome. The patient must be involved in their care and decision making. Even the most conscientious clinician soon gets "ground down" by the relentless demands for productivity, efficiency and "patient satisfaction". Ultimately, short cuts develop that limit intellectual honesty and critical thinking. (part 1)
(part 2) Some very gifted colleagues are able to develop well oiled clinical machines that maximize productivity and address the ever changing administrative and regulatory demands regarding efficacy, accountability and credibility. Such "machines" are not fun for either the patient or the caring physician. A physician running a small business morphs into a businessman practicing medicine. We need one unified national template for rheumatologic disease oriented patient care regarding diagnostic, therapeutic, clinical monitoring and outcomes, functionality, quality of life, AE's and other evidence based parameters you discuss. Its time for 21st Century medical care. David Knapp, (retired rheumatologist)

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