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Hi. This is Cush, Cush, brought to you by RheumNow's expanded coverage of virtual ACR twenty twenty. This case is wrong X-ray, wrong doctor, wrong drug. 29 year old fellow comes in to see me with a history of buttock pain. You already know the diagnosis, don't you?

Turns out for the last four years, he's had some low back pain and intermittent buttock pain. The pain is worse at night. He has two to three hours of morning stiffness. He has been going to a bunch of doctors. He started out first with his primary care doctor, who did labs and x rays of his back.

They were normal. Then went to one orthopedist, then another orthopedist, then a physical therapist, then a physiatrist, then another back specialist orthopedist who did an MRI of his lower spine. Luckily enough, the MRI of his lower spine included the pelvis and SI joint, although it wasn't ordered as such. And yes, they found unilateral sacroiliitis. They found bone marrow edema on both sides of the SI joint.

There were no erosions in the SI joint, but bone marrow edema and other inflammatory changes to suggest unilateral sacroiliitis and no other diagnosis. So the story here is we have a young man, 30, who has, inflammatory low back pain. This is sort of the hallmark presentation of someone who has ankylosing spondylitis or a spondyloarthropathy. X rays, we're not done. I ordered those.

We'll see what those come back, but I'm sure there'll be some changes there so that this does, in fact, qualify as axial spondyloarthritis or ankylosing spondylitis. He is HLA B twenty seven positive, never checked before. His labs were actually normal. His SED rate, CRP, chemistries, and blood counts were all normal. The message here is, I think, again, wrong x rays.

Young men, young patients who have, inflammatory back pain should always have an x-ray that includes the, pelvis and SI joints. Problem is they always get LS spine films and will often miss this diagnosis. Wrong doctors flopping around between PM and R, PCPs and ortho didn't do very well here. And of course, he was treated with the wrong drug. He was taking Tylenol over the counter medicines, given an occasional prescription for a nonsteroidal that he didn't know that he should take on a regular basis.

So the fellow has been in pain for quite some time. This is a big problem. As you may know, there are substantial delays in the diagnosis of ankylosing spondylitis. On average, seven to eight years. It is amazing in this day and age with all the notice that spondylitis has gotten over the years, all the drugs being approved for spondylitis, you know, perpetuating the story, the presentation, the evaluation, and the new therapies, that this really hasn't changed very much.

In fact, most patients diagnosed with ankylosing spondylitis are not diagnosed by rheumatologists. It takes many years to get to the rheumatologist. In fact, that number I mentioned earlier, seven, eight years, that might be the number it takes. So maybe you have to fail three, four, five doctors before you finally get referred rheumatologist. I think we as the teachers of the masses, not just patients, but also other clinicians need to perpetuate this story that inflammatory back pain in someone, you know, under the age of 30, under the age of 40 should always prompt the B27 and pelvic x rays.

In that instance, this man would have at least been able to avert four years of pain and disability. And now he's going to go bungee jumping and join the Marines now that he's been started on, effective biologic therapy. So again, wrong x rays, wrong doctors, wrong drugs usually don't speak well for the patients, but thank God the rheumatologist is here to save the day. Be sure to check out RheumNow's expanded coverage of ACR twenty twenty, the virtual meeting. We've got a lot of new exciting things coming up.

It's a new way to learn. It's a grand new world. Aren't we enjoying it? This is QD clinic brought to you by RheumNow's expanded coverage of twenty twenty virtual ACR meeting. It's gonna be exciting.

Today's case. Oh, by the way, I'm doctor Jack Cush. I work for RheumNow. Today's case, Nancy no show. Nancy no show did the show this morning, and I had a free hour to begin my day.

That was kinda nice because I got a lot of work in, answered some emails, you know, took a walk around the block, and and didn't make any money and didn't do any good. So Nancy no show has done this before. Maybe Nancy no show is a first time consults like my new patient today that didn't show. The question is, how do you handle no shows and how do I handle them? I struggle with these just as much as anyone else.

The no show rate that most rheumatologists experience varies quite a bit. It can be as low as single digits, but most of you have a no show rate of somewhere between twelve and twenty percent. Most business models in rheumatology would say that you need to keep your no show rate down less than ten percent. If you had a static number that in fact was predictable, you could work against that and do what the airlines do and just overbook. And then when everybody shows up, just throw it into high gear so that you can meet your workload for that day.

On the other hand, most of us don't do that. Most of us wanna have our time accounted for, knowing that at 02:00 I'm seeing this patient, at 03:00 I'm seeing that patient, and at 04:30 I'm checking out. But, unpredictability is bad for business. Again, it's frustrating. It's frustrating for you.

It's frustrating for the patients. No shows often have lots of good excuses. And by no show, I mean people who don't call ahead of time and say, my car broke down, my child is sick, I can't make it tomorrow, can I reschedule? You know, there you have the opportunity to fill in. So let me give you some perspective on this.

Number one, there is research out there about no shows that it is higher in non whites, meaning whites are more likely to be on time and actually make the visit. It's about 10% lower for non whites compared to whites in a few studies. It is people are more likely to keep their appointments when they're over the age of 65. I don't think that has to do with whether or not they're working or retired. I think it just is that medicine becomes more important as one gets older.

Younger people are less likely to make those appointments. You could also predict no shows based on patients who have psychosocial problems and certainly people who have a prior history of prior no shows. They're likely to be recidivists and make that mistake. There is a again, there are studies showing that you can actually predict no shows based on those four factors of age, race, whether it's psychosocial factors or prior no shows. What can you do about this?

Well, the number one way of of reducing no shows is reminders. There are a lot of reminder system systems out there. You can be as simple as snail mail and sending someone a reminder in the mail, having automated systems where patients can choose how they're gonna get their receive their notice by text, by email, by phone call, Pony Express, whatever they want, it's tailored to them. Those are fee or services one pays for. Many of you just have your staff as part of today's duties to call tomorrow's patients to remind them.

The data shows that no show rates drop by, as much as 50%. So one study showed it went from ten to five percent. Another study showed it went from eight to four percent. Think when you've got like a 20% no show rate, don't think it's gonna go to ten percent, but it certainly gets better. So, reminders make sense.

The other thing that is often not done and should be done is setting expectations. Meaning, you as the clinician need to at the end of your visit say, next time when I see you in three months, we're going to discuss x, and z. It's very important that I see you then so we know whether this drug is working, whether your labs have gotten better, whether we can show that this medicine has continued to be safe. You know, again, we next time we could talk about pregnancy because we didn't have time to talk about it this time. You know, set an expectation, make it like a soap opera, tune in tomorrow, days of our rheumatologic lives.

And again, it makes sort of sense to set an expectation. Likewise, your staff, when they check patients out, can set an expectation. There's an interesting model in one of the family practice journals that talked about setting up a virtual doctor visit, meaning the patients who are criminals, the no showers, they now go into a bin and they are notified that you're now in an alternative schedule, meaning you don't really have an appointment, but you have an appointment with our virtual doctor. And then if and when you show up, you get slotted in in sort of a chronological order beside someone who has a scheduled appointment, and the doctor will try to squeeze you in. I kinda do a version of this on my own right now, although I kinda tell patients, you're last in line.

I've got three people waiting. You're the fourth person I'm gonna see, and that's the price you're gonna have to pay to be when you're been called a repeat no show. And that's usually people who've had more than three no show events in a one or two year period. And lastly, you could go with what you're now becoming expert at, and that is virtual medical visits. Meaning, it's no it's less skin off of your shoulder that when a patient doesn't show for a virtual visit because there are other virtual consults that you could slot in in very short notice.

So the idea is use your virtual medicine days as a way of seeing those no show patients. Now that's a bit problematic because sometimes the virtual no shows are are the are the real no shows are people who really do need to be seen face to face for an accurate joint exam for better instruction for things that one can only do in a face to face visit. But, again, we're trying to salvage, one, the patient care and two, the the finances, and three, the workflow by having a strategy for no shows. Think about it. Let me know what you think.

That's it for this edition of QD Clinic. You can, again, follow us, on RheumNow, see what we're going to do for ACR 2020. We'll see you there. This is QD Clinic. Hi.

I'm doctor Jack Cush with RheumNow. QD clinic is brought to you by the twenty twenty ACR annual meeting. It's all virtual. RheumNow will be there. You give us two hours.

We'll give you the meeting. Today's case, the DMARD bailout. Saw a gentleman few days ago, 70 year old male, serious, bad, erosive deforming polyarticular RA, been on a lot of different medicines. More recently, was on prednisone, leflunomide, Xeljanz, and a few other drugs. And at this visit, the patient said, Yeah.

I'm no longer taking that leflunomide medicine. And, of course, I do my little cocked head, quizzical look. Again, when I'm wearing a mask and goggles, I'm not sure it makes any difference. And I say, what's that about? And, you know, he told me a story about what happened.

And so, and I think the question is how do you handle the, DMARR bailout? Patient, makes the decision or someone else makes the decision, not you, that, this drug is no longer needed. This could be we could be talking about any drug here, but I'm choosing DMARDs because they're supposed to be disease modifying, and that's the intent by which you gave it. Hence, patient's not taking it. We're looking at suboptimal therapy, are we not?

I think if you think about this in three different ways, the patients bail out on a drug either because of the patient choice or because another MD got involved or third, external forces beyond our control, you know, like a hurricane or something. When the patient chooses to stop the drug for whatever reason, I think rather than getting all pissy and looking at them like, you crazy? Like, what were you thinking? You know, these are all my inclinations. I think the interesting thing is to say, well, tell me what that's all about and tell me how you're doing.

Because they bailed out, the question is, was that a good idea or a bad idea? They already have the history that's going give you the answer. If it turned out to be okay and not a bad idea, there's no point in coming down hard on the patient. If it was a bad idea, you say, gee, that wasn't really a good idea. Either way, you always make the point.

I want you to know these medicines I give you, they're mine. I'm the expert. I wrote the prescription. I'm responsible for it. Think about it like I'm lending you my Mustang and you can drive it around.

I don't want you to paint my Mustang or, you know, you know, drive on the beach with it. You know, certain things you probably should ask for for my permission. So before you sell my Mustang, give me a call. The same thing with these DMARDs or biologics. You know, realize that you should let me know when someone else or you wanna do something with my medicine.

Otherwise, you know, there's a consequence there that could be damaging, and I don't want that to happen. Call me. I'll tell you whether you can stop or not or whether you need to stop when you're gonna have surgery or because you're going on vacation or because someone else wants to stop it. Give me a call. Second scenario, the patient stopped because doctor Schmo told him, we have to stop that medicine now.

Surgery, hospitalization always like seems like a good idea to the patient. It's always a bad idea as far as we're concerned because it never needs to be stopped in those situations. It's being stopped by someone who knows nothing about the medicine or at best gets their education from the television about that medicine. There again, if it's the other physician that did this, there's only one remedy and it does take a little bit of your effort, and that is either write a note to that doctor or give them a call. Doctor.

Cush, here. Mister Smith says you stopped his methotrexate. Is that true? Why would you do that? And, you know, then they're, like, double talking and hemming and hawing and say, oh, he misunderstood.

And but you know what? Doctor Smith this is doctor Schmoe, excuse me, is never gonna do that again. Lastly, external forces. Insurance companies, you know, bad deliveries, pharmacy issues, refill issues, dog ate my homework, again, beyond the patient's control and they never restarted the medicine. And there the answer is real simple.

It's like the first scenario. This thing called the phone. If things are not going well with regard to medicine, call my office and I'll fix it. I think the bottom line is that bailing out on a DMARD is not always a bad thing. Sometimes it's a good thing.

The patient can be managed with less medicine. This way you're not contributing to polypharmacy, which is a gigantic problem in many of our patients, especially as they get older, especially as they get more complex. I think that it's really about negotiating. It's about setting expectations with patients and letting them to know that they can call you to find out what to do when considering stopping a medicine. That's it for the DMARD bailout.

Again, you give us two hours, we'll give you the ACR meeting virtually. We have a lot of interesting plans. It's all about, ways that you can engage and learn and get perspectives on the data and new studies being presented. These are the things we'll be highlighting, at RheumNow come November for the virtual ACR meeting. We'll see you then.

Take care.