A typical patient with a rheumatic disease needs a multifaceted treatment approach to address comorbidities, minimize disability, promote quality of life and improve survival. To achieve these outcomes, rheumatology research has evolved from examining a single treatment to studying the best treatment approaches. Examples of these strategy trials include how to best combine pharmaceutical therapies, identifying which treatments are best used after traditional disease-modifying agents lose efficacy, studying the utility of non-pharmaceutical approaches for rheumatic diseases and identifying the optimal treatment target for disease management.1-10
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Explore This IssueDecember 2018
The next generation of strategy trials will incorporate patient preferences, evaluate shared decision making and include societal/payer preferences for value-based decisions on specific interventions.11-15
Despite advances in research strategies, significant gaps in rheumatology care exist within our communities, particularly related to such patient-reported outcomes as pain.
Community-based rheumatology care has several challenges, including lack of resources to support treatment, lack of integrated, team-based models of care, long wait times to access a rheumatologist and a paucity of pain management strategies for most inflammatory rheumatic diseases.16
Given the expected increases in the prevalence of rheumatic diseases and associated costs to the patient and society, we propose a rheumatologist-led, team-based integrated model of care. This community-based approach can address gaps in care and mitigate future escalation of these costs.17-19
Integrated care is an approach aimed at reducing inequalities of healthcare while improving quality of care and patient outcomes.20-22 Personalized, holistic approaches to chronic conditions (e.g., chronic obstructive pulmonary disease, HIV/AIDS and chronic heart failure) in community settings have:
- Improved physical and psychological health;
- Empowered patients to self-manage their conditions;
- Increased adherence to treatment decisions; and
- Increased patient survival after a potentially life-threatening event.23-26
In January 2017, Steve Livshin, MD, my colleague and business partner—who also manages the pain clinic in close proximity to our center—and I set out to develop and lead a community-based integrated model of care in North York, Ontario, Canada, to determine: 1) its viability, 2) the ability of this model to reduce care gaps in early diagnosis and management, and 3) the impact of shared decision making on patient-reported outcomes.
The patient is an important element of this model, and shared decision making is at its center. How a patient and provider arrive at treatment choices and prioritize shared targets is of utmost importance. In this model, the patient and the provider team each have an equal voice in an informed dialogue about how to approach patient care and address patient needs. This approach necessitates holistic care, coupled with a patient empowered to participate in their own treatment decisions with their rheumatologist through education and decision support tools.
It also forces a deeper examination of how to treat musculoskeletal pain, which is a dominant symptom among our patients. This is particularly important, because disease-modifying therapies often provide only part of the solution.