Disease-activity measurement is required for treating all chronic diseases optimally, and standardized measures have been developed for virtually all of them. Yet, physicians don’t use disease-activity measures dependably and often undertreat, as Lawrence Phillips has shown most persuasively.2 Suboptimal disease control increases avoidable long-term morbidities of all chronic diseases. The Treat to Target initiative for rheumatoid arthritis (RA) advocates frequent measurement and acceleration of treatment for this reason.3 We regularly ask our colleagues, “What disease-activity score are you using for RA, how many RA patients do you care for, what percent of your patients have controlled disease, and what are you doing for those who don’t?” The most common answers are “None; I don’t know; All of them, I think; and Hmm…next question.” How can we improve care delivery for the population we serve without objectively monitoring how they are doing?
Measurement requires dependably collecting robust clinical data from patients and physicians. We must also create disease registries to move from care of individual patients during routine office visits to more intensively managing those within our disease populations with the highest disease activity and clinical morbidities “offline”—not just when they show up for a clinic visit (see below). Again, as we build interdisciplinary care teams, we must use clinical data to develop rational work flows, allocating routine monitoring, education, and therapeutic management to other health professionals and diagnostic evaluations and problem solving to rheumatologists.
Team Practice
High-performing chronic disease management is a team sport in which physicians, mid-level providers, nurses, pharmacists, and other professionals provide those aspects of patient care that each are best prepared to provide—and patients are engaged as well. This is not only required as a response to decreasing rheumatology manpower and increasing patient numbers, but also because it provides more effective care at a lower cost.4 Team care and different workflows characterize high-performing practices. Charles King, MD, chair of the ACR Committee on Rheumatologic Care, has created a team practice with other professionals, including a nurse practitioner and nurses. His team manages two to three times the patients per rheumatologist as traditional practices and increases profitability. He evaluates and solves patients’ more complex problems while others focus on coordination of care, patient education, safety monitoring, and population management.
Several Great Health Care practices, including the Henry Ford Chronic Kidney Disease Clinic and Advocate Health’s Chicago-based high-risk asthma program, emphasize the requirement for teams to achieve a common knowledge base about their diseases and guidelines for care. Again, standardized processes and electronic documentation and information sharing are required.