This is Part Two of a two-part series on early arthritis clinics. (See Part 1 on page 1 of the May 2008 issue.)
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Over the last 20 years, early, aggressive treatment has become the standard of care for patients with rheumatoid arthritis (RA). Yet, there are relatively few specialized early arthritis clinics (EACs) available to the 1.3 million RA patients in the United States, in spite of the tremendous success of EACs in Europe. Why is this?
According to physicians interviewed by The Rheumatologist, there are many reasons for the paucity of this type of clinic:
- America’s healthcare system differs from that of Europe—it’s not designed for early, easy patient access;
- The referral base is not adequately educated about the nature of early inflammatory synovitis and the importance of early diagnosis and treatment;
- Medical schools aren’t teaching new doctors enough about RA;
- The effort needed to start an EAC does not appear to justify the time and expense; and
- Many rheumatologists believe they can handle early RA patients within their existing schedules.
However, in spite of good intentions, most RA during the early stages of disease isn’t being seen in a timely manner.
Challenges for EACs in the U.S.
Ninety percent of patients with musculoskeletal and autoimmune disorders are receiving rheumatology care from their primary care physician (PCP), according to data gathered by Stephen A. Paget, MD, chair of the division of rheumatology at the Hospital for Special Surgery in New York City. In fact, less than 50% of RA patients are referred to specialists within the first six months of symptom onset.1 The actual percentage may be considerably lower, according to research by rheumatologist John J. Cush, MD, chief of rheumatology and clinical immunology at Presbyterian Hospital of Dallas. He that says fewer than 5% of RA patients are seen by rheumatologists in the first six months, and the average new RA patient comes in with disease duration of two to three years.
Is the solution to increasing access to establish an EAC? Not necessarily. It takes money to establish infrastructure, hire and train staff, and advertise to physicians and the public. Just because the EAC concept worked in Europe doesn’t mean it will in the U.S. For example, while Europe has an easier-to-negotiate single-payer insurance system, the U.S. has hundreds of payers, complicating the financial aspects. Also, European medical communities are relatively small, making it easier to educate and get referrals from local physicians. If an EAC is established in an American community, will the medical office get appropriate referrals?