Symptom assessments of patients with rheumatoid arthritis (RA) are complex and incorporate many subjective variables. Therapies must address multiple targets, many of which are measured by clinical outcomes and disease activity measures that appear to be less important to patients. Several new studies indicate a substantial divide between clinical practice and patient satisfaction with care.1-4 However, recent evaluations of multicare models suggest greater patient satisfaction compared with models where patients are treated only by primary care physicians. These models also increase confidence in nursing-led interventions to manage long-term care.
Rheumatology Advisor spoke with John M. Davis III, MD, MS, vice chair and practice chair in the Division of Rheumatology at the Mayo Clinic in Rochester, Minnesota, and Jennifer Gorman, MD, MPH, chief of subspecialty medicine at The Polyclinic in Seattle, Washington, for their insights on the evolving RA therapy model.
Rheumatology Advisor: Do collaborative care models affect patient satisfaction in rheumatology?
Dr Davis: Collaborative care models show promise of increasing patient satisfaction in rheumatology. There is a shortage of rheumatologists relative to patient demand, so collaboration between rheumatologists and other physician and nonphysician allied health professionals is increasingly necessary to meet patients’ needs. Based on my own practice, I believe that a team-based care approach, involving rheumatologists, primary care providers, nurse practitioners and physician assistants, nurses, physical therapists, and other subspecialists is really important to provide comprehensive care to people with RA.
Rheumatology Advisor: What kinds of comprehensive or collaborative care protocols are followed at your institution?
Dr Gorman: Because RA is a systemic disease process, there is an undeniable benefit to having a collaborative approach to care for these individuals. As rheumatologists, we focus not only on active treatment of the disease, but we must also prioritize preventive care. As an example, patients with inflammatory arthritis are at increased risk for cardiovascular disease, so assessment of cardiovascular risk factors and reduction of risk is important. This is generally coordinated with a patient’s primary care provider, but at The Polyclinic, we are fortunate to have a robust lipid clinic that supports a multidimensional, personalized approach to treatment. Although damage to joints is much less common with tighter disease control, we also have our patients work closely with physical and occupational therapists to improve a patient’s functional abilities and reduce pain. Our nutritionists are interested in dietary approaches to help reduce inflammation and improve overall health, so our patients benefit from these resources as well.
In 2014, we began work with an AMGA Best Practices Collaborative in RA. Through this project, we developed other processes for systematically improving our care of patients with RA. This includes standardized regular assessments of disease activity and function to more tightly monitor a patient’s progress. By assessing these measurements frequently and tailoring treatment accordingly, patients have less disease progression and disability. We also developed vaccination protocols, as patients with RA often have immunosuppression.5-7
Rheumatology Advisor: How do you evaluate patient satisfaction? How do they respond?
Dr Gorman: The Polyclinic has been obtaining information regarding patient satisfaction for the last several years. Currently, we are working with the National Research Corporation to survey patients after a visit with a provider. While the patient remains unidentified in the reports, we do report the summary data transparently to all of our providers. This helps us identify providers who have opportunities to improve their quality of care and holds providers accountable.
Rheumatology Advisor: What areas of care need to be addressed to improve patient satisfaction?
Dr Davis: First, patients commonly experience an empathy gap — our systems of care often lead patients to feel unheard and invalidated in their disease experiences. For example, the clinical realities of limited appointment times, electronic health record systems, and regulatory and administrative barriers often detract from optimal patient-provider interaction and communication. Collaborative care models that are mindful of our patients’ needs for kind and empathic care could improve patient satisfaction.
Second, the development of systems of care to address chronic pain in people with RA could improve patient satisfaction. Patients with RA often have “mixed” pain states involving not only inflammatory pain but also centralized pain. While new, more effective and safe analgesic therapies are sorely needed, multidisciplinary approaches that leverage drug-based and psychological approaches to pain management can improve patients’ functional outcomes.
Third, increasing timely access to care and decreasing the burdens and costs of care and monitoring are great challenges that need to be addressed to increase patient satisfaction. Tools to monitor patients’ disease and health status remotely and to intervene to prevent severe exacerbations are needed.
Rheumatology Advisor: A study by Arthur et al8 published in 2004 indicated that once patients are exposed to a multicare model after being exposed to a standard primary care model, their expectations of RA treatment increase. Does this still hold true today?
Dr Gorman: As our understanding of disease processes and pathophysiology becomes increasingly complex and the treatment regimens more personalized, the need for an engaged and productive relationship with a healthcare provider and integrated care model becomes essential. Our aim in each visit is to accommodate the patient’s primary expectations and needs as well as to cover preventive health topics and explore other aspects of an individual’s life that contribute to their quality of life and overall health.
Rheumatology Advisor: Dr Davis, you coauthored an article1 that described 6 areas of discord between patients and providers in determining care models. These themes of patient-provider discordance include being misunderstood by others, limitations of provider assessments, discrepancy with provider findings, inadequate active listening, unmet psychosocial needs, and lack of patient empowerment.
Can some areas be more readily addressed than others?
Dr Davis: The general misunderstanding patients experience from their families, friends, and society at large must be addressed by public awareness campaigns and general education. In addition, reimbursement for chronic disease management is an obvious major barrier that hopefully will evolve for patients and healthcare providers in coming years.
However, I do believe that rheumatology can do more to address patient-provider discordance. Patient education about the disease, test results, and treatments is sometimes overlooked but is really crucial to bridge gaps between patients and providers. New clinical approaches for aligning patient and provider goals are needed. Developing and translating tools for shared decision making could help patients and providers decide on treatment options that best align with their preferences, values, and needs. Fortunately, this work is underway. In the meantime, it is important that we as rheumatologists be aware of limitations in both diagnostic testing and treatments.
Rheumatology Advisor: What types of interventions are most cost-effective in the long run?
Dr Gorman: The direct and indirect costs associated with RA can be substantial. This includes costs related to diagnostic tests and treatments as well as loss of function and reduction in an individual’s productivity. It is now understood that early and aggressive therapy for RA is the most cost-effective strategy to reduce the severity of disease, joint damage, and disability and to increase a patient’s quality of life and maintain their ability to work.9 Early access to a rheumatologist for a prompt diagnosis and treatment strategy is essential. We work with patients very closely to quickly obtain a medication-induced remission. Although many of the newer biologic medications for RA are expensive, when all the costs are considered, prompt adequate control of inflammation is cost-effective in the long run.
Rheumatology Advisor: Do you think nurse-based interactions change patient perceptions of care compared with physician-based?
Dr Davis: A number of studies have been done looking at nurse-led care for patients with RA, and the results are generally favorable with respect to managing RA disease activity and patient satisfaction. Nurse-led care may be more cost-effective. In our practice, we are continually evaluating our nursing practice and conducting pilots to enhance the care experience for our patients.
- Kvrgic Z, Asiedu GB, Crowson CS, Ridgeway JL, Davis JM 3rd. “Like no one is listening to me”: a qualitative study of patient provider discordance between global assessments of disease activity in rheumatoid arthritis [published online December 20, 2017]. Arthritis Care Res (Hoboken). doi: 10.1002/acr.23501
- Challa DN, Kvrgic Z, Cheville AL, et al. Patient-provider discordance between global assessments of disease activity in rheumatoid arthritis: a comprehensive clinical evaluation. Arthritis Res Ther. 2017;19:212.
- Hall J, Julia Kaal K, Lee J, Duncan R, Tsao N, Harrison M. Patient satisfaction and costs of multidisciplinary models of care in rheumatology: a review of the recent literature. Curr Rheumatol Rep. 2018;20:19.
- Kievit W, van Hulst L, van Riel P, Fraenkel L. Factors that influence rheumatologists’ decisions to escalate care in rheumatoid arthritis: results from a choice-based conjoint analysis. Arthritis Care Res (Hoboken). 2010;62:842-847.
- Baker DW, Brown T, Lee JY, et al. A multifaceted intervention to improve influenza, pneumococcal, and herpes zoster vaccination among patients with rheumatoid arthritis. J Rheumatol. 2016;43(6):1030-1037.
- Desai SP, Lu B, Szent-Gyorgyi LE, et al. Increasing pneumococcal vaccination for immunosuppressed patients: a cluster quality improvement trial. Arthritis Rheum. 2013;65(1):39-47.
- Kremers HM, Bidaut-Russell M, Scott CG, Reinalda MS, Zinsmeister AR, Gabriel SE. Preventative medical services among patients with rheumatoid arthritis. J Rheumatol. 2003;30(9):1940-1947.
- Arthur V, Clifford C. Rheumatology: the expectations and preferences of patients for their follow-up monitoring care: a qualitative study to determine the dimensions of patient satisfaction. J Clin Nurs. 2004;13:234-242.
- Vermeer M, Kievit W, Kuper HH, et al. Treating to the target of remission in early rheumatoid arthritis is cost-effective: results of the DREAM registry. BMC Musculoskelet Disord. 2013;14:350.