Changing structure and resources in a rheumatology combined unit during 1977-1999.

OBJECTIVE: The aim was to study the changing structure and resources in a rheumatism hospital during the period 1977-1999 when rheumatology care was decentralized and new treatment strategies were introduced. METHODS: Data on hospital management and production were retrieved retrospectively. RESULTS: The number of beds was stepwise reduced from 133 to 44 and the average length of stay declined from 48 to 16 days. The combined unit and multidisciplinary team organization was kept, ensuring the combined effort of rheumatologists, rheumasurgeons, registered nurses, physiotherapists, occupational therapists, and social workers. One-third of the total staff was rheumateam members in 1977 compared to one-half in 1999. The proportions of physicians and registered nurses increased while the proportion of physiotherapists was stable. The number of discharges remained relatively unchanged and the number of outpatient consultations increased. Inflammatory rheumatic diseases remained the largest diagnostic group of in- and outpatients. Hospitalized care was received primarily by patients with arthritis and spondylitis. Patients with vasculitis and diffuse disorders of connective tissue accounted for an increasing proportion of the outpatient clinic production. Surgical procedures became more prevalent. Since 1995 approximately 50 large joint replacements have been performed annually. CONCLUSION: The length of stay declined and patient care was shifted towards the outpatient clinic. The multidisciplinary team was strengthened. More resources were dedicated to physician-led and nurse-dependent procedures, but physiotherapy and rehabilitation remained part of inpatient care throughout the period. The expertise concentrated on inflammatory rheumatic disorders. The modesty of the large joint replacement caseload may challenge decentralized care.

Were the patterns of treatment for rheumatoid arthritis during 1977-1992 consistent with modern clinical guidelines?

OBJECTIVE: Quality assessment of the long-term treatment of patients with rheumatoid arthritis (RA). METHODS: Treatment patterns in a cohort of 70 local and 77 distant RA patients during 1977-1992 were reviewed retrospectively and compared to modern clinical guidelines. RESULTS: In 1977 disease-modifying anti-rheumatic drugs (DMARDs) were given to 62% of the new, hospitalised patients, systemic corticosteroids to 7%, and corticosteroid joint injections to 24%. Patients with short disease duration and/or serious disease were selected for DMARD-treatment. Rheumasurgery was performed on 21%. During follow-up of local patients 54% were recorded with DMARDs for a mean duration of 29 months; approximately 1/5 of the follow-up period. Methotrexate was used infrequently. Local and systemic corticosteroids were recorded in approximately 20%. Rheumasurgery, predominantly non-prosthetic, was performed on 27%. CONCLUSIONS: Patients with early and serious disease were selected for DMARD-therapy, but the treatment duration was too short for modern requirements. Pharmaceutical and surgical treatment patterns were otherwise mainly consistent with present guidelines.

Atlanto-axial subluxation in rheumatoid arthritis. A study of 104 hospital patients.

Arthritic affection of the upper cervical spine is relatively common in rheumatoid arthritis (RA). Atlanto-axial subluxations are also reported to occur frequently, but it seems that neurological symptoms due to the subluxations seldom occur. We have studied 104 consecutive in-patients. In a group of 50 non-arthritics we have measured the distance from dens to the anterior arch of the atlas, and from dens to the foramen magnum line. By means of percentile-estimate we have defined values at risk for having pathological values for the measured distances. In 104 rheumatoid arthritis patients we found that 45% of the patients had values at risk, but only one of the patients had medullary neurological signs. A planned follow-up study will show if oncoming neurological symptoms due to subluxations will occur in the risk-group or in the group now defined as having normal values.