Caring for the chronically ill: a clinic for final-year medical students.

In 2000 the Diabetes Centre and the Medical Oncology Department of St Vincent's Hospital, Sydney established a joint clinic for the teaching of final-year medical students. The clinic was established amid concerns that hospitals are increasingly focused on acute care and have few resources available for teaching about chronic conditions. The clinic aimed to improve both patient care and learning opportunities by engaging students in useful activities with chronically ill patients. The students met with their patients regularly to monitor progress, adjust medication (under supervision) and arrange support services. The students and staff from both units met once a week in a coordination meeting where cases were reviewed and learning issues discussed. Students had informal interactions with medical and allied health staff at other times. Overall the clinic provided a rich learning environment for students with a focus on the development of the integrated skills required in the care of chronically ill people, rather than on the specific medical disciplines involved.

Outcomes for persons with rheumatoid arthritis with a rheumatologist versus a non-rheumatologist as the main physician for this condition.

OBJECTIVE: The authors compared outcomes among persons with rheumatoid arthritis (RA) with a rheumatologist versus a non-rheumatologist as the main physician for this condition. METHODS: A cohort of 1,025 persons with rheumatoid arthritis were followed for as long as 11 years. The principal measures were obtained from an annual structured telephone interview conducted by a trained survey worker. All persons with rheumatoid arthritis originally were selected from a random sample of community rheumatologists, but some subsequently had migrated to the practices of non-rheumatologists. The main outcome measures included the number of painful and swollen joints, extent of morning stiffness, a global pain rating, functional status, and a measure of global improvement. RESULTS: The persons with rheumatoid arthritis treated by rheumatologists reported significantly better functional status, fewer painful joints, and a lower overall pain rating, although the magnitude of these differences was small. A significantly greater proportion of the persons with rheumatoid arthritis treated by rheumatologists also reported improvement in a global measure of rheumatoid arthritis outcome and simultaneous improvement in all outcome measures. On all other outcome measures, the point estimate favored those with a rheumatologist as the main rheumatoid arthritis physician, although the differences did not reach statistical significance. CONCLUSIONS: The evidence suggests an advantage for persons with a rheumatologist as the main rheumatoid arthritis physician, but on several of the measures of outcome, the magnitude of the advantage was small. Because the present study was an observational design, the possibility that the advantage among persons with a rheumatologist as the main rheumatoid arthritis physician is an artifact of selection bias cannot be ruled out.

Inheritance of the shared epitope and long-term outcomes of rheumatoid arthritis among community-based Caucasian females.

Multiple HLA-DRB1 alleles encoding a shared epitope (SE) at amino acid positions 70-74 are associated with susceptibility and severity of rheumatoid arthritis (RA). We examined the relationship between the number and DRB1 genotype of SE alleles inherited and long-term outcomes of 180 community-based, Caucasian female RA patients followed annually for up to 12 years. Outcomes examined were physician assessment of RA course; annual measures of pain, function, and number of painful joint groups; history of joint surgery; and resource utilization. Models accounted for correlation among serial observations for the same patient and adjusted for patient age and disease stage. We examined two genetic models: a SE model in which patients were classified according to the number of SE copies inherited and a genotype model in which patients were categorized into one of six groups based on the inherited DRB1 genotype. We used likelihood ratio tests to compare these genetic models and to compare alternative model specifications. Our results demonstrate strong associations between inheritance of the SE and long-term outcomes of community-based Caucasian females with RA. However, the pattern of results is not consistent across the outcomes. An additive model of risk is apparent for history of joint surgery and RA hospitalization. In contrast, a near reversal of this pattern is apparent for function, joint pain, pain rating, and RA physician visits. Finally, although the genotype model did not appear to be a better predictive model for RA outcomes overall, it did reveal some striking heterogeneity of SE alleles that was masked by the more parsimonious SE model. For example, the odds ratio (OR) for joint surgery for patients with 2 SE copies (OR = 3.16) reflects an average of 2 very different ORs when patients are further categorized according to genotype groups 4 and 5 (OR = 1.3 and 11.9, respectively).

Variation among rheumatologists in clinical outcomes and frequency of office visits for rheumatoid arthritis.

OBJECTIVE: To estimate the variation among rheumatologists in clinical outcomes and frequency of office visits for patients with rheumatoid arthritis (RA), after accounting for patient demographic and clinical characteristics and treatments prescribed. METHODS: Multiple regression analysis using random effects for rheumatologists and adjustments for patient characteristics and treatments received, based on data derived from a panel study of persons with RA. RESULTS: During the years 1984-1993, rheumatologists accounted for a moderate amount of the total variation in clinical outcomes and nearly one-third of the total variation in frequency of office visits. For example, in 1993 rheumatologist associated variation in 4 clinical outcomes ranged from 16 to 25%, while the variation in office visit frequency attributable to rheumatologists stood at 46% of the total variation. However, rheumatologist associated variation in clinical outcomes was not statistically significant in any year, while variation in office visits was highly significant in all years (p < or = 0.0001). Although there was an increase in the percentage of variation attributable to rheumatologists for all outcomes examined across the years of this study, the time trend reached statistical significance only for frequency of office visits (2.4% per year; p = 0.0135) and functional status (1.6% per year; p = 0.0034). CONCLUSION: The magnitude and strength of rheumatologist associated variation in frequency of office visits, without comparable strength in the variation in clinical outcomes, may suggest inefficiencies in the use of resources for the care of persons with RA. Further work is needed to directly examine the relationship between health outcomes and resource utilization.

Differences in the use of second-line agents and prednisone for treatment of rheumatoid arthritis by rheumatologists and non-rheumatologists.

OBJECTIVE: To compare the use of methotrexate (MTX), intramuscular (i.m.) gold, hydroxychloroquine, and prednisone for rheumatoid arthritis (RA) treatment among patients managed by rheumatologists and nonrheumatologists. METHODS: Multiple regression analysis to estimate the likelihood of starting treatment and response to treatment for patients managed by rheumatologists and nonrheumatologists. All regression analyses were adjusted for patient demographic and clinical characteristics. RESULTS: Therapy with all agents studied was initiated more frequently for patients with RA with at least some contact with rheumatologists during the year than for those managed strictly by nonrheumatologists. The adjusted odds ratios for starts on these medications ranged from 1.14 for im gold to 15.11 for MTX for patients managed by rheumatologists compared to those managed by nonrheumatologists. However, due to the low frequency of initiation of treatment with most of these drugs for patients managed strictly by nonrheumatologists, only the odds ratio for prednisone reached statistical significance (OR = 2.94, p = 0.0082). In the year after initiation of therapy with these agents, patients managed by rheumatologists experienced better response to treatment than those managed by nonrheumatologists. These differences were statistically significant for MTX (p = 0.0447) and nearly significant for im gold (p = 0.0597). CONCLUSION: These results provide evidence of systematic differences in the propensity of rheumatologists and nonrheumatologists to initiate therapy with these antirheumatic drugs. If the observed differences in initial response to treatment translate into substantial differences in longterm outcomes, then these results suggest that the welfare of patients with RA may be jeopardized by the current trend toward primary care and restricted access to rheumatologists.

Cost effectiveness analysis of drug therapies for rheumatoid arthritis.

We know very little about the relative cost effectiveness of commonly used drug treatments for rheumatoid arthritis (RA), largely due to difficulty obtaining appropriate data and the complexity of the required analysis. There is growing interest in combination therapy for RA. However, it is unclear whether combination therapy will be associated with increased benefit compared to monotherapy, and whether the degree of benefit will offset the anticipated increased costs. We show 3 specific examples derived from a longitudinal database of adults with RA in which we compare the cost effectiveness of longterm drug regimens. Functional status serves as our measure of effectiveness, and we use a conservative estimate of the total annual cost of drug therapy. We also consider the analytic complexity of differences in baseline disease activity. These examples illustrate that in addition to variability in baseline disease activity, there is also substantial variability over time in both effectiveness and costs associated with drug treatment. This variability underscores the importance of considering both the relative effectiveness and costs when making treatment decisions. To make progress in the area of cost effectiveness of longterm treatments for RA and other chronic conditions, it is essential that studies of treatment continue for sufficiently long periods and that relevant cost information be collected in conjunction with measures of effectiveness.

Quantitative study of stiffness in the knee joint.

Data from a knee arthrograph, which imparts a passive sinusoidal motion to the joint and measures the resistive torque and displacement, have been shown to be reproducible. Tests carried out on joints (from 49 males, 21 females) showed that the energy loss per cycle of the joint increased with age for both sexes but the peak to peak torque (elastic stiffness) did not vary with age. Muscle bulk had a large influence on the stiffness (both dissipative and elastic) of the knee as did the size of the joint itself. Women's knee joints exhibited lower values of dissipative energy loss and peak to peak torque than men's for all ages and sizes of joints.