These data from routine rheumatology clinical practice settings highlight the effectiveness of common biologic and DMARD therapies, and provide additional data beyond those of randomized, controlled trials.
GIOP is the first organized program of care for patients who take chronic GC that has demonstrated a clinically significant improvement in outcome. The program's design can be adapted and used by other health systems and organizations.
Objective. To provide rheumatologic care to patients in a timely and patient-centered manner. Methods. We developed and implemented processes to measure and help eliminate backlog, created access time for same-day patients, and retooled the appointments process to be more efficient and patient focused. In addition, we developed a protocol to be used by our primary care colleagues to care for osteoarthritis of the knee in a standardized manner. Results. The third available rheumatology appointment fell from about 60 days to <2 days. Cancellations fell from 40% to <20%. Patient satisfaction measures (composite score, physician score, and accessibility score) improved significantly. The number of new patients seen for knee osteoarthritis decreased by 6.7%, whereas the number of new rheumatoid arthritis referrals increased by 50.4%. Financial performance improved as well. Conclusions. This advanced access model in a busy academic rheumatology practice demonstrated considerable improvement in access, patient satisfaction, and finances. Using a team approach, we are now able to give the patient the rheumatologic care they want and need at a time they want and need it.
A 49 year old woman with a four year history of rheumatoid arthritis had received aspirin 4 g/day and, for the past nine months, oral methotrexate 7 5-15 mg/week. Her blood counts were always normal during treatment. The patient presented with fever after dental extraction. The total white blood count was 1 1 x 109/1. Blood and urine cultures showed no growth and a chest radiograph was normal. She was admitted to hospital for four days and given intravenous penicillin and gentamicin. Three days later she was readmitted with a fever of 39 6°C, shortness of breath, and diarrhoea. The total white cell count was 3.5 x 109/1 (54% neutrophils, 1% band forms, 17% lymphocytes, 28% monocytes). A chest radiograph showed increased interstitial markings bilaterally, and a Grocott-Gomori methenamine silver nitrate stain of a transbronchial biopsy specimen showed P carinii. The patient required ventilatory support for nine days. She was treated with trimethoprim-sulphamethoxazole (20 mg/ 100 mg/kg a day) and later pentamidine (4 mg/kg a day), and was discharged after three weeks. She denied risk factors for human immunodeficiency virus infection, and the result of a test for antibody to the human immunodeficiency virus type 1 (HIV-1) by ELISA was negative. She has been treated with sulphasalazine, aspirin, and prednisone 5-10 mg/ day to control her symptoms of arthritis for 60 months since discharge, with no evidence of lung disease. PATIENT 3 A 64 year old woman with a 15 year history of rheumatoid arthritis had been treated for the past 30 months with sulindac 400 mg/day, prednisone 7 0 mg/day, and oral methotrexate 15 mg/week. Her blood count was always normal. She was admitted to hospital with weakness, chills, night sweats, dyspnoea, and cough. Her temperature was 39-4°C, and lung examination showed bilateral basal crackles.The total white cell count was 2-2 x 109/l (88% neutrophils, 2% band forms, 7% lymphocytes, 2% eosinophils, 1% basophils). The chest radiograph showed diffuse reticulonodular interstitial shadowing. GrocottGomori methenamine silver nitrate staining of bronchoalveolar lavage fluid showed P carinii. Despite ventilatory support and treatment
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