Novel Initiatives Address Complexities in Treating Rheumatic Diseases

Doctor consulting with patient presenting results on digital tablet tablet sitting at table

There are many challenges to treating autoimmune diseases such as rheumatoid arthritis and lupus. Brigham and Women’s Hospital has recently undertaken a number of new initiatives to address some of these challenges and improve patient care.

“One of the biggest problems we see is lack of access, especially for more specialized rheumatology services,” said Susan Ritter, MD, PhD, associate medical director of the Brigham and Women’s Arthritis Center. “This is a larger issue in other parts of the country, where there are not enough providers to meet the needs of the population. However, it’s a problem even in Boston. We have a large number of providers, but there is so much demand.”

One project that the Brigham has undertaken to address this concern involves optimizing best practices for recurring functions in patient care. Through a pilot program, members of the rheumatology team—including physicians, nurses and medical assistants—took a closer look at common questions and requests from patients and identified ways to establish and enhance processes for meeting these needs.

“We focused on ways to improve best practices for 20 of the most common things that we do on a regular basis,” Dr. Ritter said. “For example: What do we do when a patient calls and has a question about medication? How do we optimize referrals for lab tests? We’ve created documentation to streamline all of these frequently occurring processes.”

Meeting Demands Through Education and Prioritization

Continuing medical education programs for primary care providers that focus on rheumatic diseases, offered through Harvard Medical School, are another important way the Brigham is meeting increasing demands in patient care. Patients stand to benefit significantly when primary care providers are educated on the initial steps needed for evaluation and management of these diseases as well as on the signs and symptoms that should prompt more urgent referrals to rheumatology specialists.

In diseases for which it’s vital for patients to see a specialist right away, the team at the Brigham has put systems in place to ensure those with more urgent needs are prioritized. “One example of this is giant cell arteritis, where it’s important that we get a biopsy within two weeks,” Dr. Ritter explained. “We’ve created a button right in our computer system that flags these patients in our system. It allows us to fast-track their care.”

Another recurring challenge is getting buy-in from insurance companies to approve some of the newer small molecule and biologic therapies. This is a particular concern in the treatment of rheumatoid arthritis because a number of medications are now available, but these drugs are expensive. When patients can benefit, however, it’s important that they start taking these medications as soon as possible to prevent the permanent damage to joints that can result from unresolved inflammation.

“When patients check in for their appointments, we give them iPads and they’re asked a series of questions about their medications and symptoms,” Dr. Ritter said. “We can use that data to show over time how well somebody is responding to a particular therapy. These data allow us to identify when the therapy isn’t working, so we know that we should try something different. All of this goes right into our electronic medical records and is also available within the clinic documentation.”

Dr. Ritter noted that this system has the added benefit of helping patients become more active in their own care by allowing them to see trends in their data. “We will be moving toward doing this for other rheumatic diseases,” she said. “It helps us to better care for our patients and to justify to the insurance companies the therapies that they need.”

High Volume Leads to Specialized Expertise

Because of the high volume of patients seen at the Brigham, individual rheumatologists can develop special areas of expertise in conditions that are not commonly seen at other centers. One emerging specialization is in immune-related adverse events caused by checkpoint inhibitors for cancer.

“We have several doctors who are specifically interested in seeing these patients,” Dr. Ritter said. “We work with the oncologists at the Dana-Farber Cancer Institute to make sure patients are seen quickly.” The goal of this collaboration is to optimize cancer care while managing the many immune-related adverse events from these drugs.

Another example of a team approach is in the treatment of Raynaud’s disease. A specialized clinic allows patients to see experts in rheumatology and cardiovascular disease on the same day. In addition, it enables physicians to collaborate and communicate with each other on treatment methods.

The Brigham also has experts with an interest in working with people who have lupus. “As part of our Lupus Center, we provide additional information to patients in the form of regular newsletters as well as other services,” Dr. Ritter said. “The health care system can be a challenge for people with lupus, many of whom come from disadvantaged backgrounds. We want to help them get the care they need.”

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