EDITORIAL - Physician ... attorney of the poor

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Editorial

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Physician... Attorney of the Poor

RAJAN MADHOK, MD, FRCP;

NICOLA ALCORN, BSc, MBchB;

HILARY A. CAPELL, MD, FRCP, MBchB,

Consultant Rheumatologist;

Centre for Rheumatic Diseases, Wards 14/15,

Glasgow Royal Infirmary,

Castle Street, Glasgow G4 0SF Scotland

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It was first suggested in the editorial pages of this journal that the

pyramidal approach to managing rheumatoid arthritis (RA) should be

deconstructed2. This shift in paradigm prompted studies suggesting a

window of opportunity in early RA and greater benefit from use of

disease modifying antirheumatic drugs. Received wisdom, reinforced by

an increasing evidence base, now supports the view that RA should be

treated early with disease modifying antirheumatic drugs (DMARD).

Further, better outcomes can be achieved by disease-activity-targeted

treatment strategies as shown in the TICORA study (Tight Control for

RA)3. This concept, borrowed from diabetes but first championed in RA

in Glasgow, confirmed that achieving and maintaining low disease

activity as defined by Disease Activity Score (DAS) reduces

radiological progression and improves function as measured by the

Health Assessment Questionnaire (HAQ)3. These findings were endorsed

by the more recent BeSt study4. In parallel, a better understanding of

the biology of the inflamed synovium has resulted in targeted

approaches to treatment. The availability of these drugs has, for the

first time, allowed us to achieve better control of synovitis and also

raised the tantalizing opportunity of achieving disease remission.

Patients with newly diagnosed RA should thus be seen early at a

specialist clinic to initiate early and sustained use of DMARD. Delays

in initiating DMARD therapy may add not only to the morbidity but also

to the premature mortality of RA.

In this issue of The Journal Suarez-Alamazor and colleagues report on

the time to initiation of first DMARD in a cohort of RA patients seen

by the same physicians, but at 2 different sites, one serving the

disadvantaged in a public hospital and the second for those with

health insurance5. Based in an academic center, these investigators

provided a clinical service to 285 RA patients first seen by them

between 1994 and 2000 in Houston, Texas, USA. The uninsured group were

predominantly non–White (99 of 118 patients) whereas only 30 of those

attending the private institution were non–White. In a retrospective

analysis of these patients the time to initiation of a DMARD was

examined, and significant delays were found in the disadvantaged. The

authors, presumably due to resource limitations, did not explore the

reasons behind the delays.

There are many limitations to this study, some of which are

acknowledged by the authors. However the study highlights an important

issue for all professionals working in any healthcare system.

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Read the rest of the article here:

http://www.jrheum.com/subscribers/07/12/2320.html

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Not an MD