Ward M M, Leigh J P, Fries J F
Department of Medicine, Palo Alto Veterans Affairs Medical Center, Calif.
Arch Intern Med. 1993 Oct 11;153(19):2229-37.
To determine whether patients with rheumatoid arthritis and their physicians make appropriate decisions regarding referral to rheumatologists and the need for continuing rheumatology care, we examined the relationship between the progression of functional disability in these patients and their use of rheumatology subspecialty care over time.
A cohort of 282 patients with rheumatoid arthritis was followed prospectively for up to 10 years. Participants were categorized into three subgroups based on the pattern of care received from rheumatologists over the study period: patients who were never treated by a rheumatologist; patients treated by a rheumatologist only intermittently; and patients treated by a rheumatologist at least once during each 6-month study period. The outcome was the rate of progression of functional disability, measured using the Health Assessment Questionnaire Disability Index.
Among the 52 patients who had not been referred to a rheumatologist, 30 (58%) had rates of progression of functional disability that were stable or improving over time (rate < 0.01 Disability Index units per year), while 22 (42%) had rates that were worsening (rate > or = 0.01 Disability Index units per year). Among patients treated by rheumatologists, the average rate of progression was substantially lower among the 69 patients who were treated regularly by a rheumatologist than among 161 patients treated by rheumatologists intermittently (0.008 Disability Index units per year vs 0.020 Disability Index units per year). This difference was associated with more intensive use of second-line antirheumatic medications, and more frequent joint surgeries, among patients treated by rheumatologists on a regular basis.
Most patients with rheumatoid arthritis in this community cohort were treated by a rheumatologist, but 42% of those not referred had progressively increasing functional disability. Among patients treated by rheumatologists, those who had continuing care from rheumatologists experienced lower rates of progression of functional disability than those who had only intermittent care. These results suggest that use of rheumatology subspecialty care is associated with better health outcomes in rheumatoid arthritis.
为了确定类风湿关节炎患者及其医生在转诊至风湿病专科医生以及持续接受风湿病护理需求方面是否做出了恰当决策，我们研究了这些患者功能残疾进展情况与他们长期使用风湿病专科护理之间的关系。
对282例类风湿关节炎患者进行了长达10年的前瞻性随访。根据研究期间从风湿病专科医生处接受治疗的模式，将参与者分为三个亚组：从未接受过风湿病专科医生治疗的患者；仅间歇性接受风湿病专科医生治疗的患者；在每6个月的研究期间至少接受过一次风湿病专科医生治疗的患者。观察指标为功能残疾进展率，采用健康评估问卷残疾指数进行测量。
在未转诊至风湿病专科医生的52例患者中，30例（58%）功能残疾进展率随时间稳定或改善（每年进展率<0.01残疾指数单位），而22例（42%）进展率恶化（每年进展率≥0.01残疾指数单位）。在接受风湿病专科医生治疗的患者中，69例定期接受治疗的患者的平均进展率显著低于161例间歇性接受治疗的患者（每年0.008残疾指数单位对每年0.020残疾指数单位）。这种差异与定期接受治疗的患者更多地使用二线抗风湿药物以及更频繁地进行关节手术有关。
该社区队列中的大多数类风湿关节炎患者接受了风湿病专科医生的治疗，但未转诊的患者中有42%功能残疾逐渐加重。在接受风湿病专科医生治疗的患者中，持续接受治疗的患者功能残疾进展率低于仅接受间歇性治疗的患者。这些结果表明，使用风湿病专科护理与类风湿关节炎更好的健康结局相关。
