Modern rheumatology- A dynamic and accessible service. Jeremy Jones. Consultant Rheumatologist Clinical Lead CMATS* Honorary Research Fellow

Transcription

1 *CMATS = Clinical Musculoskeletal and Treatment Service Modern rheumatology- A dynamic and accessible service Jeremy Jones Consultant Rheumatologist Clinical Lead CMATS* Betsi Cadwaladr University Health Board, North West Wales Honorary Research Fellow The School of Sport, Health and Exercise Sciences, Bangor University

2 Rheumatology (used in its widest sense) Geography History Development of Services with time Prudent Health care MSK Service in 2016 Rheumatology Service in 2016 Early Synovitis Clinic Update on Gout From heart sink to stout-heartedness; Ten top tips from the fibromyalgia clinic

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4 North West Wales 250,000 people Retired/second homes Agriculture Outdoor tourism Bangor University Long and winding roads; full of tractors, milk trucks etc Public transport; rural

5 Curriculum vitae Qualified at St Marys Hospital Registrar Rheumatology at Guys Hospital Senior Registrar Rheum and Rehab at Kings College Hospital Sabbatical; ARC Research Fellow at Addenbrookes Hospital, Cambridge Specialist in Rheumatology and Rehabilitation Medicine, Queen Elizabeth Hospital for Rheumatic Diseases, Rotorua, New Zealand 2002 present: North West Wales Rheumatologist Clinical lead for TEAMS/CMATS THE fibromyalgia doctor Appointment at Sports Science School, Bangor University

6 The 1970s Rheumatology and Rehabilitation

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8 Ann rheum Dis

9 Management of rheumatoid arthritis Steroids Gold/Penicillamine Aspirin Phenylbutazone Early days for surgery, anaesthetics etc Bed rest Splinting Hydrotherapy

10 1970 s; Skills required of trainee rheumatologist Rheumatic diseases Make POP splints Corticosteroid injections Yttrium injections Polarising light microscopy for crystals Nerve conduction tests and EMG Physical medicine Spinal epidurals Oversight of physiotherapists Electrotherapy Hydrotherapy Remedial gymnasts Sports medicine Osteoporosis Orthopaedic clinics Rehabilitation Neurological conditions MS strokes etc Orthotics Surgical footwear Wheelchairs Callipers Artificial limbs Phenol injections for spasticity Research and publications General medicine Medical student teaching Lectures for nurses and PTs

11 Case mix; Rheumatology Sen Reg KCH Total New Patients 818 Soft Tissue Rheumatism Backs 170 (20%) Shoulders 97 Knees 87 Hand/wrist 88 Necks 73 Elbows 57 Feet 52 Hips 39 Nerve (ex CTS) 15 Total 674 (82%) Inflammatory RA + Inflam arthritis 30 Gout 9 PMR 6 Ank Spond 5 Psoriatic arth/spond 6 Reiters Syndrome 3 AOSD 2 Wegeners 2 Scleroderma 1 Various 3 Total 67 (8%) Others 10%

12 Where was fibromyalgia? Smythe HA, Moldofsky H. Two contributions to understanding of the "fibrositis" syndrome Bull Rheum Dis. 1977

13 1980s Queen Elizabeth Hospital Rotorua, NZ

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17 Queen Elizabeth Hospital, Rotorua Nursing staff

18 Sister Mary Lean writes from Rotorua NZ 16/6/11 A thing that I remember well in the 70's when inflammatory arthritis was not well controlled was the pain that patients experienced from their inflamed joints. The handling of the patients, getting them up, settling them, transferring them etc was a mission. You had to be so careful and listen to the patient who knew best the least painful way to be moved I was going to mention the Duthies" and how we had to take 1 limb out of the splint at a time, wash the limb and then put the splint back on before we did the next one.

19 Muscle atrophy in chronic arthritis

20 RA medication timeline Aspirin GOLD steroids MTX TNF RTX Abatacept Tocilizumab Cetroluzimab Golimumab?????? s 1950s 1980s Treat signs and symptoms in established disease Aggressive MTX dosing, combination therapy, disease modification

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22 TEAMS History Started as TEAMS (Targeted Early Access Musculoskeletal Services*) 2002 Introduced to rationalise MSK referrals to orthopaedic, rheumatology, physiotherapy, pain management Established MSK, Spinal Services Introduced GPwiSIs and Extended Scope practitioners (ESP)s Electronic referral Clinician rather than GP based triage Each patient to see most appropriate clinician Interface primary/secondary care *Improved access and targeting of musculoskeletal services in northwest Wales: targeted early access to musculoskeletal services (TEAMS) programme. Peter Maddison, Jeremy Jones,...Craig Barton,... Chris Tilson. British Medical Journal 2004; 329:

23 Before TEAMS Musculoskeletal symptoms GP 1 ORTHOPAEDIC 2 RHEUMATOLOGY 3 CHRONIC PAIN 4 PHYSIOTHERAPY 15 MONTHS 9 MONTHS 14 MONTHS VARIABLE

24 After TEAMS 2 years on MS symptoms GP TEAMS OFFICE MSM 1 Ortho 3-15 months 2 Rheumo 6 weeks 8 Pain Management 3-6 months 3 Physio PT 1-3 months 7 Fibro Cons 4 weeks 4 MSM (GPwSIs ESPs) 10 weeks 5 Back pain ESPs 6 weeks 9 Sports clinic 5weeks

25 CMATS Centrally NOT locally designed WAG applied TEAMS model to all Health Boards in Wales in 2012 calling it CMATS. WAG based CMATS in primary care so the Clock for Referral to Treatment Time did not start WAG designed electronic referral system WAG introduced any referral for hip/knee surgery with BMI over 35 to go to lifestyle programme not surgeon WAG said no surgery for halux valgus or ganglion

26 CMATS referrals Oct 2016 MSK Spinal Orthopaedic Rheum GP referral Clinician triage Podiatry Pain Bone Tingly Fingers Physio/OT

27 CMATS Personnel West ESPs MSK x 5 ESPs Spinal x 3 GPwiSIs MSK x 3 ESP Podiatry ESPs Hand x 2 Consultant MSK ESP = Extended Scope Practitioner

28 Extended scope practitioners Injection certified Prescribing certified Privileges to order strictly defined imaging One stop shop if possible Prudent Health Care Principles

29 MSK/Spinal TRIAGE?Red flag/urgent/routine?esp/gpwisi/consultant/ Podiatrist Injection certified? Held in physio dept WHERE? Ysbyty Gwynedd Llandudno Bryn Beryl (spinal only) Holyhead Allt Wen Dolgellau

30 CMATS +/- 12 clinics per week +/- 80 patients per week Waiting time Urgent 4-6 weeks Routine weeks Waiting time for letter typing 2-3 weeks Waiting time for; MRI - 8 weeks NCTs Routine- 8 weeks Complex- 10 weeks

31 HOT OFF THE PRESS The ESP in primary care ESPs now seeing MSK patients off the street in GP surgeries for diagnosis and management plan Patients with MSK complaints directed to ESP by the receptionist Brought about by crisis (no GPs) not as part of a plan Not providing hands on Physiotherapy Seems to be working OK

32 CMATS Down side Only a limited number of physios Now providing diagnostic/treatment services Reducing resource for therapy Reducing resource for supervision/ management of just qualified Physios

33 Prudent health care The way forward for NHS Wales The Bevan Commission

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35 A group of international experts giving advice to the Minister for Health and Social Services to help ensure that increasingly Wales can draw on best practice from across the world while remaining true to the principles of the NHS as established by Aneurin Bevan.

36 The challenge Considerable challenge to improve health and heath/social systems in an era of:- 1) Increasing demand 2) Increasing expectation 3) Increasing inequality 4) Severe financial restraint 5) Shortage of clinicians i.e. AUSTERITY

37 Prudent healthcare Definition Healthcare which is conceived, managed and delivered in a cautious and wise way, characterised by forethought, vigilance and careful budgeting which achieves tangible benefits and quality outcomes for patients By placing greater value on patient outcomes rather than volume of activity and procedures delivered, as we currently do, prudent healthcare aims to rebalance the NHS around the patient or population it serves

38 Developing the principles 1 - Equity based care, treating greatest need first 2 - Do no harm- do some measureable good 3- Do the minimum appropriate to achieve desired outcome 4- Choose the most prudent health care openly with the patient 5- Consistently apply evidence based medicine in practice 6- Co-create health with the public, patients and partners

39 4 principles of prudent healthcare 1. Achieve health and well being with the public, patients and professionals as equal partners through co-production 2. Care for those with the greatest health need first, making most effective use of all skills and resources 3. Do only what is needed, no more, no less; and do no harm 4. Reduce inappropriate variation using evidence based practices consistently and transparently Prudent Healthcare - Securing Health and Wellbeing for Future Generations. 12 February Welsh Government. CID

40 MSK intervention evidence base A controlled trial of arthroscopic surgery for osteoarthritis of the knee. Mosely et al N Eng J Med 2002: 347; Arthroscopic Partial meniscectomy versus sham surgery for a degenerative medial meniscus. Sihvonen et al. N Eng J Med 2013: 369; No evidence of long-term benefits of arthroscopic acromioplasty in the treatment of shoulder impingement syndrome; five-year results of a randomized controlled trial. Ketola et al. Bone and Joint Research DOI: / Published 9 July 2013 Systematic Review of Caudal Epidural Injections in the Management of Chronic Back Pain. Dighe and Friedman. RIMJ There is no convincing evidence for the efficacy of Corticosteroid injection in chronic low back pain

41 MSK and prudent health care Will referral result in change in management? Will investigation result in change in management? Will the referral show incidentaloma Often the referral is made because the patient is very distressed, the patient is pushy or important The opportunity cost of the lost appointment or MRI for the case in whom it will change management Try to get the best value for patient from our (very) limited resources

42 RHEUMATOLOGY

43 Before TEAMS Musculoskeletal symptoms GP 1 ORTHOPAEDIC 2 RHEUMATOLOGY 3 CHRONIC PAIN 4 PHYSIOTHERAPY 15 MONTHS 9 MONTHS 14 MONTHS VARIABLE

44 Problems Pre-TEAMS New patients Long wait for appointments (9 months) Lots of DNAs Inappropriate casemix (40% medical; 60% aches and pains) Unpredictable casemix Might have very medical case (30 mins), then sore elbow (15 minutes), then Fibromyalgia (40mins) So sometimes thumb twiddling and sometimes way behind time (unpopular patients, clinicians and nursing staff) Inpatient beds

45 Problems Pre-TEAMS (cont) Follow up Clog up (FuCu) Masses of follow up patients (traditional model)* Inflexible ++++ All follow up appointments taken for foreseeable future When patients came to routine appointments they were usually well When they were ill there was no appointment for them They would not allow themselves to be discharged because of the long wait (months) for a new appointment. *75% of British rheumatologists work load is with FU pts. Kirwan & Snow BJR 1991;30:285-7

46 After TEAMS 2 years on MS symptoms GP TEAMS OFFICE MSM 1 Ortho 3-15 months 2 Rheumo 6 weeks 8 Pain Management 3-6 months 3 Physio PT 1-3 months 7 Fibro Cons 4 weeks 4 MSM (GPwSIs ESPs) 10 weeks 5 Back pain ESPs 6 weeks 9 Sports clinic 5weeks

47 CMATS TRIAGE OCT 2016 MSK Spinal Orthopaedic Rheumo GP referral Clinician triage Podiatry Pain Bone Tingly Fingers Physio/OT

48 RHEUMATOLOGY TRIAGE Oct 2016 URGENT CLINIC EARLY SYNOVITIS CLINIC ANK SPOND CLINIC BONE CLINIC CMATS RHEUMO LUPUS/VASCULITIS CLINIC GOUT CLINIC PAEDIATRIC CLINIC FIBRO CLINIC ROUTINE

49 Rheumatology Multidisciplinary Team Rheumatologists X 3 Nurses x 3 * # Occupational therapist x1 Physiotherapists X 1.5 * Pharmacist x 1 * GPwiSI Trainee *Prescribing privileges Injecting privileges # Ultrasound privileges

50 Peter Maddison Rheumatology Centre Llandudno Hospital Hub Base Clinic rooms etc Own staff Ultrasound Helpline Admin Not acute hospital No Beds Spokes at; Bangor Caernarfon Porthmadoc Pwllheli Holyhead Blaenau Ffestiniog Dolgellau

51 Now New patients Purely outpatient service Outpatient case mix is predictable Appropriate clinician Appropriate length of time Appropriate setting Follow up Patients Nurses FU re DMARDS Helpline Shared care Annual practitioner clinics Patient initiated referral rather than regular FU

52 Challenges Can t get the staff! (Doctors/physios/nurses) Irrational central government dictats Poor lines of communication between Primary and secondary care Silo hospital management Geography Prudent Health Care versus Defensive Medicine

53 1970 s; Skills required of trainee rheumatologist Rheumatic diseases Make POP splints Corticosteroid injections Yttrium injections Polarising light microscopy for crystals Nerve conduction tests and EMG Physical medicine Spinal epidurals Oversight of physiotherapists Electrotherapy Hydrotherapy Remedial gymnasts Sports medicine Osteoporosis Orthopaedic clinics Rehabilitation Neurological conditions MS strokes etc Orthotics Surgical footwear Wheelchairs Callipers Artificial limbs Phenol injections for spasticity Research and publications General medicine Medical student teaching Lectures for nurses and PTs

54 Four Decades of Rheumatology Clinical Practice; The future Huge changes in the understanding and management of rheumatic disease Much of what used to be rheumatology has been captured by others Rheumatology is now an outpatient activity and care of long term conditions is moving into primary care Rheumatologists are in danger of becoming rheumatoidologists The management of RA is largely cook book medicine and no longer needs a consultant rheumatologist to oversee it There will soon be a cure for RA (or it will die out) What will become of the rheumatoidologist then?

55 There s always fibromyalgia!

56 Should rheumatologists retain ownership of fibromyalgia? Shir Y, Fitzcharles MA. J Rheumatol 2009;36(4):

57 Modern rheumatology- A dynamic and accessible service

58 Whatever will things be like in 2062?? 1970s 2016