Primary Care Epidemiology and Global Health

Editorial

The Burden of Rheumatic Diseases in the Community: Raising Awareness in Primary Care

Irini Gergianaki*

Health Planning Unit, Medical School, University of Crete, Greece

Received: 21 December, 2018

Accepted: 24 December, 2018

Version of Record Online: 29 December, 2018

Citation

Gergianaki I (2018) The Burden of Rheumatic Diseases in the Community: Raising Awareness in Primary Care. Prim Care Epidemiol Glob Health 2018(1): 10-12.

Correspondence should be addressed to

Irini Gergianaki, Greece

E-mail: med4p1030241@med.uoc.gr

DOI: https://doi.org/10.33513/PEGH/1801-05

Rheumatic and Musculoskeletal Diseases (RMDs) are a highly diverse group of diseases and conditions, that can present in people of any age, including children. They are one of the leading causes of disability, affecting not only the joints, but almost any organ of the body [1,2]. Recently, a European League Against Rheumatism (EULAR)-American College of Rheumatology working group acknowledged that there is still lack of awareness regarding the complexity and importance of RMDs in the community [1]. Despite tremendous progress in early diagnosis and therapeutics of RMDs that has been achieved, various unmet needs remain, and significant consequences emerge at individual or societal level [3]. The role of Primary Care Physicians (PCPs) is strongly encouraged towards the direction of rigorous detection and referral to specialist, as well as, the co-management of comorbidities and other preventive measures, recommended for patients diagnosed with RMDs [4].

Interestingly, a number of high-quality reports on the clinical and epidemiological profile of RMDs that have been published during last decade, revitalized our interest to describe the burden of RMDs, through specific indicators, and broaden our knowledge about case definitions/classification criteria, prevalence, incidence, survival, risk factors and co-occurrence rates with other non-communicable diseases [5,6]. Notwithstanding, methodological problems in epidemiological studies of RMDs have long been discussed [5,7]. Among the less reported difficulties to obtain a clear picture of RMDs’ epidemiology, are the cost of obtaining data, the evolving case definitions, the limited number of population-based registries which describe the diseases’ occurrence/profile at the community and not only at hospital settings, and scarce data from the developing word [1]. Nevertheless, the current reports, although not completely representative, provide a number of interest messages for the PCPs that are discussed below in brief.

In the following paragraphs, illustrative examples of RMDs are given, highlighting the role that PCPs can have in early detection of RMDs and relevant comorbidities, based on their clinico-epidemiological characteristics. In total, RMDs are among the most common disorders, yet the individual diseases that constitute this group may be not [1]. Polymyalgia Rheumatica (PMR) remains one of the most prevalent inflammatory rheumatic diseases, especially in elderly patients, in fact, the second most common one after rheumatoid arthritis [8], with prevalence 0.85%, and overall incidence rate as high as 95.9 per 100, 000 general population, with stabilizing trends [9]. Although PMR is generally considered a disease that can be managed in primary care settings, at least the typical cases, primary care physicians’ diagnostic accuracy is lower than expected, leaving much room for improvement [10]. Additionally, patients with polymyalgia rheumatica receive high doses of corticosteroids for a prolonged time, much longer than the relevant recommendations suggest, presenting with increased risk of fracture (by 63%) [11] thus, there is need to rigorously identify these patients [12].

Furthermore, although the role that PCPs can play in the most prevalent RMDs, such as rheumatoid arthritis, has been generally broadly reported, the existing diagnostic delay of about two months (from PCP to rheumatologist) is not negligible [13], since early diagnosis may prevent progression of joint damage in more than 90% of patients. It is of high importance that PCPs be aware of the “therapeutic window” of very early arthritis that represents a distinct pathophysiologic phase of the first months, during which if treatment begins, a better prognosis can be achieved [14,15]. It is also important to remember that atypical presentations of rheumatoid arthritis, such as numbness or weakness, may lead to a referral delay, among others [4].

Interestingly, some of the uncommon RMDs, such as Systemic Lupus Erythematosus, are not considered as rare as they used to, in the past [16,17]. Yet, for a PCP, it is not only the cases that a decision to referral with “possible SLE diagnosis” will be made, but all the cases that SLE is suspected, with low probability, and the patient should be reassured or re-evaluated [18]. In addition, it has to be stressed out that the clinical features of SLE may actually differ from “text-book” descriptions, as SLE does not present only in young girls, but also in middle-aged women and, increasingly, in men and, commonly, manifest with milder/atypical presentation at early stages [18].

Lastly, the concept of multimorbidity is a “hot topic” in RMDs, with 30% of patients at diagnosis of Rheumatoid Arthritis and 80% during follow-up, presenting with at least one comorbidity, whist patients with established RA have on average two comorbidities [19,20]. Depression, obesity, hyperlipidemia, increased cardiovascular risk and risk of specific malignancies, as well as osteoporotic fractures and infections are commonly seen in patients with RMDs [21], and they are considered as one of the main factors for non-declining mortality rates [20]. Importantly, RMDs are highly prevalent in patients with non-communicable chronic diseases (i.e., 38.6% in cardiometabolic diseases) [22]. Skills of PCPs and hospital specialists can be complementary in approaching multimorbid patients in a holistic manner [4].

Education of PCPs is a priority not only in early identification and referral, but also in the multimorbidity management, with previous studies reporting under-recognition and under-assessment of cardiovascular risk, in patients with rheumatoid arthritis in primary care, with only 15% and 34% of PCPs assessing their patients with diagnosed RA for primary and secondary prevention of cardiovascular risk. Although this was increased after relevant education, PCPs were not consistently engaged in their clinical routine [23]. As robust diagnostic criteria do not exist for the majority of RMDs and the existing prediction models for rare conditions are not likely to be effective in primary care software [24], the education of PCPs on rheumatic and musculoskeletal conditions re-emerges as challenging but promising task [25,26].

In conclusion, there are some points of epidemiological studies of rheumatic diseases that can be meaningful in primary care, where the diagnostic uncertainty is higher than hospital settings. “Translating” occurrence trends and epidemiological features into practical messages for the PCPs, may be extremely helpful for the everyday clinical practice. To this direction, more research focused on primary care level, more robust prediction models and diagnostic questionnaires and PCPs tailored training on RMDs are highly needed.

References

  1. van der Heijde D, Daikh DI, Betteridge N, Burmester GR, Hassett AL, et al. (2018) Common language description of the term Rheumatic and Musculoskeletal Diseases (RMDs) for use in communication with the lay public, healthcare providers and other stakeholders endorsed by the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR). Ann Rheum Dis 77: 829-832.
  2. Palazzo C, Ravaud J, Papelard A, Ravaud P, Poiraudeau S (2014) The burden of musculoskeletal conditions. PLoS One 9: 90633.
  3. Taylor PC, Moore A, Vasilescu R, Alvir J, Tarallo M (2016) A structured literature review of the burden of illness and unmet needs in patients with rheumatoid arthritis: a current perspective. Rheumatol Int 36: 685-695.
  4. Mallen CD, Helliwell T, Scott IC (2018) How can primary care physicians enhance the early diagnosis of rheumatic diseases? Expert Rev Clin Immunol 14: 171-173.
  5. Guillemin F (2012) Describing the epidemiology of rheumatic diseases: methodological aspects. Curr Opin Rheumatol 24: 187-192.
  6. Carter EE, Barr SG, Clarke AE (2016) The global burden of SLE: prevalence, health disparities and socioeconomic impact. Nat Rev Rheumatol 12: 605-620.
  7. Lim SS, Drenkard C (2008) Epidemiology of systemic lupus erythematosus: capturing the butterfly. Curr Rheumatol Rep 10: 265-272.
  8. Camellino D, Dejaco C (2018) Update on treatment of polymyalgia rheumatica. Reumatismo 70: 59-66.
  9. Partington RJ, Muller S, Helliwell T, Mallen CD, Abdul Sultan A (2018) Incidence, prevalence and treatment burden of polymyalgia rheumatica in the UK over two decades: a population-based study. Ann Rheum Dis 77: 1750-1756.
  10. Muller S, Hider SL, Helliwell T, Lawton S, Barraclough K, et al. (2016) Characterising those with incident polymyalgia rheumatica in primary care: results from the PMR Cohort Study. Arthritis Res Ther 18: 200.
  11. Paskins Z, Whittle R, Sultan AA, Muller S, Blagojevic-Bucknall M, et al. (2018) Risk of fracture among patients with polymyalgia rheumatica and giant cell arteritis: a population-based study. BMC Med 16: 4.
  12. Dejaco C, Singh YP, Perel P, Hutchings A, Camellino D, et al. (2015) 2015 recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Arthritis Rheumatol 67: 2569-2580.
  13. Barhamain AS, Magliah RF, Shaheen MH, Munassar SF, Falemban AM, et al., (2017) The journey of rheumatoid arthritis patients: a review of reported lag times from the onset of symptoms. Open Access Rheumatol 9: 139-150.
  14. Bosello S, Fedele LA, Peluso G, Gremese E, Tolusso B, et al. (2011) Very early rheumatoid arthritis is the major predictor of major outcomes: clinical ACR remission and radiographic non-progression. Annals of the rheumatic diseases. 70: 1292-1295.
  15. Stack RJ, Llewellyn Z, Deighton C, Kiely P, Mallen CD, et al. (2014) General practitioners’ perspectives on campaigns to promote rapid help-seeking behaviour at the onset of rheumatoid arthritis. Scand J Prim Health Care 32: 37-43.
  16. Gergianaki I, Bortoluzzi A, Bertsias G (2018) Update on the epidemiology, risk factors, and disease outcomes of systemic lupus erythematosus. Best Pract Res Clin Rheumatol 32: 188-205.
  17. Rees F, Doherty M, Grainge M, Davenport G, Lanyon P, et al. (2016) The incidence and prevalence of systemic lupus erythematosus in the UK, 1999-2012. Ann Rheum Dis 75: 136-141.
  18. Gergianaki I, Bertsias G (2018) Systemic Lupus Erythematosus in Primary Care: An Update and Practical Messages for the General Practitioner. Front Med (Lausanne) 5 :161.
  19. Aslam F, Khan NA (2018) Tools for the Assessment of Comorbidity Burden in Rheumatoid Arthritis. Front Med (Lausanne) 5: 39-39.
  20. Radner H (2016) Multimorbidity in rheumatic conditions. Wien Klin Wochenschr 128: 786-790.
  21. Baillet A, Gossec L, Carmona L, Wit Md, van Eijk-Hustings Y, et al. (2016) Points to consider for reporting, screening for and preventing selected comorbidities in chronic inflammatory rheumatic diseases in daily practice: a EULAR initiative. Ann Rheum Dis 75: 965-973.
  22. Simões D, Araújo FA, Severo M, Monjardino T, Cruz I, et al. (2017) Patterns and Consequences of Multimorbidity in the General Population: There is No Chronic Disease Management without Rheumatic Disease Management. Arthritis Care Res (Hoboken) 69: 12-20.
  23. Bell C, Rowe IF (2011) The recognition and assessment of cardiovascular risk in people with rheumatoid arthritis in primary care: a questionnaire-based study of general practitioners. Musculoskeletal Care 9: 69-74.
  24. Pearce F, Lanyon PC, Watts RA (2018) Can prediction models in primary care enable earlier diagnosis of rare rheumatic diseases? Rheumatology (Oxford) 57: 2065-2066.
  25. van Onna M, Gorter S, Maiburg B, Waagenaar G, van Tubergen A (2017) GPs’ patterns of clinical assessment when faced with a patient suspected for spondyloarthritis: a prospective educational intervention study. BJGP Open 1: bjgpopen17X100689.
  26. Hausmann JS, Schwartzstein RM (2018) Using Questions to Enhance Rheumatology Education. Arthritis Care Res (Hoboken). DOI: 10.1002/acr.23753.
Ocimum Scientific Publishers

This work is licensed under a Creative Commons Attribution 4.0 International License.  Creative Commons License

Copyright © 2019 - All Rights Reserved - ocimumpublishers.com