Everyday Health recently posted an article about the benefits of combined dermatology and rheumatology clinics in the treatment of psoriatic arthritis. Does research show a patient care benefit? What are ways dermatology and rheumatology providers can work better together outside of a combined clinic model?
For expert advice, I reached out to Brad Glick, DO, MPH, clinical assistant professor of dermatology and the dermatology residency program director at Larkin Community Hospital in South Miami, Fla., and Andrea Nguyen, PA-C, MPAS, with First OC Dermatology in Irvine, Calif. Dr. Glick and Andrea recently participated in a panel discussion on collaborative care across dermatology and rheumatology at DERM2022 in Las Vegas.
How prevalent are dermatology-rheumatology clinics and how is this changing over time?
Andrea: Combined dermatology-rheumatology clinics are rare. Most clinics that are combined dermatology-rheumatology specialty clinics are structured for a dermatology specialist to see patients on a specific day of the week at a rheumatology clinic, or vice versa. Patients are scheduled appointments to mirror the availability of the desired specialist. To have both dermatology and rheumatology specialists at the same site full-time is very rare. The availability of these combined specialty clinics is likely going to continue to be rare due to the limited number of trained specialists to treat the growing population. One potential opportunity to increase the number of dermatology-rheumatology clinical sites is with the help of large healthcare organizations that are occupying a larger market share in today’s healthcare landscape. Since these large healthcare organizations employ clinicians directly and have more available resources, they can create vertically integrated multispecialty clinics with fewer obstacles than small, individual private practices would have.
Dr. Glick: From the academic institution perspective, they constitute around 25 programs around the United States with a concept and its intent at a rapid pace. Interdisciplinary “dual” disciplines caring for patients is logical and impactful, and surveys indicate that this is generally university accepted by patients undergoing this experience.
Does research indicate a patient care benefit in psoriatic arthritis treatment at a combined or multispecialty clinic?
Dr. Glick: Yes, there are small studies and survey results that indicate having two different disciplines see the same person at the same time allows both physicians and the patient to discuss options in real time. This resuls in improvement in overall shared decision making.
Andrea: There are publications available showing the utility and benefit of combined rheumatology-dermatology clinics. The findings of these publications are generally positive and suggest patients benefit from receiving care from the collaboration of dual specialties. In my clinical experience, patient care greatly improves with combined multispecialty clinics because the patients are seen by both specialties expeditiously. This allows for both specialists to confer and discuss specific patient cases in real time, which minimizes any confusion or delays in care. This improves the timeline of work up, diagnosis and treatment by minimizing long wait times (of several weeks or months) between visits with each specialist.
On average, do referrals for psoriatic arthritis at combined or multispecialty clinics occur sooner, therefore helping prevent joint erosion and disability?
Glick: Yes — the dual and or multidisciplinary impact does appear to result in prompt patient assessment and more effective collaborative care.
Andrea: When patients are seen in dermatology-rheumatology clinics, the patients are referred and scheduled within the same clinic, which should allow for expedited appointments. There is clinical evidence supporting early diagnosis and treatment in psoriatic arthritis patients with improved long-term patient outcomes with respect to joint erosion and disease burden. Delays in diagnosis and treatment, for even as short as six months, have been associated with structural joint damage and poor physical function. One would expect improved patient outcomes with these multispecialty clinic patients, but more information is needed comparing real world data of psoriatic arthritis patient outcomes seen in multispecialty clinics versus single specialty clinics.
What barriers can arise when patients are not treated at a combined clinic, such as barriers in provider communication or access to timely appointments?
Dr. Glick: Primarily the likelihood of “longer wait times” compared to these more targeted clinics that are focused primarily on rheumatic diseases with dermatological manifestations.
Andrea: The first barrier is specialist communication and coordination. Dermatology sees the patient and has a care plan, which is forwarded to the rheumatology clinic for further consideration. If medical records are lost in transit, or potentially not reviewed in time for the patient’s initial consultation, treatment can subsequently be delayed. Also, there can be long waiting times for these specialists, which can cause problems with disease progression for these psoriatic arthritis patients if left untreated during the waiting period.
If dermatology providers are not practicing in a combined or multispecialty clinic, what are some tips for better communication with rheumatology providers for a continuum of patient care?
Dr. Glick: Establish a posse early on! Develop relationships with colleagues in rheumatology, GI, psych, and ophthalmology.
Andrea: A shared electronic medical record (EMR) system is one potential opportunity for improving communication between specialties and reducing delays in patient care. This is one aspect large healthcare organizations can assist with since they have the resources to facilitate this type of communication and medical staffing. There is also an idea of having a dedicated clinician phone line where specialists can directly contact one another to discuss patient cases. Alternatively, the treating clinician can give a physical copy of the patient’s medical note, or a medical letter, to the patient to hand carry to their scheduled rheumatology visit.
What additional tips or advice do you have for dermatology practitioners in working with rheumatology?
Dr. Glick: Pick up the phone. Call or text. Create a conduit for access so patients can get timely appointments. Partner up with general physicians to assure patients’ overall health is being managed in the context of disease management and attention to comorbidities. Also, screen for psoriatic arthritis at every visit.
Andrea: Dermatologists and dermatology HCPs can network within their community to engage with their rheumatology colleagues. Having that personal connection can make all the difference for both specialists to refer patients and communicate effectively. I hope to see further strengthening of dermatology-rheumatology collaboration in the future.
CO-MANAGEMENT IS RECOMMENDED FOR THE BENEFIT OF PATIENT OUTCOMES
Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) Recommendations:
- Patients should be offered regular evaluation by appropriate specialists and have treatment adjusted as needed.
- Early diagnosis and timely treatment are likely to be of benefit
American Academy of Dermatology and National Psoriasis Foundation Recommendations:
- Psoriasis patients should be educated to watch out for potential signs and symptoms of psoriatic arthritis.
- Offer regular screenings for signs and symptoms of psoriatic arthritis and have treatment adjusted as needed.
Increased Patient Satisfaction Among Patients Receiving Multidisciplinary Care,*
92.7% rated care as better or much better; 100% rated their disease as better controlled.
- Haberman R, Perez-Chada LM, Merola JF, et al. Bridging the gaps in the care of psoriasis and psoriatic arthritis: The role of combined clinics. Curr Rheumatol Rep. 2018 Oct 26;20(12):76.
- Elmets, CA et al, J Am Acad Dermatol. 2019;80: 1073-1113; 2. Coates LC, et al, Arthritis Rheumatol. 2016;68:1060- 1071; 3. Urruticoechea-Arana A, et al. Reumatol Clin. 2019;15:237-241.
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