SMART referral: How to improve the Access in busy rheumatology practice. Providing guidelines for primary care providers and referring physicians to improve the quality of referral in timely fashion (working with AbbVie in the project): Currently working on rheumatoid arthritis which is an ongoing project and looking for collaboration with other rheumatologist about it.
How to safely include nurse practitioners (NP) and Physician Assistants (PA) in your busy rheumatology practice.
Rheumatology, Dermatology Combine at Henry Ford to Deliver Coordinated Care
What if you could refer your patient for one consultation and get a second opinion and a look from a dermatologist? Well that is exactly what is happening at Henry Ford Health System.
“We have a regularly scheduled rheumatology/dermatology clinic where a patient sees both a dermatologist and a rheumatologist and trainees,” said Henry Ford rheumatologist Bernard Rubin, DO. The clinic sees a lot of patients with lupus and many with dermatomyositis, which are two specific diseases that overlap between rheumatology and dermatology, said Dr. Rubin, who is Division Head, Rheumatology at Henry Ford Health System and a clinical professor of medicine at the Wayne State University School of Medicine.
“The idea came about because we share a lot of diseases and we also share a lot of drug treatments. There are several of these (programs) around the country. There are probably about a dozen of these combined clinics in academic health care centers,” said Dr. Rubin.
About five years ago a dermatology resident who graduated from Henry Ford came to Dr. Rubin and asked if he would be interested in pursuing the clinic idea. Dr. Rubin was supportive and took the idea to Henry Lim, MD, the head of dermatology at Henry Ford. Dr. Lim, who is now the president-elect of the American Academy of Dermatology, was supportive of the idea.
At Henry Ford’s downtown Detroit campus, rheumatology and dermatology are next door to one another, so the marriage was one of convenience as well as passion.
The program worked as a pilot program for a year and is now more institutionalized, said Dr. Rubin. It is not a continuing care program, but provides second opinions and consultation to area rheumatologists.
As it provides a service for referring physicians, the clinic itself gains from furthering Henry Ford’s research. The clinic is focused on the triggers of disease as opposed to studying new drug treatments, so it doesn’t need to see patients on an ongoing basis.
Dr. Rubin said clinic’s research is funded through a variety of sources. “A lot of this is our own investigative-sponsored research—the musculoskeletal research. So we’ve internally funded it through a large Henry Ford endowment. We have pilot grants that we have applied for that have been funded through the Henry Ford educational endowment. In addition, we do have NIH grants.”
Henry Ford partners in its rheumatology program with Wayne State University, the Detroit Medical Center and the Veterans Administration.
“I have been here six years and since I have been here, I would say that the major focus for Henry Ford right now is immunologic diseases and difficult to manage rheumatic diseases. We focus on educating the fellows. We’re not trying to be all things to all people. There are excellent private rheumatologists in southeastern Michigan. What we’re trying to do is become a resource for very difficult patients that we would be happy to provide expertise and care,” said Dr. Rubin.
“We are trying to give people an alternative and easier access for complex cases. For example, we have five-day-a-week, same-day appointments downtown. If a patient calls at seven o’clock in the morning, we have several openings every single day at noon. “
HFHSRDClinic@hfhs.org is the email address for the HFHS Rheumatology Dermatology Clinic.
Early Screenings, Clinical Trials Key to Improving Scleroderma Treatment
As with many diseases, early detection is important to managing patients with scleroderma. But it’s not enough. There is a strong need for effective drugs to treat patients and clinical trials are vital in developing them, said Dinesh Khanna, MD, MS.
Rheumatologists play an important role in early detection through patient screenings, particularly in systemic scleroderma cases, said Dr. Khanna, who has directed the University of Michigan Scleroderma Program since 2011. Prompt referrals to scleroderma centers, such as the program and U of M, result in early treatment and often mitigate damage to vital organs, particularly the lungs, he said.
Primary care physicians can help by identifying primary cases of Raynaud’s Phenomenon, in which small blood vessels shut down and cause patients’ hands to turn red or blue. Raynaud’s Phenomenon affects 8 to 10 percent of the general population, according to Dr. Khanna. Distinguishing secondary cases, which could indicate scleroderma, from primary cases with other causes is a key skill for primary care physicians.
“If you diagnose (systemic scleroderma) with lung fibrosis early, with little scarring, you tend to do much better than if you diagnose it much later,” said Dr. Khanna. “I can emphasize that compared to 20 years ago the survival (rate) is much, much better—at least for five or 10 years. And the only difference is that we are screening patients quite early and aggressively.”
But early treatment only works to extend lives and slow the damage caused by the disease. As many as 20 percent of patients experience a progressive worsening of symptoms and require lung transplants or die, said Dr. Khanna.
“We always emphasize that clinical trials are preferable for management of this disease because we don’t have very effective treatments and cures,” he said. “Until we are able to do the appropriate, robust, large clinical trials that can get FDA-approved medications, we continue to…treat these patients without any good evidence data.
“What we are leading here is a trial of Orencia®, which is a medication that is approved for rheumatoid arthritis, to look at whether that will improve skin fibrosis and also have a beneficial effect on lung fibrosis.”
Dr. Khanna is leading the recently funded investigator-initiated trial and was recently given a $7 million investigator-initiated award from Bristol-Myers Squibb and from the National Institutes of Health to conduct an international clinical trial in patients with diffuse systemic sclerosis.
In addition to the Orencia trial, U of M is engaged in a Digital Ulcers RESCUE Pilot study to assess the efficacy and safety of the drug riociguat compared to a placebo in scleroderma-associated digital ulcers.
A full list of clinical trials at U of M’s Scleroderma Department accompanies this story.
Dr. Khanna is the author of over 250 peer-reviewed publications and book chapters. He has won numerous awards, including the 2007 Spirit of Leadership Award and the 2011 “Best Doctor of the Year” award from the Scleroderma Foundation. He is board certified in rheumatology. Dr. Khanna is currently funded by the National Institutes of Health and is particularly interested in the design of clinical trials and assessing patient reported outcomes in patients with scleroderma and leading novel international clinical trials in scleroderma.