And a new University of Michigan Health System study finds that entrenched attitudes and lack of communication among rheumatologists and hand surgeons, and a dearth of data comparing the two strategies, are keeping the controversy going.
Only large studies evaluating the effectiveness of various hand operations, the researchers say, will quell the debate and help patients get consistent and beneficial care no matter what kind of doctor they see or where they live.
The multidisciplinary U-M research team reports its latest findings about attitudes among rheumatologists and surgeons in the current issue of the Journal of Rheumatology. They published previous attitude-related results in the Journal of Hand Surgery earlier this year, and last October they reported dramatic state-by-state variation in hand surgery rates in the journal Arthritis & Rheumatism.
"What we're finding is that rheumatoid arthritis care can vary tremendously depending on where patients live, what type of physician they're referred to, how much cross-training and interaction those physicians have with others, and what an individual doctor personally thinks of other specialties," says Amy Alderman, M.D., M.P.H., lead author of all three studies and a resident in Plastic & Reconstructive surgery at UMHS. "Since this is a debilitating, chronic condition that affects so many, it's very concerning that we don't have a consensus or communication among providers."
Alderman and her U-M colleagues -- who include a rheumatologist, a senior hand surgeon, general internists and a statistician -- surveyed nearly 1,000 doctors selected by random sampling from among the members of top rheumatology and hand surgery societies. For the October paper, they also analyzed data on numbers of hand operations performed on rheumatoid arthritis patients in each state, compared with the number of people diagnosed with the condition overall.
"We see dramatic differences of opinion and practice over an important clinical problem that will only increase in importance as the population grows older," says co-author Peter Ubel, M.D., associate professor of internal medicine and psychology. "We don't know yet what will work best for individual patients, and so physicians don't agree about the best way to treat this condition. Patients need to be aware of this, and they may need to talk to several doctors to decide what's right for them."
Rheumatoid arthritis affects about 1 percent of the American population, and causes prolonged, painful and often debilitating inflammation and deformity in joints and tendons. Caused by a mysterious autoimmune malfunction, it affects patients for the rest of their lives, often worsening year by year. The condition especially strikes the hands and wrists, where it has a major impact on a patient's ability to perform daily functions such as lifting, eating, personal care and writing.
Medications have long been used to reduce inflammation, and work for many patients for years after diagnosis. But hand surgery has been seen as an option for patients who do not respond to medicines or whose hands have become so twisted and contorted that they no longer work.
The U-M survey studies show that physicians of different specialties are miles apart in their perception of how well surgery can help ease pain, restore function and prevent further problems. And, they're just as divided over how well they think members of the opposite specialty do at managing rheumatoid arthritis patients.
For instance, in the newly published paper, 70 percent of the rheumatologists surveyed considered hand surgeons deficient in their understanding of the non-surgical treatment options for rheumatoid arthritis, while 73.6 percent of the surgeons thought rheumatologists didn't know enough about the surgical options available to their patients.
The two groups of doctors differed significantly in their opinions of when particular operations might be appropriate for particular patients. Presented with case studies of hypothetical patients, they disagreed across the board on when joint replacement (arthroplasty), joint lining removal (synovectomy) and wrist bone surgery (resection of distal ulna) were indicated.
In the Journal of Hand Surgery paper published earlier this year, the U-M team found that the two types of doctors differed greatly on their perceptions of what surgery could actually do for patients. More than 82 percent of the hand surgeons, for example, felt that joint replacement improves hand function, as opposed to 34 percent of rheumatologists.
Meanwhile, 93 percent of the surgeons thought that removing the sheath around a tendon (tenosynovectomy) could prevent future ruptures of the tendon, compared with 54 percent of rheumatologists. And 52 percent of surgeons felt that small-joint synovectomy could delay the destruction of a knuckle joint, compared with 12 percent of rheumatologists. Thirty-five percent of rheumatologists felt that operation was never a good idea for patients.
These different world views on surgery are reflected in the state-by-state variation in surgery for rheumatoid arthritis that the researchers reported last fall. They found that some operations were performed as much as 12 times more often in some states than in others.
The different "management concepts" that rheumatologists and hand surgeons have for rheumatoid arthritis patients are only further divided by the fact that specialists in the two fields tend to read and publish research findings in their own field's journals, says Alderman.
And, she notes, only small uncontrolled studies have been performed to see how well the different operations work to repair arthritis-damaged hands or prevent more damage. Larger studies, aimed at measuring outcomes for different operations performed at different times, are needed. At the same time, plenty of such data are available for new medications that have come on the market in recent years -- data from the major controlled studies required for drug approval by the U.S. Food and Drug Administration.
As those new medications come into widespread use to help control the damage caused by the inflammation of rheumatoid arthritis and prevent progression of the disease, fewer patients may need early, aggressive surgery that preventively removes joint linings, Alderman notes.
But more may eventually need joint replacement or synovial surgery after medications start losing their effectiveness -- and the speed with which they get that surgery may have a lasting impact on how well their hands regain function.
That means communication between specialists will become more important than ever – but at the moment, the U-M studies seem to indicate that the two fields aren't talking with each other.
The new paper shows that 67 percent of hand surgeons and 79 percent of rheumatologists had no exposure to the other specialty during their medical training, and only about 10 percent of the physicians worked in combined-specialty hand clinics. And only 62 percent of all the physicians said they communicate with the other specialist treating a patient when they disagree with how a patient's care is being managed by that doctor.
The U-M Medical School is trying to bridge the gap in cross-training, by exposing medical residents in surgery and rheumatology to the other specialty during joint sessions.
All in all, say the authors, patients need to ask about all possible treatment options when they see primary care doctors and specialists, and decide what's right for them based on the level of their symptoms and the response to medications.
"Health care providers treating the rheumatoid arthritis population must recognize that they provide uncoordinated care, and work to improve quality of care through collaboration," says Alderman. "To create a coordinated approach, we need an international effort to collect solid data on surgical outcomes, disseminate the data to members of both specialties and to primary care providers, and design treatment plans tailored to specific disease characteristics."
The U-M researchers also hope they'll be able to help gather the data needed to prove surgery's effectiveness, and the best timing for certain operations. Kevin C. Chung, M.D., M.S., an associate professor of plastic and reconstructive surgery and the hand surgeon in these publications, will be leading a team of international researchers to study outcomes of surgical procedures in the rheumatoid population. These studies will be an important first step to bridge the gap between the two specialties.
In addition to Alderman, Chung and Ubel, the new paper's authors include David A. Fox, M.D., professor and chief of rheumatology; and H. Myra Kim, Sc.D., an associate research scientist in the biostatistics division of the U-M School of Public Health.
The study was supported in part by a grant from the Robert Wood Johnson Foundation and the American Society for Surgery of the Hand. Alderman is a former Robert Wood Johnson Clinical Scholar at the University of Michigan, and was mentored by Ubel, who also directs the Program for Understanding Health Care Decisions at the U-M Medical School.
Journal
The Journal of Rheumatology