Inflammatory-rheumatic disorders are a widespread ailment, affecting at least 1.5 million people in Germany alone. Because there is a shortage of rheumatologists, however, only half of the patients in this country are adequately treated (1,2). The use of other health care professionals, as is the case in Denmark and the UK, could help to improve the situation. A study in Germany has shown for the first time that the care of patients with inflammatory-rheumatic diseases by 'rheumatological assistants' (RFA*) is just as effective as treatment by specialist rheumatologists. To reduce waiting times and prevent damage to health, the European League Against Rheumatism (EULAR) strongly recommends the use of RFAs in Germany, which will be announced at a press conference on 3 June 2020 held for its annual congress.
Around two percent of the adult population in Germany is affected by chronic inflammatory rheumatic diseases, such as rheumatoid arthritis (RA), axial spondyloarthritis (axSpA) or psoriatic arthritis (PsA) (1). "These patients have a considerable medical condition," explains Dr. Kirsten Hoeper from the Clinic for Rheumatology and Immunology at the Hanover Medical School in Germany.
Missed opportunities for treating patients due to long waiting times
Severe pain, extreme fatigue, lack of strength, stiffness and physical deformity can have a significant impact on activities, education and career, partnership and family and can lead to occupational disability. Early diagnosis and therapy are essential to prevent as far as possible such serious consequences of damage to the joints. "But the existing medical resources do not suffice to provide early, patient-centred and guideline-based care. The waiting times are far too long," states Hoeper. "This is despite the fact that new drugs could almost completely force the disease back into so-called remission for the majority of patients - provided that treatment is administered in good time."
The deployment of RFAs could improve the situation, as is already well-established in some Northern European countries. RFAs are members of related medical professions such as paramedic, nurse, student nurse or road traffic/motor traffic accidents, who have acquired additional theoretical and practical knowledge about the care of patients suffering from rheumatic and musculoskeletal diseases (RMDs) (3). Such a delegation of medical care in rheumatology is recommended worldwide (4-8, 9). "The legal framework for this also exists in Germany," says Hoeper (10). "In addition, the curriculum for the RFA degree exists since 2006, which is currently available to the German Medical Association for certification in an extended form (3).
In order to examine whether and how RFAs can also be used in the German health care system, a prospective, randomised, controlled and multi-centre study was conducted, which was completed in December 2019. "A total of 236 patients from eight German centres participated in the study, where a blood test had confirmed the diagnosis of rheumatoid arthritis," explains the author of the study Hoeper.
Study Involvement of RFAs produces the same treatment results
On average, the patients were 58 years of age, over 70 percent were female and suffered from rheumatic complaints for a period of 130 (ranging from 12 to 144) months on average. While one study group was exclusively treated by rheumatologists during the twelve-month study period, the other study group RFAs temporarily took over the care at three fixed intervals with only brief contact to the physicians. The patients' condition was measured using the standard assessment form DAS28 (Disease Activity Score at 28 joints), which assesses the activity of the disease on an ascending scale from 2.0 to 10.0. Values between 3.2 and 5.1 are considered moderate.
Result of the study: The structured delegation of medical tasks to an RFA does not undermine the current standard of care. While the disease activity for the group co-treated by RFAs was on average DAS28 2.43, the value for the group with continuous rheumatologist consultation was on average DAS28 2.29. "This difference is not clinically or statistically significant", concludes EULAR President Professor Dr. Iain B. McInnes from Glasgow, Scotland, UK. "For the first time it can be shown for Germany that an RFA consultation is a safe way to complement the care of patients suffering from rheumatoid arthritis", says Professor Dr. med. John Isaacs from Newcastle, Great Britain, EULAR Scientific Programme Committee Chair.
Better care in a cost-efficient way
"Integrating a team approach comprising rheumatologists with other health professionals into the treatment of patients with inflammatory rheumatic diseases presents great opportunities," emphasises McInnes. "RFAs can complement a physician's workload, who in turn can use freed-up resources for more complex or new patients," Hoeper adds. The long waiting times for an appointment with a rheumatologist could thus be cut shorter. Hoeper concludes, "by following the international EULAR Recommendations regarding RFAs, Germany will lead to better patient care in a cost-efficient way".
*RFA: Rheumatologische Fachassistenz
Notes to editors:
1. Zink A, Braun J, Gromnica-Ihle E, et al. [Memorandum of the German Society for Rheumatology on the quality of treatment in rheumatology - Update 2016]. Zeitschrift fur Rheumatologie 2017;76:195-207.
2. Edelmann E. Outpatient rheumatologic treatment in Germany. Z Rheumatol 2014; 73:123-34.
3. Rheumaakademie. Rheumatologische Fachassistenz. https:/
4. Koksvik H, Hagen K, R_devand E, Mowinckel P, Kvien T, Zangi H. Patient satisfaction with nursing consultations in a rheumatology outpatient clinic: a 21-month randomised controlled trial in patients with inflammatory arthritides. Annals of the rheumatic diseases 2013:836-43.
5. Ndosi M, Lewis M, Hale C, et al. The outcome and cost-effectiveness of nurse-led care in people with rheumatoid arthritis: a multicentre randomised controlled trial. Annals of the rheumatic diseases 2014:1975-82.
6. Hill J, Thorpe R, Bird H. Outcomes for patients with RA: a rheumatology nurse practitioner clinic compared to standard outpatient care. Musculoskeletal Care 2003;1:5-20.
7. Primdahl J, Sorensen J, Horn H, Petersen R, Horslev-Petersen K. Shared care or nursing consultations as an alternative to rheumatologist follow-up for rheumatoid arthritis outpatients with low disease activity--patient outcomes from a 2-year, randomised controlled trial. Annals of the rheumatic diseases 2014:357-64.
8. de Thurah A, Esbensen BA, Roelsgaard IK, et al. Efficacy of embedded nurse-led versus conventional physician-led follow-up in rheumatoid arthritis: a systematic review and meta-analysis. RMD Open 2017;3:e000481.
9. Bech B et al. 2018 update of the EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis. Ann Rheum Dis 2020; 79:61-68.
10. KBV, GKV. Kassenärztliche Bundesvereinigung/GKV Spitzenverband. Vereinbarung u?ber die Delegation ärztlicher Leistungen an nichtärztliches Personal in der ambulanten vertragsärztlichen Versorgung gemäß § 28 Abs. 1 S. 3 SGB V: Anlage 24 zum Bundesmantelvertrag-Ärzte (BMV-Ä). Dtsches Ärzteblatt 2013;110: A-1757/B-1549/C-1525.