Elderly Multimorbidity Clinic Model Offers No Sustained Benefit for Patients With Rheumatoid Arthritis

After realizing that the current approach to managing elderly patients with rheumatoid arthritis and multimorbidity was not working because “their needs are more than just those for the sum of individual diseases,” investigators set out to create an Elderly Multimorbidity Clinic (EMC) in hopes of improving care and quality of life. According to a pilot study, published in ACR Open Rheumatology¹, the difficulty in treating this population group is in part due to the “pathophysiology, symptoms, and management of rheumatoid arthritis and other disease might interact and alter the course of each disease, amplifying their effect on overall functioning and health.”

The head rheumatologist of the EMC, Marloes van Onna, MD, PhD, explained, “Single-disease oriented care organization is often inefficient in patients with multimorbidity and becomes burdensome for patients [as well as] physicians because of poor healthcare planning. Patients can become confused about who is responsible for particular aspects of their health issues. Physicians may not recognize that a patient has interrelated problems, resulting in more investigations, unnecessary referral to other healthcare providers, or polypharmacy. Polypharmacy leads to an increase in morbidity, hospital admissions, health-related costs, and mortality.”

Marloes van Onna, MD, PhD

Multimorbidity is incredibly common in patients with rheumatoid arthritis. According to the study, multimorbidity is present in 2 out of 3 people diagnosed with rheumatoid arthritis and “is associated with greater functional impairment, a negative impact on rheumatoid arthritis disease course, and a shorter life span.” Elderly patients are at an even greater disadvantage, as they are more prone to acquire any number of geriatric syndromes (GS) in addition to their rheumatoid arthritis diagnosis.

Investigators aimed to improve the quality of care by creating effective management plans using the goals of both the patient and physician. During the course of the EMC program, 75% of patients accomplished at least 1 of their goals. Unfortunately, no sustained benefits were observed because of low follow-up.

Patients with rheumatoid arthritis (≥ 55 years) were considered and interviewed for the year-long EMC pilot conducted at the Maastricht University Medical Center, The Netherlands, between April 2018 and March 2019. The study was evaluated using a quantitative-qualitative approach. The patient’s ability to formulate personal goals was considered during the selection process.

Once the 20 patients were chosen, they each met with a rheumatologist and internist-geriatrician in order to create personal goals and review their current medication schedules. They then developed an action plan based on these aspects. The subsequent appointments followed the same structure. Clinic visits were excluded from the study if the rheumatologist felt the intervention offered no benefit, if the patient was unable to create any personal goals, if the patient exhibited severe cognitive decline, and if the patient failed to provide informed consent.

Baseline characteristics were collected, including age, sex, marital status, smoking status, alcohol use, presence of polypharmacy, comorbidities, and hospitalizations and outpatient visits over the last 6 months. Of the patients involved in the pilot study, the mean age was 76.8±7.7 years and 70% of participants were female.

After the completion of the study, the rheumatologist and internist-geriatrician conducted interviews with the patients in order to ascertain their satisfaction with the pilot study, as well as evaluate whether patients reached their goals and how they perceived the care they received.

Only 12 (60%) patients attended the first follow-up and only 3 (15%) attended the second. Some patients indicated that the caregiver burden was too high, while others had achieved their predetermined goals and believed that there would be no benefit in coming in attending the follow-up appointment. One patient was wrongly referred to the study.

Personal goals developed by participants included a reduction of physical symptoms not caused by rheumatoid arthritis (8/20), less pain (15/20), medication remediation (9/20), and social goals (6/20). Investigators were able to track goals in the 12 (60%) of patients that were able to attend at least one follow-up appointment. Of the 12 remaining patients, 75% were able to achieve 1 or more of their goals. 6 out of 8 patients who had indicated medication remediation as a goal had initially accomplished this, but medications were eventually changed back. In addition to work done in the clinic, doctors referred patients to specialists like cardiologists, physiotherapists, occupational therapists, and pedorthists.

Investigators discovered several challenges during the course of the program. First, the referral strategy was difficult as rheumatologists were unable to adequately select patients due to lack of clear criteria and underperforming referral instruments. The next issue faced was that while patients enjoyed the care provided at the clinic, the effects on health and wellbeing were not easily demonstrated. Additionally, “the personal goals that were formulated were often not related to rheumatoid arthritis but to common geriatric complaints (eg, less vertigo) or social issues (eg, going out with friends again).” Further, although the medication remediation was initially successful, long-term analysis showed that the medication was “often changed back because of regaining complains or new complaints.”

When asked if van Onna was surprised by the results, she explained, “Yes and no. We expected that the medication review would be one of the more successful parts of the initiative. We did not expect that it would be so difficult to select the correct patient for this outpatient clinic, as we only selected patients with rheumatoid arthritis and complex multimorbidity…We tested 5 referral instruments (1 published referral tool, 2 frailty instruments, and the perspective of the rheumatologist or patient), but none of these instruments proved to be accurate enough.”

Although the study was successful in some ways (eg, patient satisfaction and the level of comprehensive care), the study “could not demonstrate an improvement in the delivery of health care (high loss to follow-up) or improvement of the health status of the patient,” investigators concluded. In the future, the research team hopes to develop a better system to select patients who would benefit from this type of program and ensure that the care provided would not increase resource use and caregiver burden. Van Onna added that “as soon as we know what patient might benefit from these care interventions, the care intervention itself can hopefully become efficient and effective.”

Reference:

van Moerbeke A, Magdelijns F, Cleutjens F, Boonen A, van Onna M. Development and Evaluation of a Clinic for Elderly Patients with Rheumatoid Arthritis and Multimorbidity: A Pilot Study [published online ahead of print, 2020 Dec 31]. ACR Open Rheumatol. 2020;10.1002/acr2.11213. doi:10.1002/acr2.11213