Rheumatic expertise expanded access to improve community health REACH-RA

风湿性关节炎（RA）是最常见的自身免疫性关节炎，患病率在0.5 - 2.5%之间。它与大量的发病率、死亡率和成本相关。疾病缓解抗风湿药物（DMARD）通过多种机制减少炎症，改善RA的短期和长期结局。虽然有各种药物相关的毒性，DMARDs现在被接受为RA医疗管理的标准治疗，由国家质量保证委员会，美国风湿病学会（ACR）和欧洲抗风湿联盟推荐。 尽管DMARDs的益处已被公认，但美国、加拿大和欧洲的几项已发表的研究发现，25-50%的诊断为RA的患者不使用DMARDs，这表明治疗效果不佳。似乎有两个主要因素驱动DMARD不使用：缺乏获得专家风湿性疾病护理和病人的喜好。获得风湿病学家是一个公认的问题，根据ACR的一份报告发现，到2025年，美国人口老龄化将导致风湿病学家短缺50%。风湿病学培训计划不太可能弥补这一不足，这表明初级保健提供者（PCP）需要增加他们对管理风湿病（包括RA）的熟悉程度。这一趋势与当前推动初级保健重新设计的趋势相吻合，这使得有时由专家管理的疾病能够得到更全面和更协作的管理。需要一个改进的系统，用于PCP和风湿病学家之间围绕RA等疾病的共同管理。该项目的第一个目标是一项2x2析因随机对照试验，将测试两种不同的干预措施。一个将试图建立新的合作护理关系的PCP和风湿病学家，在管理RA的背景下。第二个将侧重于患者和他们对RA治疗的偏好。与其他药物一样，患者对DMARD毒性以及如何平衡风险和益处表示担忧。解决这些问题似乎可以提高其他条件下的治疗依从性，并可能有助于减少DMARD不使用。我们将尝试通过电话健康教育计划来解决这些问题。第二个目标是研究干预的经济影响。我们将使用模拟模型来计算目标一中测试的干预措施的长期影响。

Rheumatoid arthritis (RA) is the most common auto-immune arthritis with a prevalence between 0.5 - 2.5%. It is associated with substantial morbidity, mortality, and cost. Disease modifying anti-rheumatic drugs (DMARDs) reduce inflammation through a variety of mechanisms, improving short and long-term outcomes in RA. While there are a variety of drug-related toxicities, DMARDs are now accepted as standard of care for the medical management of RA, being recommended by the National Committee on Quality Assurance, the American College of Rheumatology (ACR), and the European League Against Rheumatism. Despite the recognized benefits of DMARDs, several published studies from the US, Canada, and Europe have found that 25-50% of patients diagnosed with RA do not use DMARDs, indicating sub-optimal care. There seem to be two major factors driving DMARD non-use: lack of access to expert rheumatic disease care and patient preferences. Access to rheumatologists is an acknowledged problem based on a report of the ACR finding that the aging US population will contribute to a 50% shortage of rheumatologists by 2025. It is very unlikely that rheumatology training programs can make up the deficit, suggesting that primary care providers (PCPs) will need to increase their familiarity with managing rheumatologic conditions, including RA. This trend coincides with the current push for primary care redesign, allowing for more comprehensive and collaborative management of diseases sometimes managed by specialists. An improved system for co-management between PCPs and rheumatologists around diseases like RA is needed. The first aim of this project, a 2x2 factorial randomized controlled trial, will test two different interventions. One will attempt to forge new collaborative care relationships between PCPs and rheumatologists, within the context of managing RA. The second will focus on patients and their preferences regarding RA treatment. Like other medications, patients express concerns about DMARD toxicities and how to balance risks and benefits. Addressing such issues appears to improve treatment compliance in other conditions and may help reduce DMARD non-use. We will attempt to address these issues through a telephonic health education program. The second aim will examine the economic implications of the intervention. We will use simulation models to calculate the long-term implications of the interventions tested in the aim one.