Help the development of the site, sharing the article with friends!
Rheumatology ranks third in the ranking of the fastest growing medical fields in Poland, right after oncology and cardiology. Unfortunately, this often does not translate into the quality of medical care. We talk to prof. dr hab. med. Piotr Głuszko.
Rheumatology is developing - this is a fact that is hard to deny. But does this translate into better care for the sick? Patients complain about difficulties in accessing specialists and limited possibilities of using modern treatment. What is our rheumatological reality - we talk to prof. dr hab. med. Piotr Głuszko from the National Institute of Geriatrics, Rheumatology and Rehabilitation prof. Eleonora Reicher in Warsaw.
- Many years of research in the field of immunology and molecular biology have translated into new treatment options for rheumatic diseases.
Prof. Piotr Głuszko:It's true. Progress has been made over the last dozen or so years and thanks to this we have been able to treat the sick more and more effectively. Not only new drugs have appeared, but also new and more perfect methods of diagnosing rheumatic diseases.
Besides, rheumatic diseases have been noticed as a great social problem. And while we still cannot heal them, we know how we can delay their progress. We can also greatly improve the quality of life of patients, provided that the patient quickly receives effective and modern treatment.
Unfortunately, access to such treatment is still limited due to high costs of therapy and reimbursement restrictions.
- But rheumatologists are also missing. It is practiced by 1,510 people, 1/3 of which are specialists over 60 years of age.
In my opinion, the problem is not the lack of specialists. It is primarily a problem of contracts signed by rheumatology clinics with the National He alth Fund. According to the maps of he alth needs, we have about 700 rheumatology clinics for adults in Poland. This is not an impressive number, but much more important is what a doctor in an average clinic can do for the patient, what tests to order, and how to guide the diagnosis. And the possibilities in this regard are small.
It is not the doctor who decides whether he will order, for example, 10tests that will allow you to quickly make a diagnosis, but a contract and type of visit, during which you can only order, for example, 4 tests.
According to the rules devised by officials, rheumatological diagnostics must be spread over time.
A visit to a rheumatologist often takes six months, and in some parts of the country even a year, so there is no question of properly conducted diagnostics. Let me put it straight - it's not a treatment, it's pretending that we're helping a sick person.
In rheumatology, especially in inflammatory diseases of the joints, quick diagnostics is needed, because only then can the progress of the disease be effectively stopped. The pool of tests that must be ordered by a rheumatologist is large. Some are costly, but no exaggeration. They do not exceed our budget capabilities.
But the worst thing is that decision-makers forget that rheumatic diseases - such as cardiological or oncological diseases - threaten life, he alth and, above all, can lead to disability faster than other diseases.
- The report "The state of rheumatological care in Poland", prepared at the Lazarski University, shows that annually, due to rheumatic diseases, approx. people go on disability pension, and the number of hospitalizations for this reason is 18%.
I think this is understated. The data provided by the Social Insurance Institution (ZUS) show that due to diseases of the locomotor system, the greatest number of sick leaves is issued.
Besides, there is no mention of absenteeism, especially presentism, i.e. being at work despite being ill. This is a situation when a sick person comes to work, but due to his widely understood disability, i.e. chronic pain, joint stiffness, depression, etc., he does not fulfill his duties properly. The employee is at work, but is acting inefficiently, so in fact is loss-making.
We would like our diagnostic and treatment procedures, both in the case of rheumatic inflammatory and degenerative diseases, to guarantee the longest possible maintenance of fitness, life in a certain comfort, and not make even young people have to go on a disability pension.
- And this is not so now?
Taking into account the state of medical knowledge and access to drugs, we can ensure long-term maintenance of fitness, lead to remission of the disease … But this is often not the case, because the rheumatological care system in our country has limitations.
- You mentioned that the waiting time for an appointment with a rheumatologist is six months or even longer. Why is this happening, if the number of specialists is sufficient to care for the sick?
This is a question for the National He alth Fund. The doctor can see a certain number of patients per day - that's once. Secondly, long lines are closely related to the amount of money that is spent on the functioning of specialist clinics. And the third issue - the possibilities of the clinic itself: how many doctors are employed, what is the amount of the contract with the National He alth Fund, but also whether the clinic can perform the necessary tests not within 3, but within one visit.
I do not go into the rules of settlement of the clinic, because it is a complicated system and it should be changed so that the doctor has more freedom in ordering tests. There is no such freedom at present. How is he doing? He issues a referral to the hospital and hopes that the patient will get there and be properly diagnosed. But hospitalization is another cost that can be avoided.
I will come back to the maps of he alth needs in rheumatology. I regret that they are not carefully analyzed, because the maps show not only the needs of the sick, but also the way of caring for them. If a patient with inflammatory rheumatic disease can be admitted at least 3 times a year, his care is probably correct. But the maps show that in most provinces there are only 2 visits per year.
This does not guarantee proper patient management. One visit is a real disaster. Most of the rheumatologist's patients are people with degenerative or non-inflammatory changes. Nationally, there are over 10 million patients who could and should be treated by orthopedic surgeons or medical rehabilitators. The role of a rheumatologist should only be to diagnose the disease and indicate the way of further treatment.
This cannot be said. I think that much more than 5 million people take painkillers regularly. Pain medications are readily available. A person who suffers from pain wants to get rid of it. It's natural.
The course of rheumatic diseases involves chronic pain, but also joint stiffness, movement limitations that hinder everyday functioning, and a specific disability. This does not mean that pain in rheumatology is neglected. But the basis of fighting it is the correct treatment of the underlying disease with the available disease-modifying drugs.
However, we must not forget that like all other drugs, these drugs have side effects. And the trick is to give the patient a safe dose, that is, one that helps with the disease and not harms it. Sometimes it is very muchdifficult. If we want to effectively fight RA or lupus, we can expose the patient to side effects, i.e. harm him.
People with RA are 6 times more likely to develop diabetes than he althy people. So it's worth paying attention to what you put on the plate.
But one more thing is important. Pain accompanies many diseases. It is present in oncology, traumatology, orthopedics, but - without diminishing anything - it is not a pain that accompanies the patient for half of his life. In addition to rheumatology, you can afford to use strong painkillers, because the time of their administration is short. In rheumatic patients, this cannot be done because pain has been with them for decades. That is why we limit the use of painkillers, especially non-steroidal anti-inflammatory drugs, to minimize harm.
The basis of pain management in rheumatological diseases is the administration of disease-modifying drugs, the use of which leads to remission of the disease. And then the pain is much less or it goes away at all. Pain management in rheumatic diseases is also a serious problem because access to pain clinics is limited.
- Methotrexate is the gold standard in treatment, but patients have great hope for biological treatment.
It's true. Patients are wrongly afraid of methotrexate. It is a good, proven and safe drug. The bad press of this drug is due to the fact that it is - of course in doses higher than in rheumatology - also used in oncology. There are many more such drugs, including biological ones, e.g. those previously used in oncological hematology.
Patients must understand that there is a price to pay for proper treatment. Not everyone tolerates drugs equally. Nausea, loss of appetite may occur. Then we are looking for another effective drug. In addition, you need to be aware that the treatment of rheumatic diseases is a chronic treatment. It happens that the effects of the drug on the body are exhausted and the disease gets out of control.
What about biological drugs? This is indeed a new era in rheumatology. However, what I want to emphasize, these are not drugs for all patients, and their effectiveness is not 100%. Let's be clear - only 30% of patients have remission after using biological drugs. These drugs have side effects, e.g. they significantly reduce the body's resistance. There are also contraindications to the use of these drugs.
Find out more: BIOLOGICAL TREATMENT: indications, contraindications, side effects
The choice of therapy is one thing. It is more important to quickly qualify or disqualify patientsfor biological treatment. Delaying this decision leads to a worse prognosis. We know that the best therapeutic effects are achieved by introducing biological drugs in the early stages of the disease.
Our patients enter biological treatment late, because the reimbursement regulations require them to be included when the patient is in a worse condition, with high disease activity. After 10 years of suffering from, for example, RA, even biological treatment will not be effective enough, because the changes in the joints cannot be reversed. Approx. 15 thousand people are in the biological treatment reimbursement system, and in my opinion there should be at least twice as many people.
- What about rehabilitation, to which access is very limited?
Rehabilitation is the basis of treatment. In inflammatory diseases, especially in the acute stages, rehabilitation is not always recommended. When the patient goes into remission, he or she should be constantly rehabilitated.
But most physiotherapists and physiotherapists are not prepared to deal with patients suffering from inflammatory rheumatic diseases. There are few of them in Poland. And in many places there are no rheumorehabilitation specialists, i.e. people who will be able to take care of a rheumatoid hand or foot. It is also impossible to effectively treat AS without rehabilitation. Here, rehabilitation techniques are used even in the acute phase of the disease, because movement reduces pain. In short, there is a lot to do here.
- What do you think about diets used in rheumatoid diseases?
There are no diets that can cure rheumatoid arthritis or lupus. I am very critical of such assurances. The exception is gout, which is known to be often provoked by a poor diet.
In the case of degenerative changes, when an overweight person loads the joints with an additional 30-40 kg, a diet is very necessary to relieve the body. We should eat everything but in moderation. Of course, you shouldn't eat anything that is harmful to you.
Patients with inflammatory rheumatoid diseases are usually not overweight. They often have no appetite, and the inflammation that goes on in their body and the secreted cytokines raise their body temperature and speed up metabolism. But it should not be forgotten that some drugs, such as glucocorticosteroids, promote obesity because they increase appetite and change metabolism.
It is important for the patient to know that he will not gain weight from the pill itself, but from what he is going to eat. It's best to limit your intake of carbohydrates and, above all, sugars.
monthly "Zdrowie"