current DMARDs treat elements of disease pathogenesis andnot disease etiology, we may anticipate their use for prolongedperiods of time. Postmarketing surveillance is essential so thatthe risk:benefit ratio in the community can be monitoredclosely.

Wallace V. Epstein, MD, MACRUniversity of California, San Francisco

1. Pincus T, Gibofsky A, Weinblatt ME. Urgent care and tightcontrol of rheumatoid arthritis as in diabetes and hypertension:better treatments but a shortage of rheumatologists. ArthritisRheum 2002;46:851–4.

2. Mottonen T, Hannonen P, Korpela M, Nissila M, Kautiainen H,Ilonen J, et al. Delay to institution of therapy and induction ofremission using single-drug or combination–disease-modifyingantirheumatic drug therapy in early rheumatoid arthritis. ArthritisRheum 2002;46:894–8.

3. Egsmose C, Lund B, Borg G, Pettersson H, Berg E, Brodin U, etal. Patients with rheumatoid arthritis benefit from early 2nd linetherapy: 5 year followup of a prospective double blind placebocontrolled study. J Rheumatol 1995;22:2208–13.

4. Tsakonas E, Fitzgerald AA, Fitzcharles MA, Cividino A, ThorneJC, M’Seffar A, et al. Consequences of delayed therapy withsecond-line agents in rheumatoid arthritis: a 3 year followup onthe hydroxychloroquine in early rheumatoid arthritis (HERA)study. J Rheumatol 2000;27:623–9.

5. O’Dell JR. Treating rheumatoid arthritis early: a window ofopportunity? Arthritis Rheum 2002;46:283–5.

6. Visser H, le Cessie S, Vos K, Breedveld FC, Hazes JMW. How todiagnose rheumatoid arthritis early: a prediction model for persis-tent (erosive) arthritis. Arthritis Rheum 2002;46:357–65.

7. Harrison BJ, Symmons DP, Brennan P, Barrett EM, Silman AJ.Natural remission in inflammatory polyarthritis: issues of defini-tion and prediction. Br J Rheumatol 1996;35:1096–100.

8. American College of Rheumatology Subcommittee on Rheuma-toid Arthritis Guidelines. Guidelines for the management ofrheumatoid arthritis: 2002 update. Arthritis Rheum 2002;46:328–46.

9. Saraux A, Berthelot JM, Chales G, Le Henaff C, Thorel JB,Hoang S, et al. Ability of the American College of Rheumatology1987 criteria to predict rheumatoid arthritis in patients with earlyarthritis and classification of these patients two years later. Arthri-tis Rheum 2001;44:2485–91.

10. Berthelot JM, Saraux A, Maugars Y, Prost A, Le Goff P. Thenosology-taxonomy of recent-onset arthritis: the experience ofearly-arthritis clinics. Semin Arthritis Rheum 2001;30:354–65.

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14. Brennan P, Harrison B, Barrett E, Chakravarty K, Scott D, SilmanA, et al. A simple algorithm to predict the development ofradiological erosions in patients with early rheumatoid arthritis:prospective cohort study. BMJ 1996;313:471–6.

15. Bukhari M, Lunt M, Harrison BJ, Scott DGI, Symmons DPM,Silman AJ. Rheumatoid factor is the major predictor of increasingseverity of radiographic erosions in rheumatoid arthritis: resultsfrom the Norfolk Arthritis Register Study, a large inceptioncohort. Arthritis Rheum 2002;46:906–12.

16. Felson DT, Anderson JJ, Boers M, Bombardier C, Furst D,Goldsmith C, et al. American College of Rheumatology prelimi-nary definition of improvement in rheumatoid arthritis. ArthritisRheum 1995;38:727–35.

17. Felson DT, Anderson JJ, Lange MLM, Wells G, LaValley MP.Should improvement in rheumatoid arthritis clinical trials bedefined as fifty percent or seventy percent improvement in core setmeasures rather than twenty percent? Arthritis Rheum 1998;41:1564–70.

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DOI 10.1002/art.10741

An alternative perspective on treatment for diabetes,hypertension, and rheumatoid arthritis: comment onthe editorial by Pincus et al

To the Editor:It is encouraging that prominent leaders in rheumatol-

ogy are concerned about the growing disparity between therapidly improving treatments for RA and the care patients areactually receiving (1). Further, we appreciate Drs. Pincus,Gibofsky, and Weinblatt’s citing our work with preappoint-ment management of new patients, although we are concernedthat their characterizing this practice redesign as “telephonescreening” does not recognize the fundamental process changeinvolved and its impact on practice effectiveness and patientaccess. Preappointment management involves review ofrecords and other information by our rheumatologists for allnew patient referrals before an appointment is provided. Ourarticle in Arthritis Care & Research explores its advantagescompared with traditional appointment processes (2).

If we expect to improve the delivery of care, we mustdefine the problems correctly, and we have concerns withPincus et al’s viewpoints in this respect. Contrasting the care ofRA with that of diabetes and hypertension misses the pointthat the care of all chronic diseases, not just RA, is failing tokeep pace with new knowledge, as most recently documentedby the Institute of Medicine and others (3,4). The coreproblem recognized by health policy leaders is that our currentdelivery processes and systems are not capable of deliveringeffective care. At least 30% of chronic disease care is without

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value, and at the same time an even greater amount ofnecessary care is not being provided in a timely manner.

We also believe that linking improved care for RA andother rheumatic diseases to increased rheumatology man-power and resources for academic rheumatology programs isprobably wishful thinking. There is no way that any number ofrheumatologists practicing as we do now can deliver effective,dependable care, and we cannot do it by ourselves. Until weredesign our practices and better define cooperative andintegrated roles with primary internists and other medicalsubspecialists, we will really have no idea how many rheuma-tologists we need.

What if rheumatology manpower doesn’t increase,which seems very possible? Our preappointment managementprocess was initiated after we lost 50% of our practice’smanpower. We discovered that 40% of patients referred to usdid not require consultation. Their care was continued withtheir primary physician, another more appropriate consulta-tion was arranged, or, in some cases, consultation was clearlyinappropriate and was denied. We have continued to offeraccessible care for more of those with serious rheumaticdiseases, with fewer rheumatologists. We rheumatologistsmust actively manage access to our practices and how we spendour time if we are to better serve the patients who need us mostwith our current manpower and, perhaps, make our specialtymore appealing to trainees.

We believe that the responsibility for breakthroughimprovement in care of chronic diseases resides primarily withacademic departments of medicine. Until our academic lead-ership makes improving health care delivery a priority equal toexpanding and imparting scientific knowledge, improvement isunlikely. Our perspective must shift from treating individualsto managing chronic disease populations. Variance in deliveryprocesses must be as unacceptable as it is in clinical research.Our dependence on inefficient, visit-related care and tradi-tional teaching methods must be reconsidered.

Until primary and subspecialty trainees are providedwith clear, cogent, and complementary roles in caring forpatients with chronic diseases, those patients at highest risk areunlikely to receive timely, expert care. Further, until academichealth centers become laboratories for improving health caredelivery, community physicians are likely to perpetuate theineffective practices they acquire in training. We are far morelikely to earn increased resource support and trainee interestin the health care marketplace by delivering greater value thanby continuing to seek these as our entitlement.

Doing health care improvement requires a knowledgebase and skill set different from those needed in performingclinical or basic research. This knowledge has been developedlargely in industries outside of health care. The Institute ofMedicine, Institute for Healthcare Improvement, and othersare advocating its application to the health care industry (5).We hope the ACR will make the dissemination of this infor-mation a priority for our specialty.

Timothy Harrington, MDMichael B. Walsh, DOUniversity of Wisconsin Medical SchoolMadison, WI

1. Pincus T, Gibofsky A, Weinblatt ME. Urgent care and tight controlof rheumatoid arthritis as in diabetes and hypertension: bettertreatments but a shortage of rheumatologists. Arthritis Rheum2002;46:851–4.

2. Harrington JT, Walsh MB. Pre-appointment management of newpatient referrals in rheumatology: a key strategy for improvinghealth care delivery. Arthritis Rheum (Arthritis Care Res) 2001;45:295–300.

3. Institute of Medicine, Committee on Quality of Health Care inAmerica. Crossing the quality chasm: a new health system for the21st century. Washington (DC): National Academy Press; 2001.

4. Phillips LS, Branch WT Jr, Cook CB, Doyle JP, El-Kebbi IM,Gallina DL, et al. Clinical inertia. Ann Intern Med 2001;135:825–34.

5. Berwick DM, Nolan TW. Physicians as leaders in improving healthcare: a new series in Annals of Internal Medicine. Ann Intern Med1998;128:289–92.

DOI 10.1002/art.00000

Reply

To the Editor:We appreciate the excellent comments of Drs. Epstein,

Harrington, and Walsh, which provide an opportunity toclarify several matters. We agree with many points made by Dr.Epstein, as noted in published reports:

1. Most people who meet criteria for RA in population studies(in contrast to rheumatology care) have a self-limiteddisease likely to disappear by 6 months (1,2). Recent studiesof Visser et al (3) and Harrison et al (4) confirm observa-tions made by Mikkelsen and Dodge (5) and O’Sullivan andCathcart (6) in the 1960s and 1970s that most people whomeet criteria for RA in populations have a self-limitedpolyarthritis. Many of these people never see a physician. InNashville, people with self-limited polyarthritis are referredto as having “Cathcart’s disease.”

2. One cannot tell at a single visit whether an individualpatient with mild RA will develop progressive disease (2,7).We have suggested that optimal staging of RA wouldrequire more than a single visit (2).

3. Radiographic progression and RF titer are correlated sig-nificantly with one another (8), although these measures arecorrelated at lower levels with functional and questionnairemeasures of clinical status.

4. Selection biases exist in clinical trials for patients who havemore severe disease than the general population of patientswith RA (9–11), and we have advocated broadening inclu-sion criteria to allow more patients to participate in moregeneralizable clinical trials.

5. Classification criteria are not diagnostic for RA (2), and wehave advocated assessment of prognosis according to qual-itative markers, such as questionnaire and radiographicscores, rather than qualitative criteria (12).

6. The ACR20 is limited as an outcome measure (13), andfurther research is needed.

At the same time, we do recognize some meaningfuldifferences with Dr. Epstein. In the first place, we are surprisedthat Dr. Epstein appears to regard development of erosions as

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