[Is treat to target compatible with health insurance and health insurance funds?]. / Treat to Target, mit der KV und den Kassen vereinbar?

Can treat to target (T2T) evidence-based recommendations of the T2T initiative in routine outpatient care be implemented in Germany? Regional selective agreements were made with individual health insurance companies, which included among others structured assessment, target-oriented basic therapy and tight control. A federal universal implementation seems, however, to be distant. A substantial deficit is the poor availibility of rheumatological care. In the currently implemented routine care by health insurance institutions a realization of the T2T recommendations is not only impossible but even impeded. Selective agreements and outpatient specialist treatment of the new treatment structure act make allowances for rheumatological treatment but only the practical implementation will reveal the true possibilities. The current situation needs a national action plan for rheumatological care by which the content of T2T can be implemented.

[Diagnostic spectrum, treatment indication and symptom duration in initial referrals to the rheumatologist]. / Diagnosespektrum, Behandlungsindikation und Symptomdauer von Erstzuweisungen zum Rheumatologen.

There is evidence that early initiation of therapy in inflammatory rheumatic diseases, in particular rheumatoid arthritis (RA), has a positive effect on disease course.To investigate referral procedures, 198 German rheumatologists reported over a 3-month period and for each patient seen for the first time on: patient characteristics, specialization of the referring physician, symptom duration, time interval between making the appointment and the first visit, diagnoses and relevant drug history. Multivariate logistic regression analyses were performed to investigate the odds ratios for a first consultation within 3 months after symptom onset.The 17,908 newly referred adult patients were 54 years old on average and 72% were women. Inflammatory rheumatic disease was diagnosed in 53%. Mean disease duration was 30 ± 57 months (median 7.3 months). There was no apparent association between patient age, education, disease severity or specialisation of the referring physician; however, there was a clear association with waiting times to first consultation.A higher number of early arthritis clinics could significantly shorten the time to first rheumatological consultation. Therefore, more efforts need to be made to fast-track referrals from primary care physicians to rheumatologists as well as to optimise rheumatologists' appointment regulations for new patients. However, these efforts can only succeed with a significant increase in the number of rheumatologists, while ensuring a firm economic basis.

[Current status of ambulatory rheumatologic health care in Germany. Structure of health care and range of services]. / Bestandsaufnahme der ambulanten rheumatologischen Versorgung in Deutschland. Versorgungsstruktur und Leistungsspektrum.

AIM: To gather information on current organizational structures in rheumatologic ambulatory health care in Germany. Based on the results recommendations on future structures will be discussed. METHODS: This study involved data collection and statistical analysis via a structured 10-page questionnaire among the members of the German Association of Rheumatologists. The questions concerned a variety of topics including information on office structures, patient structure, structure of services offered, co-operation with colleagues and hospitals, quality assurance measures, economic factors, and a subjective assessment of the health care structures in rheumatology by the participants. RESULTS: Data obtained from 197 rheumatologists who participate in health care were analyzed. In this paper results concerning the organizational as well as the medical ambulatory health care structure will be presented. Data on economic factors will be presented in part 2 of this study. CONCLUSIONS: The organization of ambulatory treatment regarding processes and treatment differences between office-based physicians and rheumatologic outpatient departments in hospitals was very homogeneous. However, physicians in the eastern regions treated significantly more patients compared with the western parts of Germany. This difference was also observed between the north and south. Differences in patient groups (e.g. underlying diseases) were reported between different sub-groups of rheumatologists (e.g. internal specialists vs. GP vs. orthopedic rheumatologists). Integrated health care, as promoted by German social law, did not play a major role. Overall there was a high level of self-initiated training of physicians and participation in education of patients and other physicians.

[Current status and perspectives of ambulatory rheumatologic health care in Germany : economic structural conditions and motivation of rheumatologists]. / Bestandsaufnahme und Perspektiven der ambulanten rheumatologischen Versorgung in Deutschland : Okonomische Rahmenbedingungen und Motivation der Rheumatologen.

AIM: To gather information about current structures in rheumatologic ambulatory health care in Germany. Based on the results recommendations on future structures will be evaluated. METHODS: Data collection and statistical analysis via a structured 10-page questionnaire answered by members of the German Association of Rheumatologists. Questions in this second part of the study related to two topics: economic factors and a subjective assessment of the health care structures by the participants. RESULTS: Data from 197 ambulatory rheumatologists who participated in health care could be included in the analyses. Extensive and detailed data on economic issues surrounding ambulatory patient treatment and practice management from the perspective of ambulatory rheumatologists are presented (e.g., revenue, income, income differences between regions or practice size). In addition, perceptions of participating rheumatologists on future perspectives of patient treatment, health policy, and their own economical survival are reported. CONCLUSIONS: As in other specialties there is a significant difference not only between the eastern and western regions in Germany but also between the north and the south looking at e.g., revenue, income, with rheumatologists in the east treating significantly more patients. Reasons for those differences are not only related to regional remuneration schemes or the number of patients with a private but statutory health insurance, but are also driven by the number of different services provided (e.g., own laboratory). Physicians perceptions towards their own future in rheumatology are generally positive. Scepticism was reported for the individual economic survival in ambulatory treatment and future changes in health policy.

[Imaging methods in rheumatology: imaging in psoriasis arthritis (PsA)]. / Bildgebende Verfahren in der Rheumatologie: Bildgebung bei der Psoriasisarthritis (PsA).

Conventional radiography is still the standard method of imaging in PsA since it displays many joints at the same time, thereby allowing different types of joint involvement to be recognized. Moreover, thanks to the high resolution of radiography, bony changes in a single joint are depicted in a brilliant way. Several features of psoriatic arthritis allow the distinction from rheumatoid arthritis, including the frequent involvement of the distal interphalangeal joints, asymmetry of joint involvement, axial involvement of finger joints, oligoarticular involvement; however, symmetric polyarthritis is also possible. At the level of the single joint, there are signs of severe destructive changes potentially leading to mutilation and at the same time signs of periostal bone proliferation and ankylosis may be present. Bony proliferation and/or osteolysis are not restricted to the joint region but can affect also the total phalanx with bone apposition or concentric osteolysis which may lead to a complete disappearance of phalanxes. For purposes of quantification of radiographic changes scoring methods are used that were originally developed for rheumatoid arthritis. So far, there is only one validated scoring method that was specifically designed for PsA and that takes into account both features of PsA, damage as well as proliferation of bone. In contrast to conventional radiography, MRI and sonography are able to visualize inflammatory processes within the soft tissue (joint capsules, tendon sheaths, tendon insertions, etc.), allowing an estimation of disease activity. Scintigraphy is nonspecific and can only be used to detect clinically silent inflammatory spots. The relatively frequent spinal (axial) involvement is similar to that seen in ankylosing spondylitis. However, unilateral sacroiliitis, asymmetry of syndesmophytes and development of parsyndesmophytes may distinguish PsA from ankylosing spondylitis. While conventional radiography demonstrates the bony consequences of inflammation in the spine, MRI also shows the active inflammatory changes in sacroiliacal joints and vertebrae.

[Current therapeutic strategy for rheumatoid arthritis]. / Aktuelle Therapiestrategien bei rheumatoider Arthritis. Entzündung rasch beherrschen ist entscheidend für die Prognose.

The success of the treatment of rheumatoid arthritis depends primarily on early diagnosis. In most cases, basic therapy begins with methotrexate. Depending on the stage and course of the disease (radiographically detected early erosion and/or progression), basic immunosuppressive therapy can be combined or supplemented with cytokine antagonists. Furthermore, for specific indications, several alternative active substances (DMARD monotherapies) are available. Today the goal of therapy is always remission.

WHO Collaborating Centre consensus meeting on anti-cytokine therapy in rheumatoid arthritis.

Severe adult rheumatoid arthritis is a cause of progressive disability and increased mortality across Europe. A cure for the disease remains elusive, but control of symptoms and maintenance of individual independence is possible. Anti-cytokine therapies offer a new approach to disease management. They are effective after the failure of full doses of methotrexate, and are at least as effective as methotrexate in retarding the progression of radiological changes. Until more is known about the long-term safety and efficacy of these drugs they should be reserved for patients with severe disease who are progressing despite adequate doses of methotrexate or other disease-modifying anti-rheumatic drugs. They should be continued until therapeutic failure or intolerance. A comprehensive health economic evaluation is needed to optimally direct the use of these drugs. This should be undertaken when long-term safety and efficacy studies are completed.

[Evidence-based medicine and applying new therapies in general practice: wish and reality]. / Evidence Based Medicine und die Umsetzung neuer Therapien in die Praxis: Wunsch und Realität.

In the last years some important therapies were introduced in the treatment of rheumatoid arthritis (RA), which represent a significant clinical advance. This concerns the introduction of TNF blockade with etanercept and inflixmab, the combination of DMARDs, leflunomide and the COX-2-specific inhibitors. In the year 2000 the restrictive social law in Germany, the collective and individual budgets for medicaments, did prevent a broader use of the very expensive therapy with TNF blockade. A rising number of international healthcare studies shows a profound potential for saving costs by improving the functional capacity (HAQ) in patients with RA. The biologicals and leflunomide have this potential. To realise the potential of reducing healthcare costs by an optimal therapy of RA some modification of the restrictive social law is necessary as well as the introduction of disease-management programs.

A mutational analysis of receptor binding sites of interleukin-1 beta: differences in binding of human interleukin-1 beta muteins to human and mouse receptors.

The 3-D crystal structure of interleukin-1 beta (IL-1 beta) has been used to define its receptor binding surface by mutational analysis. The surface of IL-1 beta was probed by site-directed mutagenesis. A total of 27 different IL-1 beta muteins were constructed, purified and analyzed. Receptor binding measurements on mouse and human cell lines were performed to identify receptor affinities. IL-1 beta muteins with modified receptor affinity were evaluated for structural integrity by CD spectroscopy or X-ray crystallography. Changes in six surface loops, as well as in the C- and N-termini, yielded muteins with lower binding affinities. Two muteins with intact binding affinities showed 10- to 100-fold reduced biological activity. The surface region involved in receptor binding constitutes a discontinuous area of approximately 1000 A2 formed by discontinuous polypeptide chain stretches. Based on these results, a subdivision into two distinct local areas is proposed. Differences in receptor binding affinities for human and mouse receptors have been observed for some muteins, but not for wild-type IL-1 beta. This is the first time a difference in binding affinity of IL-1 beta muteins to human and mouse receptors has been demonstrated.

Clinical utility of nonenzymatically glycosylated blood proteins as an index of glucose control.

This study compares the utility of nonenzymatically glycosylated serum proteins (lys-GSP) to glycosylated hemoglobins (HbA1a-c) as control indices of glucose homeostasis in patients with IDDM. The diagnostic value of lys-GSP was also examined in patients with non-insulin-dependent diabetes mellitus, in subjects with impaired glucose tolerance, and in two patients with insulinoma. The intraindividual fluctuation of lys-GSP in normoglycemic subjects is very small, resulting in an interindividual range of 3.0 +/- 0.3 lysine-bound glucose/mg protein (means +/- SD, N = 52). HbA1a-c with a normal range of 6.4 +/- 0.9% (N = 52) shows greater variability. In IDDM there is no overlap of lys-GSP levels between the normal and the diabetic range at the 95% confidence level. In patients treated with an open-loop insulin delivery system failure of normalization of the glucose balance was clearly discernible by an elevation of GSP. In contrast, in about 40% of the patients with incomplete glycemic control the HbA1a-c levels fell within the normal range. The utility of lys-GSP for diagnosis of diabetes is compared with the results of 60 oral glucose tolerance tests. Two patients suffering from insulinoma displayed decreased lys-GSP values. From these results it appears that determination of lys-GSP represents a more sensitive parameter for long-term control than HbA1a-c and is suitable for monitoring even small fluctuations of blood glucose.