[Disease-related knowledge acquisition through structured patient information in rheumatoid arthritis (StruPI-RA) : First results of the StruPI-RA study in Germany]. / Krankheitsbezogener Wissenserwerb durch strukturierte Patienteninformation bei Rheumatoider Arthritis (StruPI-RA) : Erste Ergebnisse der StruPI-RA-Studie in Deutschland.

BACKGROUND/OBJECTIVE: The structured patient information for rheumatoid arthritis (StruPi-RA) program was the first standardized outpatient education program in rheumatoid arthritis (RA) in Germany. The main objective of the study was to determine the efficacy of the StruPi-RA program concerning disease-specific knowledge acquisition in patients with early stage RA or after changing the treatment regimen. METHODS: A total of 61 patients were included in a control group design, 32 in the intervention group (IG) and 29 in the control group (CG). Patients of the IG attended 3 modules of 90 min in a structured patient information program (StruPI-RA) including the topics of diagnostics, treatment and living with RA. Patients in the CG only received information material from the German Rheumatism League. The primary target criterion was the disease-related acquisition of knowledge, measured with the patient knowledge questionnaire (PKQ). Data were collected before and after participation in StruPI-RA. RESULTS: The improvement in knowledge in the IG attending the StruPI-RA compared to the CG was significant in time and group comparisons. No influence of disease duration or educational level was observed. The subscale treatment alone showed a significant difference in the group and time comparison. CONCLUSION: Participation in the StruPI-RA program in early RA was associated with a significant increase in disease-specific knowledge compared to the control group of patients. This leads to better decision-making in terms of treatment, a more beneficial doctor-patient communication and better self-management. In the long term an improvement in treatment adherence and quality of life is expected.

[Current state, goals and quality standards of outpatient care in rheumatology: position paper of the Professional Association of German Rheumatologists (BDRh)]. / Aktueller Stand, Ziele und Qualitätsstandards der ambulanten Versorgung in der Rheumatologie: Positionspapier des Berufsverbandes der deutschen Rheumatologen (BDRh).

Even in the era of modern guidelines, the treatment of rheumatic diseases is only as good as the framework of rheumatological care within which the treatment is carried out. The access to high-quality medical treatment for all patients is therefore essentially decisive for the prognosis of the patients. This article describes the current state of outpatient treatment in rheumatology and demonstrates which quality projects, such as treatment contracts, outpatient specialized medical treatment (ASV), digitalization and training as specialized rheumatological assistant (RFA), have been created in order to ensure the treatment of our patients. Furthermore, standards are defined that can guarantee a contemporary and guideline-conform treatment in outpatient rheumatological units. As an example it is an affirmation of the Professional Association of German Rheumatologists (BDRh) for ensuring optimal care for all rheumatology patients through early or emergency rheumatology clinics, treat to target, appropriate delegation of medical duties and diversification of treatment, thus an assurance of the quality and comprehensive treatment in rheumatology. The important topic of safeguarding the next generation of rheumatologists, which is indispensable for this, is also discussed.

[Outpatient specialist medical treatment (ASV)-a new treatment level in rheumatology]. / Ambulante spezialfachärztliche Versorgung (ASV) ­ eine neue Versorgungsebene in der Rheumatologie.

Since April 2018, the new third level care model of outpatient specialist care (ASV) according to §116b of the Social Code Book V (SGBV) has been available for patients with chronic inflammatory rheumatic diseases in Germany. Not only is a multiprofessional cooperation between the disciplines involved in treating rheumatic diseases promoted but also the cooperation between specialized rheumatologists and other specialists in private practice and in hospitals is encouraged. As budget capping limiting services and number of cases do not apply in ASV, a significant improvement of patient care in rheumatology is expected due to an increase in provider capacity. At the end of May 2019, 72 rheumatologists in the first 9 newly approved ASV teams had qualified for this new care concept. Bureaucratic obstacles have so far delayed the implementation of ASV. Difficulties arose in building a team with different specialties, in the process of registration of the teams and the assessment of the registration by certain regional boards responsible for access control. The national associations of rheumatologists, the Professional Association of German Rheumatologists (BDRh), the VRA (Verband der Rheumatologischen Akutkliniken e. V.) and the German Society of Rheumatology (DGRh) campaign for an easier admission of providers to the ASV and for adequate financing of all specialties involved in the ASV. The aim is to realize the chance of the ASV for better rheumatological care nationwide with shorter waiting times for a medical appointment and a better cooperation between specialists.

[Special treatment in rheumatology-cross-sectoral quality-oriented selective contracts]. / Vertragsentwicklung der Selektivverträge in der Versorgungslandschaft Rheuma.

In the last 4 years selective contracts according to §140a of the German Social Code Book V (SGB V) with three different health insurers were signed by the Professional Association of German Rheumatologists (BDRh) and from the beginning of the year 2018 by the management company of the association. The contracts were rolled out in five regions of Germany (Bavaria, Hesse, Mecklenburg-Western Pomerania, North Rhine and Saxony). Up to the end of 2018, 12,000 patients with chronic inflammatory rheumatic diseases were treated within the managed care of these contracts. The interface and the treatment pathways were initially consented with the associations of rheumatologists and general practitioners. The aim of the managed care was to provide the optimal quality in diagnostics and treatment and to improve management of rheumatic diseases. Quality indicators, such as treat-to-target principles, tight control, delegation to specially trained assistance personnel, patient education in rheumatoid arthritis (StruPi) and early arthritis consultation, are part of the managed care and are successfully promoted with incentive payments. Thus approximately 20% of the patients were enrolled for the first time in rheumatological care. The BDRh wants to promote the nationwide roll-out of this managed care in Germany with more participating health insurance funds.

[Clinical remission in rheumatoid arthritis. Data from the early arthritis cohort study CAPEA]. / Klinische Remission bei rheumatoider Arthritis. Daten aus der Früharthritiskohortenstudie CAPEA.

OBJECTIVE: To evaluate remission rates and therapeutic strategies in the routine care of early rheumatoid arthritis. METHODS: Between 2010 and 2013, a total of 1,301 patients with early arthritis were followed by 89 rheumatologists for up to 2 years in an early arthritis cohort (CAPEA). Complete 2-year data are available for 669 patients with rheumatoid arthritis. RESULTS: Ninety-three percent of patients were diagnosed with a moderate or high disease activity score (DAS28 > 3.2). Within 6 months, 40 % were in clinical remission (DAS28 < 2.6) and 21 % reached a low disease activity score (DAS28 > 2.6 to < 3.2). This proportion did not substantially increase during the 2-year follow-up. Methotrexate was the standard first-line treatment in 82 % of patients. During follow-up, 10 % were treated with a combination of disease-modifying antirheumatic drugs (DMARDs) and 12 % with biological agents. In 60 % of the patients who did not reach remission within 3 months (and 54 % of patients without remission by 6 months), treatment was not changed. At the beginning, 77 % of patients were treated with glucocorticoids at different starting doses (26 % < 7.5 mg, 29 % 7.5-20 mg, and 45 % ≥ 20 mg of prednisolone per day). After 2 years, 47 % remained on glucocorticoids. CONCLUSION: While 40 % of patients achieved clinical remission through standard care within 6 months, disease activity remained moderate to high in 37 % of patients at 2 years. In these patients a more consistent application of treatment may have increased the response rates.

[Treatment reduction in well-controlled rheumatoid arthritis. State of knowledge]. / Therapieabbau bei stabil eingestellter rheumatoider Arthritis. Stand des Wissens.

Nowadays, the excellent treatment options available for rheumatoid arthritis (RA) result in ambitious therapeutic goals, such as remission, which can actually be achieved for many RA patients. In a state of sustained remission many patients request reduction in drug treatment and this as well as economic reasons makes treatment reduction or even drug-free remission a reasonable target. Increasingly successful reduction of disease-modifying antirheumatic drug (DMARD) treatment has been shown in studies for approximately 30-60 % of patients in sustained remission, at least for some period of time. Because flare retreatment is successful in nearly all cases, the risk of treatment de-escalation can be minimized, so long as patients are continuously monitored after reduction or termination of drug treatment. No study has yet shown an elevated risk for unfavorable long-term outcome in cases of controlled treatment reduction. Current treatment recommendations are that glucocorticoids should first be withdrawn followed by reduction and termination of biologics and in cases of sustained remission finally, conventional DMARDs, such as methotrexate should be reduced and possibly terminated to achieve the defined target of drug-free remission. Factors facilitating success of tapering antirheumatic drugs are low disease activity at initiation, negative serological tests and short disease duration after starting DMARD treatment. A joint decision between rheumatologists and patients as well as continuous remission for at least 6 months are prerequisites for drug reduction.

[Interfaces in outpatient and inpatient rheumatological treatment]. / Schnittstellen in der ambulanten und stationären rheumatologischen Versorgung.

In healthcare the term interface describes the communication and the sharing of responsibilities between different aspects of medical care und the different professional groups in medicine. It enables cooperation without conflicts and can contribute to an improvement of healthcare and reduce healthcare costs. The postgraduate professional education, medical guidelines and therapy recommendations are an important basis for the definition of interfaces. The definition of such an interface between different healthcare groups is essential for the implementation of selective contracts with health insurance companies. An appropriate health care interface between general practitioners and rheumatologists has been defined as well as between hospital and ambulant rheumatology treatment. The division of responsibilities between orthopedists and rheumatologists is still under discussion. A proposal for such an interface from the point of view of rheumatology is presented.

[Outpatient rheumatologic treatment in Germany]. / Ambulante rheumatologische Versorgung in Deutschland.

Outpatient rheumatologic treatment in Germany is managed by rheumatologists in private practice (n = 557), by authorized rheumatism outpatient centers (n = 116), by rheumatism centers according to §116b (n = 43) and by university outpatient departments. A total number of 975 rheumatologists were registered by the end of 2012 of whom approximately 830 were active in outpatient care. With this number of rheumatologists Germany is in the middle range in comparison to eight industrial nations including the USA. This number is not sufficient to provide adequate medical care and the consequences are too long waiting times for an appointment with a rheumatologist. Statistical data of the Kassenärztliche Bundesvereinigung (KBV, National Association of Statutory Health Insurance Physicians) showed 688,000 general insurance patients with rheumatoid arthritis (RA). As some 68.9 % of the population are in this insurance scheme there are some 770,000 RA patients in Germany (almost 1 % of the population). One way to improve rheumatology care in spite of the lack of rheumatologists could be special agreements with the general health insurance providers to improve cooperation and division of responsibilities between rheumatologists and general practitioners, to implement patient education, tighter control and treat to target in rheumatology care. Another way could be a new treatment level called "ambulant specialist care", with no budget for medical care and no budget for the number of patients treated and therefore the chance for rheumatologists to treat more patients and have a better income. To achieve that more young doctors receive approval as a specialist in rheumatology, more chairs of rheumatology at universities and a nationwide stipendium for training assistants are needed.

[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.

[Low-field magnetic resonance imaging for rheumatoid arthritis]. / Niederfeldmagnetresonanztomographie bei rheumatoider Arthritis.

Magnetic resonance imaging (MRI) as a cross-sectional imaging procedure allows a three-dimensional representation of musculature, ligaments, tendons, capsules, synovial membranes, bones and cartilage with high resolution quality. An activity assessment is further possible by application of a contrast medium (gadolinium-DTPA) to differentiate between active and chronic inflammatory processes. Evidence of a bone marrow edema detected by MRI in patients with rheumatoid arthritis (RA) can be interpreted as a prognostic and predictive factor for the development of bone erosions. On the basis of these advantages MRI is being employed more and more in the early diagnosis of inflammatory joint diseases. Semi-quantitative scores for analysis and grading of findings have already been developed and are in clinical use. Because MRI technical performances are invariably reproducible they can be practically retrieved in the course of examination which is particularly relevant in rheumatology. Therapy response or progression can thus be adequately displayed. Open, dedicated low-field MRI with a low signal strength of 0.2 Tesla (T) has been known since the 90s and now represents new MRI examination options in rheumatology. Smaller devices with lower acquisition and maintenance expenses as well as considerably more convenience due to the device itself result in a higher subjective acceptability by the patients as well as objectively more data records of low-field MRI scans of RA, which underline the significance of this new technical method. The German Society for Rheumatology (DGRh), represented by the Committee for "Diagnostic Imaging", meets this development with the release of recommendations and standards for the procedures of low-field MRI and their scoring and summarizes the most important technical data and information on clinical indications.

[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.

[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.

[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.

Swimming behaviour and calcium incorporation into inner ear otoliths of fish after vestibular nerve transection.

Previous investigations on neonate swordtail fish (Xiphophorus helleri) revealed that otolithic calcium incorporation (visualized using the calcium tracer alizarin complexone) and thus otolith growth had ceased after nerve transection, supporting a hypothesis according to which the gravity-dependent otolith growth is regulated neuronally. Subsequent investigations on larval cichlid fish (Oreochromis mossambicus) yielded contrasting results, repeatedly depending on the particular batch of cichlids investigated. Like most neonate swordtails, Type I cichlids revealed a stop of calcium incorporation after unilateral vestibular nerve transection. Their behaviour after transection was normal, and the otolithic calcium incorporation in controls of the same batch was symmetric. In Type II cichlids, however, vestibular nerve transection had no effect on otolithic calcium incorporation. They behaved kinetotically after transection (this kind of kinetosis was qualitatively similar to the swimming behaviour exhibited by larval cichlids during microgravity in the course of parabolic aircraft flights). The otolithic calcium incorporation in control animals was asymmetric. These results show that the effects of vestibular nerve transection as well as the efficacy of the mechanism, which regulates otolith growth/otolithic calcium incorporation, are--depending on the particular batch of animals--genetically predispositioned. In conclusion, the regulation of otolithic calcium incorporation is guided neuronally, in part via the vestibular nerve and, in part, via a further pathway, which remains to be addressed in the course of future investigations.

[Imaging techniques in rheumatology: magnetic resonance imaging in rheumatoid arthritis]. / Bildgebende Verfahren in der Rheumatologie: Magnetresonanztomographie bei Rheumatoider Arthritis.

Magnetic resonance imaging (MRI) is currently the most modern and, at the same time, most technically advanced instrument of sectional imaging in diagnostic radiology. MRI is superior to other radiological procedures because of its excellent soft-tissue contrast, the possibility of multiplanar imaging and the missing of ionizing radiation. Exact differentiation and imaging of soft tissue and bony alterations is of significant evidence in early diagnosis and monitoring of inflammatory joint diseases, such as rheumatoid arthritis (RA). Besides securing of technical quality management, the physician's qualification in indication, conduction and evaluation of MRI plays a pivotal role. This development of MRI for rheumatological purposes needs standardized recommendations and investigation protocols, which are now summarized and presented by the rheumatologists and radiologists of the study group of "diagnostic imaging procedures" of the German Society for Rheumatology (DGRh).