Deployment of health care professionals can improve inflammatory-rheumatic disorders

Inflammatory-rheumatic disorders are a widespread ailment, affecting at least 1.5 million people in Germany alone. Because there is a shortage of rheumatologists, however, only half of the patients in this country are adequately treated.

The use of other health care professionals, as is the case in Denmark and the UK, could help to improve the situation. A study in Germany has shown for the first time that the care of patients with inflammatory-rheumatic diseases by ‘rheumatological assistants’ (RFA) is just as effective as treatment by specialist rheumatologists.

To reduce waiting times and prevent damage to health, the European League Against Rheumatism (EULAR) strongly recommends the use of RFAs in Germany, which will be announced at a press conference on 3 June 2020 held for its annual congress.

Around two percent of the adult population in Germany is affected by chronic inflammatory rheumatic diseases, such as rheumatoid arthritis (RA), axial spondyloarthritis (axSpA) or psoriatic arthritis (PsA). “These patients have a considerable medical condition,” explains Dr. Kirsten Hoeper from the Clinic for Rheumatology and Immunology at the Hanover Medical School in Germany.

Missed opportunities for treating patients due to long waiting times

Severe pain, extreme fatigue, lack of strength, stiffness and physical deformity can have a significant impact on activities, education and career, partnership and family and can lead to occupational disability. Early diagnosis and therapy are essential to prevent as far as possible such serious consequences of damage to the joints.

But the existing medical resources do not suffice to provide early, patient-centred and guideline-based care. The waiting times are far too long,this is despite the fact that new drugs could almost completely force the disease back into so-called remission for the majority of patients – provided that treatment is administered in good time.”

Dr Kirsten Hoeper, Clinic for Rheumatology and Immunology, Hanover Medical School, European League Against Rheumatism

The deployment of RFAs could improve the situation, as is already well-established in some Northern European countries.

RFAs are members of related medical professions such as paramedic, nurse, student nurse or road traffic/motor traffic accidents, who have acquired additional theoretical and practical knowledge about the care of patients suffering from rheumatic and musculoskeletal diseases (RMDs). Such a delegation of medical care in rheumatology is recommended worldwide.

“The legal framework for this also exists in Germany,” says Hoeper. “In addition, the curriculum for the RFA degree exists since 2006, which is currently available to the German Medical Association for certification in an extended form.

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In order to examine whether and how RFAs can also be used in the German health care system, a prospective, randomised, controlled and multi-centre study was conducted, which was completed in December 2019.

“A total of 236 patients from eight German centres participated in the study, where a blood test had confirmed the diagnosis of rheumatoid arthritis,” explains the author of the study Hoeper.

Study involvement of RFAs produces the same treatment results

On average, the patients were 58 years of age, over 70 percent were female and suffered from rheumatic complaints for a period of 130 (ranging from 12 to 144) months on average.

While one study group was exclusively treated by rheumatologists during the twelve-month study period, the other study group RFAs temporarily took over the care at three fixed intervals with only brief contact to the physicians.

The patients’ condition was measured using the standard assessment form DAS28 (Disease Activity Score at 28 joints), which assesses the activity of the disease on an ascending scale from 2.0 to 10.0. Values between 3.2 and 5.1 are considered moderate.

Result of the study: The structured delegation of medical tasks to an RFA does not undermine the current standard of care. While the disease activity for the group co-treated by RFAs was on average DAS28 2.43, the value for the group with continuous rheumatologist consultation was on average DAS28 2.29.

“This difference is not clinically or statistically significant”, concludes EULAR President Professor Dr. Iain B. McInnes from Glasgow, Scotland, UK. “For the first time it can be shown for Germany that an RFA consultation is a safe way to complement the care of patients suffering from rheumatoid arthritis”, says Professor Dr. med. John Isaacs from Newcastle, Great Britain, EULAR Scientific Programme Committee Chair.

Better care in a cost-efficient way

“Integrating a team approach comprising rheumatologists with other health professionals into the treatment of patients with inflammatory rheumatic diseases presents great opportunities,” emphasises McInnes.

“RFAs can complement a physician’s workload, who in turn can use freed-up resources for more complex or new patients,” Hoeper adds. The long waiting times for an appointment with a rheumatologist could thus be cut shorter. Hoeper concludes, “by following the international EULAR Recommendations regarding RFAs, Germany will lead to better patient care in a cost-efficient way”.


European League Against Rheumatism

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When A Doctor No Longer Accepts Medicare, Patients Left Holding The Bag

Pneumonia. Heart problems. High cholesterol. Betsy Carrier, 71, and her husband, Don Resnikoff, 79, relied on their primary care doctor in Montgomery County, Maryland, for help managing their ailments.

But after seven years, the couple was surprised when the doctor informed them she was opting out of Medicare, the couple’s insurer.

“It’s a serious loss,” Resnikoff said of their doctor.

Patients can lose doctors for a variety of reasons, including a physician’s retirement or when either patient or doctor moves away. But economic forces are also at play. Many primary care doctors have long argued that Medicare, the federal health insurance program for seniors and people with disabilities, doesn’t reimburse them adequately and requires too much paperwork to get paid.

These frustrations have prompted some physicians to experiment with converting their practices to more lucrative payment models, such as concierge medicine, in which patients pay a fee upfront to retain the doctor. Patients who cannot afford that arrangement may have to search for a new physician.

The exact number of physicians with concierge practices is unknown, health care experts said. One physician consulting company, Concierge Choice Physicians, estimates that roughly 10,000 doctors practice some form of membership medicine, although it may not strictly apply to Medicare patients.

Shawn Martin, senior vice president of the American Academy of Family Physicians, estimated that fewer than 3% of their 134,000 members use this model but the number is slowly growing.

The move to concierge medicine may be more prevalent in wealthier areas.

Travis Singleton, executive vice president for the medical staffing company Merritt Hawkins, said doctors switching to other payment systems or those charging Medicare patients a higher price for care are likely “in more affluent, well-to-do areas where, frankly, they can get fees.”

It is far easier for physicians than hospitals to opt out of taking Medicare patients. Most hospitals have to accept them since they rely on Medicare payments to fund inpatient stays, doctor training and other functions.

The majority of physicians do still accept Medicare, and most people insured by the federal program for seniors and people with disabilities have no problem finding another health care provider. But that transition can be tough, particularly for older adults with multiple medical conditions.

“When transition of care happens, from one provider to another, that trust is often lost and it takes time to build that trust again,” said Dr. Fatima Sheikh, a geriatrician and the chief medical officer of FutureCare, which operates 15 rehabilitation and skilled nursing centers in Maryland.

Shuffling doctors also heightens the risk of mishaps.

A study of at least 2,200 older adults published in 2016 found that nearly 4 in 10 were taking at least five medications at the same time. Fifteen percent of them were at risk of drug-to-drug interaction.

Primary care providers mitigate this risk by coordinating among doctors on behalf of the patient, said Dr. Kellie Flood, a geriatrician at the University of Alabama-Birmingham.

“You really need the primary care physicians to serve as the quarterback of the health care team,” said Flood. “If that’s suddenly lost, there’s really not a written document that can sum all that up and just be sent” to the new doctor.

Finding a physician who accepts Medicare depends partly on workforce demographics. From 2010 to 2017, doctors providing primary care services to Medicare beneficiaries increased by 13%, according to the Medicare Payment Advisory Commission (MedPAC), a nonpartisan group that advises Congress.

However, the swell of seniors who qualify for Medicare has outpaced the number of doctors available to treat them. Every day, an estimated 10,000 Americans turn 65 and become eligible for the government program, the Census Bureau reported.

The impact: In 2010, MedPAC reported, there were 3.8 primary care doctors for every 1,000 Medicare enrollees. In 2017, it was 3.5.

Authors of a MedPAC report out last June suggested that the number of available primary care providers could be an overestimate. Their calculation assumed all internal medicine doctors provided these services when, in reality, many specialize in certain medical conditions, or accept only a limited number of Medicare patients into their practices.

But MedPAC concluded seniors are not at a disadvantage finding a doctor.

“We found that beneficiaries have access to clinician services that is largely comparable with (or in some cases better) access for privately insured individuals, although a small number of beneficiaries report problems finding a new primary care doctor,” the MedPAC researchers wrote.

The coronavirus outbreak has complicated the ability for many Americans to access care, regardless of their insurer. However, many older patients now have an opportunity to connect with their doctors virtually after the Centers for Medicare & Medicaid Services (CMS) broadened access to telemedicine services under Medicare.

Experts said the long-term effects of the virus on doctors and Medicare remain unknown. But Martin said the shortage of cash that many doctors are experiencing because of the coronavirus epidemic has revealed the shortcomings of how primary care doctors are paid.

“The COVID crisis really brought to life the challenges of fee for service,” said Martin.
Despite these challenges, the number of doctors choosing to opt out of Medicare has been on the decline, according to data from CMS.

Singleton, of Merritt Hawkins, said concern about doctors leaving the Medicare system is part of larger workforce issues. Those include the need to recruit more medical students to concentrate on primary care.

One estimate predicts the nation will face a shortage of 23,600 primary care physicians by 2025. The majority of residents in internal medicine ― those who care for adults — are choosing a subspecialty such as cardiac care or gastroenterology, MedPAC reported.

In 2017, MedPAC reported, the median compensation for all doctors was $300,000 a year. Among primary care doctors, it was $242,000.

Creative business models can make up that difference. Under the concierge model, the doctor charges patients an annual fee — akin to a gym membership ― to access their practice. The provider still bills the insurer ― including Medicare — for all patient care.

Another model ― called direct primary care — charges the patient an annual fee for access and care; doctors do not bill health insurance plans.

Proponents say that the model enables them to take more time with their patients without dealing with the bureaucracy of getting paid by health insurers.

“I think what is most attractive to direct primary care is that they just practice medicine,” Martin said.

The size of a physician practice can also determine whether it accepts Medicare. Large practices can better offset the lower Medicare payment rates by leveraging their influence with private insurers to raise those reimbursements, said Paul Ginsburg, director of the USC-Brookings Schaeffer Initiative for Health Policy. But small, independent clinics may not have the same clout.

“If you’re a large primary care practice, private insurers are really going to want to have you in their network,” he said. “And they’re willing to pay more than they might pay an individual solo practitioner who they’re not as concerned [with] because it’s only one physician.”

Luckily, after more than a dozen calls to physicians, Carrier and Resnikoff said they found another primary care doctor. They said she accepts Medicare and impressed them during their meet-and-greet with her knowledge of their medical history. She also met their criteria for age and expertise.

“At this point in our lives, I’d be eager to find somebody who’s young enough that they might be in practice for the next 10 years,” Carrier said.

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Gilead’s remdesivir prevents lung damage in COVID-19 study on monkeys

(Reuters) – Gilead Sciences Inc’s (GILD.O) antiviral drug remdesivir prevented lung disease in macaque monkeys infected with the new coronavirus, according to a study published in the journal Nature on Tuesday.

FILE PHOTO: Two ampules of Ebola drug Remdesivir are pictured during a news conference at the University Hospital Eppendorf (UKE) in Hamburg, Germany, April 8, 2020, as the spread of coronavirus disease (COVID-19) continues. Ulrich Perrey/Pool via REUTERS/File Photo

The findings were first reported in April by the U.S. National Institutes of Health (NIH) as a “preprint,” prior to traditional academic validation provided by a medical journal.

Remdesivir is the first drug shown to be effective against COVID-19 in human trials. Other clinical studies involving the drug are being closely watched as nations look for treatments for the disease that has infected more than 7 million people and killed over 400,000 globally.

Remdesivir was approved last month in Japan under the brand name Veklury. It has been cleared for emergency use in severely-ill patients in the United States, India and South Korea. Some European nations are also using it under compassionate programs.

In the study published on Tuesday, 12 monkeys were infected with the new coronavirus, and half of them were given early treatment with remdesivir.

Macaques that received remdesivir did not show signs of respiratory disease and had reduced damage to the lungs. (

Authors of the study also said the viral load, or amount of virus, in the lungs of remdesivir-treated animals was lower.

The authors suggested that remdesivir should be considered as a treatment as early as possible to prevent progression to pneumonia in COVID-19 patients.

In a U.S.-run clinical trial released in late April, remdesivir reduced hospitalization stays by 31%, or about four days, compared to a placebo.

Gilead last week reported data from its own trial of remdesivir, showing that the drug provided a modest benefit for patients with moderate COVID-19 given a five-day course of the treatment.

Reporting by Manas Mishra in Bengaluru and Deena Beasley in Los Angeles; Editing by Saumyadeb Chakrabarty and Bill Berkrot

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U.S. CDC reports 1,956,421 coronavirus cases, 110,925 deaths

FILE PHOTO: Commuters ride the subway on the first day of New York City’s phase one reopening during the outbreak of the coronavirus disease (COVID-19) in New York City, New York, U.S., June 8, 2020. REUTERS/Mike Segar/File Photo

(Reuters) – The U.S. Centers for Disease Control and Prevention (CDC) on Tuesday reported 1,956,421 cases of new coronavirus, an increase of 17,598 cases from its previous count, and said the number of deaths rose by 550 to 110,925.

The CDC reported its tally of cases of the respiratory illness known as COVID-19, caused by the new coronavirus, as of 4 pm ET on June 8, versus its previous report released on Monday. (

The CDC figures do not necessarily reflect cases reported by individual states.

Reporting by Trisha Roy in Bengaluru; Editing by Shinjini Ganguli

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Georgia State researcher receives $1.95 million NIH grant to study cause of autoimmunity

Reviewed by Emily Henderson, B.Sc.Jun 8 2020

Dr. Leszek Ignatowicz, a professor in the Institute for Biomedical Sciences at Georgia State University, has received a five-year, $1.95 million federal grant to study what causes autoimmunity in the human body.

Autoimmune diseases, which occur when the immune system mistakenly attacks the body’s own organs, tissues and cells, are the third most common group of diseases in the United States after cancer and heart disease. More than 100 types of autoimmune diseases have been identified, including Type 1 diabetes, rheumatoid arthritis, multiple sclerosis, lupus, psoriasis, thyroid diseases and inflammatory bowel disease.

Most autoimmune diseases have no cure, which results in debilitating symptoms, organ function loss and even death. Despite how common and increasingly prevalent autoimmune diseases have become, they largely remain a mystery.

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This grant from the National Institutes of Health’s National Institute of Allergy and Infectious Diseases will fund research to understand why the immune system attacks its own body, referred to as compromised tolerance, and how autoimmunity develops.

All vertebrates, including humans, have two levels of immunity. The first is the innate immune system, which is activated by molecules common in bacteria, parasites or viruses. The second layer of defense is the adaptive immune system, which depends on lymphocytes (B cells or T cells), one of the body’s main types of immune cells. Autoimmunity takes place when lymphocytes become activated by peptides derived from the body’s own proteins rather than those from pathogens, activating an immune response.

Most people don’t get autoimmune diseases because tolerance works properly in their body. With central tolerance, T cells that have a capacity to be pathogenic and autoreactive, or activated by self-antigens, are supposed to be eliminated and die in the thymus gland where they originally developed. This process is not 100 percent reliable, and an unknown percent of potentially autoreactive T cells escape and may cause autoimmunity. Then, a second line of security called peripheral tolerance identifies these remaining T cells that have the potential to be autoreactive and inhibits them.

The goal of this work is to better understand how the natural limitations of thymic selection predispose us to autoimmunity. This research will provide a better understanding of cellular and molecular mechanisms driving autoimmunity and help to develop therapeutic strategies targeting autoreactive T cells that escaped central tolerance. From a clinical perspective, identification of dormant, autoreactive T cells is critically important for saving a new category of autoimmune patients with peripheral tolerance deliberately broken by regulatory T cells that silence treatments to enhance immunity to infection or cancer.”

Dr. Leszek Ignatowicz, Professor, Institute for Biomedical Sciences, Georgia State University


Georgia State University

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Brazil ‘driving in the dark’ on COVID-19 as contradictory data deepens confusion

RIO DE JANEIRO/SAO PAULO (Reuters) – Brazil drew further criticism for its handling of the coronavirus pandemic on Monday after it published contradictory figures on fatalities and infections, deepening a scandal over the country’s COVID-19 data.

FILE PHOTO: Gravediggers wearing protective suits bury the coffin of 70-year-old Manuel Farias, who died from the coronavirus disease (COVID-19), at Recanto da Paz cemetery, in Breves, southwest of Marajo island in Para state, Brazil, June 7, 2020. REUTERS/Ueslei Marcelino

Initial data released on Sunday from the health ministry on the number of cases and death toll in Brazil was later contradicted by numbers uploaded to the ministry’s online data portal.

On Monday, the ministry said in a statement the discrepancy was predominantly due to mistakes in the numbers from two states that were later corrected. It explained that the later, lower daily death toll of 525 was the correct one.

It said it had “been improving the means for releasing information on the national situation of the handling of COVID-19.”

The discrepancy followed recent decisions to remove from a national website a trove of data about the country’s outbreak, and to push back the daily release of new numbers late into the evening and after the country’s main television news program.

“By changing the numbers, the Ministry of Health covers the sun with a sieve,” Rodrigo Maia, speaker of the lower house, said on Twitter.

“The credibility of the statistics needs to be urgently recovered. A ministry that manipulates numbers creates a parallel world in order not to face the reality of the facts,” he added.

The World Health Organization (WHO) on Monday stressed the importance of “consistent and transparent” communication from Brazil, which is now one of the main coronavirus epicenters. It has the second highest number of confirmed cases behind the United States, and a death toll that last week surpassed Italy’s.

Far-right President Jair Bolsonaro has come under growing criticism for the way his government has handled the pandemic, which he has regularly played down as a “little flu.”

For Carlos Machado, head of research at the National School of Public Health, part of the respected public institute Oswaldo Cruz Foundation, the lack of dependable data is dangerous.

“Not having updated and reliable data during a pandemic of this proportion is like driving in the dark,” he said.

“While we do not have a vaccine, information is the best weapon we have at our disposal,” he added.

Confusion over the figures has led a group of Brazil’s largest media outlets to launch their own data tracking system, according to a report in newspaper Folha de S.Paulo.

The National Council of Health Secretaries (Conass), which brings together the heads of Brazil’s state health departments and is separate from the health ministry, has also created its own platform.

According to the council, Brazil had recorded 680,456 cases of COVID-19 and 36,151 deaths from the disease by the end of Sunday afternoon.

Reporting by Pedro Fonseca and Eduardo Simoes; additional reporting by Emma Farge in Geneva, writing by Jamie McGeever and Stephen Eisenhammer; editing by Jonathan Oatis and Rosalba O’Brien

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If you’re unhappy with your care, let us know – File a Medicare complaint.

When you’re unhappy with the quality of your health care, you might first want to talk with the person who gave you the care. If you don’t want to talk to that person or need more help, you can file a Medicare complaint. Filing a complaint is your right, so if you think you aren’t getting high-quality care, we want to know.

How you file a complaint depends on what it’s about: 

If you’re enrolled in a Medicare health or drug plan, each plan has its own rules for filing Medicare complaints. If you still need help after you file a complaint with your plan, call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

If you’ve contacted 1-800-MEDICARE about a Medicare complaint and still need help, ask the person you talk with at 1-800-MEDICARE to send your complaint to the Medicare Beneficiary Ombudsman. The Ombudsman staff will help make sure your complaint is resolved.

You can also file an appeal if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or Medicare Prescription Drug Plan. 

For other kinds of Medicare-related complaints, call your State Health Insurance Assistance Program (SHIP) for free, personalized help. 

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CDC reports 1,920,904 coronavirus cases in United States

FILE PHOTO: Eloina Marquez cleans the protective plexiglass dividers at a blackjack table during the reopening of Bellagio hotel-casino, closed since March 16, 2020 as part of steps to slow the spread of the coronavirus disease (COVID-19), in Las Vegas, Nevada, U.S., June 4, 2020. REUTERS/Steve Marcus

(Reuters) – The U.S. Centers for Disease Control and Prevention (CDC) on Sunday reported 1,920,904 cases of new coronavirus, an increase of 29,214 cases from its previous count, and said COVID-19 deaths in the United States had risen by 709 to 109,901.

The CDC reported its tally of cases of COVID-19, the respiratory illness caused by the new coronavirus, as of 4 p.m. EDT on June 6. Its previous tally was released on Friday. (

The CDC figures do not necessarily reflect cases reported by individual states.

Reporting by Bhargav Acharya in Bengaluru; Editing by Paul Simao

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France reports 13 more coronavirus deaths, total at 29,155

PARIS (Reuters) – France’s coronavirus death toll, the fifth-highest in the world, rose by 13 on Sunday to 29,155, the government said.

The number of people in hospital intensive care units fell by six to 1,053, a smaller decrease than the previous day but extending a steady drop in critical cases since a peak of over 7,000 in early April, according to data posted on a government website.

The total number of people being treated in hospital for COVID-19 fell by 18 to 12,461.

The number of confirmed cases of COVID-19 rose by 343 to 153,997.

According to Reuters calculations, if probable cases of coronavirus in long-term care homes are added, France’s total number of cases stands at around 190,000, the ninth-highest tally in the world on that basis, now slightly below that in Peru.

Reporting by Gus Trompiz and Blandine Henault; Editing by Kevin Liffey

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