The management of many closely related comorbidities in patients with non-radiographic axial spondyloarthritis (nr-axSpA) requires the involvement of multidisciplinary teams.
Multidisciplinary teams are helmed by rheumatologists, with dermatology, gastroenterology, ophthalmology, psychiatry, and primary care specialists also on board.
Meetings of multidisciplinary teams offer a valuable resource to the patient and healthcare team, thus allowing for the discussion of complex presentations and treatment strategies.
Multidisciplinary teams are an important aspect of treating non-radiographic axial spondyloarthritis (nr-axSpA), as these patients frequently have coexisting immune-mediated inflammatory diseases (IMIDs)—such as psoriasis, psoriatic arthritis, and inflammatory bowel disease—that share an underlying pathology.
The coexistence of multiple IMIDs requires input from several specialists, such as a rheumatologist, dermatologist, gastroenterologist, and others. However, multidisciplinary teams for managing nr-axSpA are complex, and their effectiveness depends on close collaboration between specialists.
Multispecialty team guidance
Caring for patients with IMIDs by multidisciplinary teams is supported by various guidelines and recommendations, including those from specialty societies for patients with nr-axSpA.
The guidance from such specialty societies highlights the importance of rheumatologists managing musculoskeletal presentations, and collaborating with dermatologists as needed.
A recommendation noted in the Advances in Therapy research recognized that nr-axSpA is a potentially severe disease with different manifestations, so multidisciplinary management coordinated by the rheumatologist is necessary.
In light of the high prevalence of overlapping IMID comorbidities, the related nature of IMIDs, and the understanding that a multidisciplinary strategy yields a more extensive evaluation and comprehensive approach to treatment, the Advances in Therapy researchers summed up the important aspects of multidisciplinary care.
"The goals of a multidisciplinary team should be to increase diagnosis of concomitant IMIDs, improve the decision-making process, and increase patient satisfaction and adherence. "
— Rizzello F, et al., Advances in Therapy
“Early referral and diagnosis, early recognition of concomitant IMIDs and optimizing treatment to improve patient quality of life are some of the advantages of using multidisciplinary teams,” the researchers wrote.
They added that an effective multidisciplinary team should be outfitted with the appropriate tools for diagnosis and follow-up. At a minimum, the team should be staffed with a dermatologist, gastroenterologist, and rheumatologist, as well as a psychologist, ophthalmologist, PCP, and nurses.
Models of multidisciplinary care
Several delivery methods for the multidisciplinary care of spondylarthritis are described in the literature. The most popular is the multidisciplinary care unit.
This multidisciplinary care unit entails a combined clinic where the patient is seen by several staff in a coordinated fashion. Diagnosis and therapy follow an algorithm, with team composition and workflow varying from unit to unit.
There are three types of combined clinics, according to the authors of a review published in TherapeuticAdvances in Musculoskeletal Disease (TAMD). They include the following:
Face to face. This care model is concurrent and synchronous, with the patient seen by all members of the team on the same day.
Parallel model. Members of the team see the patient separately and in parallel, with visits staggered throughout the day, and the team later decides on best management.
Preferential derivation or circuit approach. Akin to real-life clinical practice, every team member sets their own agenda, but there are predefined referral criteria, as well as the possibility of referral to other team members on a very early basis.
Team meeting options
Research on multidisciplinary team meetings in the context of spondyloarthropathies is limited. But authors of the TAMD review supported its use, noting the success of group meetings in other fields, such as oncology and dermatology.
Telemedicine has lowered the barriers for the participation of diverse specialists separated by geography, as well as improving relationships among primary, secondary, and tertiary healthcare professionals and patients.
"By including diverse health professionals, [multidisciplinary team] meetings have the advantage of providing a holistic service, which is essential in heterogeneous diseases such as SpA where [multidisciplinary] input is needed. "
— Gudu T, et al., TAMD
“The multiperspective view on the patient and disease makes these meetings suitable for discussing complex cases and diagnostic or treatment challenges,” the authors wrote.
“However, the patients are most often not present at the meeting, and treatment recommendations may be made without considering patient preferences and personal needs, which is a major limitation of this [multidisciplinary] model. Our experience of [multidisciplinary team] meetings running in our own institution illustrates well this type of [multidisciplinary] working,” they added.
As our understanding of nr-axSpA continues to expand, with a better elucidation of disease pathophysiology and treatment options such as biologics rapidly advancing the field, the utilization and efficacy of multidisciplinary teams for treating patients with nr-axSpA will hopefully continue to grow accordingly. The option of telemedicine, enabling specialists from different locations to participate in teams remotely, may further expand the capabilities and potential for these teams.
What this means for you
Multidisciplinary teams are supported by experts as valuable in the treatment of patients with nr-axSpA and other IMIDs. These teams are led by rheumatologists, and include dermatologists, gastroenterologists, psychologists, and ophthalmologists, and occasionally physical therapists. Multidisciplinary team meetings provide important opportunities to coordinate care from multiple clinical perspectives. Advances such as telemedicine allow for specialist groups from diverse locales to meet, thus improving access to specialist care.
This article is part of Room for Better Rheum Care, where physicians and patients share the latest research, tips, and strategies for raising treatment expectations and delivering improved care in RA, PsA, and nr-AxSpA.