At the primary care level, the physician will be the first liner in managing patients with variety of health problems. Thus, the management of the patient will highly depends on the physician skill and recognition of diseases, including the possibility of systemic lupus erythematosus (SLE). The patients usually presented to primary care center for mild disease like skin lesions and arthritis. If the physician is not careful, he/she might mistakenly diagnose the patient with skin disease or perhaps just minimal joint pain. On the other hand, the patient also may present with young hypertension or dyslipidaemia which warrants further investigations. When there is high index of suspicion that it can be a connective tissue disease, it is advisable for early referral to tertiary centre. However, there is no role of primary prevention of this disease so it is unethical to screen everybody because it is not cost effective.
There is no doubt that SLE is a great masquerader. It can disguise itself well with many faces. In view of the complexity of the disease, it is important for medical practitioners at the primary care level to recognize the signs and symptoms of SLE. Early diagnosis is the best possible resolution for these patients. This could minimize the risk of long-term organ damage that associated with SLE and the prognosis will be highly improved (1). The recognition would allow proper screening test and specific serology test to assist in validate the diagnosis.
The diagnostic accuracy of rheumatic complaints by primary care physicians may be low. That is why early access to rheumatology care may be associated with improved health status in rheumatology patients (2). Early referral to rheumatologist usually ensures prompt diagnosis (3). There is an argument between primary healthcare and rheumatologist in diagnosing rheumatic diseases. About 41% of primary care diagnosis has been modified by rheumatologist (4).
In terms of follow up, SLE patients that have been followed up by rheumatologist have a few advantages. One example is osteopenia is diagnosed more often when the case is reviewed by rheumatologist (3). According to a study, rheumatologist are likely to order for SLE biomarkers (like ESR, dsDNA antibodies and serum complements) compared to healthcare physicians. Rheumatologist also more frequent prescribes hydroxychloroquine compared to primary healthcare.
SLE is more common and severe for people in Asia and Africa as compared to people in industrialized countries. In addition, survival rates for SLE patients in industrialized countries are lesser than developing countries (5). As far as I am concern, primary healthcare in Malaysia do not play many roles of treating and managing SLE. The diseases usually involve internal organs and become more complicated to be handled at primary care setting. On top of this, in other developed countries, the physicians sometimes treat the patient with mild disease (which involves the skin and arthritis only) at the primary care level. Malaysia is perhaps still far from this but if early preparation is made, I am sure we can reach there in shorter time.
The primary healthcare practitioners can prepare them to monitor the patients before the next visit to Rheumatology Clinic. In terms of patient monitoring, laboratory assessment should be done during every visit. The assessments include full blood count (FBC), creatinine determination and urinalysis (6). Other important laboratory assessment that should be carried is liver function test and ESR. This is to monitor possible target organ damage. Erythrocyte sedimentation rate (ESR) is mainly used to monitor activity of the disease (7). Therefore, the primary healthcare should be equipped with the suitable facilities and trained healthcare workers that will allow effective and efficient monitoring.
SLE has affect towards the economic well being of sufferers, their family and nationwide. In the USA for example, the average cost for children with SLE is about USD 14,944 per patient per year (8). In UK, generally the total cost in patients with SLE is £7913 per patient per year (9). Direct medical costs in patients with SLE is almost the same among Canadian, American, and British patients, despite significant differences in the mechanisms by which medical care is financed and delivered in these three countries (2). Considering that it involves thousands of money for each patient, the disease should be diagnosed as earliest as possible at the initial stage. If the disease can be managed at the beginning, it will help a lot in reducing the complication and ultimately reduce the economic burden.
In the future, the primary healthcare should play more active role in managing rheumatology cases. Primary healthcare workers should be more comfortable in screening suspected cases and monitoring stable. Perhaps, this will minimize the burden of both patients and government, physically ad economically.
Other related articles:
• Systemic Lupus Erythematosus (SLE)
• Clinical manifestations of SLE
• Evaluation of SLE
• Criteria for the classification of SLE
• Management of SLE
• SLE and in vitro fertilization (IVF)
• SLE and oral contraceptive pills (OCP)
• Living with SLE
• Role of primary healthcare in SLE
• Overall view of SLE
Reference:
1. Lehman, TJA. Early diagnosis of SLE in childhood. Lupus News. 2003; 22(3).
2. Ward MM. Health services in rheumatology. Current opinion in Rheumatology. 2000;12(2): 99-103
3. Molina MJ, Mayor AM, Angel MM, Franco AE, Morell CA, Lo´pez MA et al. Utilization of health services and prescription patterns among lupus patients followed by primary care physiciansand rheumatologists in Puerto Rico. Ethn & Dis, 2008; 18: S2-205-210.
4. Gamez-Nava J, Gonzalez-Lopez L, Davis P, Suarez-Almazor ME. Referral and diagnosis of common rheumatic disease by primary case physicians. Br J Rheumatol. 1998;37:1215–1219.
5. Tikly M, Navarra SV. Lupus in the developing world – is it any different?Best Practice & Research Clinical Rheumatology. 2008; 22 (4): 643-655.
6. American College of Rheumatology Ad Hoc Committee on Systemic Lupus Erythematosus Guidelines. Guidelines for Referral and Management of systemic lupus erythematosus in adults. Arthritis Rheum. 1999;42:1785-1796.
7. Fernando MMA, Isenberg, DA .How to monitor SLE in routine clinical practice. Annals of the Rheum Dis. 2005;64:524-527.
8. Brunner HI, Sherrard Tina M, Klein-Gitelman M S. Cost of treatment of childhood-onset systemic lupus erythematosus. Arthritis care and research. 2006; 55(2); 184-188.
9. Sutcliffe N, Clarke AE, Taylor R, Frost C, and Isenberg, DA. Total costs and predictors of costs in patients with systemic lupus erythematosus. Rheumatology 2001; 40:37-47.
