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Good examples

Register data from SRQ improves healthcare for patients with rheumatological diseases

Johan Wallman is a rheumatology specialist at Skåne University Hospital. He combines clinical work with research and uses the Swedish Rheumatology Quality Register, SRQ, to improve the treatment and follow-up of patients with rheumatological diseases.

 

It only takes 20 minutes to walk from Lund central station to Skåne University Hospital and the rheumatology clinic. The clinic is located in an older building from the 1920s. Johan Wallman appears at the clinic and shows the way to the temporary office, right at the top of the house under the roof.

– I have a position that allows me to work half time as a physician and half time as researcher. I like this combination; in the end it is about developing better care for our patients.

Johan Wallman studied on the physician programme at Lund University, and started his research career early. Two years before qualifying as a specialist in rheumatology in 2016, he was awarded a PhD with a thesis on health economics aspects of rheumatoid arthritis (RA). This is an autoimmune disease, and the most common inflammatory joint disease. Around 0.7 per cent of the population suffers from it, and approximately two-thirds of the sufferers are women. The disease causes inflammation, mainly in joints, and can cause damage to cartilage and surrounding skeletal parts. Blood vessels and the pericardium and pleura can also become damaged. Many sufferers bear witness of aches, stiffness and swelling in joints, which may cause significant functional disability.

– The cost to society of RA is high, partly due to the cost of medical care, and partly due to production decreases due to persons not working due to sickness and early retirement.

Breath-taking development

Being diagnosed with RA today does not mean the same as it did 20 years ago. Aggressive, targeted treatment and biological medications have revolutionised the care and made it possible for many sufferers to lead practically normal lives. But new treatments usually also mean higher costs.

– A common feature of both traditional and modern treatments is that they inhibit the immune system from breaking down the joints, in different ways. But the price of biological treatment is significantly higher than for the traditional, synthetic alternatives. In my thesis, I studied the health economics outcomes, and whether a higher cost was defensible by achieving better long-term therapeutic results with biological treatment, says Johan Wallman.

The result of the thesis showed, surprisingly, that the amount of time off taken or healthcare consumption did not reduce with modern biological treatments compared to traditional treatments (using ‘triple therapy’).

– It is fine to choose conventional triple therapy to begin with. If that isn’t enough, then you can continue with biological treatment.

– Our research and that of others shows that it is important to evaluate different therapies. It is in the interest of social economics to do so, and it is also about the prioritisation and use of our resources, says Johan Wallman.

SRQ – quality register

An important tool in Johan Wallman’s work on his thesis was the use of data from SRQ, the Swedish Rheumatology Quality Register. This is a national quality register that collects patient data from various rheumatology clinics around the country. Physicians, nurses, physiotherapists and occupational therapists input data about factors such as pain, functional ability, disease activity and medication therapy. Data from SRQ is used on a daily basis in patient appointments, but also in operational development and research.

To support the development of healthcare quality and new treatment methods, there is also SRQ Biobank, which collects blood samples from patients with RA. The biobank samples are used in research to enable prediction of the onset, progress and therapy response of RA. The hope is that the research can lead to improved therapy, and in the longer term prevent the disease.

– Besides its use in research, we use SRQ very much in our patient-related work, and that is a great strength. Before I see patients, I have access to data that has been collected and that the patients have registered themselves. It might concern things like pain, quality of life, and what the patient can manage in daily life. This forms a good basis for a conversation with the patient about disease activity and quality of life, and how the treatment is working, for example. SRQ is an important tool in the clinic, and functions both as a register and as support in decision-making about the continued care and treatment.

Ongoing research

Johan Wallman’s current research project concerns gut problems arising from axial spondylarthritis, SpA. This is a rheumatic, chronic inflammatory disease, where the patient normally has symptoms in the spine, the pelvic joints and the lower back.

– The onset of the disease often occurs in younger persons under the age of 45, and causes pain, sleep disturbances and stiffness. I want to see if there is a link between a changed bacterial flora and raised permeability of the gut and the development of the disease. In this project too, I am looking at health economics aspects, and what gut problems caused by SpA can impact on quality of life, healthcare consumption and the ability to work.

– Based on the data collected to date, there appears to be a link between the degree of gut inflammation and disease symptoms; the greater the inflammation in the gut, the more severe the symptoms and the greater the disease activity of SpA. One hypothesis is that if you could start treatment and reduce the inflammation in the gut, then the disease activity would also reduce.

For the inflammatory gut disease IBD, there is today convincing research that shows that a change in the bacterial flora and increased permeability of the gut are central for the development of the disease. Might this perhaps be the case also for axial spondylarthritis?

– The gut inflammation in SpA is an interesting research area, but we don’t as yet know which is the hen and which is the egg, whether it is the disease that drives the gut inflammation, or if the inflammation drives the disease.

Although Johan Wallman is stimulated by research and meetings with patients, it is not always easy to combine the two roles as researcher and physician. There is just not enough time.

– Although I have a combination position, where both research and clinical work are accommodated, the patients always come first. There is a lack of specialists, and the clinic is under severe pressure. The work as a physician also entails a lot of administration, which means that I often have to work with research at weekends and in my spare time. This takes time away from the family, which isn’t always easy.

– If it wasn’t so that I think research is fun and educational, I would probably not have the energy to continue. Of course I know that research is a prerequisite for improved care quality and improved diagnostics and treatment of patients. If I could have my wish, I would hope that in a few years I could have my own research team, and achieve a better balance between research and clinical work.