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Through much of the 20th century, dedicated rheumatic disease units were found in hospitals across the U.S. and countries around the world. In the latter part of the century, this began to change, with hospitals moving toward the consult model of care for rheumatic patients. This change reflects larger shifts in the medical world toward increased outpatient care as well as improvements in rheumatological treatments.
Background
The loose concept of a special center for the treatment of rheumatology patients is at least a couple of centuries old. In the 19th century and into the 20th century, many rheumatology patients flocked to spas in Europe and in the U.S., such as in Hot Springs, Ark.
Eric Matteson, MD, MPH, is a professor of medicine in the divisions of rheumatology and epidemiology at the Mayo Clinic in Rochester, Minn. He explains, “These spas were places where people with musculoskeletal diseases could go and get various treatments, such as mud treatments and physical therapy. Different spas had different mineral waters with different concentrations of minerals that were said to be good for gout or inflammatory arthritis or any number of other diseases. So patients would go and spend a few days, a week or a whole summer at one of these spas.”
The idea of the modern inpatient rheumatic disease unit first began to appear in the early part of the 20th century. One of the earliest developments was the 1912 opening of the Landesbad Hospital in Aachen, Germany.1 In the U.S., the Robert Breck Brigham Hospital opened in Boston in 1914, the first institution in the U.S. dedicated to the treatment of rheumatic and orthopedic conditions. The idea was that many debilitated patients needed extended periods of hospital therapy with dedicated treatments.2
In 1928, James Allison Glover, MD, DPH, first described in detail the idea of the arthritis unit working as a department of a general hospital. He argued that, ideally, these should work in close coordination with a school of medicine or a university, enabling the unit to perform both research and treatment functions.1 Subsequently, rheumatic disease units appeared at Good Samaritan Hospital in Baltimore, at the Alpert Arthritis Center in Denver, and in many other locations.3
Eventually these units became quite common. Most institutions had a dedicated rheumatic unit as part of their inpatient care, often more than one. The idea was that on such floors rheumatic patients could receive better targeted and more coordinated care than if they were scattered throughout a hospital. Having a separate rheumatic unit also decreased competition with nonrheumatic patients for hospital admission.1
Partly because treatment options were so limited for rheumatic diseases, rehabilitation via hospitalization was seen as a key mode of management. Early studies of these units documented that, on average, patients with rheumatoid arthritis were hospitalized for two to three months, with some staying a year or longer.3
Dr. Matteson notes that on the whole, the shift reflects a change for the best. People do not have to stay in the hospital as much, & he believes the model generally fosters good patient outcomes.
Inpatient Rheumatic Disease Units
Jonathan Scott Coblyn, MD, is the director of clinical rheumatology at Brigham and Women’s Hospital, Boston, and an associate professor at Harvard Medical School. He completed his fellowship in the late 1970s at Robert Breck Brigham Hospital (RBBH; which became Brigham and Women’s Hospital in 1980, after merging with the Boston Hospital for Women and the Peter Bent Brigham Hospital). He notes that, at the time, RBBH was filled with people with rheumatic disease or people who were there for orthopedic surgery. “There were no hospitalists at that time, so we would all take our turn, like you do in a general medical service, but it would be on the inpatient rheumatology service. We had hospital-employed doctors, and we had private practice doctors who admitted there as well.”
“When I was a fellow,” Dr. Coblyn says, “the indication for someone with rheumatoid arthritis to be admitted to the hospital was new-onset rheumatoid arthritis or a flare of their rheumatoid arthritis. That’s inconceivable now. People were admitted, and they stayed in for almost two weeks—three weeks or more. We gave them aspirin and paraffin wax and Hubbard tubs and physical therapy and started them on gold shots. The service was covered by housestaff.”
The patients would often have quite severe symptoms. As Dr. Coblyn remembers, “You would see people who would come in—they would have both hips, both knees, maybe their neck fused, and they’d be in there for months and see the rheumatologists, orthopedists and therapists. It is now a totally different patient population and almost a different disease than it was then.”
When Dr. Matteson came to the Mayo Clinic in the late 1980s, it had an inpatient rheumatology service, as well as a consulting service that went to different hospitals. “This was for patients with rheumatic diseases—for example, rheumatoid arthritis flares or lupus flares—and we would have them hospitalized on the rheumatology service. And in fact there were three inpatient services, because frankly we didn’t have very effective treatments. Patients would be in the hospital for extended periods of time for physical therapy, to receive steroids, maybe to get started on a drug like sulfasalazine or Plaquenil.”
Dr. Coblyn notes the length of medical stay has dramatically decreased during his time as a practicing physician. “It was nice to have our patients in for a long time, and we would see them every day. With hip replacements, some patients are discharged the same day now. We used to have people in for almost two weeks for hip replacements. They would come in; they would climb stairs and see therapists and consults. So it’s really so different.”
‘I think this happened from cost pressures & from improved efficiency of care. It has changed because of economics, because of the requirements to get people in & out & because of the shifts in disease severity—especially for rheumatoid arthritis.’ —Dr. Coblyn
Transition Away
Through the 1980s and ’90s, a gradual shift occurred as more and more dedicated rheumatic disease units began to close. Instead, rheumatology patients were admitted to a general medicine service that was given the primary responsibility for the patient’s care. The general medical team would then contact the rheumatology service to see the patient and make their own treatment recommendations from a rheumatological standpoint.
Dr. Coblyn explains, “If it is an actual rheumatic disease, such as vasculitis or severe rheumatoid arthritis or bad lupus, we will see them with our rheum fellow and sometimes house staff and medical students. We will see them every day along with the other care team, usually the hospitalist service. Eventually the medical service evolved into a hospitalist world where none of us attend. We consult, but we don’t attend on the day-to-day care of our patients.” Dr. Coblyn also notes the patients they see now through the inpatient rheum service are usually much sicker. “It’s rarely rheumatoid arthritis unless they are having infection or some terrible complication. And the inpatient service volume is so much less because of that.”
In part, this shift occurred due to the availability of much better treatments. During the early part of the 20th century, physicians had access only to symptomatic treatments for rheumatic diseases, such as salicylates and physical therapy. The discovery of the effectiveness of corticosteroids in the 1940s was followed by other new agents: parenteral gold salts, sulfasalazine, chloroquine, hydroxychloroquine, cyclosporine, azathioprine and, eventually, methotrexate in 1988. In the late 1990s, the first biologic drugs became available, further revolutionizing disease treatment.4
Of course, many patients with rheumatic disease still require hospitalization, even if their rheumatic disease is not the primary reason. Patients with rheumatic disease are more likely to have heart attacks, strokes, kidney disease and other systemic issues. Rheumatic patients are much less likely to be seen for advanced, untreated disease than they were in the past. Still, serious sequelae of these diseases do sometimes occur, whether related to the disease process itself or secondary to medication side effects.5 The consult model ensures rheumatologists can still provide input on these patients when needed, as well as contribute their insights when patient diagnosis is uncertain.
The shift away from inpatient rheumatic units also reflected a more general shift in medicine to more outpatient care and less management of chronic conditions in the hospital. Dr. Matteson explains, “There were fewer patients that needed to be hospitalized, and when they did need to be hospitalized, they needed hospitalization for acute problems. That’s the standard today, that we can bring patients in only for acute problems like acute kidney failure, acute pulmonary failure, heart failure, things like that, and then the problems are addressed in an acute fashion.”
He notes that most rheumatic drugs, even ones given by infusion, are now administered in an outpatient setting. “The hospital duration has gone down a lot, and you can see also that hospital censuses have generally gone down,” says Dr. Matteson. Fewer patients are hospitalized than in the past, both rheumatologic patients and patients of other types.
Dr. Matteson explains that at Mayo and other large institutions, the hospital had to start admitting patients who did not have rheumatologic problems to keep up the general census in the rheumatic disease units. “As time went on, there were actually more of those kinds of patients than patients with actual rheumatic disease problems. The whole discipline was more and more evolving to an outpatient discipline, mainly because we just have better treatments for our patients. Our patients are just doing better; they don’t need to be in the hospital for extended periods.”
Dr. Coblyn agrees that it would now be difficult to keep a dedicated rheumatic disease unit full. “I think this happened from cost pressures and from improved efficiency of care. It has changed because of economics, because of the requirements to get people in and out and because of the shifts in disease severity—especially for rheumatoid arthritis.”
A 1993 editorial in Arthritis & Rheumatism questioned whether these units were of benefit, given the shift toward pharmacological treatments and the challenges of constraining healthcare costs. By this time, most studies suggested inpatient care was no more effective than outpatient care for rheumatic disease patients. It was also quite clear that inpatient rheumatic disease units did not save money.3
By then, Brigham and Women’s Hospital no longer had a dedicated rheumatic floor, and other units (such as the one at Denver) had also closed. Dr. Matteson notes that almost all remaining inpatient rheumatology units closed after 1993, partly due to pressures for Medicare reform. Mayo closed its hospital service in 1997, and the University of Michigan closed its service around 15 years ago.
Drawbacks & Benefits to the Consult Model
Dr. Matteson notes that on the whole, the shift reflects a change for the best. People do not have to stay in the hospital as much, and he believes the model generally fosters good patient outcomes. “From a learning standpoint of how to manage disease, I think there are drawbacks that we don’t have a primary service, but in general I think it’s for all the right reasons.”
He continues, “It is a little bit different than when you have primary responsibility for a patient, but everyone takes responsibility. You take responsibility for assuring that your recommendations are reasonable in the context of the patient’s problem.”
From Dr. Coblyn’s perspective, patients with acute problems benefit from the fact that now an attending is always available: In the rheumatic unit model, the attending rheumatologist would often be away seeing clinic patients during the day. In terms of patients’ perspectives, he notes, “I think it’s a little harder for them, because there are so many more people now involved in their care. They get mixed messages from attendings, from residents—there are just so many more people involved.”
Some dedicated rheumatic disease units still operate internationally, with patients hospitalized for rehabilitation over longer periods of time. Yet Dr. Matteson notes that Western Europe is transitioning more toward hospitalization for acute care only.
Dr. Matteson describes another model: “In Berlin, they have something called ‘Daycare hospital.’ You come in for a full day to the hospital and do rehab. You might go home and come back the next day and do that for a week or two. But you’re not really staying in a hospital bed then. You are coming to an intensive rehabilitation program. That’s another variant of the modern rheumatology hospital service.”
He also notes he has colleagues in China who still work on dedicated wards for rheumatology patients, similar to the model that used to be so common. But in the U.S., such units are a thing of the past, an organizational structure from a bygone medical era.
Ruth Jessen Hickman, MD, is a graduate of the Indiana University School of Medicine. She is a freelance medical and science writer living in Bloomington, Ind.
References
- Ogryzlo MA, Gordon A, Smythe HA. The rheumatic disease unit (R.D.U.) concept. Arthritis & Rheumatism. 1967;10(5):479–485.
- Liang MH. History of the Robert Breck Brigham Hospital for Incurables. Boston,:2013;Brigham and Women’s Hospital Inc.
- Clarke AE, Esdaile JM, Hawkins D. Inpatient rheumatic disease units: Are they worth it? Arthritis & Rheumatism. 1993;36(10):1337–1340.
- Upchurch KS, Kay J. Evolution of treatment for rheumatoid arthritis. Rheumatology (Oxford). 2012;51(Suppl 6):vi28-36.
- Rheumatic diseases in America: The problem, the impact, and the answers. American College of Rheumatology. (n.d.);1–17.
