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        "titulo" => "Modelos de atenci&#243;n multidisciplinar en pacientes con artritis psori&#225;sica en Espa&#241;a"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Psoriatic arthritis &#40;PsA&#41; is a potentially severe&#44; chronic&#44; progressive&#44; multiorgan disease&#46; Patients should be properly and indefinitely evaluated from the first visit&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#8211;4</span></a> Many of them are studied by dermatologists and rheumatologists separately&#44; meaning that the care process may not be optimal from a clinical perspective&#44; and is not ideal for the patient&#44; or even for the system&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5&#8211;7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">On the other hand&#44; the 2012 recommendations of the European League Against Rheumatism &#40;EULAR&#41; propose a multidisciplinary approach in PsA&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> as do expert groups and patients&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> Thus&#44; in recent years&#44; dermatologists and rheumatologists have teamed together to introduce multidisciplinary units to treat PsA patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">10&#44;11</span></a> Now that they have been established&#44; it is essential that their activity be evaluated to demonstrate their efficacy and pinpoint areas for improvement&#46; Moreover&#44; their experience can serve other professionals interested in introducing a multidisciplinary strategy in their management of these patients&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">One of these units&#44; in which both a rheumatologist and a dermatologist see patients jointly and in collaboration&#44; recently reported their 4-year experience&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> During this period&#44; they received a total of 259 visits &#40;71&#37; first appointments&#41;&#46; Joint visits resulted in a change in diagnosis in 1 third of the patients&#44; and a therapeutic change in nearly half of those cases&#46; Aside from the aforementioned impact on care&#44; the introduction of this multidisciplinary model in patients with PsA led to an increase in the collaboration between the 2 specialties&#44; and has been exported to other Spanish hospitals&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Taking the above into account&#44; the objective of the NEXUS project&#44; which includes the work described in that first report&#44; was to promote and standardize multidisciplinary care in PsA patients being provided in Spain&#46; The work presented here constitutes the first objective of the NEXUS project and consists in depicting the different features of the multidisciplinary care model in this country&#44; as well as the barriers and facilitators involved in introducing it&#46; This could serve as a guideline for those professionals who would like to undertake multidisciplinary care in patients with PsA&#44; and for the subsequent development of quality standards and indicators&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study Design</span><p id="par0025" class="elsevierStylePara elsevierViewall">The study was designed to characterize the different multidisciplinary care units currently functioning in Spain&#44; including the barriers and facilitators associated with their introduction&#46; This work is part of the NEXUS project&#44; an undertaking with the participation of the Spondyloarthropathy Study Group of the Spanish Society of Rheumatology &#40;GRESSER&#41;&#44; the Spanish Group on Psoriatic Arthritis &#40;GEAPSO&#41; and the Spanish Academy of Dermatology and Venereology &#40;AEDV&#41;&#46; Their main objective is to produce quality standards and indicators for multidisciplinary care of the PsA patient&#46; This project was developed in different phases that included a meeting of a nominal group of experts&#44; a systematic literature review and&#44; ultimately&#44; structured telephone interviews&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Nominal Group Meeting and Literature Review</span><p id="par0030" class="elsevierStylePara elsevierViewall">In a nominal group meeting&#44; with a total of 24 professionals &#40;12 rheumatologists and 12 dermatologists who were involved in multidisciplinary care of PsA patients&#41;&#44; the subject was the different models&#44; and the variables that should be brought together to describe these models&#46; The participants were selected on the basis of their experience and interest in the topic being studied &#40;this included a Medline search to locate professionals with publications in this area&#44; who were asked about other professionals who might participate in the project&#41;&#46; In the selection&#44; the geographic representativeness was taken into account&#44; and the professionals had to come from both large hospitals and from smaller centers&#44; as well&#46; A literature search on models of multidisciplinary care in PsA was conducted&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Structured Telephone Interviews and Variables Gathered</span><p id="par0035" class="elsevierStylePara elsevierViewall">Using the information obtained in the literature review and in the nominal group meeting&#44; a specific outline was designed to collect data on the different models of multidisciplinary care provided in Spain&#46; Teleconferences enabled us to contact members of the multidisciplinary units and interview them &#40;jointly when possible&#41;&#46; We had sent a summary of the outline so that the interviewee could prepare the necessary data and responses&#46; The following variables were collected&#58; &#40;a&#41; related to the workplace&#44; including hospital level&#44; city&#44; reference population&#44; distribution of the population attended to &#40;&#37; urban&#44; &#37; rural&#41; and computer literacy&#59; &#40;b&#41; regarding the department&#44; such as the organizational structure &#40;unit&#44; service&#44; section&#41;&#44; PsA patient care &#40;hospital or ambulatory&#44; or both&#41;&#44; and the number of physicians on the staff&#59; &#40;c&#41; related to multidisciplinary care and the model employed&#44; including material resources &#40;office&#44; equipment&#44; etc&#46;&#41;&#44; human resources &#40;specialists&#44; nursing&#44; etc&#46;&#41;&#44; qualifications of the professionals &#40;training&#44; interest in those affected&#44; etc&#46;&#41;&#44; definition of objectives&#44; criteria for access and discharge &#40;document authorizing referral from or to another department&#44; a form on paper&#44; etc&#46;&#41;&#44; development of the agenda&#44; activity protocol &#40;diagnosis&#44; follow-up&#44; treatment&#41;&#44; the evaluation of the outcome &#40;recording clinical data&#44; administrative tasks&#44; costs&#44; of the unit itself&#44; etc&#46;&#41;&#44; defining responsibilities&#44; decision making&#44; research or teaching&#44; joint clinical meetings&#44; creation&#47;initiation &#40;evaluation of needs of the center&#47;health area and resources&#44; contacts among specialties&#44; hospital management&#44; information&#44; distribution to the different departments&#44; specific training&#41;&#44; strategies for introducing an innovative measure&#44; leadership&#44; planning&#44; service portfolio&#44; incentives&#44; diffusion beyond the rheumatology and dermatology setting&#44; advantages&#47;disadvantages of the models&#44; and barriers to&#47;facilitators of the introduction of models&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical Analysis</span><p id="par0040" class="elsevierStylePara elsevierViewall">We present a description of the different models of multidisciplinary care of PsA patients&#46; Given the nature of the study&#44; there was no comparative statistical analysis&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">We analyzed a total of 12 models of multidisciplinary care&#46; Jointly&#44; they can be classified as 3 different subtypes&#58; face-to-face &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#41;&#44; parallel &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41; and preferential circuit &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41;&#46; Most had been functioning for 1&#8211;2<span class="elsevierStyleHsp" style=""></span>years and the main objective of all of them was to improve the health care received by their patients&#46; More specifically&#44; the objectives were to achieve an early diagnosis of PsA&#44; the detection and management of complications of the disease&#44; as well as counseling in terms of treatment &#40;in patients with psoriasis as well as PsA&#41;&#46; They were always evaluated from a multidisciplinary approach and were studied in these units during the time considered necessary by those responsible for referring them&#46; Once the reason for their visit had been attended to&#44; they usually returned to their attending physician&#46; We wish to indicate that active and systematic data collection was carried out only to enable their correct utilization&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">With regard to hospitals&#44; these models are applied to level 3 or 4 centers&#44; with reference populations that ranged from nearly 150&#44;000 to almost 500&#44;000 inhabitants&#44; mostly corresponding to an urban population&#44; with a very high level of computer literacy&#46; The organizational and structural characteristics of the rheumatology and dermatology departments vary widely&#46;</p><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Multidisciplinary Care Models in Patients With Psoriatic Arthritis</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Face-to-face Approach</span><p id="par0055" class="elsevierStylePara elsevierViewall">In the model involving the face-to-face method &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; the 2 specialists are physically in the same office and attend to the patient during the same appointment&#46; The offices are in the department of rheumatology or in that of dermatology&#46; They all have the necessary equipment&#44; with the exception of an ultrasound scanner &#40;depending on the center&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">All of the offices have at least 1 permanent dermatologist and a permanent rheumatologist&#46; Some offices have more than 1 specialist&#44; and they take turns&#46; Each has a colleague to substitute for the permanent physician if the latter is going to miss a patient&#39;s appointment&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">There is no specific nurse assigned to the unit&#44; but access to members of the nursing staff is ensured&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Most have no explicit written objectives &#40;in the form of an agreement&#44; for example&#41;&#44; but they coincide in that the main aim is to improve the care provided to PsA patients&#44; in the attempt to make the health care system more efficient and enhance the relationship among specialists&#46; These units are mainly characterized as &#8220;one-stop&#8221;&#46; However&#44; the users include a growing number of complex patients who require a larger number of follow-up visits&#44; and some end up transferred to these offices&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Regarding the norms for the admission and discharge of patients&#44; they are controlled by the departments of rheumatology and dermatology&#44; who follow transfer criteria that are generally well-defined&#46; In most of the patients&#44; there are uncertainties concerning the diagnosis and&#47;or the therapeutic approach &#40;including safety&#41;&#46; In the majority of cases&#44; the transfer has involved the usual form &#40;on paper&#41;&#44; but not always&#46; The reason for seeing the patient may appear in the electronic medical record&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The patients return to their attending physicians once the motive has been attended to&#46; Depending on the patient and&#47;or center&#44; the patient may be referred with treatment recommendations and&#44; in other cases&#44; with the prescription of a new treatment&#44; for which the patient is being controlled&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Except in a few circumstances&#44; most of these units have had&#44; and continue to have&#44; problems with their agendas&#46; The admissions department does not allow the generation of a single agenda in which the activity simultaneously processes 2 different specialties&#46; Thus&#44; some centers have found diverse strategies to handle the situation&#46; Some have 2 agendas with different names &#40;1 for each specialty&#44; with different patients&#41;&#46; The patients from the other agenda are later included in the first &#40;as emergencies&#44; unforeseen&#44; etc&#46;&#41;&#46; Therefore&#44; all the patients attended to are processed as though they had been seen by both specialties&#46; The patients are scheduled for successive appointments &#40;first&#44; one from one agenda and&#44; a little later&#44; another patient from the other agenda&#41;&#46; In another center&#44; on an unspecified agenda of this activity in a department&#44; all of the patients will be scheduled in multidisciplinary visits&#46; This means that this has to be reviewed systematically to ensure that only those of the multidisciplinary unit are recorded&#46; Later&#44; the other specialist processes them in his or her department as emergencies&#44; unforeseen&#44; etc&#46; In another&#44; each year&#44; the activity is processed for 1 of the 2 departments&#46; Finally&#44; in 1 center&#44; the activity is processed as being from only 1 department&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The frequency of these visits is variable&#44; 1 or 2 appointment each month&#59; normally&#44; 1 each month&#46; The number of patients seen&#44; like the time devoted to each&#44; is variable&#44; from 20 to 40<span class="elsevierStyleHsp" style=""></span>min per patient&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">On the other hand&#44; all of the professionals follow the consensus and guideline recommendations&#44; both Spanish and international&#44; in addition to their acquired personal experience&#46; This is all adapted to the features of the health center or area&#46; Specific protocols for these units have not been designed&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In most cases&#44; a specific report is given to the patient&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Data collection is electronic in all the centers that provide joint multidisciplinary care&#46; There is wide variability in the data gathered and where&#8212;in the record&#8212;they are stored&#46; There are centers in which each department has a copy of the same record and&#47;or process&#44; and others in which they are filed among the documents corresponding to the department from which each patient is referred&#44; and still others in which another process is created for the other department&#46; On the other hand&#44; there are units that have a specific database apart from the medical report in which they store data &#40;mostly retrospective&#41; to evaluate the health outcomes of the measures taken&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Patients are seen by both specialists at each visit&#46; Depending on the reason for the appointment&#44; one specialist may have to attend to some other activity&#46; Both are responsible for attending to the patient&#44; including decision making&#46; There is no need to wait for a patient to visit to discuss any occurrence by phone&#44; e-mail&#44; etc&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">With the development of these joint multidisciplinary care units&#44; many professionals have decided to participate in research projects and hope to get involved in more &#40;if they can&#41;&#46; Moreover&#44; their knowledge and skills in the management of PsA have increased considerably&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In addition&#44; dermatology&#44; rheumatology and&#47;or family residents are rotating in many of these units&#46; In some&#44; there are even students&#46; However&#44; they do not usually hold joint clinical meetings&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In contrast to traditional care&#44; patients see 2 specialists on the same day&#44; which means it can be timesaving&#46; Moreover&#44; joint care can avoid the duplication of ancillary tests and prevent diagnostic or therapeutic delays&#46; These face-to-face encounters may be the model of choice &#40;if they can be adjusted to the characteristics and needs of the center and&#47;or those of the professionals&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Parallel Approach</span><p id="par0130" class="elsevierStylePara elsevierViewall">In these models &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; the dermatological and rheumatology visits are separate&#44; but physically are close together and the patients are attended to at the same time&#46; Patients go to one office and then to the other&#46; The specialists discuss the patients or can even see them jointly&#44; but only in cases in which a specialist considers it necessary&#46; Doubts are often resolved by phone&#46; The patients go to one appointment&#44; where they are seen by the specialist and the process is recorded&#44; and then they go to the other&#44; where the specialist can see what his or her companion has written&#46; With this exception&#44; everything described above for the face-to-face multidisciplinary model can be applied here&#46; The remainder of the characteristics are similar to the face-to-face approach&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">Although there is less time spent together&#44; to see how each professional works as occurs in the face-to-face appointments&#44; those taking part in these visits also comment that they learn a great deal about the other specialty&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Preferential Circuits</span><p id="par0140" class="elsevierStylePara elsevierViewall">In this model &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; each specialist continues in his or her usual office in the corresponding department&#44; with their customary agendas&#46; In visits of this type&#44; there is no interval or specific time allotted&#46; It is very much like the habitual clinical appointment and&#44; although it seems to be very different from the other 2 models&#44; many of the aspects commented above also apply here&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">The major difference with regard to usual clinical practice is that the 2 specialists are qualified&#44; trained in PsA&#44; with their referral criteria&#44; and can schedule a rapid multidisciplinary appointment or other undertaking&#44; at any time&#44; or whenever necessary and effective&#46; Each specialist remains in his or her usual office&#44; but will be able to find time if the other specialist&#44; when it arises&#44; studies a patient who could be amenable and decides to arrange for his or her referral&#46; These patients should be seen that same day or in a maximum of 48<span class="elsevierStyleHsp" style=""></span>h&#46; There are certain patients&#44; very complex patients&#44; for example&#44; that can be seen jointly&#46; Although this occurs&#44; it is an exception&#46; This functions&#44; as we say&#44; in a more independent way&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">As in the parallel visits&#44; the telephone also helps to resolve doubts that arise or to discuss patients&#44; always following pre-established criteria&#46; As in the other approaches&#44; the participants in these models make it clear that each has learned a lot from the other&#46;</p></span></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Experience in Introducing Models of Multidisciplinary Care</span><p id="par0155" class="elsevierStylePara elsevierViewall">There is certain variability in the training requirements when establishing multidisciplinary models&#46; In some centers the interest and experience in treating PsA patients was sufficient&#46; In others&#44; it was necessary to set up some type of previous training&#44; including a rotation in the other department in the multidisciplinary care project&#46; All of those interviewed coincided in that it is essential that those participating get along well&#44; as is the need to measure these models for multidisciplinary care in terms of health &#40;not of activity&#41;&#46; This is one of the present challenges to these models&#59; that the data that has to be systematically gathered to evaluate the outcomes of these approaches&#44; must be expressed in terms of health&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">When it comes time to introducing a multidisciplinary care model&#44; those interviewed refer to the good planning of the entire process and recommended following a series of steps &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; One of the major barriers mentioned with regard to establishing these units is the organization of the agenda&#47;s&#44; which should be decided before beginning&#46; In principal&#44; the model should be evaluated every 3&#8211;6 months and the necessary adjustments should be made over time &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; this during approximately the first 2 years&#46; From the start&#44; and especially after that period&#44; it is important to have a strategic plan that must be evaluated&#44; as well as others that must be undertaken when the first are accomplished&#44; and there has to be a plan for improving the model on the basis of errors&#44; events&#44; etc&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0165" class="elsevierStylePara elsevierViewall">In this article&#44; we have described 3 different types of multidisciplinary care for PsA patients&#44; as well as the experience of introducing them&#46; Although they may differ in structure and organization&#44; they are all focused on providing better care to those patients&#44; as well as to improve the efficiency of the health care system&#46; Moreover&#44; they have promoted collaboration between specialties&#46; At the present time&#44; they are recommended for the care of patients with PsA&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">There are previous experiences reported on multidisciplinary care in PsA&#46; One involves the a model of face-to-face multidisciplinary care in the United States&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">12&#44;13</span></a> After 6 years it was established that&#44; in this modality&#8212;and in comparison with the previous traditional system &#40;in which each specialist attends to a patient independently&#41;&#44; more diagnoses were reviewed&#44; facilitating the detection and confirmation of arthritis&#46; Likewise&#44; more systemic treatments were prescribed&#44; including biologic therapies&#46; On the other hand&#44; a report presented at a meeting shows that a face-to-face multidisciplinary unit in the United Kingdom achieved high levels of satisfaction on the part of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> However&#44; more data are necessary to determine whether these multidisciplinary units&#44; in comparison with the usual clinical approach&#44; improve the course and outcome of these patients&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">In Spain&#44; data have also been published on a unit that follows a similar model of care&#44; although it is functioning with existing resources&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> In this clinic&#44; there was an improvement in patient management of those who had problems involving the diagnosis or disease control&#46; There has also been an increase in the early diagnosis of arthritis&#44; which has made it possible to initiate early treatment&#46; Moreover&#44; since the unit was introduced&#44; collaboration between the specialties of rheumatology and dermatology has increased and the model has also been exported to other hospitals&#46; This is one of the models analyzed and described in the present article&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">This face-to-face multidisciplinary model has been found to be ideal on the part of professionals&#46; It offers the possibility of standardizing the patient visit&#44; gathering and analyzing its activity and&#44; using a very special approach&#44; reinforce the collaboration between the 2 specialties with the creation of referral criteria and protocols for patient management accorded by consensus&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">There is also a work published in an international congress that refers to the 2-year experience in a parallel approach in Spain&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> In this model &#40;included in this study&#41;&#44; each patient is seen first by 1 specialist and&#44; subsequently&#44; by the other&#46; After 3 years of follow-up&#44; among other things&#44; it has been found that the treatment has been modified in more than half of the patients&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">A possible advantage to the parallel model over the face-to-face model is that not all of the patients require that the 2 specialists see them in depth&#46; A patient expresses his or her doubts on arrival&#44; and the necessary decisions are then considered&#46; The other specialist can then pose any questions very rapidly&#46; This can save time&#44; would enable a larger number of patients to be seen&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Finally&#44; we have found a third type of multidisciplinary care&#44; which is the preferential circuit&#46; This model is more similar to usual clinical care&#44; although&#44; it must be remembered that there is a very close collaboration among specialists and the possibility that the patient be evaluated by the 2 specialists the same day&#44; in accordance with the protocols and arrangements in this respect&#46; This model could be proposed in smaller centers&#44; with fewer resources&#44; or as a form of multidisciplinary care prior to the establishment of 1 of the models described above&#46; In principal&#44; this approach would be easier to introduce&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Regardless of what has been portrayed here&#44; there is no doubt that the election of one model or another will depend on the needs of the center&#47;health area&#44; of the departments and professionals&#44; as well as the available resources&#46; As we mentioned earlier&#44; this can start with a strategy that is easier to establish&#44; like the preferential circuit&#44; and another may be adopted later on&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">On the other hand&#44; regarding its introduction&#44; good planning of the process can help enormously in the success of the undertaking&#46; In this respect&#44; it is essential that the participants in the multidisciplinary clinics be interested in the subject and that they get along well&#46; Moreover&#44; it is necessary that questions concerning agendas be accorded prior to beginning to introduce any of these models&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Finally&#44; although at the present time&#44; we need more data on the efficacy of these multidisciplinary care models&#46; It seems clear that we can improve the management of patients with psoriasis or PsA&#44; despite diagnostic uncertainties or questions on the treatment&#44; as well as the results of the health care system&#46; All this can be done&#44; as we also promote collaboration among different medical specialties&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Ethical Disclosures</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Protection of human and animal subjects</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Confidentiality of data</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Right to privacy and informed consent</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Funding</span><p id="par0230" class="elsevierStylePara elsevierViewall">This project was funded by the Spanish Rheumatology Foundation&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflicts of Interest</span><p id="par0235" class="elsevierStylePara elsevierViewall">Jos&#233; Carlos Ruiz Carrascosa has received fees for conferences and for trials promoted by Abbvie&#44; Pfizer&#44; Novartis&#44; MSD and Janssen&#46; Conrad Pujol has received grants and fees related to research&#44; as a consultant&#44; and for training in the following companies&#58; Abbvie&#44; Janssen&#44; LEO&#44; MSD&#44; Novartis and Pfizer&#46; Raquel Rivera has participated in clinical trials&#44; and worked as a consultant and a speaker for Abbvie&#44; Celgene&#44; Janssen&#44; Leo-Pharma&#44; Lilly&#44; MSD&#44; Novartis&#44; Pfizer and Novartis&#46; The remaining participants declare they have no conflicts of interest&#46;</p></span></span>"
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              "titulo" => "Multidisciplinary Care Models in Patients With Psoriatic Arthritis"
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                  "titulo" => "Face-to-face Approach"
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              "titulo" => "Experience in Introducing Models of Multidisciplinary Care"
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    "fechaAceptado" => "2016-03-03"
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          "clase" => "keyword"
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            0 => "Psoriatic arthritis"
            1 => "Psoriasis"
            2 => "Multidisciplinary care"
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          "clase" => "keyword"
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            0 => "Artritis psori&#225;sica"
            1 => "Psoriasis"
            2 => "Atenci&#243;n multidisciplinar"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetive</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To describe &#40;structure&#44; processes&#41; of the multidisciplinary care models in psoriatic arthritis &#40;PsA&#41; in Spain&#44; as well as barriers and facilitators of their implementation&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A qualitative study was performed following structured interviews with 24 professionals &#40;12 rheumatologists&#44; 12 dermatologists who provide multidisciplinary care for patients with PsA&#41;&#46; We collected data related to the hospital&#44; department&#44; population and multidisciplinary care model &#40;type&#44; physical and human resources&#44; professional requirements&#44; objectives&#44; referral criteria&#44; agendas&#44; protocols&#44; responsibilities&#44; decision-making&#44; research and education&#44; clinical sessions&#44; development and planning of the model&#44; advantages and disadvantages of the model&#44; barriers and facilitators in the implementation of the model&#41;&#46; The models characteristics are described&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We analyzed 12 multidisciplinary care models in PsA&#44; with at least 1&#8211;2 years of experience&#44; and 3 subtypes of models&#44; face-to-face&#44; parallel&#44; and preferential circuit&#46; All are adapted to the hospital and professionals characteristics&#46; A proper implementation planning is essential&#46; The involvement and empathy between professionals and an access and well-defined referral criteria are important facilitators in the implementation of a model&#46; The management of agendas and data collection to measure the multidisciplinary care models health outcomes are the main barriers&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">There are different multidisciplinary care models in PsA that can improve patient outcomes&#44; system efficiency and collaboration between specialists&#46;</p></span>"
        "secciones" => array:4 [
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          2 => array:2 [
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Describir la estructura y procesos de distintos modelos de atenci&#243;n multidisciplinar de pacientes con artritis psori&#225;sica &#40;APs&#41; en Espa&#241;a&#44; as&#237; como las barreras y facilitadores en su implantaci&#243;n&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio cualitativo mediante entrevistas estructuradas a 24 profesionales &#40;12 reumat&#243;logos y 12 dermat&#243;logos que realizan atenci&#243;n multidisciplinar en pacientes con APs&#41;&#46; Se recogieron datos relacionados con el centro&#44; servicio&#44; poblaci&#243;n atendida y sobre el modelo de atenci&#243;n multidisciplinar &#40;tipo&#44; recursos materiales y humanos&#44; requerimientos de los profesionales&#44; objetivos&#44; criterios de entrada y salida&#44; agendas&#44; protocolos de actuaci&#243;n&#44; responsabilidades&#44; toma de decisiones&#44; actividad investigadora y docente&#44; sesiones cl&#237;nicas conjuntas&#44; creaci&#243;n&#47;inicio&#44; planificaci&#243;n&#44; ventajas&#47;desventajas del modelo y barreras&#47;facilitadores en la implantaci&#243;n del modelo&#46; Se describen sus caracter&#237;sticas&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Analizamos 12 modelos de atenci&#243;n multidisciplinar en APs&#44; implantados desde hace al menos 1-2<span class="elsevierStyleHsp" style=""></span>a&#241;os&#44; que globalmente pueden resumirse en 3 subtipos diferentes&#58; presencial conjunto&#44; presencial paralelo y circuito preferencial&#46; La implantaci&#243;n de uno u otro modelo es consecuencia de la adaptaci&#243;n a las circunstancias del centro y profesionales&#46; Una correcta planificaci&#243;n de la implantaci&#243;n es fundamental&#46; La implicaci&#243;n y buena sinton&#237;a entre profesionales as&#237; como un acceso y criterios de derivaci&#243;n bien definidos son facilitadores muy importantes en la implantaci&#243;n de un modelo&#46; La gesti&#243;n de las agendas y la recogida de datos para medir resultados de salud de estos modelos son las principales barreras&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Existen distintos modelos de atenci&#243;n multidisciplinar implantados que tienen como objetivo intentar mejorar la atenci&#243;n del paciente con APs&#44; la eficiencia del sistema y la colaboraci&#243;n entre especialistas&#46;</p></span>"
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      0 => array:2 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Preintroduction steps&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">1&#46; Look for 2 involved specialists&#44; with experience and interest&#44; and who get along well</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">2&#46; Communication between directors or others responsible for the department to get their approval</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">3&#46; If necessary&#44; present the proposal to the management and&#47;or medical direction</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">4&#46; Define collectively&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Type of model that best fits the circumstances of the center&#47;professionals</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Criteria for patient access and discharge</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Intervals between visits and no&#46; patients&#47;visit &#40;joint models&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; How and which days to communicate by phone&#44; e-mail&#44; in person</span>&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Location for multidisciplinary visits &#40;joint models&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Necessary materials &#40;computer&#44; chairs</span>&#44; etc&#46;<span class="elsevierStyleItalic">&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; If necessary&#58; protocols&#44; guidelines</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Level of responsibility&#47;implication in patient follow-up and treatment&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Decide whether to recommend or to directly change therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Should biologic therapy be indicated&#44; establish a criteria as to who has to calculate the prescription&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Planned objectives</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Recording and evaluation of the activity &#40;what&#44; who&#44; when</span>&#44; etc&#46;<span class="elsevierStyleItalic">&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Measures &#40;activity of the visit&#44; activity and damage due to PsA&#44; quality of life&#46;</span> etc&#46;<span class="elsevierStyleItalic">&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">5&#46; Prepare the logistics of the agenda</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; <span class="elsevierStyleItalic">Attempt to prepare a single agenda with the activities of both departments</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">6&#46; Present the project to the 2 departments</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">General Steps to Follow in the Introduction of a Multidisciplinary Care Model for Patients With Psoriatic Arthritis &#40;PsA&#41;&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Steps during establishment &#40;first 2 years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">1&#46; Look for efficient formulas to expedite the visits</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">2&#46; One report to the patient and another to the attending physician &#40;can be different&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">3&#46; Evaluate the multidisciplinary visit and make adjustments&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Once started&#44; evaluate every 3&#8211;6 months&#44; making necessary adjustments&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- On the agenda&#44; changes in intervals and&#47;or no&#46; of patients per visit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Remind departments of the service and the referral criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Implicate&#44; train nursing staff&#47;nursing assistant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Define more specifically the attitude to adopt with certain types of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Need of adjustments in the electronic medical record&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- In the case of data collection&#44; determine if it takes too much time&#44; if it is feasible&#44; if variables have to be modified&#44; reduce the number to be collected&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; At the end of one year&#44; evaluation of the specific objectives proposed</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Postestablishment steps &#40;after the first 2 years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">1&#46; Evaluation of the unit and its objectives</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Should be performed every 1 or 2 years</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Analysis of anything that is not going well&#44; events&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- If some objective has not been accomplished&#44; examine why&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- This will help to design an improvement plan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">2&#46; Together with the improvement plan&#44; new objectives can be proposed&#46; In addition to the clinical objectives&#44; others related to the investigation and&#47;or teaching can be assessed</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">3&#46; Once consolidated&#44; it can be seen whether the unit meets the quality standards put forward in NEXUS</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">4&#46; Likewise&#44; the introduction of the quality indicators also generated in NEXUS can be considered</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">General Steps to Follow During Establishment &#40;First 2 Years&#41; and After That Period&#44; From a Multidisciplinary Care Model&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:15 [
            0 => array:3 [
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              "etiqueta" => "1"
              "referencia" => array:1 [
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                      "titulo" => "Psoriatic arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            1 => "V&#46; Wright"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4581554"
                            "web" => "Medline"
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            1 => array:3 [
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              "etiqueta" => "2"
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                      "titulo" => "Psoriasis and arthritis"
                      "autores" => array:1 [
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                          "etal" => false
                          "autores" => array:1 [
                            0 => "A&#46; Cats"
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                  "contribucion" => array:1 [
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                      "titulo" => "Psoriatic arthritis &#40;PA&#41;&#58; a clinical&#44; immunological and radiological study of 180 patients"
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                            0 => "J&#46;C&#46; Torre Alonso"
                            1 => "A&#46; Rodriguez Perez"
                            2 => "J&#46;M&#46; Arribas Castrillo"
                            3 => "J&#46; Ballina Garcia"
                            4 => "J&#46;L&#46; Riestra Noriega"
                            5 => "C&#46; Lopez Larrea"
                          ]
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                  ]
                  "host" => array:1 [
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                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Rheumatol"
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            3 => array:3 [
              "identificador" => "bib0095"
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Global epidemiology of psoriasis&#58; a systematic review of incidence and prevalence"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "Identification and Management of Psoriasis and Associated Comorbidity &#40;IMPACT&#41; project team"
                          "etal" => false
                          "autores" => array:4 [
                            0 => "R&#46; Parisi"
                            1 => "D&#46;P&#46; Symmons"
                            2 => "C&#46;E&#46; Griffiths"
                            3 => "D&#46;M&#46; Ashcroft"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/jid.2012.339"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Invest Dermatol"
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Original Article
Multidisciplinary Care Models for Patients With Psoriatic Arthritis
Modelos de atención multidisciplinar en pacientes con artritis psoriásica en España
Rubén Queiroa,
Corresponding author
rubenque7@yahoo.es

Corresponding author.
, Pablo Cotob, Jesús Rodríguezc, Jaume Notariod, Teresa Navío Marcoe, Pablo de la Cuevaf, Manel Pujol Busquetsg, Mercè García Fonth, Beatriz Joveni, Raquel Riveraj, Jose Luis Alvarez Vegak, Antonio Javier Chaves Álvarezl, Ricardo Sánchez Pareram, Jose Carlos Ruiz Carrascosan, Fernando José Rodríguez Martínezo, José Pardo Sánchezp, Carlos Feced Olmosq, Conrad Pujolr, Eva Galindezs, Silvia Pérez Barriot..., Ana Urruticoechea Aranau, Mercedes Herguetav, Jesús Luelmow, Jordi GratacósxVer más
a Servicio de Reumatología, Hospital Universitario Central de Asturias, Oviedo, Spain
b Servicio de Dermatología, Hospital Universitario Central de Asturias, Oviedo, Spain
c Servicio de Reumatología, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
d Servicio de Dermatología, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
e Servicio de Reumatología, Hospital Universitario Infanta Leonor, Madrid, Spain
f Servicio de Dermatología, Hospital Universitario Infanta Leonor, Madrid, Spain
g Servicio de Reumatología, Hospital Mutua de Terrassa, Terrassa, Barcelona, Spain
h Servicio de Dermatología, Hospital Mutua de Terrassa, Terrassa, Barcelona, Spain
i Servicio de Reumatología, Hospital Universitario 12 de Octubre, Madrid, Spain
j Servicio de Dermatología, Hospital Universitario 12 de Octubre, Madrid, Spain
k Servicio de Reumatología, Complejo Hospitalario Universitario Infanta Cristina, Badajoz, Spain
l Servicio de Dermatología, Complejo Hospitalario Universitario Infanta Cristina, Badajoz, Spain
m Servicio de Reumatología, Hospital Universitario San Cecilio, Granada, Spain
n Servicio de Dermatología, Hospital Universitario San Cecilio, Granada, Spain
o Servicio de Reumatología, Hospital General Universitario Santa Lucía, Cartagena, Murcia, Spain
p Servicio de Dermatología, Hospital General Universitario Santa Lucía, Cartagena, Murcia, Spain
q Servicio de Reumatología, Hospital Universitari i Politècnic La Fe, Valencia, Spain
r Servicio de Dermatología, Hospital Universitari i Politècnic La Fe, Valencia, Spain
s Servicio de Reumatología, Hospital de Basurto, Bilbao, Bizkaia, Spain
t Servicio de Dermatología, Hospital de Basurto, Bilbao, Bizkaia, Spain
u Servicio de Reumatología, Hospital Can Misses, Ibiza, Spain
v Servicio de Dermatología, Hospital Can Misses, Ibiza, Spain
w Servicio de Dermatología, Corporació Sanitària Parc Taulí de Sabadell, Sabadell, Barcelona, Spain
x Servicio de Reumatología, Corporació Sanitària Parc Taulí de Sabadell, Sabadell, Barcelona, Spain
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        "titulo" => "Modelos de atenci&#243;n multidisciplinar en pacientes con artritis psori&#225;sica en Espa&#241;a"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Psoriatic arthritis &#40;PsA&#41; is a potentially severe&#44; chronic&#44; progressive&#44; multiorgan disease&#46; Patients should be properly and indefinitely evaluated from the first visit&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#8211;4</span></a> Many of them are studied by dermatologists and rheumatologists separately&#44; meaning that the care process may not be optimal from a clinical perspective&#44; and is not ideal for the patient&#44; or even for the system&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5&#8211;7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">On the other hand&#44; the 2012 recommendations of the European League Against Rheumatism &#40;EULAR&#41; propose a multidisciplinary approach in PsA&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> as do expert groups and patients&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> Thus&#44; in recent years&#44; dermatologists and rheumatologists have teamed together to introduce multidisciplinary units to treat PsA patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">10&#44;11</span></a> Now that they have been established&#44; it is essential that their activity be evaluated to demonstrate their efficacy and pinpoint areas for improvement&#46; Moreover&#44; their experience can serve other professionals interested in introducing a multidisciplinary strategy in their management of these patients&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">One of these units&#44; in which both a rheumatologist and a dermatologist see patients jointly and in collaboration&#44; recently reported their 4-year experience&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> During this period&#44; they received a total of 259 visits &#40;71&#37; first appointments&#41;&#46; Joint visits resulted in a change in diagnosis in 1 third of the patients&#44; and a therapeutic change in nearly half of those cases&#46; Aside from the aforementioned impact on care&#44; the introduction of this multidisciplinary model in patients with PsA led to an increase in the collaboration between the 2 specialties&#44; and has been exported to other Spanish hospitals&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Taking the above into account&#44; the objective of the NEXUS project&#44; which includes the work described in that first report&#44; was to promote and standardize multidisciplinary care in PsA patients being provided in Spain&#46; The work presented here constitutes the first objective of the NEXUS project and consists in depicting the different features of the multidisciplinary care model in this country&#44; as well as the barriers and facilitators involved in introducing it&#46; This could serve as a guideline for those professionals who would like to undertake multidisciplinary care in patients with PsA&#44; and for the subsequent development of quality standards and indicators&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study Design</span><p id="par0025" class="elsevierStylePara elsevierViewall">The study was designed to characterize the different multidisciplinary care units currently functioning in Spain&#44; including the barriers and facilitators associated with their introduction&#46; This work is part of the NEXUS project&#44; an undertaking with the participation of the Spondyloarthropathy Study Group of the Spanish Society of Rheumatology &#40;GRESSER&#41;&#44; the Spanish Group on Psoriatic Arthritis &#40;GEAPSO&#41; and the Spanish Academy of Dermatology and Venereology &#40;AEDV&#41;&#46; Their main objective is to produce quality standards and indicators for multidisciplinary care of the PsA patient&#46; This project was developed in different phases that included a meeting of a nominal group of experts&#44; a systematic literature review and&#44; ultimately&#44; structured telephone interviews&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Nominal Group Meeting and Literature Review</span><p id="par0030" class="elsevierStylePara elsevierViewall">In a nominal group meeting&#44; with a total of 24 professionals &#40;12 rheumatologists and 12 dermatologists who were involved in multidisciplinary care of PsA patients&#41;&#44; the subject was the different models&#44; and the variables that should be brought together to describe these models&#46; The participants were selected on the basis of their experience and interest in the topic being studied &#40;this included a Medline search to locate professionals with publications in this area&#44; who were asked about other professionals who might participate in the project&#41;&#46; In the selection&#44; the geographic representativeness was taken into account&#44; and the professionals had to come from both large hospitals and from smaller centers&#44; as well&#46; A literature search on models of multidisciplinary care in PsA was conducted&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Structured Telephone Interviews and Variables Gathered</span><p id="par0035" class="elsevierStylePara elsevierViewall">Using the information obtained in the literature review and in the nominal group meeting&#44; a specific outline was designed to collect data on the different models of multidisciplinary care provided in Spain&#46; Teleconferences enabled us to contact members of the multidisciplinary units and interview them &#40;jointly when possible&#41;&#46; We had sent a summary of the outline so that the interviewee could prepare the necessary data and responses&#46; The following variables were collected&#58; &#40;a&#41; related to the workplace&#44; including hospital level&#44; city&#44; reference population&#44; distribution of the population attended to &#40;&#37; urban&#44; &#37; rural&#41; and computer literacy&#59; &#40;b&#41; regarding the department&#44; such as the organizational structure &#40;unit&#44; service&#44; section&#41;&#44; PsA patient care &#40;hospital or ambulatory&#44; or both&#41;&#44; and the number of physicians on the staff&#59; &#40;c&#41; related to multidisciplinary care and the model employed&#44; including material resources &#40;office&#44; equipment&#44; etc&#46;&#41;&#44; human resources &#40;specialists&#44; nursing&#44; etc&#46;&#41;&#44; qualifications of the professionals &#40;training&#44; interest in those affected&#44; etc&#46;&#41;&#44; definition of objectives&#44; criteria for access and discharge &#40;document authorizing referral from or to another department&#44; a form on paper&#44; etc&#46;&#41;&#44; development of the agenda&#44; activity protocol &#40;diagnosis&#44; follow-up&#44; treatment&#41;&#44; the evaluation of the outcome &#40;recording clinical data&#44; administrative tasks&#44; costs&#44; of the unit itself&#44; etc&#46;&#41;&#44; defining responsibilities&#44; decision making&#44; research or teaching&#44; joint clinical meetings&#44; creation&#47;initiation &#40;evaluation of needs of the center&#47;health area and resources&#44; contacts among specialties&#44; hospital management&#44; information&#44; distribution to the different departments&#44; specific training&#41;&#44; strategies for introducing an innovative measure&#44; leadership&#44; planning&#44; service portfolio&#44; incentives&#44; diffusion beyond the rheumatology and dermatology setting&#44; advantages&#47;disadvantages of the models&#44; and barriers to&#47;facilitators of the introduction of models&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical Analysis</span><p id="par0040" class="elsevierStylePara elsevierViewall">We present a description of the different models of multidisciplinary care of PsA patients&#46; Given the nature of the study&#44; there was no comparative statistical analysis&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">We analyzed a total of 12 models of multidisciplinary care&#46; Jointly&#44; they can be classified as 3 different subtypes&#58; face-to-face &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#41;&#44; parallel &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41; and preferential circuit &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41;&#46; Most had been functioning for 1&#8211;2<span class="elsevierStyleHsp" style=""></span>years and the main objective of all of them was to improve the health care received by their patients&#46; More specifically&#44; the objectives were to achieve an early diagnosis of PsA&#44; the detection and management of complications of the disease&#44; as well as counseling in terms of treatment &#40;in patients with psoriasis as well as PsA&#41;&#46; They were always evaluated from a multidisciplinary approach and were studied in these units during the time considered necessary by those responsible for referring them&#46; Once the reason for their visit had been attended to&#44; they usually returned to their attending physician&#46; We wish to indicate that active and systematic data collection was carried out only to enable their correct utilization&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">With regard to hospitals&#44; these models are applied to level 3 or 4 centers&#44; with reference populations that ranged from nearly 150&#44;000 to almost 500&#44;000 inhabitants&#44; mostly corresponding to an urban population&#44; with a very high level of computer literacy&#46; The organizational and structural characteristics of the rheumatology and dermatology departments vary widely&#46;</p><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Multidisciplinary Care Models in Patients With Psoriatic Arthritis</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Face-to-face Approach</span><p id="par0055" class="elsevierStylePara elsevierViewall">In the model involving the face-to-face method &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; the 2 specialists are physically in the same office and attend to the patient during the same appointment&#46; The offices are in the department of rheumatology or in that of dermatology&#46; They all have the necessary equipment&#44; with the exception of an ultrasound scanner &#40;depending on the center&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">All of the offices have at least 1 permanent dermatologist and a permanent rheumatologist&#46; Some offices have more than 1 specialist&#44; and they take turns&#46; Each has a colleague to substitute for the permanent physician if the latter is going to miss a patient&#39;s appointment&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">There is no specific nurse assigned to the unit&#44; but access to members of the nursing staff is ensured&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Most have no explicit written objectives &#40;in the form of an agreement&#44; for example&#41;&#44; but they coincide in that the main aim is to improve the care provided to PsA patients&#44; in the attempt to make the health care system more efficient and enhance the relationship among specialists&#46; These units are mainly characterized as &#8220;one-stop&#8221;&#46; However&#44; the users include a growing number of complex patients who require a larger number of follow-up visits&#44; and some end up transferred to these offices&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Regarding the norms for the admission and discharge of patients&#44; they are controlled by the departments of rheumatology and dermatology&#44; who follow transfer criteria that are generally well-defined&#46; In most of the patients&#44; there are uncertainties concerning the diagnosis and&#47;or the therapeutic approach &#40;including safety&#41;&#46; In the majority of cases&#44; the transfer has involved the usual form &#40;on paper&#41;&#44; but not always&#46; The reason for seeing the patient may appear in the electronic medical record&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The patients return to their attending physicians once the motive has been attended to&#46; Depending on the patient and&#47;or center&#44; the patient may be referred with treatment recommendations and&#44; in other cases&#44; with the prescription of a new treatment&#44; for which the patient is being controlled&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Except in a few circumstances&#44; most of these units have had&#44; and continue to have&#44; problems with their agendas&#46; The admissions department does not allow the generation of a single agenda in which the activity simultaneously processes 2 different specialties&#46; Thus&#44; some centers have found diverse strategies to handle the situation&#46; Some have 2 agendas with different names &#40;1 for each specialty&#44; with different patients&#41;&#46; The patients from the other agenda are later included in the first &#40;as emergencies&#44; unforeseen&#44; etc&#46;&#41;&#46; Therefore&#44; all the patients attended to are processed as though they had been seen by both specialties&#46; The patients are scheduled for successive appointments &#40;first&#44; one from one agenda and&#44; a little later&#44; another patient from the other agenda&#41;&#46; In another center&#44; on an unspecified agenda of this activity in a department&#44; all of the patients will be scheduled in multidisciplinary visits&#46; This means that this has to be reviewed systematically to ensure that only those of the multidisciplinary unit are recorded&#46; Later&#44; the other specialist processes them in his or her department as emergencies&#44; unforeseen&#44; etc&#46; In another&#44; each year&#44; the activity is processed for 1 of the 2 departments&#46; Finally&#44; in 1 center&#44; the activity is processed as being from only 1 department&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The frequency of these visits is variable&#44; 1 or 2 appointment each month&#59; normally&#44; 1 each month&#46; The number of patients seen&#44; like the time devoted to each&#44; is variable&#44; from 20 to 40<span class="elsevierStyleHsp" style=""></span>min per patient&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">On the other hand&#44; all of the professionals follow the consensus and guideline recommendations&#44; both Spanish and international&#44; in addition to their acquired personal experience&#46; This is all adapted to the features of the health center or area&#46; Specific protocols for these units have not been designed&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In most cases&#44; a specific report is given to the patient&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Data collection is electronic in all the centers that provide joint multidisciplinary care&#46; There is wide variability in the data gathered and where&#8212;in the record&#8212;they are stored&#46; There are centers in which each department has a copy of the same record and&#47;or process&#44; and others in which they are filed among the documents corresponding to the department from which each patient is referred&#44; and still others in which another process is created for the other department&#46; On the other hand&#44; there are units that have a specific database apart from the medical report in which they store data &#40;mostly retrospective&#41; to evaluate the health outcomes of the measures taken&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Patients are seen by both specialists at each visit&#46; Depending on the reason for the appointment&#44; one specialist may have to attend to some other activity&#46; Both are responsible for attending to the patient&#44; including decision making&#46; There is no need to wait for a patient to visit to discuss any occurrence by phone&#44; e-mail&#44; etc&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">With the development of these joint multidisciplinary care units&#44; many professionals have decided to participate in research projects and hope to get involved in more &#40;if they can&#41;&#46; Moreover&#44; their knowledge and skills in the management of PsA have increased considerably&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In addition&#44; dermatology&#44; rheumatology and&#47;or family residents are rotating in many of these units&#46; In some&#44; there are even students&#46; However&#44; they do not usually hold joint clinical meetings&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In contrast to traditional care&#44; patients see 2 specialists on the same day&#44; which means it can be timesaving&#46; Moreover&#44; joint care can avoid the duplication of ancillary tests and prevent diagnostic or therapeutic delays&#46; These face-to-face encounters may be the model of choice &#40;if they can be adjusted to the characteristics and needs of the center and&#47;or those of the professionals&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Parallel Approach</span><p id="par0130" class="elsevierStylePara elsevierViewall">In these models &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; the dermatological and rheumatology visits are separate&#44; but physically are close together and the patients are attended to at the same time&#46; Patients go to one office and then to the other&#46; The specialists discuss the patients or can even see them jointly&#44; but only in cases in which a specialist considers it necessary&#46; Doubts are often resolved by phone&#46; The patients go to one appointment&#44; where they are seen by the specialist and the process is recorded&#44; and then they go to the other&#44; where the specialist can see what his or her companion has written&#46; With this exception&#44; everything described above for the face-to-face multidisciplinary model can be applied here&#46; The remainder of the characteristics are similar to the face-to-face approach&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">Although there is less time spent together&#44; to see how each professional works as occurs in the face-to-face appointments&#44; those taking part in these visits also comment that they learn a great deal about the other specialty&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Preferential Circuits</span><p id="par0140" class="elsevierStylePara elsevierViewall">In this model &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; each specialist continues in his or her usual office in the corresponding department&#44; with their customary agendas&#46; In visits of this type&#44; there is no interval or specific time allotted&#46; It is very much like the habitual clinical appointment and&#44; although it seems to be very different from the other 2 models&#44; many of the aspects commented above also apply here&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">The major difference with regard to usual clinical practice is that the 2 specialists are qualified&#44; trained in PsA&#44; with their referral criteria&#44; and can schedule a rapid multidisciplinary appointment or other undertaking&#44; at any time&#44; or whenever necessary and effective&#46; Each specialist remains in his or her usual office&#44; but will be able to find time if the other specialist&#44; when it arises&#44; studies a patient who could be amenable and decides to arrange for his or her referral&#46; These patients should be seen that same day or in a maximum of 48<span class="elsevierStyleHsp" style=""></span>h&#46; There are certain patients&#44; very complex patients&#44; for example&#44; that can be seen jointly&#46; Although this occurs&#44; it is an exception&#46; This functions&#44; as we say&#44; in a more independent way&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">As in the parallel visits&#44; the telephone also helps to resolve doubts that arise or to discuss patients&#44; always following pre-established criteria&#46; As in the other approaches&#44; the participants in these models make it clear that each has learned a lot from the other&#46;</p></span></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Experience in Introducing Models of Multidisciplinary Care</span><p id="par0155" class="elsevierStylePara elsevierViewall">There is certain variability in the training requirements when establishing multidisciplinary models&#46; In some centers the interest and experience in treating PsA patients was sufficient&#46; In others&#44; it was necessary to set up some type of previous training&#44; including a rotation in the other department in the multidisciplinary care project&#46; All of those interviewed coincided in that it is essential that those participating get along well&#44; as is the need to measure these models for multidisciplinary care in terms of health &#40;not of activity&#41;&#46; This is one of the present challenges to these models&#59; that the data that has to be systematically gathered to evaluate the outcomes of these approaches&#44; must be expressed in terms of health&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">When it comes time to introducing a multidisciplinary care model&#44; those interviewed refer to the good planning of the entire process and recommended following a series of steps &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; One of the major barriers mentioned with regard to establishing these units is the organization of the agenda&#47;s&#44; which should be decided before beginning&#46; In principal&#44; the model should be evaluated every 3&#8211;6 months and the necessary adjustments should be made over time &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; this during approximately the first 2 years&#46; From the start&#44; and especially after that period&#44; it is important to have a strategic plan that must be evaluated&#44; as well as others that must be undertaken when the first are accomplished&#44; and there has to be a plan for improving the model on the basis of errors&#44; events&#44; etc&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0165" class="elsevierStylePara elsevierViewall">In this article&#44; we have described 3 different types of multidisciplinary care for PsA patients&#44; as well as the experience of introducing them&#46; Although they may differ in structure and organization&#44; they are all focused on providing better care to those patients&#44; as well as to improve the efficiency of the health care system&#46; Moreover&#44; they have promoted collaboration between specialties&#46; At the present time&#44; they are recommended for the care of patients with PsA&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">There are previous experiences reported on multidisciplinary care in PsA&#46; One involves the a model of face-to-face multidisciplinary care in the United States&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">12&#44;13</span></a> After 6 years it was established that&#44; in this modality&#8212;and in comparison with the previous traditional system &#40;in which each specialist attends to a patient independently&#41;&#44; more diagnoses were reviewed&#44; facilitating the detection and confirmation of arthritis&#46; Likewise&#44; more systemic treatments were prescribed&#44; including biologic therapies&#46; On the other hand&#44; a report presented at a meeting shows that a face-to-face multidisciplinary unit in the United Kingdom achieved high levels of satisfaction on the part of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> However&#44; more data are necessary to determine whether these multidisciplinary units&#44; in comparison with the usual clinical approach&#44; improve the course and outcome of these patients&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">In Spain&#44; data have also been published on a unit that follows a similar model of care&#44; although it is functioning with existing resources&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> In this clinic&#44; there was an improvement in patient management of those who had problems involving the diagnosis or disease control&#46; There has also been an increase in the early diagnosis of arthritis&#44; which has made it possible to initiate early treatment&#46; Moreover&#44; since the unit was introduced&#44; collaboration between the specialties of rheumatology and dermatology has increased and the model has also been exported to other hospitals&#46; This is one of the models analyzed and described in the present article&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">This face-to-face multidisciplinary model has been found to be ideal on the part of professionals&#46; It offers the possibility of standardizing the patient visit&#44; gathering and analyzing its activity and&#44; using a very special approach&#44; reinforce the collaboration between the 2 specialties with the creation of referral criteria and protocols for patient management accorded by consensus&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">There is also a work published in an international congress that refers to the 2-year experience in a parallel approach in Spain&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> In this model &#40;included in this study&#41;&#44; each patient is seen first by 1 specialist and&#44; subsequently&#44; by the other&#46; After 3 years of follow-up&#44; among other things&#44; it has been found that the treatment has been modified in more than half of the patients&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">A possible advantage to the parallel model over the face-to-face model is that not all of the patients require that the 2 specialists see them in depth&#46; A patient expresses his or her doubts on arrival&#44; and the necessary decisions are then considered&#46; The other specialist can then pose any questions very rapidly&#46; This can save time&#44; would enable a larger number of patients to be seen&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Finally&#44; we have found a third type of multidisciplinary care&#44; which is the preferential circuit&#46; This model is more similar to usual clinical care&#44; although&#44; it must be remembered that there is a very close collaboration among specialists and the possibility that the patient be evaluated by the 2 specialists the same day&#44; in accordance with the protocols and arrangements in this respect&#46; This model could be proposed in smaller centers&#44; with fewer resources&#44; or as a form of multidisciplinary care prior to the establishment of 1 of the models described above&#46; In principal&#44; this approach would be easier to introduce&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Regardless of what has been portrayed here&#44; there is no doubt that the election of one model or another will depend on the needs of the center&#47;health area&#44; of the departments and professionals&#44; as well as the available resources&#46; As we mentioned earlier&#44; this can start with a strategy that is easier to establish&#44; like the preferential circuit&#44; and another may be adopted later on&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">On the other hand&#44; regarding its introduction&#44; good planning of the process can help enormously in the success of the undertaking&#46; In this respect&#44; it is essential that the participants in the multidisciplinary clinics be interested in the subject and that they get along well&#46; Moreover&#44; it is necessary that questions concerning agendas be accorded prior to beginning to introduce any of these models&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Finally&#44; although at the present time&#44; we need more data on the efficacy of these multidisciplinary care models&#46; It seems clear that we can improve the management of patients with psoriasis or PsA&#44; despite diagnostic uncertainties or questions on the treatment&#44; as well as the results of the health care system&#46; All this can be done&#44; as we also promote collaboration among different medical specialties&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Ethical Disclosures</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Protection of human and animal subjects</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Confidentiality of data</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Right to privacy and informed consent</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Funding</span><p id="par0230" class="elsevierStylePara elsevierViewall">This project was funded by the Spanish Rheumatology Foundation&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflicts of Interest</span><p id="par0235" class="elsevierStylePara elsevierViewall">Jos&#233; Carlos Ruiz Carrascosa has received fees for conferences and for trials promoted by Abbvie&#44; Pfizer&#44; Novartis&#44; MSD and Janssen&#46; Conrad Pujol has received grants and fees related to research&#44; as a consultant&#44; and for training in the following companies&#58; Abbvie&#44; Janssen&#44; LEO&#44; MSD&#44; Novartis and Pfizer&#46; Raquel Rivera has participated in clinical trials&#44; and worked as a consultant and a speaker for Abbvie&#44; Celgene&#44; Janssen&#44; Leo-Pharma&#44; Lilly&#44; MSD&#44; Novartis&#44; Pfizer and Novartis&#46; The remaining participants declare they have no conflicts of interest&#46;</p></span></span>"
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              "titulo" => "Multidisciplinary Care Models in Patients With Psoriatic Arthritis"
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                  "titulo" => "Face-to-face Approach"
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              "titulo" => "Experience in Introducing Models of Multidisciplinary Care"
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    "fechaRecibido" => "2015-12-07"
    "fechaAceptado" => "2016-03-03"
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            0 => "Psoriatic arthritis"
            1 => "Psoriasis"
            2 => "Multidisciplinary care"
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          "clase" => "keyword"
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            0 => "Artritis psori&#225;sica"
            1 => "Psoriasis"
            2 => "Atenci&#243;n multidisciplinar"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetive</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To describe &#40;structure&#44; processes&#41; of the multidisciplinary care models in psoriatic arthritis &#40;PsA&#41; in Spain&#44; as well as barriers and facilitators of their implementation&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A qualitative study was performed following structured interviews with 24 professionals &#40;12 rheumatologists&#44; 12 dermatologists who provide multidisciplinary care for patients with PsA&#41;&#46; We collected data related to the hospital&#44; department&#44; population and multidisciplinary care model &#40;type&#44; physical and human resources&#44; professional requirements&#44; objectives&#44; referral criteria&#44; agendas&#44; protocols&#44; responsibilities&#44; decision-making&#44; research and education&#44; clinical sessions&#44; development and planning of the model&#44; advantages and disadvantages of the model&#44; barriers and facilitators in the implementation of the model&#41;&#46; The models characteristics are described&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We analyzed 12 multidisciplinary care models in PsA&#44; with at least 1&#8211;2 years of experience&#44; and 3 subtypes of models&#44; face-to-face&#44; parallel&#44; and preferential circuit&#46; All are adapted to the hospital and professionals characteristics&#46; A proper implementation planning is essential&#46; The involvement and empathy between professionals and an access and well-defined referral criteria are important facilitators in the implementation of a model&#46; The management of agendas and data collection to measure the multidisciplinary care models health outcomes are the main barriers&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">There are different multidisciplinary care models in PsA that can improve patient outcomes&#44; system efficiency and collaboration between specialists&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Describir la estructura y procesos de distintos modelos de atenci&#243;n multidisciplinar de pacientes con artritis psori&#225;sica &#40;APs&#41; en Espa&#241;a&#44; as&#237; como las barreras y facilitadores en su implantaci&#243;n&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio cualitativo mediante entrevistas estructuradas a 24 profesionales &#40;12 reumat&#243;logos y 12 dermat&#243;logos que realizan atenci&#243;n multidisciplinar en pacientes con APs&#41;&#46; Se recogieron datos relacionados con el centro&#44; servicio&#44; poblaci&#243;n atendida y sobre el modelo de atenci&#243;n multidisciplinar &#40;tipo&#44; recursos materiales y humanos&#44; requerimientos de los profesionales&#44; objetivos&#44; criterios de entrada y salida&#44; agendas&#44; protocolos de actuaci&#243;n&#44; responsabilidades&#44; toma de decisiones&#44; actividad investigadora y docente&#44; sesiones cl&#237;nicas conjuntas&#44; creaci&#243;n&#47;inicio&#44; planificaci&#243;n&#44; ventajas&#47;desventajas del modelo y barreras&#47;facilitadores en la implantaci&#243;n del modelo&#46; Se describen sus caracter&#237;sticas&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Analizamos 12 modelos de atenci&#243;n multidisciplinar en APs&#44; implantados desde hace al menos 1-2<span class="elsevierStyleHsp" style=""></span>a&#241;os&#44; que globalmente pueden resumirse en 3 subtipos diferentes&#58; presencial conjunto&#44; presencial paralelo y circuito preferencial&#46; La implantaci&#243;n de uno u otro modelo es consecuencia de la adaptaci&#243;n a las circunstancias del centro y profesionales&#46; Una correcta planificaci&#243;n de la implantaci&#243;n es fundamental&#46; La implicaci&#243;n y buena sinton&#237;a entre profesionales as&#237; como un acceso y criterios de derivaci&#243;n bien definidos son facilitadores muy importantes en la implantaci&#243;n de un modelo&#46; La gesti&#243;n de las agendas y la recogida de datos para medir resultados de salud de estos modelos son las principales barreras&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Existen distintos modelos de atenci&#243;n multidisciplinar implantados que tienen como objetivo intentar mejorar la atenci&#243;n del paciente con APs&#44; la eficiencia del sistema y la colaboraci&#243;n entre especialistas&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Queiro R&#44; Coto P&#44; Rodr&#237;guez J&#44; Notario J&#44; Nav&#237;o Marco T&#44; de la Cueva P&#44; et al&#46; Modelos de atenci&#243;n multidisciplinar en pacientes con artritis psori&#225;sica en Espa&#241;a&#46; Reumatol Clin&#46; 2017&#59;13&#58;85&#8211;90&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Preintroduction steps&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">1&#46; Look for 2 involved specialists&#44; with experience and interest&#44; and who get along well</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">2&#46; Communication between directors or others responsible for the department to get their approval</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">3&#46; If necessary&#44; present the proposal to the management and&#47;or medical direction</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">4&#46; Define collectively&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Type of model that best fits the circumstances of the center&#47;professionals</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Criteria for patient access and discharge</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Intervals between visits and no&#46; patients&#47;visit &#40;joint models&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; How and which days to communicate by phone&#44; e-mail&#44; in person</span>&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Location for multidisciplinary visits &#40;joint models&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Necessary materials &#40;computer&#44; chairs</span>&#44; etc&#46;<span class="elsevierStyleItalic">&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; If necessary&#58; protocols&#44; guidelines</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Level of responsibility&#47;implication in patient follow-up and treatment&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Decide whether to recommend or to directly change therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Should biologic therapy be indicated&#44; establish a criteria as to who has to calculate the prescription&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Planned objectives</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Recording and evaluation of the activity &#40;what&#44; who&#44; when</span>&#44; etc&#46;<span class="elsevierStyleItalic">&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Measures &#40;activity of the visit&#44; activity and damage due to PsA&#44; quality of life&#46;</span> etc&#46;<span class="elsevierStyleItalic">&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">5&#46; Prepare the logistics of the agenda</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; <span class="elsevierStyleItalic">Attempt to prepare a single agenda with the activities of both departments</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">6&#46; Present the project to the 2 departments</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">General Steps to Follow in the Introduction of a Multidisciplinary Care Model for Patients With Psoriatic Arthritis &#40;PsA&#41;&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Steps during establishment &#40;first 2 years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">1&#46; Look for efficient formulas to expedite the visits</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">3&#46; Evaluate the multidisciplinary visit and make adjustments&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Once started&#44; evaluate every 3&#8211;6 months&#44; making necessary adjustments&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- On the agenda&#44; changes in intervals and&#47;or no&#46; of patients per visit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Remind departments of the service and the referral criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Implicate&#44; train nursing staff&#47;nursing assistant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Define more specifically the attitude to adopt with certain types of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Need of adjustments in the electronic medical record&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- In the case of data collection&#44; determine if it takes too much time&#44; if it is feasible&#44; if variables have to be modified&#44; reduce the number to be collected&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; At the end of one year&#44; evaluation of the specific objectives proposed</span>&nbsp;\t\t\t\t\t\t\n
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Postestablishment steps &#40;after the first 2 years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">1&#46; Evaluation of the unit and its objectives</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8226; Should be performed every 1 or 2 years</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Analysis of anything that is not going well&#44; events&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- If some objective has not been accomplished&#44; examine why&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- This will help to design an improvement plan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">2&#46; Together with the improvement plan&#44; new objectives can be proposed&#46; In addition to the clinical objectives&#44; others related to the investigation and&#47;or teaching can be assessed</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">3&#46; Once consolidated&#44; it can be seen whether the unit meets the quality standards put forward in NEXUS</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">4&#46; Likewise&#44; the introduction of the quality indicators also generated in NEXUS can be considered</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">General Steps to Follow During Establishment &#40;First 2 Years&#41; and After That Period&#44; From a Multidisciplinary Care Model&#46;</p>"
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    "bibliografia" => array:2 [
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                      "titulo" => "Global epidemiology of psoriasis&#58; a systematic review of incidence and prevalence"
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                        0 => array:3 [
                          "colaboracion" => "Identification and Management of Psoriasis and Associated Comorbidity &#40;IMPACT&#41; project team"
                          "etal" => false
                          "autores" => array:4 [
                            0 => "R&#46; Parisi"
                            1 => "D&#46;P&#46; Symmons"
                            2 => "C&#46;E&#46; Griffiths"
                            3 => "D&#46;M&#46; Ashcroft"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/jid.2012.339"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Invest Dermatol"
                        "fecha" => "2013"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23014338"
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            4 => array:3 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Burden of disease&#58; psoriasis and psoriatic arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "W&#46;H&#46; Boehncke"
                            1 => "A&#46; Menter"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s40257-013-0032-x"
                      "Revista" => array:6 [
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                        "fecha" => "2013"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23771648"
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            5 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence and predictors of reduced work productivity in patients with psoriatic arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "M&#46; Kennedy"
                            1 => "A&#46; Papneja"
                            2 => "A&#46; Thavaneswaran"
                            3 => "V&#46; Chandran"
                            4 => "D&#46;D&#46; Gladman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Exp Rheumatol"
                        "fecha" => "2014"
                        "volumen" => "32"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24708934"
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                          ]
                        ]
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            ]
            6 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Systematic literature review on economic implications and pharmacoeconomic issues of psoriatic arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46;A&#46; Cortesi"
                            1 => "L&#46; Scalone"
                            2 => "L&#46; d&#8217;Angiolella"
                            3 => "A&#46; Belisari"
                            4 => "F&#46; Fusco"
                            5 => "I&#46; Olivieri"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
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Article information
ISSN: 21735743
Original language: English
DOI:10.1016/j.reumae.2016.03.007
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