Rheumatic diseases are a prevalent health problem. According to the 2006 Catalan Health Survey (ESCA2006), dorsal and lumbar pain, neck pain and more rheumatoid arthritis, among other types of arthritis are the three chronic health problems most frequently reported by our population.1 The prevalence of these problems is higher in women and increases with age and low socioeconomic status.1 The impact of these diseases can be enormous for the individual who presents them, as well as for her/his family and society in general, both socially and economically. These disorders are one of the main reasons for work disability and the leading cause of lost work days,3 while in the elderly often they often involve dependence on others. The cost to health systems is between 1% and 1.5% of European countries gross national income.4 In Catalonia, the activity related to these processes occupies 32% of the time of primary care physicians (PC), generates a large volume of activity in rheumatology, orthopedic surgery and traumatology (TOC), and is the main consultation reason in pain units and rehabilitation5 services. Attention to these disorders is characterized by high fragmentation of care with inadequate flow of patients between different specialties and levels of care, duplication of visits, additional examinations and dissatisfaction of patients and professionals.

In order to improve the care of rheumatic diseases, the Department of Health launched in 2008 the Master Plan for rheumatic and musculoskeletal diseases (MP), in line with previous6 master plans, constituting the planning tool to comprehensively address these problems. The aim of this paper is to describe the methodology that was used and the final proposals that have been finally approved. The prioritization criteria of health problems to be addressed have resulted from population prevalence and impact on health services studies rather than specialty clinics. In this sense, some rheumatic processes with significant impact on affected individuals have a low prevalence population and have not been specifically addressed in this MP. The description of the operational lines of the MP and subsequent evaluation are not the subject of this article.

The structure of the MP (Fig. 1) is organized according to the Directorate for Planning and Evaluation, Department of Health, in coordination with the Directorate General of Public Health and the CatSalut Management Services Quality Area. Two rheumatologists (ML and XS) joined the Directorate General to direct it and who were responsible for promoting, directing and coordinating the process of developing the MP. It was an Advisory Board with two chairs, a specialist in TOS and a rheumatologist, and 70 members linked to the field of rheumatic diseases from universities, health centers, scientific societies, professional associations, patient associations, suppliers and representatives of Public Administration. There was also a standing committee with 18 members of the advisory council, chosen for their expertise in musculoskeletal diseases and who eventually formed working groups, coordinated by an orthopedic surgeon (JA). Together with them worked 114 professionals in the groups and the final proposals were endorsed by patients, professionals, planners and managers.

Figure 1.

Organization chart.

(0.13MB).

The work was carried out in phases (Table 1), the first of which an analysis of the overall situation of rheumatic diseases in Catalonia. For the analysis of morbidity were used ESCA20061 data, which also allowed evaluation of the impact of these diseases in the quality of life, restriction of activities and use of health services.2 Hospital activity data was analyzed by recording hospitalization and social health (MDS-AH and SS), while the impact on work disability was obtained from the Catalan Institute of Medical Assessments records.3 Data were also obtained of the medications and joint replacement registry of Catalonia (official registry established to collect information on patients undergoing arthroplasty).7 Simultaneously, we conducted a literature search to compare the epidemiological and health services use in Catalonia with those published in other environments. From the initiative of the MP two studies were derived: a study on the current delay in surgery of osteoporotic hip fracture through the Catalan Society of TOS and an opinion survey among primary care physicians and related specialties with the musculoskeletal system (TOS, rheumatology, rehabilitation and medical pain units), to obtain qualitative information on aspects of care organization, relationship between levels of care and some improvement proposals.5

Table 1.

Director Plan Timeline.

The outcome of this analysis derived from the MP targets was chosen and the strategies were prioritized based on the following criteria: magnitude of the problem, social importance (impact on activity and work disability, processes that cause dependence) and impact on the use of health services. The problems identified related to the management of health services led a strategic change in a specific health care model.

In a second phase, we developed the working groups, in the case of clinical trials, made by experts in the specific issue in question and both PC and medical specialties as mentioned above and others (geriatrics, pediatrics, neurosurgery, pharmacology, psychology, occupational health, public health), and representatives of nursing and physiotherapy. Patients’ associations, as well as being represented in decision-making bodies of the plan (advisory council and standing committee) participated in a working group that drafted their own proposals that were discussed at the Standing Committee and incorporated into the final conclusions. They were also members of the working group on health care model. Each group had one or two officials, with the functions of directing and coordinating the group, who set the work plan and the proposed actions, always within the framework of the general objectives as defined by the MP. The working methodology consisted of regular meetings for discussion and evaluation of the proposals made by members of the group. The established care model working group was a team of people representing relevant scientific societies (rheumatology, family medicine, TOS, physical medicine and rehabilitation, anesthesia and pain management), schools or companies (physiotherapists and nurses), patient associations, entities providing different services and areas of the Department of Health. The objectives of this group were to evaluate existing models of care in other settings and make a proposal for a new model of care.

The proposals from each working group were presented in a technical report that was given to the team manager and, if approved by the Permanent Commission, presented to the advisory board for approval. The results of the MP were collected in a final document, currently available on the website of the Department of Health.8

The overall objectives set by the MP were: (a) strengthening health promotion, prevention and self-care in diseases of the musculoskeletal system, (b) improving the response capacity of PC in these diseases, (c) reducing the variability and increasing the efficiency of the diagnostic and therapeutic process, (d) improving continuity of care and efficiency of care through the definition of a new model of care, and (e) promoting the training of professionals.

In addition to the care model group, the other groups worked on back pain, osteoarthritis, osteoporosis, arthritis, chronic shoulder pain and fibromyalgia.

Since the general objectives of the MP were common to all groups, their proposals had were marked similarities between them. For the presentation of results in this paper we will initially introduce the proposed care model and then the specific proposals of the different strategies. MP proposals are summarized in Table 2.

The mission of the MP led by the Department of Health is to improve the care of rheumatic diseases through interventions of proven efficacy and effectiveness, and to establish a model of care focused on the needs of the population. Following these principles, the proposals include aspects of prevention, rational use of resources, improved efficiency of services, use of information technology as an aid to decision making, implementation of measures and demonstrated evidence in professional training.

Care for chronic diseases involves different levels of health care professionals and makes coordination a key process of care. Only with coordination between research and professionals can adequate care be given in the right place, ensuring continuity of care by avoiding duplication and optimally managing transitions between levels of care.

It is not usual in our country to have a health planning focused on musculoskeletal problems. Back in the nineties, the Health Plan of the Ministry of Health and Consumption9 recognized these diseases as a priority intervention area due to its high morbidity and potential for impaired quality of life, disability, restricted activity and high consumption of drugs, as well as health and labor costs associated with it. Since then, different regions have been introducing elements unevenly. Certain lines, such as cancer, cardiovascular diseases or mental disorders are common to many, but in this case there are only are isolated lines specifically targeted to rheumatic problems. Several health plans, such as Galicia's and Andalusia's advocate generic measures, such as promoting healthy lifestyles (exercise, control of obesity, improved postural hygiene), the protocols for certain processes or formation of PC professionals. Among the objectives directed to specific problems we can find the plan of Valencia, aimed at the prevention and management of osteoporosis, which has shown positive results.10 A different situation is presented by several developed countries where the “Bone and Joint Decade 2000–2010”11 led to the implementation of different initiatives. This project began in 1990, backed by the United Nations Organization and the World Health Organization as a global initiative whose objectives were to promote research and increase awareness and education on musculoskeletal diseases. The ‘Decade’ objective was to improve the quality of life of people with these conditions, raising awareness about the growing burden to society, promoting effective preventive measures and treatment, and stimulating research in order to generate appropriate prevention strategies and treatment. 63 governments gave support to this initiative, including 28 European countries (not Spain) and more than 850 entities, of which 7 were Spanish. The activities of the “Decade” ended in September 2010 and due to the success and recognized the importance of their actions have been extended another decade (http://www.boneandjointdecade.org).

The statement of the European Parliament on rheumatic4 diseases lies in this direction, in which a number of considerations recall their high prevalence, chronic condition and the fact that they are a leading cause of disability and early retirement for workers. The adoption of adequate social and health policies reduces economic and social costs associated with these diseases. Therefore, the Parliament urges Member States to establish and implement national plans to fight rheumatic diseases, and develop a strategy on them.

The MP is designed for a period of 4 years, time for the goals of care to the population and the actions that will make it possible to achieve these objectives through operational planning and buying services to the various suppliers to be achieved. The future phase of the plan is the gradual implementation and evaluation of results. We hope these will vouch for the validity of their proposals and content, and efficiently display their generalization to benefit the health of our citizens.

The authors declare no conflict of interest.