REAL-PANLAR Project for the Implementation and Accreditation of Centers of Excellence in Rheumatoid Arthritis Throughout Latin America: A Consensus Position Paper From REAL-PANLAR Group on Improvement of Rheumatoid Arthritis Care in Latin America Establishing Centers of Excellence.

The mission of PANLAR (Pan American League of Associations for Rheumatology) is 2-fold: (1) to stimulate and promote the study and research of rheumatic diseases for the prevention, treatment, and rehabilitation of patients with rheumatic conditions in the American continent and (2) to stimulate the continuing development of the specialty of rheumatology. PANLAR is committed to encourage and facilitate patient access to care as it affects the ability of rheumatic disease patients to obtain affordable, high-quality, and specialized health care. The national health care systems within the Latin America (LA) and Caribbean area are heterogeneous in their organizational structure and complex in their operational configuration and the principles guiding the public and private sector roles in the provision of health care services. Latin American and Caribbean countries exhibit wide variations regarding their main health care systems objectives and operation. Chronic illnesses, which greatly impact health and quality of life, are actually 1 of their priorities despite requiring efforts to manage the burden of infectious diseases, providing care for the reproductive-age female population, childhood pathology, and violence-related injuries, among others.1 Patients with rheumatoid arthritis (RA) have substantial unmet medical needs. The World Health Organization recommends at least 1 rheumatologist per 100,000 people, that is, an estimated need of 6000 specialists in LA. Currently excluding the United States and Canada, the 19 LA and Caribbean Rheumatology National Societies have a workforce of around 3900 specialists to serve 588 million inhabitants. Not all rheumatologists are active, nor are they accredited according to country requirements.2 Although this number could be higher because some active practicing rheumatologists are not affiliated to their local societies, therefore, the actual number of specialists cannot be determined accurately. In addition to the shortage of rheumatologists in Latin American and Caribbean countries, the regional distribution on supply of specialists is mainly in metropolitan areas, whereas other areas have a low density of specialists, such as in rural areas and small towns, resulting in several underserved areas. These factors not only constitute barriers to patient access to specialized health care, but also contribute to a suboptimal quality of care provided, poor diagnosis, and treatment of RA in a large proportion of affected individuals.3,4 However this is not the only problem that RA patients face. Most patients in the region have limited access to medicines, rehabilitation programs, and orthopedic interventions, all of which are highly recommended for optimal disease management. Moreover, they do not have substantial education programs, which are necessary to empower them and their families in their daily management and adjustment to their illnesses, because drug therapy alone does not substantially improve quality of life.3,4 The data also reveal the importance of considering early diagnosis and adequate treatment of RA as a public health priority in Latin American and Caribbean countries, because early treatment of RA has shown to effectively reduce disability in the long run.3,4 Accurate measures known as quality indicators (QIs) are needed to assess quality of care. Quality indicators are usually more specific as compared with treatment recommendation guidelines, because they precisely describe who must do what, to whom, and exactly when.5 In 2007, the American College of Rheumatology (ACR) submitted a set of minimum QIs for RA patient care; patient adherence to these standards seems possible. Introduction of these QIs presents clinicians with an enormous opportunity to clearly understand the minimum standards expected in the profession.6 An essential goal of QIs is establishing minimum standards of care that should be delivered to patients as a means to evaluate care across patients and provider groups and stimulate quality improvement efforts that ultimately lead to better patient care and outcomes.6 The involvement of national scientific specialty organizations is an important way of delivering the message that implementing these measures is necessary for patients with RA. Eventually, it may be feasible to move beyond the specification of minimal care and reach a consensus regarding good and excellent care for our patients. There is a great potential to reduce the large and growing burden of RA across the PANLAR member societies through evidence-based interventions and harmonization of the standards of care. The REAL (Red de Excelencia en Artritis para la America Latina) project evolved as a strategic need to implement Centers of Excellence (CoEs) in RA throughout the LA and Caribbean region to help ensure affordable, high-quality, and specialized health care for these patients, improving their quality of life and managing their health care costs. Taking into account the difficulties posed by diverse health system organizations across countries and lack of resources, the REAL main goals are as follows: To promote assessment of standards of care for RA in alignment with PANLAR clinical guidelines and the Treat to Target (T2T) strategy7 To accomplish the need to measure and document disease activity, disability, comorbidities, quality of life, and adherence to treatment by RA patients To establish harmonized minimum standards of care for RA patients To inform doctors and other allied health professionals about all aspects of RA To educate patients and their family members about the facts of RA in order to help them to cope with the disease and collaborate, improving adherence to treatment and rehabilitation programs To improve patient accessibility to arthritis centers and implement continuous health care quality programs To establish and foster Latin American and Caribbean regional registries and databases To form a strategic alliance with Latin American and Caribbean governments and nongovernmental organizations in order to implement the T2T strategy and CoEs in RA throughout the LA and Caribbean region To raise awareness about the need for CoEs in RA among policy makers, private and public health payers, and insurers in the region