Low Hanging FruitI do not like to use the term “low hanging fruit” when it comes to serious issues of public health but the metaphor conveys meaning and the message is clear. Improvement in the outcomes of certain conditions is not difficult. Hardly any effort will be required to harvest the fruit and one can easily imagine someone stretching a bit to pick an apple from the lowest branch and enjoying its sweet taste.
In improving the outcomes of musculoskeletal disease, fortunately, there is low hanging fruit. Among conditions ripe for advance, gout is an obvious example. Gout is epidemic and is now considered to be the most common form of inflammatory arthritis, passing rheumatoid arthritis in its frequency. Not only that, but the frequency is rising, hospitalization for gout is soaring, and management appears in serious need of improvement. Some studies suggest that 90% of hospitalizations for acute gout are entirely preventable.
This situation is strange since gout is very well understood. The pathophysiology is straightforward. Gout is a metabolic condition in which uric acid accumulates in the body and crystals form when levels exceed the saturation point. When released into the joint, the crystals can potently stimulate a host defense system called the inflammasome and lead to very painful attacks. Over time, gout can cause severe joint damage and exacerbate other conditions such as osteoarthritis. The frequency of gout tracks along with that of the metabolic syndrome and patients with gout often have comorbidities such as hypertension, diabetes and atherosclerosis.
At present, we have agents that effectively reduce levels of uric acid in the blood, promote the dissolution of crystals, and thereby remove the driving force of the inflammation. We also have agents that can stop acute attacks and prevent attacks from occurring. Furthermore, more new drugs are becoming available, promising greater choice in developing a plan to lower uric acid.
Nevertheless, despite all of the knowledge about the causes of gout and its treatment, the treatment is suboptimal, an example of a situation that occurs all too commonly for musculoskeletal diseases. The explanations are many: teaching on musculoskeletal disease in health professional schools is sporadic and spotty; too few primary care providers are up to date on disease management; and misunderstandings on the use of medication abounds. Not surprisingly, patients often do not receive the appropriate education on their conditions. For a busy primary care provider, the blood pressure of 160/100 and the glucose of 250 seem to be greater priorities than the uric acid of 9 even if the patient will complain of repeated gout attacks that lead to severe disability. The disability furthermore reduces the opportunity for an exercise program to lessen the impact of the comorbidities.
The USBJI is committed to improving the care of people with musculoskeletal conditions, a supremely important goal that requires education, awareness and the development of interdisciplinary care teams. In medicine, there are conditions that fall between specialties. Osteoporosis is one. Gout is another.
When the provider who is responsible for care is not certain, often the care does not get done and the fruit that accumulates often falls rotten.
By making clear the burden of musculoskeletal disease by BMUS and conducting education programs on the management of disease and the value of exercise, the USBJI is taking important steps to improving the care of patients with many different forms of musculoskeletal disease; gout is a prime example. The USBJI provides a framework for interdisciplinary communication and a unique venue to bring all the stakeholders together. The USBJI, beginning with its origin in the Bone and Joint Decade, has had an important goal in informing the public, the policy makers and various providers about the burden of musculoskeletal disease. It is time now to pursue another goal: to make clear the benefits of musculoskeletal care. The benefits are great and, indeed, the fruit is worth picking.