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St. Luke's Doing Trailblazing Work in Treatment of Juvenile and Adult Arthritis

Dr. Patrick Knibbe spends time with 11-year-old patient Ezekiel Grundon.                                               

Dr. Knibbe and his team have developed a very special rapport with the young patients who visit during pediatric clinic days
May 29, 2014

By Roya Camp, St. Luke's News

May is National Arthritis Awareness Month, but Dr. Patrick Knibbe and the team at St. Luke’s Clinic – Rheumatology don’t need additional reasons to focus on the challenges of the diseases they treat.

Dr. Knibbe, who is board certified in internal medicine and rheumatology and is a fellow of the American College of Rheumatology, specializes in the treatment of rheumatoid arthritis, lupus, osteoporosis, and pediatric rheumatologic diseases.

He’s also the director of pediatric rheumatology for St. Luke’s Children’s and, because there are so few physicians specializing in the areas of pediatric arthritis, in combination with the well-known and concerning physician shortage nationally and in the region, his team is doing trailblazing work on three fronts at the same time. They’re developing optimal clinical care models for both adults and children while taking part in multiple research studies.

Dr. Knibbe trained in the Internal Medicine Honors Program at the University of Utah in Salt Lake City and completed his fellowship at Children's Hospital Los Angeles before entering rheumatology practice at LDS and Primary Children’s Hospital in Salt Lake City in 1981. He moved to Idaho in 2001 and joined St. Luke’s three years ago.

Arthritis may be viewed as a disease affecting adults, and older adults, but there are an estimated 500,000 children in the United States with juvenile arthritis, and Dr. Knibbe and his team, who oversee the only children’s arthritis program in the state, see as many as 20 young patients on special pediatric clinic days. Patients come, sometimes as frequently as every three months, from as far away as Elko, Nev. Dr. Knibbe also see patients once a month in Hailey.

Dr. Knibbe, his Medical Assistant Sarah Christie, and Nurse Practitioner Michelle Hicks see pediatric patients, who may start with the team when they are as young as 2 years old or even younger, into their adult years, which is a continuum of care that’s relatively unusual in medicine. Cystic fibrosis, diabetes, and inflammatory bowel disease are other examples where the care team may attend patients through most of their lives, Dr. Knibbe notes, but the model of care remains an exception.

“It’s the same personnel, whereas elsewhere, it can be an entire change of providers,” he said. “We are trying to do better transitioning kids to adult care, but it’s really a new area of study for St. Luke’s and nationwide and not easy, given our mobile society.”

The team has designed the pediatric program to take into account the extremely long distances that some families need to travel for appointments. The kids clinics, held Thursdays and Friday mornings at the clinic in Meridian, are structured to make the young patients feel less isolated and to minimize time away from school.

Between visits, Sarah Christie ensures that the families feel connected through a Facebook community function, use of Instagram, and special quarterly “JIA Days” (for juvenile idiopathic arthritis) that allow families associated with the clinic to come together for social activities. The kids might play games or tour the zoo, for example, while Dr. Knibbe checks in with parents and the adults can honestly share their fears and concerns.

“Families can feel kind of alone,” Christie said, adding that the activities send the message that “Your kids are OK to be normal.”

One area of concern and opportunity the team sees when it comes to access to and continuity of care for younger patients is the connection with colleges and universities.

They worry, and rightly so, when their patients go off to college, where the complexities of managing meds and lab tests can overwhelm teens heady with the freedom of leaving home. They do what they can, starting a few years out from high school graduation, to arm young patients with education and skill-building. They’re also now able to stay in touch with the students through their electronic health records.

The clinic has not limited its clinic model innovations to the needs of pediatric patients, however.

The team also has been flooded with adult patients, and receives 30 to 40 new referrals each month. They are building out a clinical model that now allows them to see as many as two-dozen adult patients each day and will accommodate as many as 50 adult patients when the practice model is completed.

In the new model, which launched near the beginning of the year, Dr. Knibbe sees new patients, he and his team attend shared visits, and he collaborates with Hicks and the others on those patients that can be seen strictly by other team members.

“We’re able to see more patients that way,” he said. “We have developed a unique care model to attempt to deal with the overwhelming number of patients needing our input.”

And then there’s the research activity.

Until the late 1990s, Dr. Knibbe notes, treatment for arthritis by and large was considered rehabilitative. The specialty wasn’t considered particularly interesting, because there was not a lot care providers could offer patients.

Advances in medication have made all the difference, and remission and return to normalcy are now not only a goal but are possible, he said, observing that from the start of his career to about 1995, he wrote a steady stream of prescriptions for canes and wheelchairs.

“I don’t write those prescriptions at all anymore,” he said. “Zero.”

Dr. Knibbe initially came to Idaho to join Dr. James Loveless, St. Luke’s head of clinical research for rheumatology, in clinical research at Intermountain Orthopaedics and to work with pediatric orthopedic surgeons Dr. Kevin Shea and Dr. Larry Showalter. All three are now affiliated with St. Luke’s and the research has continued apace, with Dr. Knibbe’s team involved in four enrolling studies now and another 20 in various phases of completion.

St. Luke’s area of coverage has been an ideal location from which to treat patients and conduct research, Dr. Knibbe said. He’s able to collaborate with colleagues in Portland, Seattle, and Salt Lake City, all with solid tertiary programs when those needs arise. He has attended monthly clinics at Seattle Children’s Hospital, serving as a clinical instructor from 2002 to 2008 and solidifying consulting relationships with that institution.

And St. Luke’s and Idaho health care in general have benefited greatly from an influx of very good care providers from the University of Washington and its WWAMI physician training program, the VA system, the Oregon Health & Science University, and the University of Utah.

“Medical care here is influenced by that,” Dr. Knibbe said. “We have really high-quality medicine. It’s not a step down.”

And that’s a very good thing, because as Dr. Knibbe observes, with arthritis care and needs, “We’re never going to get to the end of the line.”