Assessing the need for improved access to rheumatology care: a survey of Massachusetts community health center medical directors

A model of care redesign within rheumatology: A mixed methods approach integrating nurse practitioners and physician assistants

BACKGROUND

Increasing patient demand and clinician burnout in rheumatology practices have highlighted the need for more efficient models of care (MOC). Interprofessional collaboration is essential for improving patient outcomes and clinician satisfaction.

LOCAL PROBLEM

Our current MOC lacks standardization and formal integration of Nurse Practitioners (NPs) and Physician Assistants (PAs), resulting in reduced clinician satisfaction and limited patient access. To optimize care quality, clinician satisfaction, and patient access, we sought to develop an interprofessional MOC tailored to an academic rheumatology practice.

METHODS

We used a mixed methods sequential-exploratory design within a quality improvement (QI) framework to create a blueprint for MOC redesign.

INTERVENTION

Intervention development proceeded in four phases: needs assessment, data collection, socializing key ideas, and team design and planning.

RESULTS

In the needs assessment phase, divisional leadership was interviewed to identify shared goals for an optimized MOC. Data collection included surveys distributed to 12 physicians and 8 NPs/PAs, addressing 11 key domains related to current and future MOC needs. In phase 3, we communicated key findings to divisional leadership, clinicians, and staff. Phase 4 involved iterative team building and MOC design. Survey results revealed low satisfaction with the current MOC and a strong preference for parallel practice, standardization, and formal NP/Physician Assistant integration. Several barriers to MOC implementation were also identified.

CONCLUSION

Redesigning the MOC in rheumatology requires aligning clinician, leadership, and organizational priorities. A mixed methods QI approach effectively uncovers clinical needs and potential barriers, supporting the successful implementation of a new MOC.

Exploring drug utilization patterns, healthcare resource utilization, and epidemiology of rheumatoid arthritis in Colombia: a retrospective claims database study

BACKGROUND

In Colombia, there is a lack of recent real- word studies that provide information on the epidemiology and healthcare resource utilization (HCRU) of rheumatoid arthritis (RA) at national level.

METHODS

To describe the burden of RA in Colombia, focusing on trends in drug utilization patterns, healthcare resource utilization (HCRU), and the epidemiology of adult patients diagnosed with RA between January 2017 and December 2022. This retrospective descriptive study used real-world data obtainedfrom a national claim database, SISPRO (Sistema de Información para la Protección Social). We included registries of adult patients diagnosed with RA between 2017 and 2022. We estimated the age-standardized incidence and prevalence of RA each year, drug utilization patterns for disease-modifying antirheumatic drugs (DMARDs) and glucocorticoids, rates of medical consultations, emergency room visits, and hospitalizations, and associated comorbidities and healthcare-related and pharmacy-related costs.

RESULTS

Overall, 327,430 unique patients with RA between 2017 and 2022 were included in the analysis, comprising 94,093 incident cases and 722,569 prevalent cases. The age-standardized incidence of RA ranged between 34.7 and 51.4 per 100,000 inhabitants, and the age-standardized prevalence ranged between 0.282 and 0.382 per 100 inhabitants between 2017 and 2022. The proportion of patients prescribed conventional synthetic DMARDs and biologic DMARDs decreased over the study period, from 39.23% in 2017 to 28.61% in 2021 and from 6.07% in 2017 to 3.72% in 2021, respectively. The proportion of patients prescribed targeted synthetic DMARDs increased from 0.9% in 2017 to 1.8% in 2021. The rate of medical consultations increased over the study period (from 2,406.6 in 2017 to 3,354.2 per 1,000 patients with RA in 2022). Consultation costs were the largest among all-cause annual healthcare-related costs.

CONCLUSION

This study described the heavy burden of RA in Colombia with an increasing incidence of RA, and significant healthcare resource utilization and associated costs. Patients with RA in the country are increasingly able to access consultations with specialists and receive advanced therapies. However, there remains a need for efforts to facilitate treatment among this population. These findings emphasize the importance of tailoring RA management strategies to the local context.

Factors in Hand Surgery Access for Rheumatoid Arthritis Before vs After the Patient Protection and Affordable Care Act

Importance

Rheumatoid arthritis (RA) has severe functional and economic consequences. The implications of the Patient Protection and Affordable Care Act (ACA) and demographic factors for access to surgical treatment are unclear.

Objective

To investigate factors associated with time to RA hand surgery, surgical incidence, and cost after implementation of the ACA.

Design, Setting, and Participants

This cross-sectional study used insurance data from the IBM MarketScan Research Databases from 2009 through 2020 to compare time to surgery, surgical incidence, and treatment cost for RA of the hand before and after ACA implementations. Included patients were 18 years or older with a new diagnosis for RA of the hand and at least 1 procedural code for arthroplasty, arthrodesis, tenolysis, tendon repair, or tendon transfer. Patients with coexisting inflammatory arthritis diagnoses were excluded. Demographic variables analyzed included patient sex, age at index date, residence within or outside a metropolitan statistical area (MSA; hereafter urban or nonurban), insurance and health plan type, Social Deprivation Index, Elixhauser Comorbidity Index score, and Rheumatic Disease Comorbidity Index. Data analysis occurred from October 2022 to April 2023.

Exposures

Surgery for RA of the hand during the pre-ACA (before 2014) vs post-ACA (2014 or later) periods.

Main Outcomes and Measures

Time to surgery, surgical incidence, and cost of treating RA in patients undergoing hand surgery for RA.

Results

Among 3643 patients (mean [SD] age, 57.6 [12.3] years) who underwent hand surgery for RA, 3046 (83.6%) were women. Post-ACA passage, 595 (86.2%) patients who resided in urban areas had a significantly lower time to surgery than those who did not (-70.5 [95% CI, -112.6 to -28.3] days; P < .001). Among urban patients, the least socially disadvantaged patients experienced the greatest decrease in time to surgery after ACA but the change was not statistically significant. For all patients, greater social disadvantage (ie, a higher SDI score) was associated with a longer time to surgery in the post-ACA period; for example, compared with the least socially disadvantaged group (SDI decile, 0-10), patients in SDI decile 10 to 20 waited an additional 254.0 days (95% CI, 65.2 to 442.9 days; P = .009) before undergoing surgery. Compared with the pre-ACA period, the mean surgical incidence in the post-ACA period was 83.4% lower (162.3 vs 26.9 surgeries per 1000 person-years; P < .001), and surgical incidence was 86.3% lower in nonurban populations (27.2 vs 3.7 surgeries per 1000 person-years; P < .001) but only 82.8% lower in urban populations (135.1 vs 23.2 surgeries per 1000 person-years; P < .001). Per capita total costs of all treatment related to RA of the hand decreased in the post-ACA period but the change was not statistically significant. Insurer-paid costs were lower in the post-ACA period but the change was not statistically significant. Out-of-pocket expenses did not change.

Conclusions and Relevance

Findings of this cross-sectional study suggest that after ACA passage, disparities exist in access to timely, cost-effective hand surgery for RA. Increased access to surgical hand specialists is needed for nonurban residents and those with greater social deprivation, along with insurance policy reforms to further decrease out-of-pocket spending for RA hand surgery.

Evaluation of Access Disparities to Biologic Disease-Modifying Antirheumatic Drugs in Rural and Urban Communities

The American College of Rheumatology guidelines provides a strong recommendation for the use of biologic disease-modifying antirheumatic drugs (bDMARDs) when conventional rheumatoid arthritis treatments fail to meet treatment targets. Although bDMARDs are an effective and important treatment component, access inequalities remain a challenge in many communities worldwide. The purpose of this analysis is to assess nationwide trends in bDMARD access in the United States, with a specific focus on rural and urban access gaps. This study combined multiple county-level databases to assess bDMARD prescriptions from 2015 to 2019. Using geospatial analysis and the Moran’s I statistic, counties were classified according to prescription levels to assess for hotspots and coldspots. Analysis of variance (ANOVA) was used to compare significant counties across 49 socioeconomic variables of interest. The analysis identified statistically significant hotspot and coldspot prescription clusters within the United States. Coldspot (Low-Low) clusters with low access to bDMARDs are located predominantly in the rural west North Central region, extending down to Oklahoma and Arkansas. Hotspot (High-High) clusters are seen in urban and metro areas of Wisconsin, Minnesota, Pennsylvania, North Carolina, Georgia, Oregon, and the southern tip of Texas. Comparing coldspot to hotspot areas of bDMARD access revealed that the Medicare populations were older, more rural, less educated, less impoverished, and less likely to get their bDMARDs from a rheumatologist.

Healthcare disparities in telemedicine for rheumatology care

PURPOSE OF REVIEW

We summarize the recent literature published in the last 2 years on healthcare disparities observed in the delivery of rheumatology care by telemedicine. We highlight recent research dissecting the underpinnings of healthcare disparities and identify potentially modifiable contributing factors.

RECENT FINDINGS

The COVID-19 pandemic has had major impacts on care delivery and has led to a pronounced increase in telemedicine use in rheumatology practice. Telemedicine services are disproportionately underutilized by racial/ethnic minority groups and among patients with lower socioeconomic status. Disparities in telemedicine access and use among vulnerable populations threatens to exacerbate existing outcome inequalities affecting people with rheumatic disease.

SUMMARY

Telemedicine has the potential to expand rheumatology services by reaching traditionally underserved communities. However, some areas lack the infrastructure and technology to engage in telemedicine. Addressing health equity and the digital divide may help foster more inclusive telemedicine care.

Comparing Rheumatology Consultation Patterns Across Telehealth Platforms and Face-to-Face Clinic in the Military Health System

OBJECTIVE

To compare patterns of rheumatology consultations and outcomes across four different platforms in the Military Health System (MHS): face-to-face, synchronous telehealth, and two asynchronous telehealth platforms.

METHODS

We conducted a retrospective review comparing face-to-face rheumatology consults during 2019 with teleconsultations from three virtual systems in the MHS: an asynchronous email-based system from May 2006 to Feb 2018, a web-based platform from 2014 to 2018, and synchronous telehealth consults from March 2020 to March 2021. Consults were reviewed for diagnosis, and if medical evacuation was required for consults originating OCONUS or if face-to-face follow-up was required for synchronous teleconsults. Diagnoses of interest included inflammatory arthritis, noninflammatory arthritis, crystalline arthritis, myositis, lupus, vasculitis, fibromyalgia, antibody positivity without diagnosis, symptoms without specified diagnosis, and a composite of other rheumatic diseases.

RESULTS

Leading diagnoses across platforms were inflammatory arthritis, noninflammatory arthritis, and a composite of other diagnoses. Consultation modality influenced the type of cases seen. Inflammatory arthritis accounted for significantly more consults in the synchronous telehealth (38.4%) and email-based (40.9%) models than in the web-based (23.7%) and face-to-face (32.0%) models. The composite of other diagnoses was the leading diagnosis for the asynchronous web-based model (32.9%), which was significantly more than the synchronous telehealth and face-to-face consults. Synchronous models saw significantly more cases of crystalline arthritis, vasculitis, and fibromyalgia.Email-based consultations resulted in medical evacuation in 25 cases and prevented evacuation in 5. Web-based consultations prompted medical evacuation in 100 cases. In the synchronous model, face-to-face follow-up was recommended in 142 (15%) cases.

CONCLUSIONS

Modality of consultation influences the type of cases seen. Both synchronous and asynchronous telerheumatology models were able to answer the consult question without referral for face-to-face evaluation in 79.9-85.0% of consults, suggesting teleconsultation is a viable method to increase access to high-quality rheumatology care.

Leveraging Telemedicine as an Approach to Address Rheumatic Disease Health Disparities

Telerheumatology is the application of telehealth to rheumatic disease. Although generally acceptable to both providers and patients, little is known about the safety of telerheumatology or about when, how, and for whom it is best used. Telerheumatology's impact on the rheumatology workforce as well as access to care and health disparities in rheumatic disease is not known. These outcomes likely will depend on the specific telemedicine modalities employed.

Examining Racial Differences in Access to Primary Care for People Living with Lupus: Use of Ambulatory Care Sensitive Conditions to Measure Access

Background

People living with lupus may experience poor access to primary care and delayed specialty care.

Purpose

To identify characteristics that lead to increased odds of poor access to primary care for minorities hospitalized with lupus.

Methods

Cross-sectional design with 2011-2012 hospitalization data from South Carolina, North Carolina, and Florida. We used ICD-9 codes to identify lupus hospitalizations. Ambulatory care sensitive conditions were used to identify preventable lupus hospitalizations and measure access to primary care. Logistic regression was used to estimate the odds ratio for the association between predictors and having poor access to primary care. Sensitivity analysis excluded patients aged >65 years.

Results

There were 23,154 total lupus hospitalizations, and 2,094 (9.04%) were preventable. An adjusted model showed minorities aged ≥65 years (OR 2.501, CI 1.501, 4.169), minorities aged 40-64 years (OR 2.248, CI: 1.394, 3.627), minorities with Medicare insurance (OR 1.669, CI:1.353,2.059) and minorities with Medicaid (OR 1.662,CI:1.321, 2.092) had the highest odds for a preventable lupus hospitalization. Minorities with Medicare had significantly higher odds for ≥3 hospital days (OR 1.275, CI: 1.149, 1.415). Whites with Medicare (OR 1.291, CI: 1.164, 1.432) had the highest odds for ≥3 days.

Conclusions

Our data show that middle-aged minorities living with lupus and on public health insurance have a higher likelihood of poor access to primary care. Health care workers and policymakers should develop plans to identify patients, explore issues affecting access, and place patients with a community health worker or social worker to promote better access to primary care.

Rural health issues in rheumatology: a review

PURPOSE OF REVIEW

Early access to rheumatology is imperative to achieve appropriate outcomes in rheumatologic diseases. But there seems to be a significant gap and disparity in the access to rheumatology care between urban and rural areas. This review was undertaken to analyze this issue.

RECENT FINDINGS

A significant delay in diagnosis of rheumatic disorder has been correlated to the travel distance to rheumatologist. It is also clear that currently, a significant rheumatology workforce shortage exists and is projected to worsen significantly, thereby making this gap and disparity much bigger.

SUMMARY

The scope of this gap and disparity in rheumatology care for rural patients remains incompletely defined and quantified. It is felt to be a significant issue and it is important to invest resources to obtain information about its scope. In addition, a number of solutions already exist which can be implemented using current network and infrastructure. These include relatively low-cost interventions such as patient navigator, remote rheumatology experts and if possible tele-rheumatology. These interventions can assist temporarily but a major improvement will require policy change at federal and state government level as well as involvement, buy-in, and incentivization of the providers and health networks providing rheumatology care.

Impact of the Affordable Care Act Medicaid Expansion on Access to Care and Hospitalization Charges for Lupus Patients

OBJECTIVE

To examine the impact of the Affordable Care Act on preventable hospitalizations and associated charges for patients living with systemic lupus erythematosus, before and after Medicaid expansion.

METHODS

A retrospective, quasi-experimental study, using an interrupted time series research design, was conducted to analyze data for 8 states from the Healthcare Cost and Utilization Project state inpatient databases. Lupus hospitalizations with a principal diagnosis of predetermined ambulatory-care sensitive (ACS) conditions were the unit of primary analysis. The primary outcome variable was access to care measured by preventable hospitalizations caused by an ACS condition.

RESULTS

There were 204,150 lupus hospitalizations in the final analysis, with the majority (53.5%) of lupus hospitalizations in states that did not expand Medicaid. In unadjusted analysis, Medicaid expansion states had significantly lower odds of having preventable lupus hospitalizations (odds ratio [OR] 0.958); however, after adjusting for several covariates, Medicaid expansion states had increased odds of having preventable lupus hospitalizations (OR 1.302). Adjusted analysis showed that those individuals with increased age, public insurance (Medicare or Medicaid), no health insurance, rural residence, or low income had significantly higher odds of having a preventable lupus hospitalization. States that expanded Medicaid had $523 significantly more charges than states that did not expand Medicaid. Older age and rural residence were associated with significantly higher charges.

CONCLUSION

Our findings suggest that while Medicaid expansion increased health insurance coverage, it did not address other issues related to access to care that could reduce the number of preventable hospitalizations.

Underserved Communities: Enhancing Care with Graduate Medical Education

The shortage of health care professionals is projected to worsen in the coming years. This is particularly concerning in underserved areas that are fraught with disparities in disease outcomes and life expectancy, quality of life, and health care access. The onus is on medical education institutions to train students to serve vulnerable communities to improve both health care access and the quality of medical school education. When health disparities are formally included in medical education curricula and the culture of medical education shifts to a community-based learning approach, patients and health care providers alike will reap the benefits.

Addressing Health Disparities in Medical Education and Clinical Practice

Health and health care disparities are present in every medical specialty, and stem from multiple etiologies. Within health care itself, issues mostly arise within medical providers and across a system with an inequitable distribution of care and resources. One potential way to address disparities is to educate our workforce, to not only know about disparities but to also actively advocate for underresourced and marginalized patients. In this review, the authors describe efforts being conducted in graduate medical education and seek to elucidate some of the curricula currently being developed and implemented in rheumatology.

The early dissemination of patient navigation interventions: results of a respondent-driven sample survey

Patient navigators (PNs) coordinate medical services and connect patients with resources to improve outcomes, satisfaction, and reduce costs. Little national information is available to inform workforce development. We analyzed 819 responses from an online PN survey conducted in 2009-2010. Study variables were mapped to the five Consolidated Framework for Implementation Research (CFIR) constructs to explore program variations by type of PN. Five logistic regression models compared each PN type to all others while adjusting for covariates. Thirty-five percent of respondents were nurse navigators, 28% lay navigators, 20% social work (SW)/counselor navigators, 7% allied health navigators, and 10% were "other" types of PNs. Most were non-Hispanic White (71%), female (94%), and at least college educated (70%). The primary differences were observed among: the core intervention tasks; position structure; work setting; health conditions navigated; navigator race/ethnicity; personal cancer experiences; navigation training; and patient populations served. Lay PNs had fewer odds of identifying as Hispanic, work in rural settings and assist underserved populations compared to others. Nurse navigators showed greater odds of clinical responsibilities, work in hospital or government settings and fewer odds of navigating minority populations compared to others. SW/counselor navigators also had additional duties, provided greater assistance to Medicare patient populations, and less odds of navigating underserved populations than others. In summary, our survey indicates that the type of PN utilized is an indicator of other substantial differences in program implementation. CFIR provides a robust method to compare differences and should incorporate care coordination outcomes in future PN research.