Stand Up and Be Counted: Measuring and Mapping the Rheumatology Workforce in Canada

Intended and unintended consequences of strategies to meet performance benchmarks for rheumatologist referrals in a centralized intake system

RATIONALE

Timely assessment of a chronic condition is critical to prevent long-term irreversible consequences. Patients with inflammatory arthritis (IA) symptoms require diagnosis by a rheumatologist and intervention initiation to minimize potential joint damage. With limited rheumatologist capacity, meeting urgency wait time benchmarks can be challenging. We investigate the impact of the maximum wait time guarantee (MWTG) policy and referral volume changes in a rheumatology central intake (CI) system on meeting this challenge.

METHODS

We applied a system simulation approach to model a high-volume CI rheumatology clinic. Model parameters were based on the referral and triage data from the CI and clinic appointment data. We compare the wait time performance of the current distribution policy MWTG and when referral volumes change.

RESULTS

The MWTG policy ensures 100% of new patients see a rheumatologist within their urgency wait time benchmark. However, the average wait time for new patients increased by 51% (178-269 days). A 10% decrease in referrals resulted in a 76% decrease on average wait times (178-43 days) for new patients and an increase in the number of patients seen by a rheumatologist within 1 year of the initial visit.

CONCLUSION

An MWTG policy can result in intended and unintended consequences-ensuring that all patients meet the wait time benchmarks but increasing wait times overall. Relatively small changes in referral volume significantly impact wait times. These relationships can assist clinic managers and policymakers decide on the best approach to manage referrals for better system performance.

Longitudinal program evaluation of an inter-institutional mentorship network for pediatric rheumatology using a quality improvement framework

Background

The American College of Rheumatology (ACR)/Childhood Arthritis and Rheumatology Research Alliance (CARRA) Mentoring Interest Group (AMIGO) is an inter-institutional mentorship program launched to target mentorship gaps within pediatric rheumatology. Initial program evaluation indicated increased mentorship access. Given the small size of the pediatric rheumatology workforce, maintaining a consistent supply of mentors was a potential threat to the longevity of the network. Our aims were to: (i) describe the sustainability of AMIGO over the period 2011-2018, (ii) highlight ongoing benefits to participants, and (iii) describe challenges in the maintenance of a mentorship network.

Methods

A mixed-methods approach centered on a quality improvement framework was used to report on process and outcomes measures associated with AMIGO annual cycles.

Results

US and Canada Pediatric rheumatology workforce surveys identified 504 possible participants during the time period. As of fall 2018, 331 unique individuals had participated in AMIGO as a mentee, mentor or both for a program response rate of 66% (331/504). Survey of mentees indicated high satisfaction with impact on general career development, research/scholarship and work-life balance. Mentors indicated increased sense of connection to the community and satisfaction with helping mentees despite minimal perceived benefit to their academic portfolios. Based on AMIGO's success, a counterpart program, Creating Adult Rheumatology Mentorship in Academia (CARMA), was launched in 2018.

Conclusions

Despite the challenges of a limited workforce, AMIGO continues to provide consistent access to mentorship opportunities for the pediatric rheumatology community. This experience can inform approaches to mentorship gaps in other academic subspecialties.

Biological Sex Inequality in Rheumatology Wait Times During the COVID-19 Pandemic

OBJECTIVE

To examine the effect of biological sex on wait times to first rheumatology appointment in a central triage system before and during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

Deidentified data of all referred patients between November 2019 and June 2022 were extracted from the electronic medical record. Variables, including time from referral to first appointment, biological sex, referral period, urgency status, age, and geographic location were collected and analyzed.

RESULTS

Twelve thousand eight hundred seventeen referrals were identified. Wait times increased by 24.23 days in the peri-COVID period (P < 0.001). In the pre-COVID period, there was no significant difference in wait times by biological sex or age. Triage urgency was a predictor of wait time, with semiurgent referrals seen 8.94 days (95% CI -15.90 to -1.99) sooner than routine referrals and urgent referrals seen 25.42 days (95% CI -50.36 to -0.47) sooner than routine referrals. In the peri-COVID period, there was a significant difference in wait time by biological sex with women waiting on average 10.03 days (95% CI 6.98-13.09) longer than men (P < 0.001). Older patients had shorter wait times than younger patients, with a difference of -4.64 days for every 10-year increase in age (95% CI -5.49 to -3.78). Triage urgency continued to be a predictor of wait time.

CONCLUSION

Women and younger patients appear to have been affected by wait time increases during the COVID-19 pandemic. This finding should be further investigated to determine its pervasiveness across other specialities and to better understand the underlying cause of this finding.

Protocol for a systematic literature review of smartphone apps to support the self-management of rheumatic and musculoskeletal diseases: development strategies, theoretical underpinnings and barriers to engagement

BACKGROUND

Rheumatic and musculoskeletal diseases (RMDs) cause significant burden to the individual and society, requiring lifelong management and specialist healthcare resource use. Costing over 200 billion euros per year in Europe, RMDs are the most expensive of all diseases for European healthcare systems. The incidence and burden of RMDs are projected to rise with the ageing global population and increase in sedentary, obesogenic lifestyles. In parallel, there is a global crisis in the rheumatology workforce, whereby capacity to deliver specialist care is being exceeded by demand. Pervasive, scalable mobile health technologies, such as apps, are being developed to support the self-management of RMDs and reduce pressure on healthcare services. However, it is unknown whether these apps are informed by theory or their use supported by an appropriate evidence base. The purpose of this review is therefore to provide a comprehensive overview of the development strategies, interventional components and theoretical underpinnings of existing smartphone apps, designed to support the self-management of RMDs.

METHODS

Searches will be conducted within PubMed, Scopus, Web of Science, Embase, MEDLINE and PsycINFO. Reference lists and citing articles of the included studies will be searched. Identified publications will be screened for eligibility by two independent reviewers. Any discrepancies between reviewers will be resolved by consensus, with input from a third reviewer if required. Data will be extracted on study designs, methods, populations, setting, utilised theoretical frameworks, intervention components, behaviour change techniques, methods to evaluate effectiveness and barriers/facilitators to intervention engagement. Exploratory outcomes include reported effectiveness, acceptability and usability. A systematic, narrative synthesis of evidence will be presented. If appropriate (depending on quality and pool of evidence identified), qualitative meta-summary techniques will be used to combine and summarise qualitative findings regarding barriers/facilitators to intervention engagement.

DISCUSSION

The results of this systematic literature review will provide insights for healthcare professionals, researchers, app designers and policy makers, to inform future development and implementation of smartphone apps to support self-management of RMDs. Evidence gaps for future research will be identified. Findings will be disseminated through a final manuscript/publication of results and via a conference abstract, patient organisations and social media.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022359704.

Healthcare resource utilization and costs in stable patients with rheumatoid arthritis: Comparing nurse-led and rheumatologist-led models of care delivery

OBJECTIVES

Having previously shown similar clinical outcomes, this study compared the healthcare resource utilization and direct costs in stable patients with RA followed in the nurse-led care (NLC) and rheumatologist-led care (RLC) models.

METHODS

Previously collected clinical data were linked to data on practitioner claims, ambulatory care, and hospital discharges. Assessed resources included physician visits; emergency department (ED) visits; hospital admissions, and disease-modifying anti-rheumatic drugs (DMARDs). The mean per-patient resource utilization and cost (2020 Canadian dollars) over 1 year were compared between the groups using Wilcoxon rank-sum test. The mean per-patient cost of health services and total cost were also estimated using Generalized Linear Models (GLMs) accounting for the baseline differences between the groups.

RESULTS

Overall, 244 patients were included. No differences in the number of visits to the ED or to general practice and internal medicine physicians and orthopedic surgeons were found. The NLC group had fewer hospitalizations than the RLC group (p-value=0.03). The mean cost of health services was not statistically different in NLC and RLC groups ($2275 vs. $3772, p-value=0.30). The RLC group included more patients on biologic DMARDs, contributing to a higher mean total cost than the NLC group ($9191 vs. $3056, p-value<0.01). The mean cost estimates with GLMs were consistent with the observed costs.

CONCLUSIONS

A nurse-led model of care delivery for stable patients with RA was not associated with increases in healthcare resource utilization or cost as compared to RLC. NLC is one approach to meeting patient needs and better managing scarce healthcare resources.

Improving access to care for rheumatology services in Canada

Rheumatic diseases are becoming increasingly prevalent in Canada, and its associated strain on the healthcare system is expected to increase over the next decades. Furthermore, there is an increasing body of evidence to suggest that access to rheumatology care is currently not meeting established quality of care benchmarks. To frame issues affecting access to care for rheumatology services in Canada, a proposed chronological framework from a rheumatology patient's perspective is proposed. Illustrating principles from a health policy lens including drawing from the stages heuristic framework and multiple streams theory, issues surrounding access to rheumatology assessment, to rheumatological investigations and lastly to appropriate treatment are explored. In particular, the current supply and demand mismatch within the rheumatology workforce presents challenges for patients in accessing rheumatic diseases providers. Potential policy solutions including increasing the pool of rheumatic diseases care providers, enhancing the clinical capacity with extended role providers and increasing uptake of virtual care are discussed. To ameliorate access to rheumatology investigations, the concept of provider education surrounding the appropriateness of investigations and merit-based funding are explored. Lastly, access to rheumatological treatment is framed using biologic therapies as an example, highlighting the policy challenges in biosimilar uptake and associated ethical and political considerations. By using a health policy lens to explore deficiencies within Canada's current system, the overarching goal of this analysis is to set the stage for reasoned and timely solutions in the future.

Effectiveness and cost-effectiveness of combined asynchronous telemonitoring and patient-initiated care for spondyloarthritis: protocol for a pragmatic multicentre randomised controlled trial (TeleSpA Study)

INTRODUCTION

During the COVID-19 pandemic, an accelerated uptake of remote monitoring strategies, replacing traditional face-to-face care, has been observed. However, data on the effects of remote care interventions for patients with rheumatic and musculoskeletal diseases remain scarce and interpretation is hampered by study heterogeneity and research quality concerns. High-quality evidence is required to guide future implementation in clinical practice, with health economic analyses identified as an important knowledge gap. Randomised controlled trials (RCTs) comparing telemonitoring with conventional care for patients with spondyloarthritis (SpA) are currently lacking.

METHODS AND ANALYSIS

TeleSpA is a pragmatic, multicentre RCT investigating the effectiveness and cost-effectiveness of combined asynchronous telemonitoring and patient-initiated follow-up for patients with SpA, compared with conventional care. Two-hundred patients will be recruited at two hospitals and randomised (1:1) to the study intervention or standard care. The primary endpoint is a reduction in the number of follow-up visits by ≥25% in the intervention compared with standard care group, during a 1-year period. Secondary endpoints are (a) non-inferiority of the study intervention with regard to health outcomes, quality of care and patient-reported experience with care; and (b) cost-effectiveness of the intervention, evaluated through a prospective trial-based cost-utility analysis. In addition, experiences with the study intervention will be assessed among patients and healthcare providers, and factors associated with primary and secondary endpoints will be identified.

ETHICS AND DISSEMINATION

This study was approved by the Medical Research Ethics Committee of the Academic Hospital Maastricht/Maastricht University (NL71041.068.19/METC 19-059). Results will be disseminated through publications in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04673825.

Understanding sex-related differences in healthcare utilisation among patients with inflammatory arthritis: a population-based study

OBJECTIVES

Our aim was to compare patterns of musculoskeletal-related healthcare utilisation between male and female patients before and after the diagnosis of inflammatory arthritis (IA).

METHODS

We used Ontario administrative health data to create three inception cohorts of adult patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA) diagnosed between April 2010 and March 2017. Healthcare utilisation indicators including visits to physicians, and use of musculoskeletal imaging and laboratory tests were assessed in each year for 3 years before and after diagnosis and compared between male and female patients using regression models adjusting for sociodemographic factors and comorbidities. Results were reported as ORs with 95% CIs for female patients compared with male patients.

RESULTS

A total of 41 277 patients with RA (69% female), 8150 patients with AS (51% female) and 6446 patients with PsA (54% female) were analysed.Similar trends of sex-related differences were observed in all three cohorts. Before diagnosis, female patients were more likely to visit rheumatologists (OR 1.32-2.28) and family physicians (OR 1.03-1.15) for musculoskeletal reasons, whereas male patients were more likely to visit the emergency for musculoskeletal reasons (OR 0.76-0.87). A similar female predominance was observed regarding musculoskeletal imaging and laboratory tests before diagnosis. After diagnosis, female patients were more likely to remain in rheumatology care (OR 1.12-1.24).

CONCLUSION

Female patients with IA have higher healthcare utilisation than male patients which may indicate biological differences in disease course or sociocultural differences in healthcare-seeking behaviour.

Rheumatology Image of the Month: A Low Resource Innovation With Measurable Results

OBJECTIVES

Strategies to increase confidence in rheumatology knowledge are valuable for medical trainees and residents. A web-based teaching innovation was implemented in an attempt to increase rheumatology exposure for internal medicine residents.

METHODS

An Image of the Month webpage was established, where a practicing rheumatologist would post a new image that could be answered online by internal medicine residents. Cumulative data was analyzed to determine the extent and change in rheumatology exposure.

RESULTS

The Image of the Month webpage posted images for a total of 76 months between July 2010 to May 2017, with a total of 1326 submitted responses. The proportion of residents who only participated in Image of the Month and only did a rheumatology rotation averaged 36.1% and 16.5%, respectively. The proportion of residents who only participated in Image of the Month was higher than the proportion who only did a rheumatology rotation for all of the 7 time periods assessed. A total of 491 residents participated in Image of the Month, with an average of 54.9% of residents participating each year. Overall, on average, 52 residents had 1 or more submissions, 3.6 entries were submitted per resident, and 17.4 entries were submitted per month. Junior residents (PGY1) participated more often than senior residents (PGY3).

CONCLUSIONS

The Image of the Month webpage successfully improves internal medicine resident exposure to rheumatology with minimal resources and manpower required. Further study is necessary to determine the impact this exposure may have on the abilities and confidence levels of internal medicine residents.

System-level performance measures of access to rheumatology care: a population-based retrospective study of trends over time and the impact of regional rheumatologist supply in Ontario, Canada, 2002-2019

OBJECTIVE

To determine whether there were improvements in rheumatology care for rheumatoid arthritis (RA) between 2002 and 2019 in Ontario, Canada, and to evaluate the impact of rheumatologist regional supply on access.

METHODS

We conducted a population-based retrospective study of all individuals diagnosed with RA between January 1, 2002 and December 31, 2019. Performance measures evaluated were: (i) percentage of RA patients seen by a rheumatologist within one year of diagnosis; and (ii) percentage of individuals with RA aged 66 years and older (whose prescription drugs are publicly funded) dispensed a disease modifying anti-rheumatic drug (DMARD) within 30 days after initial rheumatologist visit. Logistic regression was used to assess whether performance improved over time and whether the improvements differed by rheumatology supply, dichotomized as < 1 rheumatologist per 75,000 adults versus ≥1 per 75,000.

RESULTS

Among 112,494 incident RA patients, 84% saw a rheumatologist within one year: The percentage increased over time (adjusted odds ratio (OR) 2019 vs. 2002 = 1.43, p < 0.0001) and was consistently higher in regions with higher rheumatologist supply (OR = 1.73, 95% CI 1.67-1.80). Among seniors who were seen by a rheumatologist within 1 year of their diagnosis the likelihood of timely DMARD treatment was lower among individuals residing in regions with higher rheumatologist supply (OR = 0.90 95% CI 0.83-0.97). These trends persisted after adjusting for other covariates.

CONCLUSION

While access to rheumatologists and treatment improved over time, shortcomings remain, particularly for DMARD use. Patients residing in regions with higher rheumatology supply were more likely to access care but less likely to receive timely treatment.

[Health workforce development in rheumatology : A mapping exercise and wake-up call for health policy]

BACKGROUND AND OBJECTIVE

Health workforce shortage in German rheumatology has been identified as a healthcare service and delivery problem. Health policy has increased staffing targets, yet effective intervention strategies are lacking. This research aimed to systematically map the rheumatology workforce to improve the evidence for interventions and explore possibilities for more effective health workforce management.

METHODS

The WHO National Health Workforce Accounts provided a conceptual framework for the mapping exercise. Four major sets of indicators were selected, comprising staffing levels, health labor market flows, composition and education/training. A comparison of age groups and time series was applied to explore trends. Public statistics and other secondary sources served our analysis using descriptive methodology.

RESULTS

In Germany there are 1076 physicians specialized in internal medical rheumatology. Absolute numbers have nearly doubled (91%) since 2000 but with a strong demographic bias. Between 2000 and 2019 numbers markedly increased in the group aged 50 years and older but only by 9% in the younger group under 50 years; since 2010 the group aged 40-50 years even faces a decrease. In 2019, the absolute numbers of rheumatologists in retirement age exceeded those aged 40 years and under. Since 2015 an expanding workforce trend has overall flattened but this was strongest in the hospital sector; the numbers in resident training did not show any relevant growth.

CONCLUSION

Health workforce trends reveal that an available number of rheumatologists cannot meet new health policy planning targets. There is a need for effective health workforce management, focusing on innovation in resident training, improved task delegation and gender equality.

Development of an interdisciplinary early rheumatoid arthritis care pathway

Background

To develop an interdisciplinary care pathway for early rheumatoid arthritis (RA) including referral triage, diagnosis, and management.

Methods

Our process was a four-phase approach. In Phase 1, an anonymous survey was electronically distributed to division rheumatologists. This provided data to a small interprofessional working group of rheumatology team members who drafted an initial care pathway informed by evidence-based practice in Phase 2. In Phase 3, an education day was held with approximately 40 physicians (rheumatologists and rheumatology residents), members of our interprofessional team, and two clinic managers to review the proposed care elements through presentations and small group discussions. The care pathway was revised for content and implementation considerations based on feedback received. Implementation of the care pathway and development of strategies for evaluation is ongoing across multiple practice sites (Phase 4).

Results

Our care pathway promotes an approach to patient-centered early RA care using an interdisciplinary approach. Care pathway elements include triage processes, critical diagnostics, pre-treatment screening and vaccinations, and uptake of suggested RA pharmacologic treatment using shared decision-making strategies. Pathway implementation has been facilitated by nursing protocols and evaluation includes continuous monitoring of key indicators.

Conclusion

The ‘Calgary Early RA Care Pathway’ emphasizes a patient-centered and interdisciplinary approach to early RA identification and treatment. Implementation and evaluation of this care pathway is ongoing to support, highest quality care for patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-022-00267-x.

The Use of Mobile Health Apps in Clinical Practice Remains Challenging

According to several international recommendations, disease activity should be regularly monitored with validated outcome measures in patients with axial spondyloarthritis (axSpA), and therapy should be adapted accordingly.^1-3 Increasingly, healthcare providers are encouraged to also use patient-reported outcomes (PROs) for this purpose, to capture valuable data from the patient's perspective.

Healthcare utilization and costs for musculoskeletal disorders in Ontario, Canada

OBJECTIVE

To examine the magnitude and costs of ambulatory primary and specialist physician care and hospital service use for musculoskeletal disorders (MSDs) in Canada's largest province, Ontario.

METHODS

Administrative health databases were analyzed for fiscal year 2013-2014 for adults 18+ years, including data on physician services, emergency department (ED) visits and hospitalizations. ICD diagnostic codes were used to identify MSD services. A validated algorithm was used to estimate direct medical costs. Person visit rates and numbers of persons and visits were tabulated by care setting, age and sex, and physician specialty. Data were examined for all MSDs combined as well as specific diagnostic groupings.

RESULTS

Overall, 3.1 million adult Ontarians (28.5%) made 8 million outpatient physician visits associated with MSDs. These included 5.6 million primary care visits. MSDs accounted for 560,000, 12.3%, of all adult ED visits. Total costs for MSD-related care were $1.6 billion, with 12.6% of costs attributed to primary care, 9.2% to specialist care, 8.6% to ED care, 8.5% to day surgery and 61.2% of total costs associated with inpatient hospitalizations. Costs due to arthritis accounted for 40% of total MSD care costs ($639 million). MSD-related imaging costs were $169 million. Including these costs yields a total estimate of $1.8 billion for all MSDs combined.

CONCLUSION

MSDs place a significant and costly burden on the health care system. Health system planning needs to consider the large and escalating demand for care to reduce both the individual and population burden.

The impact of introducing multidisciplinary care assessments on access to rheumatology care in British Columbia: an interrupted time series analysis

Background

In 2011 the British Columbia (BC) Ministry of Health introduced a new fee-for-service billing code that allowed “Multidisciplinary Care Assessment” (MCA). This change has the potential to change access to and quality of care for patients. This study aimed to explore the impact on access to rheumatology services in the province.

Methods

Fee-for-service rheumatology billings were evaluated for each rheumatologist 2 years before and after use of the MCA code. Numbers of 1) unique patients and 2) services provided per month were used as proxy measures of access to care. A multiple-baseline interrupted time series model assessed the impact of the MCA on levels and trends of the access outcomes.

Results

Our analysis consisted of 82,360 patients cared for by 26 rheumatologists who billed for an MCA. In our primary analysis we observed a sustained increase in the mean number of unique patients of 4.9% (95% CI: 0.0% to 9.9%, p = 0.049) and the mean number of services of 7.1% (95% CI: 1.0% to 13.6%, (p = 0.021), per month provided by a rheumatologist, corresponding to the initial use of MCA.

Conclusion

The introduction of the MCA code was associated with an initial increase in the measures of access, which was maintained but did not increase over time. Our study suggests that the use of Multidisciplinary Care Assessment can contribute to expanding and/or sustaining access to care for people with complex chronic conditions, like rheumatic diseases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07715-x.

Results from the 2020 Canadian Rheumatology Association's Workforce and Wellness Survey

Objective

The Canadian Rheumatology Association (CRA) launched the Workforce and Wellness Survey to update the Canadian rheumatology workforce characteristics.

Methods

The survey included demographic and practice information, pandemic impacts, and the Mini-Z questionnaire to assess burnout. French and English survey versions were distributed to CRA members electronically between 10/14/2020-3/5/2021. The number of full-time equivalent (FTE) rheumatologists per 75,000 population was estimated from the median proportion of time in clinical practice multiplied by provincial rheumatologist numbers from the Canadian Medical Association (CMA).

Results

Forty-four percent (183/417) of the estimated practicing rheumatologists (149 adult; 34 pediatric) completed the survey. The median age was 47 years, 62% were female, and 28% planned to retire within the next 5-10 years. Respondents spent a median of 65% of their time in clinical practice. FTE rheumatologists per 75,000 ranged between 0 and 0.70 in each province/territory and 0.62 per 75,000 nationally. This represents a deficit of 1 to 78 FTE rheumatologists per province/territory and 194 FTE rheumatologists nationally to meet the CRA's workforce benchmark. Approximately half of survey respondents reported burnout (51%). Women were more likely to report burnout (OR 2.86, 95%CI: 1.42-5.93). Older age was protective against burnout (OR 0.95, 95%CI: 0.92, 0.99). As a result of the pandemic, 97% of rheumatologists reported spending more time engaged in virtual care.

Conclusion

There is a shortage of rheumatologists in Canada. This shortage may be compounded by the threat of burnout to workforce retention and productivity. Strategies to address these workforce issues are urgently needed.

Best Practices for Virtual Care, a Consensus Statement from the Canadian Rheumatology Association

Objective

To develop best practice statements for the provision of virtual care in adult and pediatric rheumatology for the Canadian Rheumatology Association's (CRA) Telehealth Working Group (TWG).

Methods

Four members of the TWG representing adult, pediatric, university-based and community rheumatology practices defined the scope of the project. A rapid literature review was conducted between April-May 2021 of existing systematic reviews, policy documents and published literature and abstracts on the topic. The review informed a candidate set of 7 statements and a supporting document. The statements were submitted to a 3-round (R) modified Delphi process with 22 panelists recruited through the CRA and patient advocacy organizations. Panelists rated the importance and feasibility of the statements on a Likert scale of 1-9. Statements with final median ratings between 7-9 with no disagreement were retained in the final set.

Results

21 (95%) panelists participated in R1, 15 (71%) in R2 and 18 (82%) in R3. All but one statement met inclusion criteria during R1. Revisions were made to 5/7 statements following R2 and an additional statement was added. All statements met inclusion criteria following R3. The statements addressed the following themes in the provision of virtual care: adherence to existing standards and regulations, appropriateness, consent, physical examination, patient-reported outcomes, use in addition to in-person visits, and complex co-management of disease.

Conclusion

The best practice statements represent a starting point for advancing virtual care in rheumatology. Future educational efforts to help implement these best practices and research to address identified knowledge gaps are planned.

Networks of Care: A Social Network Perspective of Distributed Multidisciplinary Care for People With Inflammatory Arthritis

OBJECTIVE

To explore how multidisciplinary inflammatory arthritis (IA) care is accessed from the perspectives of people with IA and their health care network members.

METHODS

In this phenomenological study, we used purposive sampling to recruit patients with IA for less than 5 years and age of more than 18 years who spoke English and reported two or more health care network members. We conducted one-to-one interviews with patients and their health care network members. Data were analysed using a social network perspective.

RESULTS

We interviewed 14 patient participants and 19 health care network members comprising health care providers and informal caregivers. An overarching theme of whole person (holistic) IA care was identified, with the following two broad multifaceted subthemes: 1) connected networks and whole person care and 2) network disconnect and disrupted access to care. The first subtheme notes how access to health care providers and social support was fundamental to holistic care and how care was facilitated by communication pathways that promoted care. The second subtheme illustrates impediments to access, including appointment time pressures, inadequacies in communication delivery modes, and family physicians' unfamiliarity with rheumatology care. Inequities in care were also reported.

CONCLUSION

Participants shared a goal of whole person care. Although health care networks included multiple disciplines, they did not always provide coordinated multidisciplinary care. Communication modes, linkages between network actors, and organizational structures governed the flow of information and resources through networks and influenced access to equitable whole person care. The development of health care system structures to support the flow of information and resource transfer is needed to promote network collaboration and equitable access to resources.

Rheumatology manpower in the public system in Catalonia (Spain)

OBJECTIVE

To determine the current state of Rheumatology in Catalonia and to update the information regarding previous studies.

MATERIAL AND METHODS DESIGN

Observational, descriptive and cross-sectional study. Data collection from January to June 2017.

SAMPLE

Rheumatologists practising public healthcare activity in Catalonia. An online questionnaire was sent to gather individual data and data from rheumatology services/sections.

RESULTS

Information was obtained on 109 rheumatologists: 39 men and 70 women; mean age: 47±9 years. The number of rheumatologists has increased by 8% over the past 5 years. One hundred and one (92.7%) doctors qualified as rheumatologists through the MIR. Rheumatology practice was mostly in a hospital setting: 68 (62.4%) physicians. Ninety-six (88.1%) rheumatologists were full-time practitioners. Fifty-four (50%) rheumatologists also practiced in the private sector. Clinical practice was predominant: 76% of daily time was devoted to this area. Of note, it was found that most of the rheumatology services, 24 (705), were dependent hierarchically on other services, namely internal medicine and orthopaedic surgery. There are still 6 hospitals in Catalonia without a rheumatologist.

CONCLUSIONS

The number of rheumatologists in the public health sector of Catalonia has increased over the past 5 years. The mean age of rheumatologists is advanced and there is a clear predominance of female practitioners in the specialty. Many rheumatology services depend on other services. Rheumatology activity is primarily focussed in the city of Barcelona.

Expectations and educational needs of rheumatologists, rheumatology fellows and patients in the field of precision medicine in Canada, a quantitative cross-sectional and descriptive study

Background

Precision medicine, as a personalized medicine approach based on biomarkers, is a booming field. In general, physicians and patients have a positive attitude toward precision medicine, but their knowledge and experience are limited. In this study, we aimed at assessing the expectations and educational needs for precision medicine among rheumatologists, rheumatology fellows and patients with rheumatic diseases in Canada.

Methods

We conducted two anonymous online surveys between June and August 2018, one with rheumatologists and fellows and one with patients assessing precision medicine expectations and educational needs. Descriptive statistics were performed.

Results

45 rheumatologists, 6 fellows and 277 patients answered the survey. 78% of rheumatologists and fellows and 97.1% of patients would like to receive training on precision medicine. Most rheumatologists and fellows agreed that precision medicine tests are relevant to medical practice (73.5%) with benefits such as helping to determine prognosis (58.9%), diagnosis (79.4%) and avoid treatment toxicity (61.8%). They are less convinced of their usefulness in helping to choose the most effective treatment and to improve patient adherence (23.5%). Most patients were eager to take precision medicine tests that could predict disease prognosis (92.4%), treatment response (98.1%) or drug toxicity (93.4%), but they feared potential negative impacts like loss of insurability (62.2%) and high cost of the test (57.5%).

Conclusions

Our study showed that rheumatologists and patients in Canada are overall interested in getting additional precision medicine education. Indeed, while convinced of the potential benefits of precision medicine tests, most physicians don’t feel confident in their abilities and consider their training insufficient to incorporate them into clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-021-00222-2.

Effectiveness of initial methotrexate-based treatment approaches in early rheumatoid arthritis: an elicitation of rheumatologists' beliefs

OBJECTIVES

To quantify rheumatologists' beliefs about the effectiveness of triple therapy (MTX + HCQ + SSZ) and other commonly used initial treatments for RA.

METHODS

In a Bayesian belief elicitation exercise, 40 rheumatologists distributed 20 chips, each representing 5% of their total weight of belief on the probability that a typical patient with moderate-severe early RA would have an ACR50 response within 6 months with MTX (oral and s.c.), MTX + HCQ (dual therapy) and triple therapy. Parametric distributions were fit, and used to calculate pairwise median relative risks (RR), with 95% credible intervals, and estimate sample sizes for new trials to shift these beliefs.

RESULTS

In the pooled analysis, triple therapy was perceived to be superior to MTX (RR 1.97; 1.35, 2.89) and dual therapy (RR 1.32; 1.03, 1.73). A pessimistic subgroup (n = 10) perceived all treatments to be similar, whereas an optimistic subgroup (n = 10) believed triple therapy to be most effective of all (RR 4.03; 2.22, 10.12). Similar variability was seen for the comparison between oral and s.c. MTX. Assuming triple therapy is truly more effective than MTX, a trial of 100 patients would be required to convince the pessimists; if triple therapy truly has no-modest effect (RR <1.5), a non-inferiority trial of 475 patients would be required to convince the optimists.

CONCLUSION

Rheumatologists' beliefs regarding the effectiveness of triple therapy vary, which may partially explain the variability in its use. Owing to the strength of beliefs, some may be reluctant to shift, even with new evidence.

Variations in Pediatric Rheumatology Workforce and Care Processes Across Canada

OBJECTIVE

To examine Canadian pediatric rheumatology workforce and care processes.

METHODS

Pediatric rheumatologists and allied health professionals (AHPs) participated. A designee from each academic centre provided workforce information including number of providers, total and breakdown of full-time equivalents (FTE), and triage processes. We calculated the clinical care FTE (cFTE) available per 75,000 (recommended benchmark) and 300,000 (adjusted) children using 2019 census data. The national workforce deficit was calculated as the difference between current and expected cFTEs. Remaining respondents were asked about ambulatory practices.

RESULTS

The response rate of survey A (workforce information) and survey B (ambulatory practice information) was 100% and 54%, respectively. The majority of rheumatologists (91%) practiced in academic centres. The median number of rheumatologists per centre was 3 (IQR:3) and median cFTE was 1.8 (IQR:1.5). The median cFTE per 75,000 was 0.2 (IQR:0.3) with a national deficit of 80 cFTEs. With the adjusted benchmark, there was no national deficit but a regional maldistribution of rheumatologists. All centres engaged in multidisciplinary practices with a median of 4 different AHPs, although the median FTE for AHPs was ≤1. Most centres (87%) utilized a centralized triage process. Of 9 (60%) centres that used an electronic triage process, 6 were able to calculate wait times. Most clinicians integrated quality improvement practices, such as pre-visit planning (68%), post-visit planning (68%), and periodic health outcome monitoring (36-59%).

CONCLUSION

This study confirms a national deficit at the current recommended benchmark. Most rheumatologists work in multidisciplinary teams, but AHP support may be inadequate.

Nurse-Led Care for Stable Patients with Rheumatoid Arthritis: Quality of Care in Routine Practice Compared to the Traditional Rheumatologist-Led Model

Introduction

This pragmatic non-inferiority study assessed quality of care within a nurse-led care (NLC) model for stable patients with rheumatoid arthritis (RA) compared to the traditional rheumatologist-led care (RLC) model.

Methods

Data were collected through a chart review. Baseline demographic and clinical characteristics were compared using Chi-square test and t test. The primary outcome measure was the percentage of patients being in remission or low disease activity (R/LDA) with the Disease Activity Score (DAS-28) ≤ 3.2 at 1-year follow-up. Process measures included the percentages of patients with chart documentation of (1) comorbidity screening; (2) education on flare management, and (3) vaccinations screening. Outcomes were summarized using descriptive statistics.

Results

Each group included 124 patients. At baseline, demographic and clinical characteristics were comparable between the groups for most variables. Exceptions were the median (Q1, Q3) Health Assessment Questionnaire Disability Index scores [0 (0, 0.25) in NLC and 0.38 (0, 0.88) in RLC, p = 0.01], and treatment patterns with 3% of NLC and 38% of RLC patients receiving a biologic agent, p = 0.01. NLC was non-inferior to RLC with 97% of NLC and 92% of RLC patients being in R/LDA at 1-year follow-up. Patients in the NLC group had better documentation across all process measures.

Conclusions

This study provided real-world evidence that the evaluated NLC model providing protocolized follow-up care for stable patients with RA is effective to address patients’ needs for ongoing disease monitoring, chronic disease management, education, and support.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00339-3.

An Advanced Clinician Practitioner in Arthritis Care (ACPAC) Maintains a Positive Patient Experience While Increasing Capacity in Rheumatology Community Care

Purpose

This study describes patient care experiences of solo-rheumatologist and co-managed care models utilizing an Advanced Clinician Practitioner in Arthritis Care-trained Extended Role Practitioner (ACPAC-ERP) in three community rheumatology practices.

Materials and Methods

Patients with inflammatory arthritis (IA) were assigned to care provided by one of three (2 senior, 1 early-career) community-based rheumatologists (usual care), or an ACPAC-ERP (co-managed care) for the 6-months following diagnosis. Patient experiences were surveyed using validated measures of patient satisfaction (Patient Doctor Interaction Scale-PDIS), global ratings of confidence and satisfaction, referral patterns, disease activity (RADAI) and self-perceived disability (HAQ-Disability) as well as demographic information. Practice capacity was evaluated 18-months prior to, and across, the study period.

Results

Of 55 participants (mean age 56.6 years, 61.8% female), 33 received co-managed care. Most participants were diagnosed with rheumatoid arthritis (65.5%) with a median symptom duration of 1.1 years. At 6-months, patients from both models of care were equally satisfied in terms of the information provided (usual care 4.6 vs co-managed care 4.7/5=greater satisfaction), rapport with health-care provider (4.6 vs 4.6/5) and having needs met (4.7 vs 4.5/5). Overall satisfaction was high (87.2 vs 85.3/100=completely satisfied) as was confidence in the system by which care was received (85.0 vs 82.1/100=completely confident). Usual care patients reported higher perceived disability than co-managed patients (HAQ-Disability 0.5 vs 0.2/3=unable to do). Significant differences in overall RADAI score (p=0.014) were found between the two models. The senior rheumatologist, with a previously saturated practice, attained a 37% capacity increase for new patients utilizing the co-managed care model.

Conclusion

The ACPAC-ERP model was equivalent to the solo-rheumatologist model with regard to patient experience and satisfaction. A co-management model utilizing a highly trained ACPAC-ERP can increase capacity in community rheumatology clinics for patients newly diagnosed with IA while maintaining confidence and satisfaction with their care.

Geographic Variation in the Prevalence of Rheumatoid Arthritis in Alberta, Canada

OBJECTIVES

Timely access to rheumatologists remains a challenge in Alberta, a Canadian province with vast rural areas, whereas rheumatologists are primarily clustered in metro areas. To address the goal of timely and equitable access to rheumatoid arthritis (RA) care, health planners require information at the regional and local level to determine the RA prevalence and the associated health care needs.

METHODS

Using Alberta Health administrative databases, we identified RA-prevalent cases (April 1, 2015-March 31, 2016) on the basis of a validated case definition. Age- and sex-standardized prevalence rates per 1000 population members and the standardized rates ratio (SRR) were calculated. We applied Global Moran's I and Gi* hotspot analysis using three different weight matrices to explore the geospatial pattern of RA prevalence in Alberta.

RESULTS

Among 38 350 RA cases (68% female; n = 26 236), the prevalence rate was 11.81 cases per 1000 population members (95% confidence interval [CI] 11.80-11.81) after age and sex standardization. Approximately 60% of RA cases resided in metro (Calgary and Edmonton) and moderate metro areas. The highest rate was observed in rural areas (14.46; 95% CI 14.45-14.47; SRR 1.28), compared with the lowest in metro areas (10.69; 95% CI 10.68-10.69; SRR 0.82). The RA prevalence across local geographic areas ranged from 4.7 to 30.6 cases. The Global Moran's I index was 0.15 using three different matrices (z-score 3.96-4.24). We identified 10 hotspots in the south and north rural areas and 18 cold spots in metro and moderate metro Calgary.

CONCLUSION

The findings highlight notable rural-urban variation in RA prevalence in Alberta. Our findings can inform strategies aimed at reducing geographic disparities by targeting areas with high health care needs.

Patient and Rheumatologist Perspectives on Tapering DMARDs in Rheumatoid Arthritis: A Qualitative Study

OBJECTIVES

To understand the perspectives of patients and rheumatologists for tapering DMARDs in RA.

METHODS

Using semi-structured interview guides, we conducted individual interviews and focus groups with RA patients and rheumatologists, which were audiotaped and transcribed. We conducted a pragmatic thematic analysis to identify major themes, comparing and contrasting different views on DMARD tapering between patients and rheumatologists.

RESULTS

We recruited 28 adult patients with RA (64% women; disease duration 1-54 years) and 23 rheumatologists (52% women). Attitudes across both groups towards tapering DMARDs were ambivalent, ranging from wary to enthusiastic. Both groups expressed concerns, particularly the inability to 'recapture' the same level of disease control, while also acknowledging potential positive outcomes such as reduced drug harms. Patient tapering perspectives (whether to and when) changed over time and commonly included non-biologic DMARDs. Patient preferences were influenced by lived experiences, side effects, previous tapering experiences, disease trajectory, remission duration, and current life roles. Rheumatologists' perspectives varied on timing and patient profile to initiate tapering, and were informed by both data and clinical experience. Patients expressed interest in shared decision making (SDM) and close monitoring during tapering, with ready access to their healthcare team if problems arose. Rheumatologists were generally open to tapering (not stopping), though sometimes only when requested by their patients.

CONCLUSION

The perspectives of patients and rheumatologists on tapering DMARDs in RA vary and evolve over time. Rheumatologists should periodically discuss DMARD tapering with patients as part of SDM, and ensure monitoring and flare management plans are in place.

Factors influencing rheumatology residents' decision on future practice location

BACKGROUND

There are regional disparities in the distribution of Canadian rheumatologists. The objective of this study was to identify factors impacting rheumatology residents' postgraduate practice decisions to inform Canadian Rheumatology Association workforce recommendations.

METHODS

An online survey was developed, and invitations were sent to all current Canadian rheumatology residents in 2019 (n = 67). Differences between subgroups of respondents were examined using the Pearson χ² test.

RESULTS

A total of 34 of 67 residents completed the survey. Seventy-three percent of residents planned to practice in the same province as their rheumatology training. The majority of residents (80%) ranked proximity to friends and family as the most important factor in planning. Half of participants had exposure to alternative modes of care delivery (e.g. telehealth) during their rheumatology training with fifteen completing a community rheumatology elective (44%).

CONCLUSIONS

The majority of rheumatology residents report plans to practice in the same province as they trained, and close to home. Gaps in training include limited exposure to community electives in smaller centers, and training in telehealth and travelling clinics for underserviced populations. Our findings highlight the need for strategies to increase exposure of rheumatology trainees to underserved areas to help address the maldistribution of rheumatologists.

Systematic Review of Outcomes and Patient Experience with Virtual Care in Rheumatoid Arthritis

OBJECTIVE

To conduct a systematic review on patient outcomes of virtual care compared to conventional care in rheumatoid arthritis (RA) including disease activity and patient experience.

METHODS

A systematic search of MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials was performed from database inception to 03/19/2020. Observational and randomized controlled trials (RCTs) describing the use of RA virtual care supplanting conventional visits and reporting on disease activity and/or patient experience were included. A narrative synthesis of results was conducted as a meta-analysis was not possible due to heterogeneity of study designs and outcome reporting.

RESULTS

352 studies were identified, and 6 were selected for final inclusion: 3 were RCTs and 3 were observational studies. Disease activity and patient experience were comparable between virtual and conventional care models. In addition, one RCT found no difference in observed outcomes between virtual care delivered by a rheumatologist and by a rheumatology nurse. Virtual care was found to have additional benefits for improved treatment adherence, maintenance of functional status, and quality of life. The overall risk of bias was low in 2/3 RCTs, but high in the observational studies. Study quality was limited by incomplete data reporting, lack of sample size justification and sufficient timeframe to assess objectives.

CONCLUSIONS

There is limited evidence that virtual RA care is an acceptable alternative to conventional care, maintaining comparable patient outcomes and experience of care. Additional research into effective implementation strategies and long-term health system and patient outcomes of virtual care are needed.

SIGNIFICANCE AND INNOVATIONS

There is a paucity of research in the use of virtual care for rheumatology, especially describing the ability of virtual care modalities to supplant in person visits. Virtual care for rheumatoid arthritis (RA) management appears in the short term to provide equivalent control of disease activity and good patient experience compared to conventional follow-up strategies. Future studies should evaluate the long-term impacts of virtual care on RA outcomes and health service utilization.

Evaluation of Rheumatology Workforce Supply Changes in Ontario, Canada, from 2000 to 2030

Rheumatology workforces are increasingly challenged by too few physicians in face of the growing burden of rheumatic and musculoskeletal diseases (RMDs). Rheumatology is one of the most frequent non-surgical specialty referrals and has the longest wait times for subspecialists. We used a population-based approach to describe changes in the rheumatology workforce, patient volumes and geographic variation in the supply of and access to rheumatologists, in Ontario, Canada, between 2000 and 2019, and projected changes in supply by 2030. Over time, we observed greater feminization of the workforce and increasing age of workforce members. We identified a large regional variation in rheumatology supply. Fewer new patients are seen annually, which likely contributes to increasing wait times and reduced access to care. Strategies and policies to raise the critical mass and improve regional distribution of supply to effectively provide rheumatology care and support the healthcare delivery of patients with RMDs are needed.

Participant-reported effect of an Indigenous health continuing professional development initiative for specialists

BACKGROUND

Health outcomes of Indigenous patients are impacted by culturally unsafe specialty care environments. The 'Educating for Equity (E4E)' program is a continuing professional development (CPD) intervention which incorporates skill-based teaching to improve Indigenous patient experiences and outcomes in healthcare interactions.

METHODS

The E4E program was delivered to rheumatologists in two phases, each delivered as experiential learning workshops where participants engaged with and applied course content within an interactive format focusing on real-time feedback. The phase 1 workshop focused on skill development of E4E Framework concepts and principles. Phase 2 concentrated on building capacity for teaching of E4E content. Evaluation of the program's effectiveness was through longitudinal responses to the Social Cultural Confidence in Care Survey (SCCCS), self-reported strategies employed to address social issues and improve therapeutic relationships, engagement with teaching others, and satisfaction with the program.

RESULTS

Two cohorts of participants have participated in the program (n = 24 Phase 1, n = 10 Phase 2). For participants completing both phases of training, statistically significant improvements were observed in exploring social factors with patients, gaining knowledge and skills related to cultural aspects of care, improved communication and relationship building, and reflections on held stereotypes. Strategies to address social issues and build therapeutic relationships remained consistent throughout participation, while the training enhanced exploration and confidence to ask about cultural and traditional practices, and stronger communication strategies for exploring beliefs, expectations, social barriers, and residential school impacts on health. Participants reported feeling prepared to teach Indigenous health concepts to others and subsequently lead teaching with residents, fellows, and allied health professionals. Satisfaction with the delivery and content of the workshops was high, and participants valued interactions with peers in learning.

CONCLUSIONS

This CPD intervention had a beneficial impact on self-reported confidence and enhanced practice strategies to engage with Indigenous patients.

Delivery of paediatric rheumatology care: a survey of current clinical practice in Southeast Asia and Asia-Pacific regions

BACKGROUND

Paediatric rheumatic diseases are a leading cause of acquired disability in Southeast Asia and Asia-Pacific Countries (SE ASIA/ASIAPAC). The aims of this study were to identify and describe the challenges to the delivery of patient care and identify solutions to raise awareness about paediatric rheumatic diseases.

METHODS

The anonymised online survey included 27 items about paediatric rheumatology (PR) clinical care and training programmes. The survey was piloted and then distributed via Survey-Monkey™ between March and July 2019. It was sent to existing group lists of physicians and allied health professionals (AHPs), who were involved in the care pathways and management of children with rheumatic diseases in SE ASIA/ASIAPAC.

RESULTS

Of 340 participants from 14 countries, 261 participants had been involved in PR care. The majority of the participants were general paediatricians. The main reported barriers to providing specialised multidisciplinary service were the absence or inadequacy of the provision of specialists and AHPs in addition to financial issues. Access to medicines was variable and financial constraints cited as the major obstacle to accessing biological drugs within clinical settings. The lack of a critical mass of specialist paediatric rheumatologists was the main perceived barrier to PR training.

CONCLUSIONS

There are multiple challenges to PR services in SE ASIA/ASIAPAC countries. There is need for more specialist multidisciplinary services and greater access to medicines and biological therapies. The lack of specialist paediatric rheumatologists is the main barrier for greater access to PR training.

Current status of the rheumatologists' workforce in Latin America: a PANLAR collaborative study

INTRODUCTION

Studies conducted by various scientific societies have shown that the demand for specialized rheumatology care is greater than the projected growth of the workforce. Our research aims to assess the current status of the rheumatology workforce in Latin America.

METHOD

This is a descriptive, cross-sectional study. A survey was created on the RedCap platform. Data were analyzed with STATA 15® Software. We present descriptive analyses. The rate of inhabitants per rheumatologist was calculated using the number of rheumatologists practicing in each country and the inhabitants for year 2020.

RESULTS

Our sample was composed by 19 PANLAR member countries in Latin America. Latin America has one rheumatologist per 106,838 inhabitants. The highest rate of rheumatologist per inhabitants was found in Uruguay (1 per 27,426 inhabitants), and the lowest was found in Nicaragua (1 per 640,648 inhabitants). Mean age was 51.59 (SD12.70), ranging between 28 and 96 years of age. Mean monthly compensation was USD $2382.6 (SD$1462.5). The country with lowest salary was Venezuela ($197), whereas the highest was Costa Rica ($4500).

CONCLUSIONS

There is a high variability in rheumatologists' workforce characteristics in Latin America. These results could lead to policies aiming to increase the availability and income of rheumatologists, in order to increase opportunity and quality of care of patients living with rheumatic diseases. Key Points • The rheumatologists' workforce varies significantly among Latin American countries. • The supply of rheumatologists is insufficient for meeting the increasing need for specialists in this field.

Feminization of the Rheumatology Workforce: A Longitudinal Evaluation of Patient Volumes, Practice Sizes, and Physician Remuneration

OBJECTIVE

To compare differences in clinical activity and remuneration between male and female rheumatologists and to evaluate associations between physician gender and practice sizes and patient volume, accounting for rheumatologists' age, and calendar year effects.

METHODS

We conducted a population-based study in Ontario, Canada, between 2000 to 2015 identifying all rheumatologists practicing as full-time equivalents (FTEs) or above and assessed differences in practice sizes (number of unique patients), practice volumes (number of patient visits), and remuneration (total fee-for-service billings) between male and female rheumatologists. Multivariable linear regression was used to evaluate the effects of gender on practice size and volume separately, accounting for age and year.

RESULTS

The number of rheumatologists practicing at ≥ 1 FTE increased from 89 to 120 from 2000 to 2015, with the percentage of females increasing from 27.0% to 41.7%. Males had larger practice sizes and practice volumes. Remuneration was consistently higher for males (median difference of CAD $46,000-102,000 annually). Our adjusted analyses estimated that in a given year, males saw a mean of 606 (95% CI 107-1105) more patients than females did, and had 1059 (95% CI 345-1773) more patient visits. Among males and females combined, there was a small but statistically significant reduction in mean annual number of patient visits, and middle-aged rheumatologists had greater practice sizes and volumes than their younger/older counterparts.

CONCLUSION

On average, female rheumatologists saw fewer patients and had fewer patient visits annually relative to males, resulting in lower earnings. Increasing feminization necessitates workforce planning to ensure that populations' needs are met.

Global Rural and Remote Patients with Rheumatoid Arthritis: A Systematic Review

Objective

Rural and remote patients with rheumatoid arthritis (RA) are at risk for inequities in health outcomes based on differences in physical environments and health care access potential compared to urban populations. The aim of this systematic review was to synthesize epidemiology, clinical outcomes, and health service use reported for global populations with RA residing in rural and remote locations.

Methods

Medline, Embase, HealthStar, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Library were searched from inception to June 2019 using librarian‐developed search terms for RA and rural and remote populations. Peer‐reviewed published manuscripts were included if they reported on epidemiologic, clinical, or health service use outcomes.

Results

Fifty‐four articles were included for data synthesis, representing studies from all continents. In 11 studies in which there was an appropriate urban population comparator, rural and remote populations were not at increased risk for RA; 1 study reported increased prevalence, and 5 studies reported decreased prevalence in rural and remote populations. Clinical characteristics of rural and remote populations in studies with an appropriate urban comparator showed no significant differences in disease activity measures or disability, but 1 study reported worse physical function and health‐related quality of life in rural and remote populations. Studies reporting on health service use provided evidence that rural and remote residence adversely impacts diagnostic time, ongoing follow‐up, access to RA‐care–related practitioners and services, and variation in medication access and use, with prominent heterogeneity noted between countries.

Conclusion

RA epidemiology and clinical outcomes are not necessarily different between rural/remote and urban populations within countries. Rural and remote patients face greater barriers to care, which increases the risk for inequities in outcomes.

National Priorities for High-quality Rheumatology Transition Care for Youth in Canada

OBJECTIVE

To conduct a needs assessment and environmental scan to support optimal transition from pediatric to adult rheumatology care in Canada.

METHODS

This initiative involved 3 phases: (1) a survey-based needs assessment of adult and pediatric rheumatologist members of the Canadian Rheumatology Association to identify perceived infrastructure, educational needs, and national resources to support transition care; (2) an environmental scan, through semistructured interviews, of existing rheumatology transition service care models and challenges in care delivery; and (3) a focus group to prioritize national activities.

RESULTS

The needs assessment survey was completed by 65 members, with 66% agreeing that a national approach to transition care was needed. Semistructured interviews reflecting activities at 9 transition care sites were conducted, and they identified candidate models of care, including direct transfer, progressive transfer, and shared care models. Challenges and needs experienced in these care models reflected resource and infrastructure needs, poor availability of mechanisms to support parents and youth through the transition process, and the need for evaluation to support quality improvement. The focus group and prioritization activity was attended by 26 participants, with each having the ability to cast 3 votes. "Supporting patient education for transition to adult rheumatology health care system" (n = 17 votes) and "advocacy activities to access allied health support, including funding" (n = 10 votes) emerged as the top priorities for national initiatives.

CONCLUSION

We have identified priorities in education and advocacy for advancing transition care in Canada that require participation of pediatric and adult rheumatology providers, patients, and arthritis stakeholders in the interest of advancing transition care outcomes.

Pulmonary arterial hypertension screening practices in scleroderma patients among Canadian rheumatologists

Background:

Current international guidelines recommend annual screening for pulmonary arterial hypertension with transthoracic echocardiogram and pulmonary function testing in all patients with scleroderma (systemic sclerosis). Our objectives were to determine Canadian rheumatologists’ screening practices for pulmonary arterial hypertension in patients with systemic sclerosis and identify reasons why current guideline recommendations may not be followed.

Methods:

A survey was emailed to all Canadian Rheumatology Association members. They self-identified as systemic sclerosis experts or non-experts and provided basic demographic data. Participants were asked how frequently they screened with transthoracic echocardiogram and pulmonary function testing and, if applicable, why they did not adhere to recommendations.

Results:

A total of 71 rheumatologists participated, of whom 43 identified as non-experts. Overall, 81.4% ordered annual transthoracic echocardiogram and 77.6% annual pulmonary function testing. Rates of annual transthoracic echocardiogram testing were similar between experts and non-experts, whereas experts ordered annual pulmonary function testing more often. Clinicians with a higher proportion of systemic sclerosis patients in their practice were more likely to follow guidelines. There was an inverse relationship between years in practice and adherence to screening guidelines. The most common reason for not following screening guidelines was disagreement with recommendations, followed by unfamiliarity with guidelines.

Conclusions:

Pulmonary arterial hypertension screening rates remain sub-optimal in Canada but have improved since 2012. Failure to adopt guidelines is due to rheumatologists disagreeing with or not knowing current recommendations. Future studies should examine why rheumatologists disagree with guidelines and how to improve awareness.

Evaluating Quality of Care for Rheumatoid Arthritis for the Population of Alberta Using System-level Performance Measures

OBJECTIVE

We evaluated 4 national rheumatoid arthritis (RA) system-level performance measures (PM) in Alberta, Canada.

METHODS

Incident and prevalent RA cases ≥ 16 years of age since 2002 were identified using a validated case definition applied in provincial administrative data. Performance was ascertained through analysis of health data between fiscal years 2012/13-2015/16. Measures evaluated were as follows: proportion of incident RA cases with a rheumatologist visit within 1 year of first RA diagnosis code (PM1); proportion of prevalent RA patients who were dispensed a disease-modifying antirheumatic drug (DMARD) annually (PM2); time from first visit with an RA code to DMARD dispensation and proportion of incident cases where the 14-day benchmark for dispensation was met (PM3); and proportion of patients seen in annual follow-up (PM4).

RESULTS

There were 31,566 prevalent and 2730 incident RA cases (2012/13). Over the analysis period, the proportion of patients seen by a rheumatologist within 1 year of onset (PM1) increased from 55% to 63%; however, the proportion of RA patients dispensed DMARD annually (PM2) remained low at 43%. While the median time to DMARD from first visit date in people who received DMARD improved over time from 39 days to 28 days, only 38-41% of patients received treatment within the 14-day benchmark (PM3). The percentage of patients seen in yearly follow-up (PM4) varied between 73-80%.

CONCLUSION

The existing Alberta healthcare system for RA is suboptimal, indicating barriers to accessing specialty care and treatment. Our results inform quality improvement initiatives required within the province to meet national standards of care.

Models of Arthritis Care: A Systems-level Evaluation of Acceptability as a Dimension of Quality of Care

OBJECTIVE

To describe a systems-level baseline evaluation of central intake (CI) and triage systems in arthritis care within Alberta, Canada. The specific objectives were to (1) describe a process for systems evaluation for the provision of arthritis care; (2) report the findings of the evaluation for different clinical sites that provide arthritis care; and (3) identify opportunities for improving appropriate and timely access based on the findings of the evaluation.

METHODS

The study used a convergent mixed methods design. Surveys and semistructured interviews were the main data collection methods. Participants were recruited through 2 rheumatology clinics and 1 hip and knee clinic providing CI and triage, and included patients, referring physicians, specialists, and clinic staff who experienced CI processes.

RESULTS

A total of 237 surveys were completed by patients (n = 169), referring physicians (n = 50), and specialists (n = 18). Interviews (n = 25) with care providers and patients provided insights to the survey data. Over 95% of referring physicians agreed that the current process of CI was satisfactory. Referring physicians and specialists reported issues with the referral process and perceived support in care for wait-listed patients. Patients reported positive experiences with access and navigation of arthritis care services but expressed concerns around communication and receiving minimal support for self-management of their arthritis before and after receiving specialist care.

CONCLUSION

This baseline evaluation of CI and triage for arthritis care indicates satisfaction with the service, but areas that require further consideration are referral completion, timely waiting lists, and further supporting patients to self-manage their arthritis.

Rheumatology Manpower in the Public System in Catalonia (Spain)

OBJECTIVE

To determine the current state of Rheumatology in Catalonia and to update the information regarding previous studies.

MATERIAL AND METHODS DESIGN

Observational, descriptive and cross-sectional study. Data collection from January to June 2017.

SAMPLE

Rheumatologists practising public healthcare activity in Catalonia. An online questionnaire was sent to gather individual data and data from rheumatology services/sections.

RESULTS

Information was obtained on 109 rheumatologists: 39 men and 70 women; mean age: 47±9 years. The number of rheumatologists has increased by 8% over the past 5 years. One hundred and one (92.7%) doctors qualified as rheumatologists through the MIR. Rheumatology practice was mostly in a hospital setting: 68 (62.4%) physicians. Ninety-six (88.1%) rheumatologists were full-time practitioners. Fifty-four (50%) rheumatologists also practiced in the private sector. Clinical practice was predominant: 76% of daily time was devoted to this area. Of note, it was found that most of the rheumatology services, 24 (705), were dependent hierarchically on other services, namely internal medicine and orthopaedic surgery. There are still 6 hospitals in Catalonia without a rheumatologist.

CONCLUSIONS

The number of rheumatologists in the public health sector of Catalonia has increased over the past 5 years. The mean age of rheumatologists is advanced and there is a clear predominance of female practitioners in the specialty. Many rheumatology services depend on other services. Rheumatology activity is primarily focussed in the city of Barcelona.

LARS study: Latin American rheumatologist survey

BACKGROUND/OBJECTIVE

Latin America has scarce information related to rheumatologist's education, working conditions, productivity, and job satisfaction. The purpose of this survey was to describe the training and clinical practice characteristics of the rheumatology community in Latin America.

METHODS

This is a cross-sectional study. A digital survey was created, approved, and endorsed by the scientific committee of the Pan-American League of Associations for Rheumatology (PANLAR) and later sent to the rheumatology associations of the region. The data was analyzed in the statistical program SPSS v.22.

RESULTS

We included 600 surveys of rheumatologists from 19 Latin American countries. The majority were females (53%) and mestizos (58%). The mean age was 46.8 ± 11.7 years. The most frequent workplace was public/government hospitals 33.5% followed by private practice 28.8%, private hospital 20.8%, and university hospital 15.5%. The average number of weekly working hours was 37.8 ± 17.7. 87.5% worked in adult rheumatology, 12.7% pediatric rheumatology, and 23.5% internal medicine. Average satisfaction with practice as a rheumatologist was 5.3/7, career options 4.3/7, location 4.7/7, income 3.5/7, job security 3.7/7, and colleagues and co-workers 4.5/7. Finally, 69.7% had an annual compensation of < 50,000 US dollars.

CONCLUSIONS

The majority of the rheumatologists in the region who responded were women, worked in public hospitals, and were satisfied with their clinical practice. There was a low level of income for the region. Key Points • This is the first study that showed the demographic and clinical practice characteristics of rheumatologists in Latin America. • The challenges faced by Latin rheumatologists are like those faced by the region: ethnic diversity, gender differences, migration, difficult access to education, limited research, and low income. • Due to the high prevalence of rheumatic diseases and the shortage of professionals in this area, it is essential to analyze the current workforce and the projections of supply and demand in rheumatology that are expected in the future.

Determination of Rheumatoid Arthritis Incidence and Prevalence in Alberta Using Administrative Health Data

OBJECTIVE

The objective of the study was to estimate the incidence and prevalence of rheumatoid arthritis (RA) in Alberta using administrative health data.

METHODS

We identified RA cases in patients 16 years and older by applying a national case definition to linked administrative health data (ie, hospital discharge abstract records, physician claims, and health insurance registry records) using a unique personal identifier. Incidence and prevalence are reported for the 2015-2016 fiscal year and a trend analysis from 2011-2012 to 2015-2016. Incidence and prevalence estimates were standardized using the 2011 Canadian census population.

RESULTS

In 2015-2016, the overall crude incidence was 0.74 [95% confidence interval (CI): 0.71-0.77] per 1000 and crude prevalence was 1.08% (95% CI: 1.07-1.09). The women-to-men crude incidence and prevalence sex ratios were 2.04 and 2.19, respectively. People aged 65 to 79 years had the highest incidence of RA, and the highest prevalence was observed among those 80 years and older. From 2011-2012 to 2015-2016, the overall age-standardized incidence decreased [0.97 (95% CI: 0.94-1.01) to 0.79 (95% CI: 0.76-0.82) per 1000], whereas age-standardized prevalence remained constant [1.17 (95% CI: 1.15-1.18) to 1.18 (95% CI: 1.17-1.19)].

CONCLUSION

In Alberta, there was a decreasing trend in RA incidence over the study period, whereas prevalence was stable. These estimates, combined with clinical data, will be used to measure system performance for quality improvement and to inform simulation modeling for planning the expected demand for health services for patients living with RA.

Alternative care providers in rheumatoid arthritis patient care: a queueing and simulation analysis

Patients diagnosed with rheumatoid arthritis require lifelong monitoring by a rheumatologist. Initiation of the disease-modifying anti-rheumatic drug therapy within twelve weeks of the onset of symptoms is crucial to prevent joint damage and functional disability. We examine the impact of the engagement of alternate care providers (ACP) in alleviating delay due to limited rheumatologist capacity. Using queueing theory and discrete-event simulation, we model rheumatologist-only and rheumatologist-with-ACP system configurations as closed, multi-class queueing networks with class switching.Using summary data from an actual rheumatology clinic for illustration, we analyze various parameter conditions to aid clinic managers and policymakers in decisions concerning capacity allocations and feasible patient panel size that impact timeliness of care and resource utilization.Results not only confirm that a substantial increase in RA patient panel size with an ACP involved in the care of follow-up patients but also demonstrates the boundaries for feasible panel sizes and workload allocation.

Patient-provider communication about medication cost in rheumatoid arthritis

OBJECTIVE

To examine the perceived importance and frequency with which out-of-pocket medication costs are discussed between rheumatologists and patients with rheumatoid arthritis (RA) in Canada.

METHODS

A cross-sectional online survey was distributed to patients with RA and rheumatologists; both were asked to rate their perceived importance of discussing medication costs, and how often these discussions occurred. Predictors of (1) patients discussing costs with their rheumatologist and (2) the perceived importance of discussing medication cost for patients were explored.

RESULTS

Seventy-eight patients and 64 rheumatologists completed the survey; 68% patients and 75% of physicians rated the perceived importance of discussing medication costs as "quite" or "very important"; 22% of patients reported never talking about medication cost, but no physicians reported never discussing costs with patients. The only predictor of talking about cost among patients (at 10% level) was whether they perceived it as highly important (p = 0.058). Higher perceived importance of discussing out-of-pocket costs was associated with a more positive attitude to shared decision-making (p = 0.044).

CONCLUSION

Discussions about cost do not always happen, even with diseases with potentially high medication costs like RA. Cost was more likely to be discussed by patients who perceived it as "very important," suggesting the onus might be on patients to initiate these conversations. Without any significant predictors regarding what may make physicians more likely to think it was important to discuss medication costs, there is a need to reinforce recommendations that all physicians seek to discuss costs with all of their patients when suggesting medications. Key Points • There is a need for patients and physicians to discuss costs in the treatment decision-making process. Our findings suggest this does not always happen. • Among patients, medication cost was more likely to be discussed by those who perceived it as "very important" and higher perceived importance of discussing out-of-pocket costs was associated with a more positive attitude to shared decision-making. • Our results did not reveal any significant predictors regarding what may make physicians more likely to think it was important to discuss medication costs, suggesting that there is a need to reinforce recommendations that all physicians seek to discuss medication costs with all of their patients when suggesting medications.

Measuring Advanced/Extended Practice Roles in Arthritis and Musculoskeletal Care in Canada

Objective

Our objective was to characterize Canadian workforce attributes of extended role practitioners (ERPs) in arthritis care.

Methods

We used an exploratory, mixed‐methods study that was based on the Canadian Rheumatology Association's Stand Up and Be Counted Rheumatologist Workforce Survey (2015). An anonymous online survey was deployed to groups of non‐physician health care professionals across Canada who potentially had post‐licensure training in arthritis care. Demographic and practice information were elicited. Qualitative responses were analyzed using grounded theory techniques.

Results

Of 141 respondents, 91 identified as practicing in extended role capacities. The mean age of ERP respondents was 48.7; 87% were female, and 41% of ERPs planned to retire within 5 to 10 years. Respondents were largely physical or occupational therapists by profession and practiced in urban/academic (46%), community (39%), and rural settings (13%). Differences in practice patterns were noted between ERPs (64.5%) and non‐ERPs (34.5%), with more ERPs working in extended role capacities while retaining activities reflective of their professional backgrounds. Most respondents (95%) agreed that formal training is necessary to work as an ERP, but only half perceived they had sufficient training opportunities. Barriers to pursuing training were varied, including personal barriers, geographic barriers, patient‐care needs, and financial/remuneration concerns.

Conclusion

To our knowledge, no previous studies have assessed the workforce capacity or the perceived need for the training of ERPs working in arthritis and musculoskeletal care. Measurement is important because in these health disciplines, practitioners’ scopes of practice evolve, and ERPs integrate into the Canadian health care system. ERPs have emerged to augment provision of arthritis care, but funding for continuing professional development opportunities and for role implementation remains tenuous.

Preferences for treatments to prevent rheumatoid arthritis in Canada and the influence of shared decision-making

OBJECTIVE

To elicit and compare preferences of patients and first-degree relatives and rheumatologists for preventive treatments for rheumatoid arthritis, understand the influence of shared decision-making, and predict the probability of uptake of the preventive treatments currently being studied.

METHODS

An online discrete choice experiment was completed by patients and their first-degree relatives and rheumatologists. Results were analysed using mixed logit model to estimate preferences for the key features of treatments. Preferences for features of treatments were used to predict the probability of uptake of seven preventive treatment options.

RESULTS

A total of 108 potential recipients (78 patients and 30 of their first-degree relatives) and 39 rheumatologists completed the survey. Preferences of patients/first-degree relatives and rheumatologists were similar (shared decision-making was most important, followed by the risk of side effects and potential benefit), but subtle differences existed; rheumatologists placed greater importance on certainty in evidence than patients/first-degree relatives, who felt that how a treatment was taken was more important. Predicted uptake suggested that 38% (95% CI 19%, 58%) of patients/first-degree relatives would not take a preventive treatment, compared with 12% (95% CI - 4%, 27%) of rheumatologists. A consistent finding across all groups was a preference for non-biologic disease-modifying anti-rheumatic drugs.

CONCLUSION

Only relatively safe options for preventive treatment are likely to be acceptable to at-risk populations. This study of preventive treatments highlights that the preferences of physicians and recipients of treatment should take a central role in the design of clinical studies as well as in decisions to initiate treatments. Key Points • This paper is the first to compare preferences for preventive treatments between rheumatologists and patients and at-risk individuals. • The results of this study indicate that patients and at-risk individuals, as well as rheumatologists, are likely to prefer the safest options as preventive treatment, even if the potential benefit of these is lower. • Although preferences of patients and at-risk individuals are similar to those of rheumatologists, the choice of preventive treatment may differ between groups; this is important as shared decision-making was a critical factor in treatment decision-making. • Preferences of physicians and recipients of treatment should take a central role in the design of clinical studies as well as in decisions to initiate treatments.

The European network for care of children with paediatric rheumatic diseases: care across borders

OBJECTIVES

To provide an overview of the paediatric rheumatology (PR) services in Europe, describe current delivery of care and training, set standards for care, identify unmet needs and inform future specialist service provision.

METHODS

An online survey was developed and presented to national coordinating centres of the Paediatric Rheumatology International Trials Organisation (PRINTO) (country survey) and to individual PR centres (centre and disease surveys) as a part of the European Union (EU) Single Hub and Access point for paediatric Rheumatology in Europe project. The survey contained components covering the organization of PR care, composition of teams, education, health care and research facilities and assessment of needs.

RESULTS

Response rates were 29/35 (83%) for country surveys and 164/288 (57%) for centre surveys. Across the EU, approximately one paediatric rheumatologist is available per million population. In all EU member states there is good access to specialist care and medications, although biologic drug availability is worse in Eastern European countries. PR education is widely available for physicians but is insufficient for allied health professionals. The ability to participate in clinical trials is generally high. Important gaps were identified, including lack of standardized clinical guidelines/recommendations and insufficient adolescent transition management planning.

CONCLUSION

This study provides a comprehensive description of current specialist PR service provision across Europe and did not reveal any major differences between EU member states. Rarity, chronicity and complexity of diseases are major challenges to PR care. Future work should facilitate the development, dissemination and implementation of standards of care, treatment and service recommendations to further improve patient-centred health care across Europe.

Planning for the Rheumatologist Workforce: Factors Associated With Work Hours and Volumes

OBJECTIVE

The aim of this study was to evaluate factors associated with rheumatologists' clinical work hours and patient volumes based on a national workforce survey in rheumatology.

METHODS

Adult rheumatologists who participated in a 2015 workforce survey were included (n = 255). Univariate analysis evaluated the relationship between demographics (sex, age, academic vs. community practice, billing fee for service vs. other plan, years in practice, retirement plans) and workload (total hours and number of ½-day clinics per week) or patient volumes (number of new and follow-up consults per week). Multiple linear regression models were used to evaluate the relationship between practice type, sex, age, and working hours or clinical volumes.

RESULTS

Male rheumatologists had more ½-day clinics (p = 0.05) and saw more new patients per week (p = 0.001) compared with females. Community rheumatologists had more ½-day clinics and new and follow-up visits per week (all p < 0.01). Fee-for-service rheumatologists reported more ½-day clinics per week (p < 0.001) and follow-ups (p = 0.04). Workload did not vary by age, years in practice, or retirement plans. In multivariate analysis, community practice remained independently associated with higher patient volumes and more clinics per week. Female rheumatologists reported fewer clinics and fewer follow-up patients per week than males, but this did not affect the duration of working hours or new consultations. Age was not associated with work volumes or hours.

CONCLUSIONS

Practice type and rheumatologist sex should be considered when evaluating rheumatologist workforce needs, as the proportion of female rheumatologists has increased over time and alternative billing practices have been introduced in many centers.