"The rheumatologist can see you now": Successful implementation of an advanced access model in a rheumatology practice

Evaluation of no-show rate in outpatient clinics with open access scheduling system: A systematic review

Background

Patients' missed appointments can cause interference in the functions of the clinics and the visit of other patients. One of the most effective strategies to solve the problem of no-show rate is the use of an open access scheduling system (OA). This systematic review was conducted with the aim of investigating the impact of OA on the rate of no-show of patients in outpatient clinics.

Methods

Relevant articles in English were investigated based on the keywords in title and abstract using PubMed, Scopus, and Web of Science databases and Google Scholar search engine (July 23, 2023). The articles using OA and reporting the no-show rate were included. Exclusion criteria were as follows: (1) review articles, opinion, and letters, (2) inpatient scheduling system articles, and (3) modeling or simulating OA articles. Data were extracted from the selected articles about such issues as study design, outcome measures, interventions, results, and quality score.

Findings

From a total of 23,403 studies, 16 articles were selected. The specialized fields included family medicine (62.5%, 10), pediatrics (25%, four), ophthalmology, podiatric, geriatrics, internal medicine, and primary care (6.25%, one). Of 16 articles, 10 papers (62.5%) showed a significant decrease in the no-show rate. In four articles (25%), the no-show rate was not significantly reduced. In two papers (12.5%), there were no significant changes.

Conclusions

According to this study results, it seems that in most outpatient clinics, the use of OA by considering some conditions such as conducting needs assessment and system design based on the patients' and providers' actual needs, and cooperating of all system stakeholders through consistent training caused a significant decrease in the no-show rate.

Predictors of inflammatory arthritis among new rheumatology referrals: a cross-sectional study

Objectives

Early diagnosis and treatment of inflammatory arthritis (IA) is essential to optimize disease control. We aimed to identify variables that distinguish IA from non-inflammatory arthropathy by performing a cross-sectional study of rheumatology referral letters and visit records. Further work describes time to assessment and documentation of variables within referral letters.

Methods

We reviewed rheumatology referral letters and new patient visits over a 6-month period. The diagnosis of IA was based on the clinical judgement of the assessing rheumatologist. IA diagnoses included RA, SpAs, unspecified IA, PMR, crystalline arthropathies and remitting seronegative symmetrical synovitis with pitting oedema. Univariate analysis was performed for each variable. Multivariable logistic regression was performed on statistically significant variables.

Results

Of 697 patients referred for arthralgia, 25.7% were diagnosed with IA. Variables predictive of IA included tenderness and swelling on examination and ≥1 h of morning stiffness. Increasing arthralgia duration, fatigue and brain fog were negative predictors. The median time from referral to IA diagnosis was 55 days and 20.7% of these patients were seen within 6 weeks. Among referral letters, documentation of arthralgia duration, morning stiffness or joint examination findings was uncommon (31%, 20.5% and 56.7%, respectively).

Conclusion

We identified positive and negative predictors of IA. Referral letters often missed key information required for the triaging process. Future efforts will be directed towards build a triaging tool to improve the referral quality and capture of those patients with IA who need earlier access to rheumatology care.

Quality of rheumatology care for patients with fibromyalgia and chronic pain syndromes

BACKGROUND

One-third of primary care providers (PCPs) refer patients with fibromyalgia or chronic pain (FM/CP) to specialist care, typically rheumatology. Yet, comprehensive data on the quality of rheumatology care for patients with FM/CP are currently lacking.

METHODS

Records of patients referred for rheumatology consultation for FM/CP and seen at a single academic centre between 2017 and 2018 were extracted by retrospective chart review. Variables were diagnostic accuracy (at referral vs consultation), resource utilisation (investigations, medications, medical and allied health referral), direct costs (physician billing, staff salary, investigation fees) and access (consult wait time). Patient experience and referring PCP experience surveys were administered.

RESULTS

79 charts were identified. Following consultation, 81% of patients (n=64) maintained the same diagnosis of FM/CP, 19% (n=15) were diagnosed with regional pain and 0% of patients (n=0) were diagnosed with an inflammatory arthritis or connective tissue disease. Investigations were ordered for 37% of patients (n=29), medication prescribed for 10% (n=8) and an allied health referral provided for 54% (n=43). Direct costs totalled $19 745 (average $250/consult; range $157-$968/consult). Consultation wait time averaged 184 days (range 62-228 days). Out of the seven (64%) responses to the patient experience survey, 86% of patients (n=6) were satisfied with provider communication but the consultation 'definitely' met the expectations of only 57% (n=4). The PCP survey returned an insufficient response rate.

CONCLUSIONS

This study found that no patient referred to rheumatology care for FM/CP was diagnosed with an inflammatory arthritis or connective tissue disease. Furthermore, patients with FM/CP experience lengthy wait times for rheumatology care which delay their management of chronic pain. Interdisciplinary and collaborative healthcare models can potentially provide higher quality care for patients with FM/CP.

Using Process Improvement and Systems Redesign to Improve Rheumatology Care Quality in a Safety Net Clinic

OBJECTIVE

To develop and evaluate interventions to improve quality of care in 4 priority areas in an urban safety net adult rheumatology clinic serving a racially/ethnically and socioeconomically diverse patient population.

METHODS

The Institute for Healthcare Improvement's Model for Improvement was used to redesign clinical processes to achieve prespecified benchmarks in the following areas from 2015 to 2017: 13-valent pneumococcal conjugate vaccine (PCV13) administration among immunocompromised patients; disease activity monitoring with the Clinical Disease Activity Index (CDAI) for patients with rheumatoid arthritis; latent tuberculosis infection (LTBI) screening for new biologic users with RA; and reproductive health counseling among women receiving potentially teratogenic medications. We measured performance for each using standardized metrics, defined as the proportion of eligible patients receiving recommended care.

RESULTS

There were 1205 patients seen in the clinic between 2015 and 2017. Regarding demographics, 71% were women, 88% identified as racial/ethnic minorities, and 45% were eligible for at least 1 of the quality measures. Shewart charts for the PCV13 and CDAI measures showed evidence of improved healthcare delivery over time. Benchmarks were achieved for the CDAI and LTBI measures with 93% and 91% performance, respectively. Performance for the PCV13 and reproductive health counseling measures was 78% and 46%, respectively, but did not meet prespecified improvement targets.

CONCLUSION

Through an interprofessional approach, we were able to achieve durable improvements in key rheumatology quality measures largely by enhancing workflow, engaging nonphysician providers, and managing practice variation.

Unscheduled Referrals and Unattended Appointments After Pediatric Subspecialty Referral

OBJECTIVES

Incomplete subspecialty referrals, whether unscheduled or unattended, represent unmet patient needs and an opportunity to improve patient safety and experiences. Our objectives were to describe the rates of appointment scheduling and visit attendance after pediatric subspecialty referral and to examine patient and systems factors associated with scheduled referrals and attended appointments.

METHODS

We conducted a retrospective review of referrals within a network of 52 primary and urgent care sites from November 2016 to October 2017. We included referrals for children ≤17 years old referred to medical or surgical subspecialists. We examined patient and health systems factors associated with (1) appointment scheduling and (2) visit attendance.

RESULTS

Of 20 466 referrals, 13 261 (65%) resulted in an appointment scheduled within 90 days and 10 514 (51%) resulted in a visit attended within 90 days. In adjusted analyses, referral to surgical subspecialists was associated with an increased likelihood of appointment scheduling but a decreased likelihood of visit attendance. Compared with appointments scheduled within 7 days, appointments with intervals from referral to scheduled appointment exceeding 7 days were associated with decreasing likelihood of visit attendance (adjusted odds ratio 8-14 days 0.48; 95% confidence interval 0.37-0.61). Patient factors associated with decreased likelihood of both appointment scheduling and visit attendance included African American race, public insurance, and lower zip code median income.

CONCLUSIONS

Patient and system factors were associated with variation in appointment scheduling and visit attendance. Decreased interval to appointment was significantly associated with visit attendance. These factors represent targets for interventions to improve referral completion.

The Effect of Pre-Appointment Consultation Triage on Patient Selection and Revenue Generation in a University Rheumatology Practice

OBJECTIVE

To evaluate the effectiveness of pre-appointment consult screening to identify patients with autoimmune and inflammatory rheumatic disease (AIRD) and to evaluate the revenue implications of routine outpatient care of patients with AIRD compared to that of non-AIRD patients.

METHODS

Using data in the electronic medical records, we retrospectively analyzed all new outpatients who were referred for rheumatology consults during a 9-month period for a final diagnosis and revenue generation for routine outpatient care over 1 year following the consult review or initial evaluation.

RESULTS

A total of 961 patients were referred to the outpatient rheumatology clinic and underwent pre-appointment triage. Overall, 673 patients were approved for evaluation of AIRD, and 288 patients were denied rheumatology consultation. Patients were seen an average of 13 days after the consult review. Among patients who were approved for consult, 597 came for evaluation, with 357 diagnosed as having an AIRD and 240 with a non-AIRD. Among patients who were denied a consult, 128 had 1-year follow-up data, with 6 patients eventually diagnosed as having an AIRD (consult triage sensitivity 98%, positive predictive value 60%). The consult triage system allowed more AIRD patients to be seen over a 1-year period. Revenue data for outpatient care was available for 318 of 357 patients with an AIRD and 192 of 240 non-AIRD patients and showed that care for patients with an AIRD generates 44 times more revenue compared to care for non-AIRD patients ($5,877 per AIRD patient versus $134 per non-AIRD patient; P < 0.001).

CONCLUSION

Pre-appointment consult screening is an effective method to identify patients with an AIRD. This approach enables timely access to care for patients with the highest need for evaluation and results in significantly more revenue generation.

“Rheum to Improve”: Quality Improvement in Outpatient Rheumatology

The commitment to improve care processes and patient outcomes is a professional mandate for clinicians and is also seen as an operational priority for institutions. Quality improvement now figures in the accreditation of training programs, specialty examinations, and hospital scorecards. Rheumatologists have traditionally focused primarily on quality problems such as guideline adherence; however, improvement goals should also include other aspects of care that are helpful to patients and are professionally rewarding for practitioners. This review makes use of improvement projects in outlining tangible tools rheumatologists can use to resolve quality concerns in their practices.

Triage of Rheumatology Referrals Facilitates Wait Time Benchmarks

OBJECTIVE

In 2014 the Canadian Rheumatology Association published wait time benchmarks for inflammatory arthritis (IA) and connective tissue disease (CTD) to improve patient outcomes. This study's aim was to determine whether centralized triage and the introduction of quality improvement initiatives would facilitate achievement of wait time benchmarks.

METHODS

Referrals from September to November 2012 were retrospectively triaged by an advanced practice physiotherapist (APP) and compared to referrals triaged by an APP from January to March 2014. Each referral was assigned a priority ranking and categorized into one of 2 groups: suspected IA/CTD, or suspected non-IA/CTD. Time to initial consult and time to notification from receipt of referral were assessed.

RESULTS

A total of 558 (n = 227 and n = 331 from 2012 and 2014, respectively) referrals were evaluated with 35 exclusions. In 2012, there were 96 (42.5%) suspected IA/CTD and 124 (54.9%) suspected non-IA/CTD patients at the time of the initial consult. Mean wait times in 2012 for patients suspected to have IA was 33.8 days, 95% CI 27.8-39.8, compared to 37.3 days, 95% CI 32.9-41.7 in suspected non-IA patients. In 2014, there were 131 patients (43%) with suspected IA based on information in the referral letter. Mean wait times in 2014 for patients suspected to have IA was 15.5 days, 95% CI 13.85-17.15, compared to 52.2 days, 95% CI 46.3-58.1 for suspected non-IA patients. Time to notification of appointment improved from 17 days to 4.37 days.

CONCLUSION

Centralized triage of rheumatology referrals and quality improvement initiatives are effective in improving wait times for priority patients as determined by paper referral.

Efficiency Gains for Rheumatology Consultation Using a Novel Electronic Referral System in a Safety-Net Health Setting

OBJECTIVE

Health information technology (HIT) holds promise in increasing access to rheumatologists by improving the quality and efficiency of referrals, but few studies have examined its use for this purpose. We evaluated the use and impact of a novel electronic referral (eReferral) system in rheumatology in a safety-net health system.

METHODS

We examined eReferrals over 4 years. Our primary outcome was use of preconsultation exchange, defined as back-and-forth communication between referring and specialty care providers, facilitating triage of referrals, requests for more information, or resolution of questions without a visit. We calculated the proportion of eReferrals that underwent preconsultation exchange, time to reviewer response, and number of visits scheduled. To increase generalizability, we selected a random sample of eReferrals to undergo additional blinded, adjudicated review to assess agreement on appropriateness for preconsultation exchange.

RESULTS

Between 2008 and 2012, 2,383 eReferrals were reviewed and 2,105 were eligible for analysis. One-fourth of eReferrals were resolved without a clinic visit. The proportion of eReferrals undergoing preconsultation exchange increased over time (55% in 2008 versus 74% in 2011), and the volume of referrals also steadily increased over time. Reviewer response time averaged between 1 and 4 days. In the random sample of eReferrals that underwent adjudicated review, agreement between reviewers was high (κ = 0.72).

CONCLUSION

HIT-enabled preconsultation exchange was used for a majority of eReferrals and facilitated communication between referring clinicians and rheumatologists. This redesigned system of care allowed for triage of a high number of referrals, with many referrals determined to be appropriate for preconsultation exchange.

Comprehensive arthritis referral study -- phase 2: analysis of the comprehensive arthritis referral tool

OBJECTIVE

Rheumatologists triage referrals to assess those patients who may benefit from early intervention. We describe a referral tool and formally evaluate its sensitivity for urgent and early inflammatory arthritis (EIA) referrals.

METHODS

All referrals received on a standardized referral tool were reviewed by a rheumatologist and, based on the information conferred, assigned a triage grade using a previously described triage system. Each referral was also dichotomized as suspected EIA or not. After the initial rheumatologic assessment, the diagnosis was recorded and a consultation grade, blinded to referral grade, was assigned to each case. Agreement between referral and consultation grades was assessed. A regression analysis was performed to determine factors that predicted truly urgent referrals including EIA.

RESULTS

We evaluated 696 referrals. A total of 210 (30.2%) were categorized as urgent at the time of consultation. The referral tool was able to successfully detect 169 of these referrals (sensitivity 80.5%, specificity 79.4%). EIA occurred in 95 (13.6%); of those referrals, 86 were correctly classified as urgent at the time of triage (sensitivity 90.5%, specificity 69.6%). Items that helped correctly discriminate urgent or EIA referrals included patient age < 60, duration of disease, morning stiffness, patient-reported joint swelling, a personal or family history of psoriasis, urgency as rated by referring physician, prior assessment by a rheumatologist, elevated C-reactive protein, and a positive rheumatoid factor.

CONCLUSION

A 1-page referral tool that includes parts completed by the referring physician and patient has good sensitivity to detect urgent referrals including EIA.

A new model to decrease time-to-appointment wait for gastroenterology evaluation

OBJECTIVE

To describe the implementation and evaluation of a quality improvement intervention to increase new-patient access and decrease time-to-appointment wait for gastroenterology care.

METHODS

We used a new model of care for gastroenterology evaluation. For specified clinical complaints, we offered new-patient appointments that were scheduled with a general pediatrician as an alternative to a subspecialist. A nurse navigator assisted in triaging patients. We analyzed all patient encounters over an 8-month period. To verify decreased time-to-appointment wait, mystery shoppers made semimonthly calls to centralized scheduling. We surveyed parents/families after visits with the pediatrician or subspecialists regarding satisfaction.

RESULTS

The "access" pediatrician evaluated and treated ∼40% of all new patients presenting to the division during the study period. Approximately 10% of new patients evaluated by the pediatrician (4% overall) were referred on to the subspecialist; fewer patients were reevaluated by the pediatrician in follow-up. The pediatrician ordered a minimal number of procedures. Semimonthly sampling revealed that overall new-patient access improved from an average time-to-appointment wait of 25 days to <1 day. Parent/family satisfaction was high for the patients evaluated by the pediatrician.

CONCLUSIONS

Embedding a general pediatrician within a subspecialty division, and navigating patients to this provider, can increase access to treatment of new low- to moderate-complexity patients. The access pediatrician can maintain patient satisfaction, provide high-quality care, and decrease need for subspecialist evaluation. The model, in the setting of a large academic medical center, may provide a solution for barriers to patient care such as lengthy time-to-appointment wait.

Quality-of-care standards for early arthritis clinics

The diagnosis and treatment of early arthritis is associated with improved patient outcomes. One way to achieve this is by organising early arthritis clinics (EACs). The objective of this project was to develop standards of quality for EACs. The standards were developed using the two-round Delphi method. The questionnaire, developed using the best-available scientific evidence, includes potentially relevant items describing the dimensions of quality of care in the EAC. The questionnaire was completed by 26 experts (physicians responsible for the EACs in Spain and chiefs of the rheumatology service in Spanish hospitals). Two hundred and forty-four items (standards) describing the quality of the EAC were developed, grouped by the following dimensions: (1) patient referral to the EAC; (2) standards of structure for an EAC; (3) standards of process; (4) relation between primary care physicians and the EAC; (5) diagnosis and assessment of early arthritis; (6) patient treatment and follow-up in the EAC; (7) research and training in an EAC; and (8) quality of care perceived by the patient. An operational definition of early arthritis was also developed based on eight criteria. The standards developed can be used to measure/establish the requirements, resources, and processes that EACs have or should have to carry out their treatment, research, and educational activities. These standards may be useful to health professionals, patient associations, and health authorities.

Health-related quality of life as a main determinant of access to rheumatologic care

To evaluate a rheumatology outpatient consultation access system for new patients. New patients seen from April 2005 to April 2006 at our rheumatology clinic (n = 4,460) were included and classified according to their appointment type: ordinary appointments (OA) to be seen within 30 days, urgent appointments (UA) and work disability appointments (WDA) to be seen within 3 days. Age, sex, diagnosis, and health-related quality of life (HRQoL) as determined by the Rosser Index were recorded. Logistic regression models were run to identify factors that contribute to each type of appointment. OA was the method of access for 1,938 new patients, while 1,194 and 1,328 patients were seen through WDA and UA appointments, respectively. Younger male patients, and those with microcrystalline arthritis, sciatica, shoulder, back, or neck pain, were more likely to use the faster access systems (UA or WDA), whereas patients with a degenerative disease were mainly seen through OA (<0.001). Subjects with poor (3.96; 95 % CI, 2.8-5.5) or very poor HRQoL (70.8; 95 % CI, 14.9-334) were strongly associated to visiting a rheumatologist through the WDA or UA access systems, respectively, compared to OA. Age, gender, diagnosis, and mainly health-related quality of life are associated with the referral pattern of access to rheumatologic outpatient care. Among new patients subjects with the worst HRQoL were more likely to access with faster methods (UA or WDA) than those with better HRQoL.

Advanced access scheduling outcomes: a systematic review

BACKGROUND

Advanced ("open") access scheduling, which promotes patient-driven scheduling in lieu of prearranged appointments, has been proposed as a more patient-centered appointment method and has been widely adopted throughout the United Kingdom, within the US Veterans Health Administration, and among US private practices.

OBJECTIVE

To describe patient and physician and/or practice outcomes resulting from implementation of advanced access scheduling in the primary care setting.

DATA SOURCES

Comprehensive search of electronic databases (MEDLINE, Scopus, Web of Science) through August, 2010, supplemented by reference lists and gray literature.

STUDY SELECTION

Studies were assessed in duplicate, and reviewers were blinded to author, journal, and date of publication. Controlled and uncontrolled English-language studies of advanced access implementation in primary care were eligible if they specified methods and reported outcomes data.

DATA EXTRACTION

Two reviewers collaboratively assessed risk for bias by using the Cochrane Effective Practice and Organisation of Care Group Risk of Bias criteria. Data were independently extracted in duplicate.

DATA SYNTHESIS

Twenty-eight articles describing 24 studies met eligibility criteria. All studies had at least 1 source of potential bias. All 8 studies evaluating time to third-next-available appointment showed reductions (range of decrease, 1.1-32 days), but only 2 achieved a third-next-available appointment in less than 48 hours (25%). No-show rates improved only in practices with baseline no-show rates higher than 15%. Effects on patient satisfaction were variable. Limited data addressed clinical outcomes and loss to follow-up.

CONCLUSIONS

Studies of advanced access support benefits to wait time and no-show rate. However, effects on patient satisfaction were mixed, and data about clinical outcomes and loss to follow-up were lacking.

Correlation of rheumatology subspecialty choice and identifiable strong motivations, including intellectual interest

OBJECTIVE

To describe motivations correlating with subspecialty choices, particularly rheumatology.

METHODS

A total of 179 respondents answered queries about various aspects affecting specialty and subspecialty choice with ordinal ratings of importance. Likert scale response data were analyzed to determine independent predictors of being a rheumatology fellow. Multivariate logistic regression analyses were used to develop models predicting rheumatology fellowship. Factor analysis methods to condense the individual responses into fewer underlying variables or factors were employed.

RESULTS

While every group ranked intellectual interest as more important than all other responses, its score in the rheumatology fellow group was significantly higher than that in the medical student group. A model using 4 composite variables based on prior literature did not fit well. Exploratory factor analysis identified 5 underlying motivations, which were designated as time, money, external constraints, practice content, and academics. All motivations except money were statistically significant, with the rheumatology fellow group attributing greater importance than medical students to time, practice content, and academics, and lesser importance than medical students to external constraints.

CONCLUSION

Values and motivations leading toward rheumatology subspecialty choice can be traced to identifiable factors. Intellectual interest appears to be split between 2 distinct significant variables: practice content and academics. Time or controllable lifestyle, external constraints, practice content, and academic issues appear to be important influences on the choice of rheumatology fellowship. Such variables appear to reflect underlying values and motivations.

Internet use and e-mail communications between patients and providers: a survey of rheumatology outpatients

BACKGROUND

As health care costs rise in the United States and elsewhere, adopting health information technology is being advocated to reduce costs and improve efficiency.

PATIENT

Physician e-mail communication is a frequently proposed tool in this strategy.

OBJECTIVES

We examined the interest of rheumatology outpatients in using E-mail for communication with their rheumatologist. We sought to identify their privacy and cost concerns on this issue, and examine the patients' demographics, internet usage, and preferences.

METHODS

An anonymous survey was given to 150 consecutive patients. Patients responded to questions on demographics, rheumatic diseases, comorbidities, computer/internet access, E-mail use, privacy concerns, payment issues, and preferences regarding communication with their rheumatologist. Statistical analyses on the relationships between demographics and patient preferences on communications with their rheumatologist were conducted.

RESULTS

There were 145 respondents; the mean age was 52.3 years, mean education level was 13.6 years. The sample tended to be women (74%), retired/disabled (46%) or employed full time (35%). Most had internet access (74.5%). Differences were found based on gender, age, education, and income levels. Younger adults were more likely to desire E-mail communication with their rheumatologists, especially if paid by insurance. More men than women had concerns about privacy; persons with higher income levels were more willing to self-pay for E-mail.

CONCLUSION

As a significant number of patients with rheumatic diseases express interest in E-mail communication with their providers, rheumatologists need to be cognizant of patients' preferences. To deliver patient-centered care, rheumatology practices might consider incorporating E-mail communication into their practices.

Watching your wait: evidence-informed strategies for reducing health care wait times

Nobody wants the health care system to be characterized by long, involuntary waits for treatment. Both a strong theoretical rationale and a growing number of case studies support approaches that address the root cause of long waits-usually a poorly designed system, rather than an absolute lack of capacity. This structured review of both peer-reviewed and "gray" literature on waitlist management identifies the 7 common problems that underlie long waitlists and describes remedies that have been successfully applied, using Canadian and British examples with international relevance. Understanding these issues can help administrators and providers develop effective wait-reduction strategies in diverse health care settings.

Implementing open-access scheduling of visits in primary care practices: a cautionary tale

BACKGROUND

Open-access scheduling (also known as advanced access or same-day access) is a popular tool for improving patient access to primary care appointments.

OBJECTIVE

To assess the effect of open-access scheduling and describe the barriers to implementing the open-access scheduling model in primary care.

DESIGN

Case series.

SETTING

Boston, Massachusetts, metropolitan area.

PARTICIPANTS

6 primary care practices studied from October 2003 through June 2006.

INTERVENTION

Implementation of open-access scheduling.

MEASUREMENTS

Time to third available appointments, no-show rates, and patient and staff satisfaction with appointment availability.

RESULTS

5 of 6 practices were able to implement open-access scheduling. Within 4 months of implementation, these 5 practices substantially reduced their mean wait for third available appointments from 21 to 8 days for 15-minute visits and from 39 to 14 days for 30-minute visits. However, none of the 5 practices attained the goal of same-day access, and waits for third available appointments increased during 2 years of follow-up. No consistent changes in patient or staff satisfaction or patient no-show rates were found. Barriers to implementation included decreases in appointment supply from provider leaves of absence and departures and increases in appointment demand when practices reopened to new patients after initial implementation of open-access scheduling.

LIMITATIONS

The study lacked control practices. The small number of practices and providers precluded formal statistical comparisons.

CONCLUSION

In 5 of 6 primary care practices, implementation of open-access scheduling improved appointment access in some practices. However, none was able to achieve same-day access and patient and staff satisfaction and patient no-show rates were unchanged. Broader evaluation of open-access scheduling in primary care is needed.

Advanced access to otolaryngology: Lessons learned

Reports of experience with implementing advanced access techniques in specialty practices are few in number. In our facility, we were able to demonstrate that patients' access to care improved from >100 days to 72 hours, patient satisfaction increased 22%, and productivity increased 29%. The lessons we learned after the successful implementation of advanced access in an academic otolaryngology practice are presented here.

The United States rheumatology workforce: supply and demand, 2005-2025

OBJECTIVE

To develop and apply a model that allows prediction of current and future supply and demand for rheumatology services in the US.

METHODS

A supply model was developed using the age and sex distribution of current physicians, retirement and mortality rates, the number of fellowship slots and fill rates, and practice patterns of rheumatologists. A Markov projection model was used to project needs in 5-year increments from 2005 to 2025.

RESULTS

The number of rheumatologists for adult patients in the US in 2005 is 4,946. Male and female rheumatologists are equally distributed up to age 44; above age 44, men predominate. The percent of women in adult rheumatology is projected to increase from 30.2% in 2005 to 43.6% in 2025. The mean number of visits per rheumatologist per year is 3,758 for male rheumatologists and 2,800 for female rheumatologists. Assuming rheumatology supply and demand are in equilibrium in 2005, the demand for rheumatologists in 2025 is projected to exceed supply by 2,576 adult and 33 pediatric rheumatologists. The primary factors in the excess demand are an aging population which will increase the number of people with rheumatic disorders, growth in the Gross Domestic Product, and flat rheumatology supply due to fixed numbers entering the workforce and to retirements. The productivity of younger rheumatologists and women, who will make up a greater percentage of the future workforce, may also have important effects on supply. Unknown effects that could influence these projections include technology advances, more efficient practice methods, changes in insurance reimbursements, and shifting lifestyles. Current data suggest that the pediatric rheumatology workforce is experiencing a substantial excess of demand versus supply.

CONCLUSION

Based on assessment of supply and demand under current scenarios, the demand for rheumatologists is expected to exceed supply in the coming decades. Strategies for the profession to adapt to this changing health care landscape include increasing the number of fellows each year, utilizing physician assistants and nurse practitioners in greater numbers, and improving practice efficiency.

Kooperation zwischen Hausärzten und Rheumatologen in Niedersachsen

AIM

Between 2000 and 2003 the collaborative arthritis center Hanover implemented a quality management program for patients with rheumatoid arthritis (RA). Fourteen rheumatologists in private practice participated in this model project. One of the aims of the project was to improve the cooperation between primary care physicians and rheumatologists. A survey of the primary care physicians was conducted to evaluate rheumatological care.

METHODS

A total of 340 patients with RA were included in the study. All primary care physicians of these patients were informed about the goals of the project and asked to answer a questionnaire on cooperation with rheumatologists. The questionnaire contained 14 questions and was sent to 270 primary care physicians.

RESULTS

Of the primary care physicians, 83% returned the questionnaire, and 81% percent of these were family practitioners. The primary care physicians treated a mean of 19 patients with RA, of whom 14 were attended in cooperation with rheumatologists. High mean values were found for satisfaction with different aspects of rheumatological patient care on a numerical rating scale from 0 (not satisfied at all) to 10 (completely satisfied). Mean values for satisfaction: diagnosis 7.9, therapy recommendations 7.6, follow-up 7.2,and usefulness of medical report 7.7. A total of 70% of primary care physicians reported difficulties in realizing the recommendations of the rheumatologists. Of the respondents, 90% saw a need for improvement in cooperation with rheumatologists, the most frequently mentioned being the difficulty of consultation with appointments.

CONCLUSION

This survey of primary care physicians of patients with RA reveals a positive assessment of the cooperation with rheumatologists. The problems which exist mainly concern the realization of recommendations. There is a great requirement for further improvement in the cooperation between primary care physicians and rheumatologists.

Productivity measures associated with a patient access initiative

OBJECTIVE

To assess financial performance associated with a patient 7-day access initiative.

BACKGROUND DATA

Patient access to clinical services is frequently an obstacle at academic medical centers. Conflicting surgeon priorities among academic, clinical, educational, and leadership duties often create difficulties for patient entry into the "system."

METHODS

The scope and objectives were identified to be: design of a standard, simple new patient appointment process, design of a standard process in cases where an appointment is not available in 7 days, use subspecialty team search capabilities, minimize/eliminate prescheduling requirements, centralize appointment scheduling, and creation and reporting of 7-day access metrics. Following maturation of the process, the 7-day access metrics from the period July 2004 to December 2004 and January 2005 to June 2005 were compared with corresponding time periods from calendar years 2001, 2002, and 2003.

RESULTS

Payor mix was unaltered. The median waiting time for a new patient appointment decreased from 21 days to 10 days. When compared with calendar years 2001, 2002, and 2003, respectively, the 2 periods of the 7-day access initiative in calendar years 2004 and 2005 were associated with significantly increased visits, new patients, operative procedures, hospital charges, and physician charges.

CONCLUSIONS

Implementation of a 7-day access initiative can significantly increase financial productivity of general surgery groups in academic medical centers. We conclude that simplifying access to services can benefit academic surgical practices. Sustaining this level of productivity will continue to prove challenging.

Remodeling a rheumatology practice to facilitate early referral

In the next 12 months, 7500 Canadians and 75,000 Americans will be afflicted with the onset of rheumatoid arthritis. Little is known about the health care use of patients with early RA. Nonetheless, rheumatologists and outcomes researchers strongly endorse the need for early diagnosis and treatment of this population. This article reviews trends and impediments to early referral of new-onset arthritis patients. The slow growth of early arthritis clinics is summarized in a survey that characterizes 23 early arthritis programs in North America. Also, several screening tools and models to capture these early-onset arthritis patients are presented.

Evidence-based rheumatology practice

PURPOSE OF REVIEW

This review is intended to update readers on recent developments in the evidence-based practice of rheumatology.

RECENT FINDINGS

Several new or updated evidence-based practice guidelines have recently emerged. In addition, a large body of evidence upon which to base practice has been addressed in the many systematic reviews and meta-analyses that have been newly published, including nine new or updated Cochrane reviews. Several studies have also investigated adherence to practice guidelines, interventions to improve clinical practice, and quality of care in the field of rheumatology in the past year.

SUMMARY

Evidence-based rheumatology is an ongoing effort, with continuing revision and update of recommendations. It may currently be used to address a wide variety of clinical questions. The initiatives on practice-based research to establish quality indicators and identify areas where rheumatology practice can be enhanced are a welcome addition to health services research in this field.