Review of a rheumatology triage system: simple, accurate, and effective

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.

Comparative Efficacy of Different Triage Methods for Psoriatic Arthritis - Prospective Study in a Rapid Access Clinic

OBJECTIVES

The study aimed to identify the optimal combination of triage methods to identify PsA among psoriasis patients with musculoskeletal symptoms in a rapid access clinic and to describe their outcome after 1 year.

METHODS

Patients with psoriasis and no prior diagnosis of PsA were referred for assessment of their musculoskeletal complaints. Each patient was assessed by the following three triage modalities: 1) assessment by an advanced practice physiotherapist; 2) targeted musculoskeletal ultrasound (MSK-US) and; 3) PsA screening questionnaires. The patients were then evaluated by a rheumatologist who determined their disease status and classified them as: "Not PsA", "Possibly PsA" or "PsA". Patients returned for a one year follow up visit and were re-assessed for change in their disease status. Sensitivity and specificity were calculated for each individual modality as well as for combinations of modalities.

RESULTS

203 patients with psoriasis and musculoskeletal symptoms were enrolled. 8.8% were classified as PsA and 23.6% as possibly PsA. There was no significant difference in the individual performance of the modalities. The highest sensitivity was seen with MSK-US (89%) and the highest specificity was found with the Psoriatic Arthritis Screening and Evaluation (PASE) questionnaire (79%). The addition of MSK-US data improved the performance of the modalities. A total of 9 patients converted to PsA after 1 year. All patient reported outcome measures have significantly improved at one year (P<0.001).

CONCLUSION

Combining MSK-US with a screening questionnaire for PsA improved the triage of patients with suspected PsA.

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.

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.

The Effect of Triage Assessments on Identifying Inflammatory Arthritis and Reducing Rheumatology Wait Times in Ontario

OBJECTIVE

We evaluated the influence of triage assessments by extended role practitioners (ERP) on improving timeliness of rheumatology consultations for patients with suspected inflammatory arthritis (IA) or systemic autoimmune rheumatic diseases (SARD).

METHODS

Rheumatologists reviewed primary care providers' referrals and identified patients with inadequate referral information, so that a decision about priority could not be made. Patients were assessed by an ERP to identify those with IA/SARD requiring an expedited rheumatologist consult. The time from referral to the first consultation was determined comparing patients who were expedited to those who were not, and to similar patients in a usual care control group identified through retrospective chart review.

RESULTS

Seven rheumatologists from 5 communities participated in the study. Among 177 patients who received an ERP triage assessment, 75 patients were expedited and 102 were not. Expedited patients had a significantly shorter median (interquartile range) wait time to rheumatologist consult: 37.0 (24.5-55.5) days compared to non-expedited patients [105 (71.0-135.0) days] and controls [58.0 (24.0-104.0) days]. Accuracy comparing the ERP identification of IA/SARD to that of the rheumatologists was fair (κ 0.39, 95% CI 0.25-0.53).

CONCLUSION

Patients triaged and expedited by ERP experienced shorter wait times compared to usual care; however, some patients with IA/SARD were missed and waited longer. Our findings suggest that ERP working in a triage role can improve access to care for those patients correctly identified with IA/SARD. Further research needs to identify an ongoing ERP educational process to ensure the success of the model.

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.

Improving access in rheumatology: Evaluating the validity of a paper triage process involving an advanced practice physiotherapist through a retrospective chart review

Objectives: This study evaluated a standardized paper triage process conducted by an advanced practice physiotherapist (APP) at a rheumatology center. The aims were to (1) determine the concordance between paper triage priority assignment and the rheumatologist's diagnosis; (2) determine the sensitivity and specificity of the paper triage process; and (3) assess reasons for incorrect priority ranking. Methods: Referrals were triaged by a formally trained APP into one of the three priorities, guided by a priority referral tool. A retrospective review of 192 charts was performed. Raw proportion of agreement between paper triage and rheumatologist's diagnosis was supplemented by a prevalence-adjusted bias-adjusted kappa (PABAK). Priority categories were collapsed to calculate sensitivity and specificity. For discordant cases, additional information was collected from the referral and chart to identify potential features leading to discrepancy. Results: Overall agreement was 76%. The PABAK was 0.80 [95% confidence interval 0.70-0.90]. Sensitivity ranged 0.64-0.92 and specificity ranged 0.81-0.94, depending on the priority category. Forty-six cases were discordant, with the APP choosing a higher priority in 37 cases. An incorrect diagnosis from the family physician with no supporting information for the paper triage led to discordance in 16 cases. Conclusion: A standardized paper triage process conducted by an APP showed substantial concordance, sensitivity, and specificity.

Feasibility of Measurement and Adherence to System Performance Measures for Rheumatoid Arthritis in 5 Models of Care

OBJECTIVE

To test the feasibility of reporting on 4 national performance measures for patients with rheumatoid arthritis (RA) in 5 different models of care.

METHODS

The following performance measures were evaluated in 5 models of care: waiting time (WT) to rheumatologist consultation, percentage of patients seen in yearly followup (FU), percentage taking disease-modifying antirheumatic drugs (DMARD), and time to starting DMARD. All models aimed to improve early access and care for patients with RA.

RESULTS

A number of feasibility issues were encountered in performance measure evaluation because of differences in site data collection and/or the duration of the model of care. For example, while 4/5 programs maintained clinical or research databases, chart reviews were still required to report on WT. Median WT for care in 2015 varied by site between 21 and 75 days. Yearly FU rates could only be calculated in 2 sites (combined owing to small numbers) and varied between 83% and 100%. Percentage of patients taking a DMARD and time to DMARD could be calculated in 3 models, and rates of DMARD use were between 90% and 100%, with median time to DMARD of 0 days in each.

CONCLUSION

Our review has shown that even in models of care designed to improve access to care and early treatment, data to document improvements are often lacking. Where data were available for measuring, deficits in WT performance were noted for some centers. Our results highlight a need to improve reporting processes to drive quality improvement.

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.

Improving Appropriate Access to Care With Central Referral and Triage in Rheumatology

OBJECTIVE

To evaluate the short-term and long-term impact of a centralized system for the intake and triage of rheumatology referrals on access to care and referral quality.

METHODS

An innovative central referral process, the Central Referral and Triage in Rheumatology (CReATe Rheum) program, was implemented in 2006, serving a referral base of 2 million people. Referrals are received in a central office, triaged by trained nurses, and assigned to the next available appointment on a prioritized basis. To evaluate the short-term impact, we compared wait times, duplicate referrals, and no-shows from a pre-implementation practice audit to a 2-year post-implementation evaluation (January 2007 to December 2008). Rheumatologists also assessed the quality and completeness of the referral information and accuracy of the urgency category assigned during triage. We evaluated the long-term impact by tracking referral volume, wait times, and rheumatologist manpower each year until December, 2013.

RESULTS

During the first 2 years, wait-time variability between rheumatologists decreased, and wait times were reduced for moderate and urgent referrals. CReATe Rheum improved the quality of referral information and eliminated duplicate referrals. The urgency of the referral was assigned correctly in 90% of referrals. Over the long term, CReATe Rheum maintained short wait times for more urgent patients despite a growing number of referrals and a stable number of rheumatologists.

CONCLUSION

A centralized system for the intake and triage of rheumatology referrals improved referral quality, reduced system inefficiencies, and effectively managed wait times on a prioritized basis for a large referral population.

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.