Meeting the challenge of the ageing of the population: Issues in access to specialist care for arthritis

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.

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.

Rheumatic Care in Under-Resourced Areas Using the Extension for Community Healthcare Outcomes Model

OBJECTIVE

To demonstrate the effectiveness of the Extension for Community Healthcare Outcomes (Project ECHO) in educating primary care clinicians (PCCs) to provide best practice rheumatic care to patients in under-resourced communities in New Mexico.

METHODS

Attendee data for weekly teleECHO sessions, lectures, grand rounds, and mini-residency trainings were evaluated from June 2006 to June 2014. Participant feedback was evaluated from January 2009 to December 2014, when the program was approved for continuing medical education (CME) credits. Retrospective review of diagnoses associated with case presentations was conducted from June 2006 to June 2014 to evaluate the types of cases presented. A focus group was conducted with a convenience sample of 8 New Mexico PCCs who participated in ECHO Rheumatology (ECHO Rheum) for 1 year or longer.

RESULTS

Over the course of 9 years, ECHO Rheum educated 2,230 clinicians, consisting primarily of physicians (53%) and nurse practitioners (22%). A total of 1,958 CME credits were awarded to those who participated. There were 1,173 cases presented; 85% of the cases reflected the 3 most common diagnoses: rheumatoid arthritis (n = 715), fibromyalgia (n = 241), and systemic lupus erythematosus (n = 54). In addition, ECHO Rheum conducted 15 two-day mini-residencies involving 30 PCCs; 21 of these clinicians subsequently completed the American College of Rheumatology online certification.

CONCLUSION

Results from this study demonstrate that participation in ECHO Rheum provides clinicians in under-resourced areas access to best-practice knowledge and training in rheumatology.

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.

Incident myocardial infarction associated with major types of arthritis in the general population: a systematic review and meta-analysis

OBJECTIVE

To synthesise, quantify and compare risks for incident myocardial infarction (MI) across five major types of arthritis in population-based studies.

METHODS

A systematic search was performed in MEDLINE, EMBASE and CINAHL databases with additional manual/hand searches for population-based cohort or case-control studies published in English of French between January 1980 and January 2015 with a measure of effect and variance for associations between incident MI and five major types of arthritis: rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), gout or osteoarthritis (OA), adjusted for at least age and sex. All search screening, data abstraction quality appraisals were performed independently by two reviewers. Where appropriate, random-effects meta-analysis was used to pool results from studies with a minimum of 10 events.

RESULTS

We identified a total of 4, 285 articles; 27 met review criteria and 25 criteria for meta-analyses. In studies adjusting for age and sex, MI risk was significantly increased in RA (pooled relative risk (RR): 1.69, 95% CI 1.50 to 1.90), gout (pooled RR: 1.47, 95% CI 1.24 to 1.73), PsA (pooled RR: 1.41, 95% CI 1.17 to 1.69), OA (pooled RR: 1.31, 95% CI 1.01 to 1.71) and tended towards increased risk in AS (pooled RR: 1.24, 95% CI 0.93 to 1.65). Traditional risk factors were more prevalent in all types of arthritis. MI risk was attenuated for each type of arthritis in studies adjusting for traditional risk factors and remained significantly increased in RA, PsA and gout.

CONCLUSIONS

MI risk was consistently increased in multiple types of arthritis in population-based studies, and was partially explained by a higher prevalence of traditional risk factors in all types of arthritis. Findings support more integrated cardiovascular (CV) prevention strategies for arthritis populations that target both reducing inflammation and enhancing management of traditional CV risk factors.

Monitoring Outcome of Joint Arthroplasty in Italy: Implementation of the National Registry

Purpose  Arthroplasty registries have an important role in improving outcomes in joint surgery. As the demand for joint arthroplasty continues to increase, growing attention is being paid to the establishment of national registries, which contribute to the enhancement of the quality of patients' care. Indeed, providing postmarketing surveillance data in terms of safety and effectiveness of medical devices, registries contribute to the best orthopaedic practice and support public health decision making. In this context, a project aimed at implementing a national arthroplasty registry in Italy has appeared to be essential, and the activities performed in the last years have consolidated data collection of hip and knee replacements.

Methods  Based on a close cooperation among public health institutions, clinicians, and involved stakeholders, the architecture of the registry is built on three pillars: (1) data collected using Hospital Discharge Records (HDRs) integrated by an additional dataset, (2) implants identified and characterized in a dedicated medical devices library, and (3) a federation of regional registries coordinated by a public health institution, the Italian National Institute of Health.

Results  Besides the organizational structure, statistical analyses on joint arthroplasty from national HDR database (2001–2014) and Italian registry data (2014) are presented. Currently, the institutions participating in the registry on a voluntary basis show 80% of completeness for hip and 58% for knee, and represent approximately 18% of the national volume.

Conclusion  To make data collection effective, participation should be mandatory and ruled by a national law.

Level of Study  Level III, observational analytic study.

Orthopedic workforce planning in Germany - an analysis of orthopedic accessibility

In Germany, orthopedic workforce planning relies on population-to-provider-ratios represented by the 'official degree of care provision'. However, with geographic information systems (GIS), more sophisticated measurements are available. By utilizing GIS-based technologies we analyzed the current state of demand and supply of the orthopedic workforce in Germany (orthopedic accessibility) with the integrated Floating Catchment Area method. The analysis of n = 153,352,220 distances revealed significant geographical variations on national scale: 5,617,595 people (6.9% of total population) lived in an area with significant low orthopedic accessibility (average z-score = -4.0), whereas 31,748,161 people (39.0% of total population) lived in an area with significant high orthopedic accessibility (average z-score = 8.0). Accessibility was positively correlated with the degree of urbanization (r = 0.49; p<0.001) and the official degree of care provision (r = 0.33; p<0.001) and negatively correlated with regional social deprivation (r = -0.47; p<0.001). Despite advantages of simpler measures regarding implementation and acceptance in health policy, more sophisticated measures of accessibility have the potential to reduce costs as well as improve health care. With this study, significant geographical variations were revealed that show the need to reduce oversupply in less deprived urban areas in order to enable adequate care in more deprived rural areas.

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

OBJECTIVE

To characterize the practicing rheumatologist workforce, the Canadian Rheumatology Association (CRA) launched the Stand Up and Be Counted workforce survey in 2015.

METHODS

The survey was distributed electronically to 695 individuals, of whom 519 were expected to be practicing rheumatologists. Demographic and practice information were elicited. We estimated the number of full-time equivalent rheumatologists per 75,000 population from the median proportion of time devoted to clinical practice multiplied by provincial rheumatologist numbers from the Canadian Medical Association.

RESULTS

The response rate was 68% (355/519) of expected practicing rheumatologists (304 were in adult practice, and 51 pediatric). The median age was 50 years, and one-third planned to retire within the next 5-10 years. The majority (81%) were university-affiliated. Rheumatologists spent a median of 70% of their time in clinical practice, holding 6 half-day clinics weekly, with 10 new consultations and 45 followups seen per week. Work characteristics varied by type of rheumatologist (adult or pediatric) and by practice setting (community- or university-based). We estimated between 0 and 0.8 full-time rheumatologists per 75,000 population in each province. This represents a deficit of 1 to 77 full-time rheumatologists per province/territory to meet the CRA recommendation of 1 rheumatologist per 75,000 population, depending on the province/territory.

CONCLUSION

Our results highlight a current shortage of rheumatologists in Canada that may worsen in the next 10 years because one-third of the workforce plans to retire. Efforts to encourage trainees to enter rheumatology and strategies to support retention are critical to address the shortage.

Commonalities and differences in the implementation of models of care for arthritis: key informant interviews from Canada

Background

Timely access to effective treatments for arthritis is a priority at national, provincial and regional levels in Canada due to population aging coupled with limited health human resources. Models of care for arthritis are being implemented across the country but mainly in local contexts, not from an evidence-informed policy or framework. The purpose of this study is to examine existing models of care for arthritis in Canada at the local level in order to identify commonalities and differences in their implementation that could point to important considerations for health policy and service delivery.

Methods

Semi-structured key informant interviews were conducted with 70 program managers and/or care providers in three Canadian provinces identified through purposive and snowball sampling followed by more detailed examination of 6 models of care (two per province). Interviews were transcribed verbatim and analyzed thematically using a qualitative descriptive approach.

Results

Two broad models of care were identified for Total Joint Replacement and Inflammatory Arthritis. Commonalities included lack of complete and appropriate referrals from primary care physicians and lack of health human resources to meet local demands. Strategies included standardized referrals and centralized intake and triage using non-specialist health care professionals. Differences included the nature of the care and follow-up, the role of the specialist, and location of service delivery.

Conclusions

Current models of care are mainly focused on Total Joint Replacement and Inflammatory Arthritis. Given the increasing prevalence of arthritis and that published data report only a small proportion of current service delivery is specialist care; provision of timely, appropriate care requires development, implementation and evaluation of models of care across the continuum of care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1634-9) contains supplementary material, which is available to authorized users.

Measuring the Rheumatology Workforce in Canada: A Literature Review

OBJECTIVE

The number of rheumatologists per capita has been proposed as a performance measure for arthritis care. This study reviews what is known about the rheumatologist workforce in Canada.

METHODS

A systematic search was conducted in EMBASE and MEDLINE using the search themes "rheumatology" AND "workforce" AND "Canada" from 2000 until December 2014. Additionally, workforce databases and rheumatology websites were searched. Data were abstracted on the numbers of rheumatologists, demographics, retirement projections, and barriers to healthcare.

RESULTS

Twenty-five sources for rheumatology workforce information were found: 6 surveys, 14 databases, 2 patient/provider resources, and 3 epidemiologic studies. Recent estimates say there are 398 to 428 rheumatologists in Canada, but there were limited data on allocation of time to clinical practice. Although the net number of rheumatologists has increased, the mean age was ≥ 47.7 years, and up to one-third are planning to retire in the next decade. There is a clustering of rheumatologists around academic centers, while some provinces/territories have suboptimal ratios of rheumatologists per capita (range 0-1.1). Limited information was found on whether rural areas are receiving adequate services. The most consistent barrier reported by rheumatologists was lack of allied health professionals.

CONCLUSION

In Canada there are regional disparities in access to rheumatologist care and an aging rheumatologist workforce. To address these workforce capacity issues, better data are needed including information on clinical full-time equivalents, delivery of care to remote communities, and use of alternative models of care to increase clinical capacity.

How to Attract Trainees, a Pan-Canadian Perspective: Phase 1 of the “Training the Rheumatologists of Tomorrow” Project

Objective.

To identify what learners and professionals associated with rheumatology programs across Canada recommend as ways to attract future trainees.

Methods.

Data from online surveys and individual interviews with participants from 9 rheumatology programs were analyzed using the thematic framework analysis to identify messages and methods to interest potential trainees in rheumatology.

Results.

There were 103 participants (78 surveyed, 25 interviewed) who indicated that many practitioners were drawn to rheumatology because of the aspects of work life, and that educational events and hands-on experiences can interest students. Messages centered on working life, career opportunities, and the lifestyle of rheumatologists. Specific ways to increase awareness about rheumatology included information about practice type, intellectual and diagnostic challenges, diversity of diseases, and patient populations. Increased opportunity for early and continued exposure for both medical students and internal medicine residents was also important, as was highlighting job flexibility and availability and a good work-life balance. Although mentors were rarely mentioned, many participants indicated educational activities of role models. The relatively low pay scale of rheumatologists was rarely identified as a barrier to choosing a career in rheumatology.

Conclusion.

This is the first pan-Canadian initiative using local data to create a work plan for developing and evaluating tools to promote interest in rheumatology that could help increase the number of future practitioners.

Optimizing the interprofessional workforce for centralized intake of patients with osteoarthritis and rheumatoid disease: case study

INTRODUCTION

This case study was part of a larger programme of research in Alberta that aims to develop an evidence-based model to optimize centralized intake province-wide to improve access to care. A centralized intake model places all referred patients on waiting lists based on severity and then directs them to the most appropriate provider or service. Our research focused on an in-depth assessment of two well-established models currently in place in Alberta to 1) enhance our understanding of the roles and responsibilities of staff in current intake processes, 2) identify workforce issues and opportunities within the current models, and 3) inform the potential use of alternative providers in the proposed centralized intake model.

CASE DESCRIPTION

Our case study included two centralized intake models in Alberta associated with three clinics. One model involved one clinic that focuses on rheumatoid disease. The other model involved two clinics that focus on osteoarthritis. We completed a document review and interviews with managers and staff from both models. Finally, we reviewed the scope of practice regulations for a range of health-care providers to examine their suitability to contribute to the centralized intake process of osteoarthritis and rheumatoid disease.

DISCUSSION AND EVALUATION

Interview findings from both models suggested a need for an electronic medical record and eReferral system to improve the efficiency of the current process and reduce staff workload. Staff interviewed also spoke of the need to have a permanent musculoskeletal screener available to streamline the intake process for osteoarthritis patients. Both models relied on registered nurses, medical office assistants, and physicians throughout their intake process. Our scope of practice review revealed that several providers have the competencies to screen, assess, and provide case management at different junctures in the centralized intake of patients with osteoarthritis and rheumatoid disease.

CONCLUSIONS

Using a broader range of providers in the centralized intake of osteoarthritis and rheumatoid disease has the potential to improve access and care specifically related to the assessment and management of patients. This may enhance the patient care experience and address current access issues.

Internet-based implementation of non-pharmacological interventions of the "people getting a grip on arthritis" educational program: an international online knowledge translation randomized controlled trial design protocol

BACKGROUND

Rheumatoid arthritis (RA) affects 2.1% of the Australian population (1.5% males; 2.6% females), with the highest prevalence from ages 55 to over 75 years (4.4-6.1%). In Canada, RA affects approximately 0.9% of adults, and within 30 years that is expected to increase to 1.3%. With an aging population and a greater number of individuals with modifiable risk factors for chronic diseases, such as arthritis, there is an urgent need for co-care management of arthritic conditions. The increasing trend and present shifts in the health services and policy sectors suggest that digital information delivery is becoming more prominent. Therefore, it is necessary to further investigate the use of online resources for RA information delivery.

OBJECTIVE

The objective is to examine the effect of implementing an online program provided to patients with RA, the People Getting a Grip on Arthritis for RA (PGrip-RA) program, using information communication technologies (ie, Facebook and emails) in combination with arthritis health care professional support and electronic educational pamphlets. We believe this can serve as a useful and economical method of knowledge translation (KT).

METHODS

This KT randomized controlled trial will use a prospective randomized open-label blinded-endpoint design to compare four different intervention approaches of the PGrip-RA program to a control group receiving general electronic educational pamphlets self-management in RA via email. Depending on group allocation, links to the Arthritis Society PGrip-RA material will be provided either through Facebook or by email. One group will receive feedback online from trained health care professionals. The intervention period is 6 weeks. Participants will have access to the Internet-based material after the completion of the baseline questionnaires until the final follow-up questionnaire at 6 months. We will invite 396 patients from Canadian and Australian Arthritis Consumers' Associations to participate using online recruitment.

RESULTS

This study will build on a pilot study using Facebook, which revealed promising effects of knowledge acquisition/integration of the evidence-based self-management PGrip educational program.

CONCLUSIONS

The use of online techniques to disseminate knowledge provides an opportunity to reduce health care costs by facilitating self-management of people with arthritis. Study design strengths include the incorporation of randomization and allocation concealment to ensure internal validity. To avoid intergroup contamination, the Facebook group page security settings will be set to "closed", thus allowing only invited participants to access it. Study limitations include the lack of participant blinding due to the characteristics of this KT randomized controlled trial and a potential bias of recruiting patients only online, though this was proven effective in the previous pilot study.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12614000397617; http://www.anzctr.org.au/TrialSearch.aspx (Archived by WebCite at http://www.webcitation.org/6PrP0kQf8).