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Widdifield J, Tu K, Carter Thorne J, Bombardier C, Michael Paterson J, Liisa Jaakkimainen R, Wing L, Butt DA, Ivers N, Hofstetter C, Lyddiatt A, Ahluwalia V, Bernatsky S. Patterns of Care Among Patients Referred to Rheumatologists in Ontario, Canada. Arthritis Care Res (Hoboken) 2016; 69:104-114. [PMID: 27110847 DOI: 10.1002/acr.22910] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 03/17/2016] [Accepted: 04/05/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Our aim was to characterize referrals to rheumatologists, the early care management of patients with rheumatic diseases, and timeliness of care and treatment. METHODS We conducted a retrospective observational study involving patients with first-time rheumatology referrals between 2000 and 2013 in the primary care Electronic Medical Record Administrative data Linked Database (EMRALD) in Ontario, Canada. Referrals were characterized in terms of diagnoses, patient demographics, diagnostic tests, treatment initiated by family physicians and rheumatologists, and other specialists seen prior to rheumatology consultation. Timeliness of referrals, rheumatologist consultations, and treatment were determined overall and for each diagnostic category. RESULTS Among 2,430 patients referred to a rheumatologist, 69% were female, with an average age of 53 years. The principal diagnosis associated with the referral included osteoarthritis (32%), systemic inflammatory rheumatic diseases (31%), regional musculoskeletal conditions (16%), chronic pain conditions (14%), osteoporosis (2%), and other/miscellaneous (5%). Family physicians most frequently prescribed nonsteroidal antiinflammatory drugs/cyclooxygenase 2 inhibitors (38%), and their pre-referral diagnostic testing practice varied considerably. The duration of time from symptom onset to rheumatology consultation varied by diagnoses, with the shortest being for patients with systemic rheumatic diseases; for rheumatoid arthritis (RA), the median time to consultation was 327 days. Most of the delay occurred prior to referral; 36% of RA patients initiated a disease-modifying antirheumatic drug within 6 months of symptom onset. CONCLUSION Approximately 1 in 3 referrals to rheumatologists were for a systemic inflammatory rheumatic disease. We observed substantial delays to rheumatology consultations and variations in patterns of care that could be amenable to quality improvement interventions.
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Affiliation(s)
- Jessica Widdifield
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada, and McGill University, Montreal, Quebec, Canada
| | - Karen Tu
- Institute for Clinical Evaluative Sciences, University of Toronto, and University Health Network, Toronto Western Hospital Family Health Team, Toronto, Ontario, Canada
| | | | | | - J Michael Paterson
- Institute for Clinical Evaluative Sciences and University of Toronto, Toronto, Ontario, Canada, and McMaster University, Hamilton, Ontario, Canada
| | - R Liisa Jaakkimainen
- Institute for Clinical Evaluative Sciences and University of Toronto, Toronto, Ontario, Canada
| | - Laura Wing
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Debra A Butt
- University of Toronto and Scarborough Hospital, Toronto, Ontario, Canada
| | - Noah Ivers
- Institute for Clinical Evaluative Sciences and Women's College Hospital, Toronto, Ontario, Canada
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Batthish M, Tse SML, Feldman BM, Baker GR, Laxer RM. Trying to improve care: the Morbidity and Mortality Conference in a division of rheumatology. J Rheumatol 2014; 41:2452-8. [PMID: 25362651 DOI: 10.3899/jrheum.140203] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To describe the frequency and types of reported adverse events and system improvement recommendations in the Morbidity and Mortality Conference (M&MC) within the Division of Rheumatology at The Hospital for Sick Children, Toronto, Ontario, Canada (SickKids). METHODS A 5-year retrospective review of the M&MC within the Division of Rheumatology at SickKids was completed. Descriptive data including the number and types of events reported were collected. Events were categorized using an adaptation of the National Coordinating Council for Medication Error Reporting and Prevention Index. Recommendations were classified according to the Institute for Safe Medication Practices Canada. RESULTS Between January 2007 and December 2011, 30 regularly scheduled M&MC were held. Eighty-three cases were reviewed. The most common types of reported events were related to "miscommunication" (34.9%), "treatment/test/procedure" (22.9%), "adverse drug reactions" (12.0%), and "medication errors" (8.4%). Category A events ("an event that has the capacity to cause error") were the most common with 39.8% of the cases, followed by Category C events ("an event occurred that reached the patient, but did not cause harm") with 28.9%. Eighty-nine recommendations were made. Over half of these were classified as "information" (58.4%), followed by 11 "rules and policies" recommendations (12.4%). Of the 36 action items generated from these recommendations, most are either complete or ongoing. CONCLUSION The M&MC within the Division of Rheumatology reviews a variety of events. Increased reporting of adverse events can lead to system improvements, and has the potential to improve and promote safer healthcare.
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Affiliation(s)
- Michelle Batthish
- From the Division of Rheumatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton; Division of Rheumatology, Department of Pediatrics, Department of Medicine, The Hospital for Sick Children; Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.M. Batthish, MD, Division of Rheumatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University; S.M.L. Tse, MD, Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto; B.M. Feldman, MD, Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, Dalla Lana School of Public Health, University of Toronto; G.R. Baker, PhD, Institute of Health Policy, Management and Evaluation, University of Toronto; R.M. Laxer, MD, Division of Rheumatology, Departments of Pediatrics and Medicine, The Hospital for Sick Children, University of Toronto.
| | - Shirley M L Tse
- From the Division of Rheumatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton; Division of Rheumatology, Department of Pediatrics, Department of Medicine, The Hospital for Sick Children; Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.M. Batthish, MD, Division of Rheumatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University; S.M.L. Tse, MD, Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto; B.M. Feldman, MD, Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, Dalla Lana School of Public Health, University of Toronto; G.R. Baker, PhD, Institute of Health Policy, Management and Evaluation, University of Toronto; R.M. Laxer, MD, Division of Rheumatology, Departments of Pediatrics and Medicine, The Hospital for Sick Children, University of Toronto
| | - Brian M Feldman
- From the Division of Rheumatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton; Division of Rheumatology, Department of Pediatrics, Department of Medicine, The Hospital for Sick Children; Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.M. Batthish, MD, Division of Rheumatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University; S.M.L. Tse, MD, Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto; B.M. Feldman, MD, Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, Dalla Lana School of Public Health, University of Toronto; G.R. Baker, PhD, Institute of Health Policy, Management and Evaluation, University of Toronto; R.M. Laxer, MD, Division of Rheumatology, Departments of Pediatrics and Medicine, The Hospital for Sick Children, University of Toronto
| | - G Ross Baker
- From the Division of Rheumatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton; Division of Rheumatology, Department of Pediatrics, Department of Medicine, The Hospital for Sick Children; Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.M. Batthish, MD, Division of Rheumatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University; S.M.L. Tse, MD, Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto; B.M. Feldman, MD, Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, Dalla Lana School of Public Health, University of Toronto; G.R. Baker, PhD, Institute of Health Policy, Management and Evaluation, University of Toronto; R.M. Laxer, MD, Division of Rheumatology, Departments of Pediatrics and Medicine, The Hospital for Sick Children, University of Toronto
| | - Ronald M Laxer
- From the Division of Rheumatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton; Division of Rheumatology, Department of Pediatrics, Department of Medicine, The Hospital for Sick Children; Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.M. Batthish, MD, Division of Rheumatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University; S.M.L. Tse, MD, Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto; B.M. Feldman, MD, Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, Dalla Lana School of Public Health, University of Toronto; G.R. Baker, PhD, Institute of Health Policy, Management and Evaluation, University of Toronto; R.M. Laxer, MD, Division of Rheumatology, Departments of Pediatrics and Medicine, The Hospital for Sick Children, University of Toronto
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Perruccio AV, Losina E, Wright EA, Katz JN. Aggregate health burden and the risk of hospitalization in older persons post hip replacement surgery. J Gerontol A Biol Sci Med Sci 2012; 68:293-300. [PMID: 22879451 DOI: 10.1093/gerona/gls151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We sought to understand the association between aggregate health burden-chronic conditions, functionally limiting health problems and mental well-being-and the likelihood of hospitalization among older persons post hip replacement surgery. METHODS Eight hundred and twenty-eight Medicare recipients from three U.S. states completed a questionnaire 3 years postsurgery. Using administrative data (Medicare Provider Analysis and Review), participants were prospectively followed for 12 months postquestionnaire to capture hospitalizations. Using logistic regression, demographic, socioeconomic, and behavioral characteristics and medical comorbidities were considered as predictors. Subsequently, musculoskeletal (MSK) functional and geriatric problems were added as predictors, then mental well-being and activity limitations. Path analysis was employed to elucidate interrelationships between these predictors, investigating whether mediated effects through mental well-being and activity limitations were operational. RESULTS Mean age was 76 years (range: 67-96); 63% were women; 23% had ≥1 hospitalization(s). When medical comorbidity, MSK limitations, and geriatric problems were considered, each was independently associated with hospitalization (odds ratios: 1.3, 1.1, 1.2, respectively). When mental well-being and activity limitations were added, these variables were predictive of hospitalization (odds ratios: 1.2, 1.1, respectively), while MSK limitations and geriatric problems were no longer predictive. Path analysis results suggested that the influence of medical comorbidity and MSK and geriatric problems were mediated through mental well-being and activity limitations. CONCLUSIONS Several health domains predict hospitalization, beyond and including medical comorbidity. Efforts aimed at delaying/minimizing hospitalizations in this population should consider an array of domains for potentially targeted intervention. These findings can serve as a baseline against which future research can assess the impact of changes to the health care system.
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Affiliation(s)
- Anthony V Perruccio
- Department of Orthopedic Surgery, Toronto Western Hospital, 399 Bathurst St, EW 1-427, Toronto, ON, Canada M5T 2S8.
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