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Improving access to care for rheumatology services in Canada. Clin Rheumatol 2023; 42:1205-1211. [PMID: 36746833 PMCID: PMC9901822 DOI: 10.1007/s10067-023-06532-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/13/2023] [Accepted: 01/30/2023] [Indexed: 02/08/2023]
Abstract
Rheumatic diseases are becoming increasingly prevalent in Canada, and its associated strain on the healthcare system is expected to increase over the next decades. Furthermore, there is an increasing body of evidence to suggest that access to rheumatology care is currently not meeting established quality of care benchmarks. To frame issues affecting access to care for rheumatology services in Canada, a proposed chronological framework from a rheumatology patient's perspective is proposed. Illustrating principles from a health policy lens including drawing from the stages heuristic framework and multiple streams theory, issues surrounding access to rheumatology assessment, to rheumatological investigations and lastly to appropriate treatment are explored. In particular, the current supply and demand mismatch within the rheumatology workforce presents challenges for patients in accessing rheumatic diseases providers. Potential policy solutions including increasing the pool of rheumatic diseases care providers, enhancing the clinical capacity with extended role providers and increasing uptake of virtual care are discussed. To ameliorate access to rheumatology investigations, the concept of provider education surrounding the appropriateness of investigations and merit-based funding are explored. Lastly, access to rheumatological treatment is framed using biologic therapies as an example, highlighting the policy challenges in biosimilar uptake and associated ethical and political considerations. By using a health policy lens to explore deficiencies within Canada's current system, the overarching goal of this analysis is to set the stage for reasoned and timely solutions in the future.
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Barber CEH, Lacaille D, Croxford R, Barnabe C, Marshall DA, Abrahamowicz M, Xie H, Avina-Zubieta JA, Esdaile JM, Hazlewood G, Faris P, Katz S, MacMullan P, Mosher D, Widdifield J. System-level performance measures of access to rheumatology care: a population-based retrospective study of trends over time and the impact of regional rheumatologist supply in Ontario, Canada, 2002-2019. BMC Rheumatol 2022; 6:86. [PMID: 36572934 PMCID: PMC9793576 DOI: 10.1186/s41927-022-00315-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 10/25/2022] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To determine whether there were improvements in rheumatology care for rheumatoid arthritis (RA) between 2002 and 2019 in Ontario, Canada, and to evaluate the impact of rheumatologist regional supply on access. METHODS We conducted a population-based retrospective study of all individuals diagnosed with RA between January 1, 2002 and December 31, 2019. Performance measures evaluated were: (i) percentage of RA patients seen by a rheumatologist within one year of diagnosis; and (ii) percentage of individuals with RA aged 66 years and older (whose prescription drugs are publicly funded) dispensed a disease modifying anti-rheumatic drug (DMARD) within 30 days after initial rheumatologist visit. Logistic regression was used to assess whether performance improved over time and whether the improvements differed by rheumatology supply, dichotomized as < 1 rheumatologist per 75,000 adults versus ≥1 per 75,000. RESULTS Among 112,494 incident RA patients, 84% saw a rheumatologist within one year: The percentage increased over time (adjusted odds ratio (OR) 2019 vs. 2002 = 1.43, p < 0.0001) and was consistently higher in regions with higher rheumatologist supply (OR = 1.73, 95% CI 1.67-1.80). Among seniors who were seen by a rheumatologist within 1 year of their diagnosis the likelihood of timely DMARD treatment was lower among individuals residing in regions with higher rheumatologist supply (OR = 0.90 95% CI 0.83-0.97). These trends persisted after adjusting for other covariates. CONCLUSION While access to rheumatologists and treatment improved over time, shortcomings remain, particularly for DMARD use. Patients residing in regions with higher rheumatology supply were more likely to access care but less likely to receive timely treatment.
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Affiliation(s)
- Claire E. H. Barber
- grid.22072.350000 0004 1936 7697Department of Medicine, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697Department of Community Health Sciences, University of Calgary, AB Calgary, Canada ,grid.22072.350000 0004 1936 7697McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB Canada ,Arthritis Research Canada, Vancouver, BC Canada
| | - Diane Lacaille
- Arthritis Research Canada, Vancouver, BC Canada ,grid.17091.3e0000 0001 2288 9830Department of Medicine, University of British Columbia, Vancouver, BC Canada
| | - Ruth Croxford
- grid.418647.80000 0000 8849 1617ICES, Toronto, Canada
| | - Cheryl Barnabe
- grid.22072.350000 0004 1936 7697Department of Medicine, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697Department of Community Health Sciences, University of Calgary, AB Calgary, Canada ,grid.22072.350000 0004 1936 7697McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB Canada ,Arthritis Research Canada, Vancouver, BC Canada
| | - Deborah A. Marshall
- grid.22072.350000 0004 1936 7697Department of Medicine, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697Department of Community Health Sciences, University of Calgary, AB Calgary, Canada ,grid.22072.350000 0004 1936 7697McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB Canada ,Arthritis Research Canada, Vancouver, BC Canada
| | - Michal Abrahamowicz
- Arthritis Research Canada, Vancouver, BC Canada ,grid.14709.3b0000 0004 1936 8649Department of Epidemiology and Biostatistics, McGill University, Montreal, QC Canada
| | - Hui Xie
- Arthritis Research Canada, Vancouver, BC Canada ,grid.61971.380000 0004 1936 7494Faculty of Health Sciences, Simon Fraser University, Burnaby, BC Canada
| | - J. Antonio Avina-Zubieta
- Arthritis Research Canada, Vancouver, BC Canada ,grid.17091.3e0000 0001 2288 9830Department of Medicine, University of British Columbia, Vancouver, BC Canada
| | - John M. Esdaile
- Arthritis Research Canada, Vancouver, BC Canada ,grid.17091.3e0000 0001 2288 9830Department of Medicine, University of British Columbia, Vancouver, BC Canada
| | - Glen Hazlewood
- grid.22072.350000 0004 1936 7697Department of Medicine, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697Department of Community Health Sciences, University of Calgary, AB Calgary, Canada ,grid.22072.350000 0004 1936 7697McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB Canada ,Arthritis Research Canada, Vancouver, BC Canada
| | - Peter Faris
- grid.413574.00000 0001 0693 8815Alberta Health Services, Calgary, AB Canada
| | - Steven Katz
- grid.17089.370000 0001 2190 316XDepartment of Medicine, University of Alberta, Edmonton, AB Canada
| | - Paul MacMullan
- grid.22072.350000 0004 1936 7697Department of Medicine, University of Calgary, Calgary, AB Canada
| | - Dianne Mosher
- grid.22072.350000 0004 1936 7697Department of Medicine, University of Calgary, Calgary, AB Canada
| | - Jessica Widdifield
- grid.418647.80000 0000 8849 1617ICES, Toronto, Canada ,grid.17063.330000 0001 2157 2938Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada ,grid.17063.330000 0001 2157 2938Holland Bone and Joint Program, Sunnybrook Research Institute, Toronto, Canada
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Power JD, Perruccio AV, Paterson JM, Canizares M, Veillette C, Coyte PC, Badley EM, Mahomed NN, Rampersaud YR. Healthcare utilization and costs for musculoskeletal disorders in Ontario, Canada. J Rheumatol Suppl 2022; 49:740-747. [PMID: 35365584 DOI: 10.3899/jrheum.210938] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To examine the magnitude and costs of ambulatory primary and specialist physician care and hospital service use for musculoskeletal disorders (MSDs) in Canada's largest province, Ontario. METHODS Administrative health databases were analyzed for fiscal year 2013-2014 for adults 18+ years, including data on physician services, emergency department (ED) visits and hospitalizations. ICD diagnostic codes were used to identify MSD services. A validated algorithm was used to estimate direct medical costs. Person visit rates and numbers of persons and visits were tabulated by care setting, age and sex, and physician specialty. Data were examined for all MSDs combined as well as specific diagnostic groupings. RESULTS Overall, 3.1 million adult Ontarians (28.5%) made 8 million outpatient physician visits associated with MSDs. These included 5.6 million primary care visits. MSDs accounted for 560,000, 12.3%, of all adult ED visits. Total costs for MSD-related care were $1.6 billion, with 12.6% of costs attributed to primary care, 9.2% to specialist care, 8.6% to ED care, 8.5% to day surgery and 61.2% of total costs associated with inpatient hospitalizations. Costs due to arthritis accounted for 40% of total MSD care costs ($639 million). MSD-related imaging costs were $169 million. Including these costs yields a total estimate of $1.8 billion for all MSDs combined. CONCLUSION MSDs place a significant and costly burden on the health care system. Health system planning needs to consider the large and escalating demand for care to reduce both the individual and population burden.
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Affiliation(s)
- J Denise Power
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Orthopaedics, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Support: This study was financially supported by the Toronto General & Western Hospital Foundation through the University Health Network Arthritis Program. The funding source had no involvement in study design or manuscript preparation. Conflict of Interest: There are no potential conflicts of interest relevant to this work. Corresponding Author: J. Denise Power, 399 Bathurst Street MP10-326, Toronto, Ontario, Canada, M5T 2S8.
| | - Anthony V Perruccio
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Orthopaedics, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Support: This study was financially supported by the Toronto General & Western Hospital Foundation through the University Health Network Arthritis Program. The funding source had no involvement in study design or manuscript preparation. Conflict of Interest: There are no potential conflicts of interest relevant to this work. Corresponding Author: J. Denise Power, 399 Bathurst Street MP10-326, Toronto, Ontario, Canada, M5T 2S8.
| | - J Michael Paterson
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Orthopaedics, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Support: This study was financially supported by the Toronto General & Western Hospital Foundation through the University Health Network Arthritis Program. The funding source had no involvement in study design or manuscript preparation. Conflict of Interest: There are no potential conflicts of interest relevant to this work. Corresponding Author: J. Denise Power, 399 Bathurst Street MP10-326, Toronto, Ontario, Canada, M5T 2S8.
| | - Mayilee Canizares
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Orthopaedics, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Support: This study was financially supported by the Toronto General & Western Hospital Foundation through the University Health Network Arthritis Program. The funding source had no involvement in study design or manuscript preparation. Conflict of Interest: There are no potential conflicts of interest relevant to this work. Corresponding Author: J. Denise Power, 399 Bathurst Street MP10-326, Toronto, Ontario, Canada, M5T 2S8.
| | - Christian Veillette
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Orthopaedics, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Support: This study was financially supported by the Toronto General & Western Hospital Foundation through the University Health Network Arthritis Program. The funding source had no involvement in study design or manuscript preparation. Conflict of Interest: There are no potential conflicts of interest relevant to this work. Corresponding Author: J. Denise Power, 399 Bathurst Street MP10-326, Toronto, Ontario, Canada, M5T 2S8.
| | - Peter C Coyte
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Orthopaedics, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Support: This study was financially supported by the Toronto General & Western Hospital Foundation through the University Health Network Arthritis Program. The funding source had no involvement in study design or manuscript preparation. Conflict of Interest: There are no potential conflicts of interest relevant to this work. Corresponding Author: J. Denise Power, 399 Bathurst Street MP10-326, Toronto, Ontario, Canada, M5T 2S8.
| | - Elizabeth M Badley
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Orthopaedics, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Support: This study was financially supported by the Toronto General & Western Hospital Foundation through the University Health Network Arthritis Program. The funding source had no involvement in study design or manuscript preparation. Conflict of Interest: There are no potential conflicts of interest relevant to this work. Corresponding Author: J. Denise Power, 399 Bathurst Street MP10-326, Toronto, Ontario, Canada, M5T 2S8.
| | - Nizar N Mahomed
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Orthopaedics, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Support: This study was financially supported by the Toronto General & Western Hospital Foundation through the University Health Network Arthritis Program. The funding source had no involvement in study design or manuscript preparation. Conflict of Interest: There are no potential conflicts of interest relevant to this work. Corresponding Author: J. Denise Power, 399 Bathurst Street MP10-326, Toronto, Ontario, Canada, M5T 2S8.
| | - Y Raja Rampersaud
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Orthopaedics, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Support: This study was financially supported by the Toronto General & Western Hospital Foundation through the University Health Network Arthritis Program. The funding source had no involvement in study design or manuscript preparation. Conflict of Interest: There are no potential conflicts of interest relevant to this work. Corresponding Author: J. Denise Power, 399 Bathurst Street MP10-326, Toronto, Ontario, Canada, M5T 2S8.
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Lee JJY, Laxer RM, Feldman BM, Barber CEH, Batthish M, Berard R, Tucker LB, Levy DM. Variations in Pediatric Rheumatology Workforce and Care Processes Across Canada. J Rheumatol 2021; 49:197-204. [PMID: 34334367 DOI: 10.3899/jrheum.201611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2021] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Jennifer J Y Lee
- The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; The Cumming School of Medicine, University of Calgary, Alberta, Canada; McMaster Children's Hospital, Hamilton, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada; Western University, London, Ontario, Canada; British Columbia Children's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, Canada. Sources of Support: Jennifer JY Lee is funded by the SickKids Clinician Scientist Training Program Study funding is provided by the Canadian Rheumatology Association. Address correspondence to: Deborah M. Levy, MD, MSc, FRCPC The Hospital for Sick Children (SickKids) 555 University Avenue Toronto, Ontario, Canada M5G 1X8.
| | - Ronald M Laxer
- The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; The Cumming School of Medicine, University of Calgary, Alberta, Canada; McMaster Children's Hospital, Hamilton, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada; Western University, London, Ontario, Canada; British Columbia Children's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, Canada. Sources of Support: Jennifer JY Lee is funded by the SickKids Clinician Scientist Training Program Study funding is provided by the Canadian Rheumatology Association. Address correspondence to: Deborah M. Levy, MD, MSc, FRCPC The Hospital for Sick Children (SickKids) 555 University Avenue Toronto, Ontario, Canada M5G 1X8.
| | - Brian M Feldman
- The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; The Cumming School of Medicine, University of Calgary, Alberta, Canada; McMaster Children's Hospital, Hamilton, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada; Western University, London, Ontario, Canada; British Columbia Children's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, Canada. Sources of Support: Jennifer JY Lee is funded by the SickKids Clinician Scientist Training Program Study funding is provided by the Canadian Rheumatology Association. Address correspondence to: Deborah M. Levy, MD, MSc, FRCPC The Hospital for Sick Children (SickKids) 555 University Avenue Toronto, Ontario, Canada M5G 1X8.
| | - Claire E H Barber
- The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; The Cumming School of Medicine, University of Calgary, Alberta, Canada; McMaster Children's Hospital, Hamilton, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada; Western University, London, Ontario, Canada; British Columbia Children's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, Canada. Sources of Support: Jennifer JY Lee is funded by the SickKids Clinician Scientist Training Program Study funding is provided by the Canadian Rheumatology Association. Address correspondence to: Deborah M. Levy, MD, MSc, FRCPC The Hospital for Sick Children (SickKids) 555 University Avenue Toronto, Ontario, Canada M5G 1X8.
| | - Michelle Batthish
- The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; The Cumming School of Medicine, University of Calgary, Alberta, Canada; McMaster Children's Hospital, Hamilton, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada; Western University, London, Ontario, Canada; British Columbia Children's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, Canada. Sources of Support: Jennifer JY Lee is funded by the SickKids Clinician Scientist Training Program Study funding is provided by the Canadian Rheumatology Association. Address correspondence to: Deborah M. Levy, MD, MSc, FRCPC The Hospital for Sick Children (SickKids) 555 University Avenue Toronto, Ontario, Canada M5G 1X8.
| | - Roberta Berard
- The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; The Cumming School of Medicine, University of Calgary, Alberta, Canada; McMaster Children's Hospital, Hamilton, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada; Western University, London, Ontario, Canada; British Columbia Children's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, Canada. Sources of Support: Jennifer JY Lee is funded by the SickKids Clinician Scientist Training Program Study funding is provided by the Canadian Rheumatology Association. Address correspondence to: Deborah M. Levy, MD, MSc, FRCPC The Hospital for Sick Children (SickKids) 555 University Avenue Toronto, Ontario, Canada M5G 1X8.
| | - Lori B Tucker
- The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; The Cumming School of Medicine, University of Calgary, Alberta, Canada; McMaster Children's Hospital, Hamilton, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada; Western University, London, Ontario, Canada; British Columbia Children's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, Canada. Sources of Support: Jennifer JY Lee is funded by the SickKids Clinician Scientist Training Program Study funding is provided by the Canadian Rheumatology Association. Address correspondence to: Deborah M. Levy, MD, MSc, FRCPC The Hospital for Sick Children (SickKids) 555 University Avenue Toronto, Ontario, Canada M5G 1X8.
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Ahluwalia V, Inrig T, Larsen T, Shupak R, Papneja T, Karasik A, Kennedy C, Lundon K. An Advanced Clinician Practitioner in Arthritis Care (ACPAC) Maintains a Positive Patient Experience While Increasing Capacity in Rheumatology Community Care. J Multidiscip Healthc 2021; 14:1299-1310. [PMID: 34113118 PMCID: PMC8184238 DOI: 10.2147/jmdh.s304206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 04/06/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose This study describes patient care experiences of solo-rheumatologist and co-managed care models utilizing an Advanced Clinician Practitioner in Arthritis Care-trained Extended Role Practitioner (ACPAC-ERP) in three community rheumatology practices. Materials and Methods Patients with inflammatory arthritis (IA) were assigned to care provided by one of three (2 senior, 1 early-career) community-based rheumatologists (usual care), or an ACPAC-ERP (co-managed care) for the 6-months following diagnosis. Patient experiences were surveyed using validated measures of patient satisfaction (Patient Doctor Interaction Scale-PDIS), global ratings of confidence and satisfaction, referral patterns, disease activity (RADAI) and self-perceived disability (HAQ-Disability) as well as demographic information. Practice capacity was evaluated 18-months prior to, and across, the study period. Results Of 55 participants (mean age 56.6 years, 61.8% female), 33 received co-managed care. Most participants were diagnosed with rheumatoid arthritis (65.5%) with a median symptom duration of 1.1 years. At 6-months, patients from both models of care were equally satisfied in terms of the information provided (usual care 4.6 vs co-managed care 4.7/5=greater satisfaction), rapport with health-care provider (4.6 vs 4.6/5) and having needs met (4.7 vs 4.5/5). Overall satisfaction was high (87.2 vs 85.3/100=completely satisfied) as was confidence in the system by which care was received (85.0 vs 82.1/100=completely confident). Usual care patients reported higher perceived disability than co-managed patients (HAQ-Disability 0.5 vs 0.2/3=unable to do). Significant differences in overall RADAI score (p=0.014) were found between the two models. The senior rheumatologist, with a previously saturated practice, attained a 37% capacity increase for new patients utilizing the co-managed care model. Conclusion The ACPAC-ERP model was equivalent to the solo-rheumatologist model with regard to patient experience and satisfaction. A co-management model utilizing a highly trained ACPAC-ERP can increase capacity in community rheumatology clinics for patients newly diagnosed with IA while maintaining confidence and satisfaction with their care.
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Affiliation(s)
- Vandana Ahluwalia
- Division of Rheumatology, Department of Internal Medicine, William Osler Health System, Brampton, ON, Canada
| | - Taucha Inrig
- Musculoskeletal Health and Outcomes Research, St. Michael's Hospital, Toronto, ON, Canada
| | - Tiffany Larsen
- Department of Physiotherapy, Headwaters Healthcare Centre, Orangeville, ON, Canada
| | - Rachel Shupak
- Division of Rheumatology, Department of Internal Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | - Tripti Papneja
- Division of Rheumatology, Department of Internal Medicine, William Osler Health System, Brampton, ON, Canada
| | - Arthur Karasik
- Independent Rheumatology Practice, Etobicoke, ON, Canada
| | - Carol Kennedy
- Musculoskeletal Health and Outcomes Research, St. Michael's Hospital, Toronto, ON, Canada
| | - Katie Lundon
- Continuing Professional Development, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Liu X, Barber CEH, Katz S, Homik J, Bertazzon S, Patel AB, Robert J, Smith C, Mosher D, Marshall DA. Geographic Variation in the Prevalence of Rheumatoid Arthritis in Alberta, Canada. ACR Open Rheumatol 2021; 3:324-332. [PMID: 33793090 PMCID: PMC8126758 DOI: 10.1002/acr2.11251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 02/22/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Timely access to rheumatologists remains a challenge in Alberta, a Canadian province with vast rural areas, whereas rheumatologists are primarily clustered in metro areas. To address the goal of timely and equitable access to rheumatoid arthritis (RA) care, health planners require information at the regional and local level to determine the RA prevalence and the associated health care needs. METHODS Using Alberta Health administrative databases, we identified RA-prevalent cases (April 1, 2015-March 31, 2016) on the basis of a validated case definition. Age- and sex-standardized prevalence rates per 1000 population members and the standardized rates ratio (SRR) were calculated. We applied Global Moran's I and Gi* hotspot analysis using three different weight matrices to explore the geospatial pattern of RA prevalence in Alberta. RESULTS Among 38 350 RA cases (68% female; n = 26 236), the prevalence rate was 11.81 cases per 1000 population members (95% confidence interval [CI] 11.80-11.81) after age and sex standardization. Approximately 60% of RA cases resided in metro (Calgary and Edmonton) and moderate metro areas. The highest rate was observed in rural areas (14.46; 95% CI 14.45-14.47; SRR 1.28), compared with the lowest in metro areas (10.69; 95% CI 10.68-10.69; SRR 0.82). The RA prevalence across local geographic areas ranged from 4.7 to 30.6 cases. The Global Moran's I index was 0.15 using three different matrices (z-score 3.96-4.24). We identified 10 hotspots in the south and north rural areas and 18 cold spots in metro and moderate metro Calgary. CONCLUSION The findings highlight notable rural-urban variation in RA prevalence in Alberta. Our findings can inform strategies aimed at reducing geographic disparities by targeting areas with high health care needs.
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Affiliation(s)
| | - Claire E. H. Barber
- University of Calgary, Calgary, Alberta, Canada, and Arthritis Research CanadaRichmondBritish ColumbiaCanada
| | | | | | | | - Alka B. Patel
- University of Calgary, Calgary, Alberta, Canada, and Alberta Health ServicesEdmontonAlbertaCanada
| | - Jill Robert
- Alberta Health ServicesEdmontonAlbertaCanada
| | | | | | - Deborah A. Marshall
- University of Calgary, Calgary, Alberta, Canada, and Arthritis Research CanadaRichmondBritish ColumbiaCanada
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Widdifield J, Bernatsky S, Pope JE, Kuriya B, Barber CEH, Eder L, Ahluwalia V, Ling V, Gozdyra P, Hofstetter C, Lyddiatt A, Paterson JM, Thorne C. Evaluation of Rheumatology Workforce Supply Changes in Ontario, Canada, from 2000 to 2030. ACTA ACUST UNITED AC 2021; 16:119-134. [PMID: 33720829 PMCID: PMC7957360 DOI: 10.12927/hcpol.2021.26428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Rheumatology workforces are increasingly challenged by too few physicians in face of the growing burden of rheumatic and musculoskeletal diseases (RMDs). Rheumatology is one of the most frequent non-surgical specialty referrals and has the longest wait times for subspecialists. We used a population-based approach to describe changes in the rheumatology workforce, patient volumes and geographic variation in the supply of and access to rheumatologists, in Ontario, Canada, between 2000 and 2019, and projected changes in supply by 2030. Over time, we observed greater feminization of the workforce and increasing age of workforce members. We identified a large regional variation in rheumatology supply. Fewer new patients are seen annually, which likely contributes to increasing wait times and reduced access to care. Strategies and policies to raise the critical mass and improve regional distribution of supply to effectively provide rheumatology care and support the healthcare delivery of patients with RMDs are needed.
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Affiliation(s)
- Jessica Widdifield
- Scientist, Sunnybrook Research Institute Holland Bone & Joint Program; Assistant Professor, University of Toronto, Institute of Health Policy, Management & Evaluation Toronto, ON; Scientist, ICES Toronto, ON
| | - Sasha Bernatsky
- Rheumatologist and Scientist, Research Institute of the McGill University Health Centre; Associate Professor, Department of Epidemiology, McGill University, Montreal, QC
| | - Janet E Pope
- Rheumatologist, St Joseph's Health Care London; Professor of Medicine Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University London, ON
| | - Bindee Kuriya
- Rheumatologist, Sinai Health System; Assistant Professor, Department of Medicine, University of Toronto, Toronto, ON
| | - Claire E H Barber
- Rheumatologist, Assistant Professor, University of Calgary, Calgary, AB; Research Scientist, Arthritis Research Canada, Richmond, BC
| | - Lihi Eder
- Rheumatologist, Clinician Scientist, Women's College Research Institute, Toronto, ON
| | | | | | | | | | | | - J Michael Paterson
- Scientist, ICES, Toronto, ON; Assistant Professor, Department of Family Medicine, McMaster University, Hamilton, ON; Assistant Professor, University of Toronto, Institute of Health Policy, Management & Evaluation, Toronto, ON
| | - Carter Thorne
- Rheumatologist, Southlake Regional Health Centre, Newmarket, ON; Assistant Professor of Medicine, University of Toronto, Toronto, ON
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Widdifield J, Gatley JM, Pope JE, Barber CEH, Kuriya B, Eder L, Thorne C, Ling V, Paterson JM, Ahluwalia V, Marks C, Bernatsky S. Feminization of the Rheumatology Workforce: A Longitudinal Evaluation of Patient Volumes, Practice Sizes, and Physician Remuneration. J Rheumatol 2020; 48:1090-1097. [PMID: 33262302 DOI: 10.3899/jrheum.201166] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To compare differences in clinical activity and remuneration between male and female rheumatologists and to evaluate associations between physician gender and practice sizes and patient volume, accounting for rheumatologists' age, and calendar year effects. METHODS We conducted a population-based study in Ontario, Canada, between 2000 to 2015 identifying all rheumatologists practicing as full-time equivalents (FTEs) or above and assessed differences in practice sizes (number of unique patients), practice volumes (number of patient visits), and remuneration (total fee-for-service billings) between male and female rheumatologists. Multivariable linear regression was used to evaluate the effects of gender on practice size and volume separately, accounting for age and year. RESULTS The number of rheumatologists practicing at ≥ 1 FTE increased from 89 to 120 from 2000 to 2015, with the percentage of females increasing from 27.0% to 41.7%. Males had larger practice sizes and practice volumes. Remuneration was consistently higher for males (median difference of CAD $46,000-102,000 annually). Our adjusted analyses estimated that in a given year, males saw a mean of 606 (95% CI 107-1105) more patients than females did, and had 1059 (95% CI 345-1773) more patient visits. Among males and females combined, there was a small but statistically significant reduction in mean annual number of patient visits, and middle-aged rheumatologists had greater practice sizes and volumes than their younger/older counterparts. CONCLUSION On average, female rheumatologists saw fewer patients and had fewer patient visits annually relative to males, resulting in lower earnings. Increasing feminization necessitates workforce planning to ensure that populations' needs are met.
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Affiliation(s)
- Jessica Widdifield
- J. Widdifield, PhD, ICES, Sunnybrook Research Institute, Holland Bone & Joint Program, Toronto, and Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario;
| | - Jodi M Gatley
- J.M. Gatley, MPH, V. Ling, MSc, ICES, Toronto, Ontario
| | - Janet E Pope
- J. E. Pope, MD, MPH, Division of Rheumatology, Western University, Schulich School of Medicine & Dentistry, and St Joseph's Health Care, London, Ontario
| | - Claire E H Barber
- C.E. Barber, MD, PhD, The Cumming School of Medicine, University of Calgary, Calgary, Alberta, and Arthritis Research Canada
| | - Bindee Kuriya
- B. Kuriya, MD, SM, Division of Rheumatology, University of Toronto, and Sinai Health System, Toronto, Ontario
| | - Lihi Eder
- L. Eder, MD, PhD, Women's College Research Institute, and University of Toronto, Toronto, Ontario
| | - Carter Thorne
- C. Thorne, MD, Department of Medicine, University of Toronto, Toronto, and Southlake Regional Health Centre, Newmarket, Ontario
| | - Vicki Ling
- J.M. Gatley, MPH, V. Ling, MSc, ICES, Toronto, Ontario
| | - J Michael Paterson
- J.M. Paterson, MSc, ICES, Toronto, and McMaster University, Department of Family Medicine, Hamilton, and Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario
| | | | - Courtney Marks
- C. Marks, Sunnybrook Research Institute, Holland Bone & Joint Program, Toronto, Ontario
| | - Sasha Bernatsky
- S. Bernatsky, MD, PhD, Department of Epidemiology, McGill University, and Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
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Colaco K, Widdifield J, Luo J, Rosen CF, Alhusayen R, Paterson JM, Campbell W, Tu K, Bernatsky S, Gladman DD, Eder L. Trends in mortality and cause-specific mortality among patients with psoriasis and psoriatic arthritis in Ontario, Canada. J Am Acad Dermatol 2020; 84:1302-1309. [PMID: 33096129 DOI: 10.1016/j.jaad.2020.10.031] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/27/2020] [Accepted: 10/13/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is limited information about mortality rates among patients with psoriasis and psoriatic arthritis (PsA) in North America and their change over the past 2 decades. OBJECTIVE To compare all-cause and cause-specific mortality rates in patients with psoriasis to the general population in Ontario, Canada, from 1996 to 2016. METHODS We conducted a population-based, retrospective cohort study of adult residents using administrative health data. All-cause and cause-specific standardized mortality rates, standardized mortality ratios, and excess mortality rates were calculated. RESULTS 176,858 (2,524 deaths) patients with psoriasis and 15,430 (221 deaths) patients with PsA were identified in 2016. Patients with psoriasis and PsA had standardized excess mortality rates of 1.44 and 2.43 per 1000 population, respectively. Standardized mortality rates decreased by approximately 30% over the study period in both disease groups but remained significantly elevated compared to the general population. The leading causes of death in psoriasis and PsA patients were cancer, circulatory disease, and respiratory conditions. LIMITATIONS We were unable to classify patients according to disease severity. CONCLUSIONS Despite improvements in psoriasis treatment, the relative excess mortality, which may be related to risk factors for psoriatic disease, remained unchanged, with an average of approximately 1 to 2 extra deaths per 1,000 patients in 2016.
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Affiliation(s)
- Keith Colaco
- Women's College Hospital, Toronto, Canada; University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada
| | - Jessica Widdifield
- University of Toronto, Toronto, Canada; ICES, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | | | - Cheryl F Rosen
- University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada
| | - Raed Alhusayen
- University of Toronto, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | | | - Willemina Campbell
- University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada
| | - Karen Tu
- University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada; North York General Hospital, Toronto, Canada
| | | | - Dafna D Gladman
- University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada
| | - Lihi Eder
- Women's College Hospital, Toronto, Canada; University of Toronto, Toronto, Canada.
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10
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Pope JE. Would a 'Rosendo' by Another Name Smell as Sweet? Gender Disparity in Academic Rank and Publications in Rheumatology. Arthritis Rheumatol 2020; 73:5-8. [PMID: 32852124 DOI: 10.1002/art.41498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 07/29/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Janet E Pope
- University of Western Ontario and St. Joseph's Health Care London, London, Ontario, Canada
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