Feminization of the Rheumatology Workforce: A Longitudinal Evaluation of Patient Volumes, Practice Sizes, and Physician Remuneration

Attending physicians' annual service volume and use of virtual end-of-life care: A population-based cohort study in Ontario, Canada

IMPORTANCE

Physicians and their practice behaviors influence access to healthcare and may represent potentially modifiable targets for practice-changing interventions. Use of virtual care at the end-of-life significantly increased during the COVID-19 pandemic, but its association with physician practice behaviors, (e.g., annual service volume) is unknown.

OBJECTIVE

Measure the association of physicians' annual service volume with their use of virtual end-of-life care (EOLC) and the magnitude of physician-attributable variation in its use, before and during the pandemic.

DESIGN, SETTING AND PARTICIPANTS

Population-based cohort study using administrative data of all physicians in Ontario, Canada who cared for adults in the last 90 days of life between 01/25/2018-12/31/2021. Multivariable modified Poisson regression models measured the association between attending physicians' use of virtual EOLC and their annual service volume. We calculated the variance partition coefficients for each regression and stratified by time period before and during the pandemic.

EXPOSURE

Annual service volume of a person's attending physician in the preceding year.

MAIN OUTCOMES AND MEASURES

Delivery of ≥1 virtual EOLC visit by a person's attending physician and the proportion of variation in its use attributable to physicians.

RESULTS

Among the 35,825 unique attending physicians caring for 315,494 adults, use of virtual EOLC was associated with receiving care from a high compared to low service volume attending physician; the magnitude of this association diminished during the pandemic (adjusted RR 1.25 [95% CI 1.14, 1.37] pre-pandemic;1.10 (95% CI 1.08, 1.12) during the pandemic). Physicians accounted for 36% of the variation in virtual EOLC use pre-pandemic and 12% of this variation during the pandemic.

CONCLUSIONS AND RELEVANCE

Physicians' annual service volume was associated with use of virtual EOLC and physicians accounted for a substantial proportion of the variation in its use. Physicians may be appropriate and potentially modifiable targets for interventions to modulate use of EOLC delivery.

An Overview of Reviews to Inform Organization-Level Interventions to Address Burnout in Rheumatologists

OBJECTIVE

To identify organization-directed strategies that could be implemented to prevent burnout among rheumatologists.

METHODS

A search of English language articles published 2011 or later was conducted on Cochrane Database of Systematic Reviews, Embase, Medline, and PsycInfo on January 25, 2022. Included reviews had ≥ 1 primary studies with ≥ 10% of participants who were physicians, recorded burnout as an outcome, and described an organization-directed intervention to prevent burnout. Overlap of primary studies across reviews was assessed. The final review inclusion was determined by study quality, minimization of overlap, and maximization of intervention breadth. The A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 tool was used for quality assessment. Included studies and interventions were assessed by rheumatologists for their applicability to rheumatology.

RESULTS

A total of 17 reviews, including 15 systematic reviews, 1 realist review, and 1 umbrella review were included. AMSTAR 2 quality ratings classified 5 systematic reviews as low quality, 1 as moderate, and 9 as critically low. There was significant heterogeneity between and within reviews. Six conducted a metaanalysis and 11 provided a qualitative summary of findings. The following intervention types were identified as having possible applicability to rheumatology: physician workflow and organizational strategies; peer support and formal communication training; leadership support; and addressing stress, mental health, and mindfulness. Across interventions, mindfulness had the highest quality of evidence to support its effectiveness.

CONCLUSION

Although the quality of evidence for interventions to prevent burnout in physicians is low, promising strategies such as mindfulness have been identified.

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

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.

The reality of Rheumatology in Spain and its autonomous communities before the pandemic

OBJECTIVES

To determine the number of rheumatologists per 100,000 inhabitants working in public or private centres in Spain as a whole, and by Autonomous Community and their distribution by age and sex.

MATERIAL AND METHOD

Cross-sectional study based on the information contained in the database of the Spanish Society of Rheumatology. Quality control was performed by contact (e-mail and telephone call) with the heads of the clinical services of each of the hospitals (public and private). The information analysed was the age, sex and place of work of active rheumatologists in February 2020. The rates of rheumatologists per 100,000 inhabitants were calculated from population data from the National Institute of Statistics.

RESULTS

The rate of rheumatology specialists per 100,000 inhabitants in Spain was estimated at 2.17. The percentage of women was 59.7%, with a higher female/male ratio at younger ages. The lowest proportion of specialists per 100,000 inhabitants was in the community of Valencia (1.6), and the highest in Cantabria (3.2).

CONCLUSIONS

Variations were found in the rate of rheumatologists per 100,000 inhabitants among the Autonomous Communities. The distribution by age and sex showed a tendency towards female rheumatologists, especially in the younger age strata.

Results from the 2020 Canadian Rheumatology Association's Workforce and Wellness Survey

Objective

The Canadian Rheumatology Association (CRA) launched the Workforce and Wellness Survey to update the Canadian rheumatology workforce characteristics.

Methods

The survey included demographic and practice information, pandemic impacts, and the Mini-Z questionnaire to assess burnout. French and English survey versions were distributed to CRA members electronically between 10/14/2020-3/5/2021. The number of full-time equivalent (FTE) rheumatologists per 75,000 population was estimated from the median proportion of time in clinical practice multiplied by provincial rheumatologist numbers from the Canadian Medical Association (CMA).

Results

Forty-four percent (183/417) of the estimated practicing rheumatologists (149 adult; 34 pediatric) completed the survey. The median age was 47 years, 62% were female, and 28% planned to retire within the next 5-10 years. Respondents spent a median of 65% of their time in clinical practice. FTE rheumatologists per 75,000 ranged between 0 and 0.70 in each province/territory and 0.62 per 75,000 nationally. This represents a deficit of 1 to 78 FTE rheumatologists per province/territory and 194 FTE rheumatologists nationally to meet the CRA's workforce benchmark. Approximately half of survey respondents reported burnout (51%). Women were more likely to report burnout (OR 2.86, 95%CI: 1.42-5.93). Older age was protective against burnout (OR 0.95, 95%CI: 0.92, 0.99). As a result of the pandemic, 97% of rheumatologists reported spending more time engaged in virtual care.

Conclusion

There is a shortage of rheumatologists in Canada. This shortage may be compounded by the threat of burnout to workforce retention and productivity. Strategies to address these workforce issues are urgently needed.

An Advanced Clinician Practitioner in Arthritis Care (ACPAC) Maintains a Positive Patient Experience While Increasing Capacity in Rheumatology Community Care

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.

The Evolving Workforce in Rheumatology: The Effect of Gender

Population shifts in the workforce have been noted for the past few decades. In the United States, the number of people aged 65 and older is expected to double, reaching almost a quarter of the population.1 By 2045, the US is expected to experience a demographic shift, with an increase in the percentage of minority populations to greater than 50%.