1
|
Biln NK, Guh D, Bansback N, Shojania K, Harrison M. The Association of Rheumatologist Supply and Multidisciplinary Care With Timely Patient Access to Rheumatologists: Evidence From British Columbia, Canada. Arthritis Care Res (Hoboken) 2024; 76:444-453. [PMID: 38018333 DOI: 10.1002/acr.25274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/25/2023] [Accepted: 11/21/2023] [Indexed: 11/30/2023]
Abstract
OBJECTIVE The objective was to understand how the expansion of rheumatology supply and the introduction of multidisciplinary care was associated with access to rheumatology services. METHODS We accessed Population Data BC, a longitudinal database with de-identified individual-level health data on all residents of British Columbia, Canada, to analyze physician visits and prescribing from 2010-2011 to 2019-2020. We calculated access as the time from referral to first rheumatologist visit and, for people with rheumatoid arthritis (RA), time to first disease-modifying antirheumatic drug (DMARD). Associations between lag time, patient characteristics, and system variables were explored using quantile regression. RESULTS Over the study period, there were 149,902 new rheumatologist visits, with 31% more visits in 2019-2020 than in 2010-2011. The proportion of first visits for patients with inflammatory arthritis increased from 28% to 51%. The median time from referral to first visit decreased by 22 days (35%) from 63 days (interquartile range 21-120 days) in 2010-2011. For people with RA, time from referral to DMARD decreased by 4 days (6%) to 62 days. Male sex, living in metropolitan areas, and having a rheumatologist who used a multidisciplinary care assessment code were associated with shorter times from referral to first DMARD. CONCLUSION Access to rheumatology care improved, and the increased proportion of patients with IA in the first visits case-mix indicates that rheumatologist supply and incentives for multidisciplinary care may have improved referral patterns. However, time to DMARDs for people with RA remained long, and we found signals of unequal access for female patients and people living outside of metropolitan areas.
Collapse
Affiliation(s)
- Norma K Biln
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Daphne Guh
- St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Nick Bansback
- University of British Columbia, St. Paul's Hospital, and Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Kam Shojania
- University of British Columbia and Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Mark Harrison
- University of British Columbia, St. Paul's Hospital, and Arthritis Research Canada, Vancouver, British Columbia, Canada
| |
Collapse
|
2
|
Biln NK, Bansback N, Shojania K, Puil L, Harrison M. A scoping review of triage approaches for the referral of patients with suspected inflammatory arthritis, from primary to rheumatology care. Rheumatol Int 2024:10.1007/s00296-024-05575-8. [PMID: 38530455 DOI: 10.1007/s00296-024-05575-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 02/29/2024] [Indexed: 03/28/2024]
Abstract
We aimed to (1) identify existing triage approaches for referral of patients with suspected inflammatory arthritis (IA) from primary care physicians (PCP) to rheumatologists, (2) describe their characteristics and methodologies for clinical use, and (3) report their level of validation for use in a publicly funded healthcare system. The comprehensive search strategy of multiple databases up to October 2023 identified relevant literature and focussed on approaches applied at the PCP-Rheumatologist referral stage. Primary, quantitative studies, reported in English were included. Triage approaches were grouped into patient conditions as defined by the authors of the reports, including IA, its subtypes and combinations. 13952 records were identified, 425 full text reviewed and 55 reports of 53 unique studies were included. Heterogeneity in disease nomenclature and study sample pretest probability was found. The number of published studies rapidly increased after 2012. Studies were mostly from Europe and North America, in IA and Axial Spondyloarthritis (AxSpa). We found tools ranging the continuum of development with those best performing, indicated by the area under the receiver operating curve (AUC) >0.8), requiring only patient-reported questions. There were AUCs for some tools reported from multiple studies, these were in the outstanding to excellent range for the Early IA Questionnaire (EIAQ) (0.88 to 0.92), acceptable for the Case Finding AxSpa (CaFaSpa) (0.70 to 0.75), and poor to outstanding for the Psoriasis Epidemiology Screening Tool (PEST) (0.61 to 0.91). Given the clinical urgency to improve rheumatology referrals and considering the good.
Collapse
Affiliation(s)
- Norma K Biln
- Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Nick Bansback
- Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, Canada
- Arthritis Research Canada, Vancouver, BC, Canada
- Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, BC, Canada
| | - Kam Shojania
- Faculty of Medicine, Department of Rheumatology, University of British Columbia, Vancouver, Canada
- Arthritis Research Canada, Vancouver, BC, Canada
- Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, BC, Canada
| | - Lorri Puil
- Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, Canada
- Faculty of Medicine, Therapeutics Initiative, Department of Anaesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada
| | - Mark Harrison
- Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, Canada.
- Faculty of Pharmaceutical Sciences, University of British Columbia, 4625-2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada.
- Arthritis Research Canada, Vancouver, BC, Canada.
- Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, BC, Canada.
| |
Collapse
|
3
|
Carrier N, de Brum-Fernandes AJ, Liang P, Masetto A, Roux S, Biln NK, Maksymowych WP, Boire G. Impending radiographic erosive progression over the following year in a cohort of consecutive patients with inflammatory polyarthritis: prediction by serum biomarkers. RMD Open 2021; 6:rmdopen-2020-001191. [PMID: 32371434 PMCID: PMC7299510 DOI: 10.1136/rmdopen-2020-001191] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/15/2020] [Accepted: 04/04/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND/PURPOSE To evaluate biomarkers as predictors of impending erosion progression. METHODS Variables were measured at baseline and annually up to 5 years in patients with recent-onset polyarthritis treated to zero swollen joints. Erosive status was defined as ≥5 Units in Sharp/van der Heijde Erosion Score; Rapid Erosive Progression (REP) was defined as an increase ≥5 Units in Erosion Scores between consecutive visits. Generalised estimating equations (GEEs) evaluated the effect on REP of positive anticyclic citrullinated peptides (ACPAs) and/or rheumatoid factor (RF), C-reactive protein ˃8.0 mg/L (High-CRP) and 14-3-3η protein ≥0.50 ng/mL (High-14-3-3η), alone and in combinations. RESULTS Out of 2155 evaluations in 749 consecutive patients, REP occurred after 186 (8.6%) visits, including 13 (2.2%) in patients recruited since 2010. Only 18/537 (3.4%; 6/411 (1.5%) in non-erosive vs 12/126 (9.5%) in patients already erosive) visits without any positive biomarker were followed by REP; at least one biomarker was positive prior to REP in 168/186 (90.3%) visits. Being positive for all four biomarkers conferred a positive predictive value (PPV) of 30.0% (RR 21.8) in patients non-erosive at the visit versus 35.5% (RR 3.07) in those already erosive. High-14-3-3η increased REP only in visits with High-CRP (eg, RR 2.5 to 3.9 when ACPA also positive) and in patients with non-erosive status (eg, RR from 4.3 to 9.4 when also High-CRP). CONCLUSIONS Adding High-14-3-3η to positive antibodies and CRP improves prediction of impending REP. Although REP is becoming rarer, signatures of biomarkers might help to adapt treatment strategies in at-risk individuals, even those already erosive.
Collapse
Affiliation(s)
- Nathalie Carrier
- Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke (CIUSSSE-CHUS), Quebec, Canada
| | - Artur J de Brum-Fernandes
- Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke (CIUSSSE-CHUS), Quebec, Canada.,Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Patrick Liang
- Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke (CIUSSSE-CHUS), Quebec, Canada.,Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Ariel Masetto
- Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke (CIUSSSE-CHUS), Quebec, Canada.,Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Sophie Roux
- Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke (CIUSSSE-CHUS), Quebec, Canada.,Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Norma K Biln
- Augurex Life Sciences Corp, Vancouver, British Columbia, Canada
| | | | - Gilles Boire
- Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke (CIUSSSE-CHUS), Quebec, Canada .,Université de Sherbrooke, Sherbrooke, Quebec, Canada
| |
Collapse
|