Access to rheumatologists among patients with newly diagnosed rheumatoid arthritis in a Canadian universal public healthcare system.
TL;DR: Increasing access to rheumatologists within 6 and 12’months occurred over time; however, consultations within 3 months did not change over time.
Abstract: Objectives Our objective was to estimate the percentage of patients with incident rheumatoid arthritis (RA) who were seen by a rheumatologist within 3, 6 and 12 months of suspected diagnosis by a family physician, and assess what factors may influence the time frame with which patients are seen. Setting Ontario, Canada. Participants Over 2000–2009, we studied patients with incident RA who were initially diagnosed by a family physician. Primary and secondary outcome measures We assessed secular trends in rheumatology encounters and differences between patients who received versus did not receive rheumatology care. We performed hierarchical logistic regression analyses to determine whether receipt of rheumatology care was associated with patient, primary care physician and geographical factors. Results Among 19 760 patients with incident RA, 59%, 75% and 84% of patients were seen by a rheumatologist within 3, 6 and 12 months, respectively. The prevalence of initial consultations within 3 months did not increase over time; however, access within 6 and 12 months increased over time. Factors positively associated with timely consultations included higher regional rheumatology supply (adjusted OR (aOR) 1.35 (95% CI 1.13 to 1.60)) and higher patient socioeconomic status (aOR 1.18 (95% CI 1.07 to 1.30)). Conversely, factors inversely associated with timely consultations included remote patient residence (aOR 0.51 (95% CI 0.41 to 0.64)) and male family physicians (aOR 0.88 (95% CI 0.81 to 0.95)). Conclusions Increasing access to rheumatologists within 6 and 12 months occurred over time; however, consultations within 3 months did not change over time. Measures of poor access (such as proximity to and density of rheumatologists) were negatively associated with timely consultations. Additional factors that contributed to disparities in access included patient socioeconomic status and physician sex.
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TL;DR: The objective of this review is to increase awareness of the RMDs and to identify opportunities to address RMD challenges on both a local and global scale, and to explore potential opportunities to improve global and local RMD care.
Abstract: Rheumatic and musculoskeletal diseases (RMDs) represent a multitude of degenerative, inflammatory and auto-immune conditions affecting millions of people worldwide Persons with these diseases may potentially experience severe chronic pain, joint damage, increasing disability and even death With an increasingly ageing population, the prevalence and burden of RMDs are predicted to increase, placing greater demands on the global practice of rheumatology and related healthcare budgets Effective treatment of RMDs currently faces a number of challenges in both the developed and developing world, and individual countries may face more specific local challenges However, limited understanding of the burden of RMDs amongst public health professionals and policy-makers means that these diseases are often not considered a public health priority The objective of this review is to increase awareness of the RMDs and to identify opportunities to address RMD challenges on both a local and global scale On 26 September 2014, rheumatology experts from five different continents met at the World Forum on Rheumatic and Musculoskeletal Diseases (WFRMD) to discuss and identify some key challenges for the RMDs community today The outcomes are presented in this review, focusing on access to rheumatology services, diagnostics and therapies, rheumatology education and training and on clinical trials, as well as investigator-initiated and epidemiological research The long-term vision of the WFRMD is to increase perception of the RMDs as a major burden to society and to explore potential opportunities to improve global and local RMD care
138 citations
Cites background from "Access to rheumatologists among pat..."
...Findings from two studies in Ontario reported fewer rheumatologist visits for arthritis and inflammatory arthritis patients who lived in less populated areas with lower socioeconomic status [19, 20]....
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TL;DR: To evaluate excess mortality over time, comparing rheumatoid arthritis (RA) patients with the general population is compared.
Abstract: Objective
To evaluate excess mortality over time, comparing rheumatoid arthritis (RA) patients with the general population.
Methods
We computed all-cause mortality rates among Ontario residents age ≥15 years with RA versus without RA from 1996 to 2009. Age- and sex-standardized mortality rates were expressed as the number of deaths per 1,000 population. Excess mortality rates were calculated as the difference between death rates among RA patients and those in the general population. We estimated standardized mortality ratios (SMRs) and mortality rate ratios (MRRs) to assess relative excess mortality over time.
Results
From 1996 to 2009, SMRs in RA ranged from 13.0 (95% confidence interval [95% CI] 12.2, 13.9) to 9.2 deaths per 1,000 RA patients (95% CI 8.4, 10.0); and for those without RA from 8.7 (95% CI 8.6, 8.7) to 6.0 deaths (95% CI 5.9, 6.0) per 1,000 general population. Over the study period, the excess mortality rate among RA patients was approximately 3 excess deaths per 1,000 population. Relative reductions in standardized mortality rates occurred over time for those with and without RA (−21.4% versus −13.4%). The SMRs for RA patients in 1996–1997, 2000–2001, 2004–2005, and 2008–2009 were 1.51 (95% CI 1.43, 1.59), 1.50 (95% CI 1.43, 1.57), 1.43 (95% CI 1.37, 1.50), and 1.41 (95% CI 1.35, 1.47), respectively. We did not find a significant change in the MRR by calendar time.
Conclusion
Mortality for RA patients has decreased over time but remains elevated compared to the general population, with 40–50% more deaths among RA patients. The relative excess mortality over time (mortality gap) remains unchanged in our sample.
74 citations
Cites background from "Access to rheumatologists among pat..."
...In Ontario, we have observed substantial increases in timely access to rheumatologists (19) and access to disease-modifying treatment for patients with RA in recent years (20)....
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TL;DR: This study aimed to identify providers involved in diagnosing ankylosing spondylitis (AS) following back pain diagnosis in the USA and to identify factors leading to the delay in rheumatology referrals.
Abstract: This study aimed to identify providers involved in diagnosing ankylosing spondylitis (AS) following back pain diagnosis in the USA and to identify factors leading to the delay in rheumatology referrals. The Truven Health MarketScan® US Commercial Database was searched for patients aged 18-64 years with back pain diagnosis in a non-rheumatology setting followed by AS diagnosis in any setting during January 2000-December 2012. Patients with a rheumatologist visit on or before AS diagnosis were considered referred. Cox regression was used to determine factors associated with referral time after adjusting for age, sex, comorbidities, physician specialty, drug therapy, and imaging procedures. Of 3336 patients included, 1244 (37 %) were referred to and diagnosed by rheumatologists; the others were diagnosed in primary care (25.7 %), chiropractic/physical therapy (7 %), orthopedic surgery (3.8 %), pain clinic (3.6 %), acute care (3.4 %), and other (19.2 %) settings. Median time from back pain diagnosis to rheumatology referral was 307 days and from first rheumatologist visit to AS diagnosis was 28 days. Referred patients were more likely to be younger (hazard ratio [HR] = 0.986; p < 0.0001), male (HR = 1.15; p = 0.0163), diagnosed with uveitis (HR = 1.49; p = 0.0050), referred by primary care physicians (HR = 1.96; p < 0.0001), prescribed non-steroidal anti-inflammatory drugs (HR = 1.55; p < 0.0001), disease-modifying antirheumatic drugs (HR = 1.33; p < 0.0001), and tumor necrosis factor inhibitors (HR = 1.40; p = 0.0036), and to have had spinal/pelvic X-ray prior to referral (HR = 1.28; p = 0.0003). During 2000-2012, most patients with AS were diagnosed outside of rheumatology practices. The delay before referral to rheumatology was 10 months; AS diagnosis generally followed within a month. Earlier referral of patients with AS signs and symptoms may lead to more timely diagnosis and appropriate treatment.
52 citations
TL;DR: There are clinical questions that can be answered quickly by an eConsult, improving access to rheumatologists, and a face-to-face referral was avoided in 38% of cases.
Abstract: Objective. To describe the use and benefits of an innovative eConsult service to improve access to rheumatologists. Methods. There were 225 eConsults directed to rheumatology that were categorized by type of question and effect on face-to-face referral rates. Results. The median response time by the rheumatologists was 1.9 days. Clinical questions included drug treatment (34%), diagnosis (26%), or management (14%). Osteoporosis was the most common diagnosis (22%), followed by pain in multiple joints (11%), and polyarthritis (10%). A face-to-face referral was avoided in 38% of cases. Conclusion. There are clinical questions that can be answered quickly by an eConsult, improving access to rheumatologists.
21 citations
TL;DR: The results show that in RA medical care utilization research, the theories and measurements of the constructs of illness trajectories, help-seeking, and accessibility are not integrated and there is a need for a comprehensive framework than can enable researchers to integrate and contextualize the study of the problems within broad theoretical and methodological perspectives.
Abstract: Early diagnosis and treatment of rheumatoid arthritis (RA) depends on the degree of fit between the characteristics of the patients and those of the health services. Ensuring timely assessment and treatment is the ideal medical care of RA. The reasons that underlay delays and the help-seeking trajectories are contextually determined. This study aims to identify the empirical evidence related to the help-seeking process and delay in RA in Latin America and to create a comprehensive model integrating the RA medical care processes of help-seeking and delay in a mixed health care system with variable accessibility. Non-systematic literature review of studies with both quantitative and qualitative methodology was conducted. Most of the research about delay and its associated variables have been undertaken in European countries and with White population and cannot be translated to the Latin America context where this research is almost inexistent. These countries have a completely different social context, and for most of the population, the health services are insufficient, inaccessible, fragmented, limited, and inequitable. Our results also show that in RA medical care utilization research, the theories and measurements of the constructs of illness trajectories, help-seeking, and accessibility are not integrated. We offer a conceptual framework that integrates help-seeking trajectories, delay, and accessibility of RA medical health services. If research on RA service utilization is to be undertaken in these countries, there is a need for a comprehensive framework than can enable researchers to integrate and contextualize the study of the problems within broad theoretical and methodological perspectives.
19 citations
Cites background from "Access to rheumatologists among pat..."
...There are also findings that show that the delay was larger when patients were seen by a male physician [6]....
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..., there was a larger delay in referral fromGPs in female patients [6, 11]....
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References
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29 Oct 1998
TL;DR: A comparison of primary care practices in the United States and Europe over the past 50 years shows improvements in both quality and quantity of treatment and the number of patients and populations has increased.
Abstract: I. PRIMARY CARE AND HEALTH II. PRIMARY CARE PRACTICE III. ACCOUNTABILITY IN PRIMARY CARE IV. PATIENTS AND POPULATIONS V. HEALTH POLICY AND PRIMARY CARE
1,051 citations
TL;DR: 12 key recommendations for the management of early arthritis or early rheumatoid arthritis were developed, based on evidence in the literature and expert consensus, in accordance with EULAR's "standardised operating procedures".
Abstract: Objective: To formulate EULAR recommendations for the management of early arthritis. Methods: In accordance with EULAR’s “standardised operating procedures”, the task force pursued an evidence based approach and an approach based on expert opinion. A steering group comprised of 14 rheumatologists representing 10 European countries. The group defined the focus of the process, the target population, and formulated an operational definition of “management”. Each participant was invited to propose issues of interest regarding the management of early arthritis or early rheumatoid arthritis. Fifteen issues for further research were selected by use of a modified Delphi technique. A systematic literature search was carried out. Evidence was categorised according to usual guidelines. A set of draft recommendations was proposed on the basis of the research questions and the results of the literature search.. The strength of the recommendations was based on the category of evidence and expert opinion. Results: 15 research questions, covering the entire spectrum of “management of early arthritis”, were formulated for further research; and 284 studies were identified and evaluated. Twelve recommendations for the management of early arthritis were selected and presented with short sentences. The selected statements included recognition of arthritis, referral, diagnosis, prognosis, classification, and treatment of early arthritis (information, education, non-pharmacological interventions, pharmacological treatments, and monitoring of the disease process). On the basis of expert opinion, 11 items were identified as being important for future research. Conclusions: 12 key recommendations for the management of early arthritis or early rheumatoid arthritis were developed, based on evidence in the literature and expert consensus.
803 citations
TL;DR: Both clinical remission and radiographic non-progression are achievable goals in patients with early severe rheumatoid arthritis within 1 year of combined treatment with etanercept plus methotrexate.
774 citations
TL;DR: There is a window of opportunity for highly successful treatment of RA in the first year, and especially within the first 3 months of therapy, indicating that early diagnosis and therapy may be the crucial step in achieving optimal control of disease progression and prognosis in RA.
Abstract: Objective. Delay of disease-modifying anti-rheumatic drug (DMARD) therapy is a major contributing factor for poor outcome in rheumatoid arthritis (RA). Although early therapy has been shown to be particularly effective, there is still uncertainty about the optimal time point of DMARD introduction. We wanted to test if a therapeutic window of opportunity may exist within the first few months of the disease. Methods. In this case-control parallel-group study, 20 very early RA (VERA) patients with median disease duration of 3 months were age and gender matched to a group of 20 late early RA (LERA) patients with median disease duration of 12 months until first DMARD initiation. Follow-up time was 36 months. Primary outcome measures were the disease activity score (DAS28) and radiological joint destruction using the Larsen method. Results. Already after 3 months of DMARD therapy we found a significant difference of improvement in favour of the VERA patients in the DAS28. This trend continued over the study period. At study end the DAS28 showed an improvement of 2.8±1.5 in the VERA vs 1.7±1.2 in the LERA group (P c < 0.05). The Larsen scores showed a statistically significant retardation of progression in the VERA compared with the LERA. Conclusion. Our results indicate that there is a window of opportunity for highly successful treatment of RA in the first year, and especially within the first 3 months of therapy. Thus, early diagnosis and therapy may be the crucial step in achieving optimal control of disease progression and prognosis in RA.
768 citations
TL;DR: A clinical prediction model was developed with an excellent ability to discriminate, at the first visit, between 3 forms of arthritis outcome, and validation in other early arthritis clinics is necessary.
Abstract: Objective
To develop a clinical model for the prediction, at the first visit, of 3 forms of arthritis outcome: self-limiting, persistent nonerosive, and persistent erosive arthritis.
Methods
A standardized diagnostic evaluation was performed on 524 consecutive, newly referred patients with early arthritis. Potentially diagnostic determinants obtained at the first visit from the patient's history, physical examination, and blood and imaging testing were entered in a logistic regression analysis. Arthritis outcome was recorded at 2 years' followup. The discriminative ability of the model was expressed as a receiver operating characteristic (ROC) area under the curve (AUC).
Results
The developed prediction model consisted of 7 variables: symptom duration at first visit, morning stiffness for ≥1 hour, arthritis in ≥3 joints, bilateral compression pain in the metatarsophalangeal joints, rheumatoid factor positivity, anti–cyclic citrullinated peptide antibody positivity, and the presence of erosions (hands/feet). Application of the model to an individual patient resulted in 3 clinically relevant predictive values: one for self-limiting arthritis, one for persistent nonerosive arthritis, and one for persistent erosive arthritis. The ROC AUC of the model was 0.84 (SE 0.02) for discrimination between self-limiting and persistent arthritis, and 0.91 (SE 0.02) for discrimination between persistent nonerosive and persistent erosive arthritis, whereas the discriminative ability of the American College of Rheumatology 1987 classification criteria for rheumatoid arthritis was significantly lower, with ROC AUC values of 0.78 (SE 0.02) and 0.79 (SE 0.03), respectively.
Conclusion
A clinical prediction model was developed with an excellent ability to discriminate, at the first visit, between 3 forms of arthritis outcome. Validation in other early arthritis clinics is necessary.
765 citations
"Access to rheumatologists among pat..." refers methods in this paper
...Recent data from a large early arthritis clinic indicated that 60% of patients had self-limited symptoms.(32) Therefore, a delay of 3 months in receipt of rheumatology care may not always be as deleterious to the likelihood of a good response or remission....
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