Lake Louise, Alberta—Members of the rheumatology community are using creative approaches in their effort to improve access to high-quality rheumatology services. They feel this is an urgent challenge in the face of healthcare budget constraints, and a small and rapidly shrinking ratio of rheumatologists to patients.
A Gap in Access to Care
One particular innovation was exemplified in a study presented at the recent 2016 Canadian Rheumatology Association Annual Scientific Meeting.1 It is a synopsis of patterns of care and referrals to rheumatologists from primary care physicians in Ontario, Canada, and shows significant variations in care patterns. For example, only one-third of rheumatologist referrals were for systemic inflammatory rheumatic diseases. Furthermore, there was an average delay of 1.74 years between symptom onset and referral to a rheumatologist for patients with systemic rheumatic diseases, and 3.13 years for patients with arthritis. Most of the delays occurred prior to referral.
“Our study shows that improving access to rheumatologists is urgently required,” explained Jessica Widdifield, PhD, lead author of the study and Postdoctoral Researcher at McGill University, Montreal, and the Institute for Clinical Evaluative Sciences, Toronto, Canada. “Optimal care for rheumatic diseases hinges on early access to rheumatologists but there are many hurdles that can impede optimal care, such as delays in patient presentation and physician referrals.”
Models of Care in Rheumatology
Another creative approach being used is the Pan-Canadian Approach to Inflammatory Arthritis Models of Care (MOC) project, which was launched in 2010 by the Arthritis Alliance of Canada, Ontario Rheumatology Association, and Ontario Best Practices Research Initiative.2,3 The result is a template for a model of care in rheumatology, and ways to evaluate that model. The Ontario Rheumatology Association is testing this template across that province.
Vandana Ahluwalia, MD, one of the co-leads for the Pan-Canadian Approach to IA MOC team, and Corporate Chief of Rheumatology, William Osler Health Center, Ontario, says that the process of care improvement is a widely distributed and evolutionary effort.
“It was created nationally, developed provincially, and will be delivered regionally. And what we’ve been doing so far is collecting data on what the problem is,” explained Dr Ahluwalia. “We don’t have any data yet on how well our MOC approach is doing to fix the problem but we will soon. We’re seeing anecdotally that there’s a significant uptake of this approach.”
Opportunities for Care Education
Dr Ahluwalia said that only St. Michael’s Hospital in Toronto provides a training and certification program for allied health professionals (eg, occupational therapists, physiotherapists, and nurses) in Ontario to become extended role providers (ERPs) in musculoskeletal care. It is called the Advanced Clinician Practitioner in Arthritis Care (ACPAC) program,4 and those who take the training must already have a good grounding in musculoskeletal disorders.
“We are in the process of evaluating the ability of these ERPs who have been trained at the ACPAC program to triage patients with inflammatory arthritis to see the rheumatologist in a timely fashion,” said Dr Ahluwalia.
In addition, the Arthritis Alliance of Canada website’s information on the Inflammatory Arthritis Care Path Toolkit provides details on inflammatory arthritis diagnoses, and management for healthcare professionals, as well as self-care advice for patients.5
The research presented by Dr Widdifield and colleagues, in addition to other publications and presentations, help in this overall movement toward a more rational approach to rheumatology care. Of the 2430 patients referred to a rheumatologist, 32% were seen for arthritis, 31% for systemic rheumatic diseases, and the rest for regional musculoskeletal conditions (16%), chronic pain conditions (14%), osteoporosis (2%), or other conditions (5%).1
The family physicians’ prereferral diagnostic testing practices, and the delay to consultation, varied widely. The duration of time from symptom onset to rheumatology consultation varied by diagnosis, with the shortest being for patients with systemic rheumatic diseases.
- Widdifield J, Tu K, Thorne C, et al. Primary care management of patients with rheumatic diseases: characterizing patterns of care and referrals to rheumatologists. Poster presented at: 2016 Canadian Rheumatology Association Annual Scientific Meeting; February 17-20, 2016; Lake Louise, Alberta.
- Arthritis Alliance of Canada. Pan-Canadian approach to IA models of care. www.arthritisalliance.ca/en/pcaia. Accessed April 8, 2016.
- Ontario Rheumatology Association. Models of care. http://ontariorheum.ca/images/uploads/content_documents/ORA_MOC_flyer_May_2014_-_PRINT_and_EMAIL_final_july_10_2014pdf.pdf. Accessed April 8, 2016.
- Advanced Clinician Practitioner in Arthritis Care. http://acpacprogram.ca. Accessed April 8, 2016.
- Inflammatory arthritis care path toolkit. www.arthritisalliance.ca/images/caremap/20140821-care-path-toolkit_EN.pdf. Published August 2014. Accessed April 8, 2016.