Gaps in rheumatologic care for people with rheumatoid arthritis

A study in ACR Open Rheumatology has identified gaps in the ongoing care and treatment of people living with rheumatoid arthritis (RA).

Researchers followed patients five years after diagnosis, ultimately including 50,883 patients with RA (26.1% aged 66 years and older). More than half (57.7%) visited a rheumatologist every five years annually. Steep declines in the percentage of those making annual visits occurred for each subsequent year after diagnosis. For people aged 66 and over (n=13,293), 82.1% of those who visited their rheumatologist every five years after diagnosis received a DMARD prescription annually, compared with 31.0% of those who did not. Older age, male gender, lower socioeconomic status, higher comorbidity score, and the presence of an older rheumatologist reduced the likelihood of remaining on rheumatology treatment.

The study’s first author, Claire Barber, MD, PhD, is a rheumatologist and researcher at the University of Calgary’s Cumming School of Medicine. Here she discusses the study and its results with the reading room. The exchange has been edited for length and clarity.

What key question was this study intended to address, and why was this an important area of ​​assessment?

Barber: We have developed some system-level performance metrics to assess quality of care. These measures primarily concern access to care, ongoing care and treatment. The aim of the present study was to evaluate existing provincial-level performance measurements in Ontario, Canada.

The first metric we evaluated looked at whether people with RA were seen by rheumatologists at least once a year, which is a minimum standard of care. The second measure records whether they have been treated with DMARD therapies.

How would you characterize what you found?

Barber: More than half of the patients visited a rheumatologist every five years annually. Although there was a sharp drop in annual visits with each additional year after diagnosis, we saw a trend towards significant improvement in performance, which was somewhat encouraging.

This signals that if you are seen regularly by rheumatologists, you are much more likely to receive appropriate therapy over time. We also found a variety of factors that influenced whether patients remained in the care of a rheumatologist: age, male gender, and economic status.

Were there any surprises with the results?

Barber: I think what might be surprising is that the age of a rheumatologist seems to affect the chances of continued treatment. We found that the presence of a senior rheumatologist reduced the likelihood of remaining on rheumatology treatment.

Although more studies need to be done, we hypothesized that this could be due to changes in practice that may be closer to retirement.

This could be due to older physicians retiring and sending more stable patients to primary care or reducing follow-up visits. It is also possible that older rheumatologists may have different practice patterns that may be less consistent with current treat-to-target guidelines that advocate more frequent follow-up visits.

They had some interesting insights about patients and socioeconomic status. Can you tell more about what you found in this area?

Barber: Canada has a universal healthcare system, and yet we found a socioeconomic divide that hampered continuity of rheumatology care.

For example, visiting a clinic can be costly for patients, especially when you factor in things like the cost of transportation or parking. People may not be able to take time off from work. And there might be other factors related to things like health literacy that we weren’t able to capture in the study.

So I think it’s important to think about these determinants of health because they affect care and access to care, even in Canada.

What are the key messages for rheumatology practices?

Barber: I think rheumatologists on a day-to-day basis might not be aware of how many patients might be followed up. I think that remains a big challenge. As such, practices would do well to develop strategies to ensure patients who need to be seen continue to be seen.

This may include reviewing rosters to ensure patients either have an annual follow-up to report to or develop other alternative models of care.

During the pandemic, we saw an increase in virtual care. I think virtual face-to-face care and a way to connect with patients can help break down those barriers and access care.

Clinical Implications

• Gaps in rheumatology care for people with RA exist in the five years after diagnosis, with significant declines in annual visits over time.
• The odds of consistently remaining in a rheumatologist’s care decreased in older patients, men, patients with lower socioeconomic status, and patients with more comorbidities.
• Practices can review rosters to ensure follow-up visits or explore new treatment models like virtual visits.

Read the study here and the expert commentary on the clinical implications here.