Dr. Mosher has received honoraria (less than $10,000) from serving on the advisory board for Pfizer, and has received speaking fees (less than $10,000 each) from Schering, Amgen, and Wyeth.
An evidence-informed, integrated framework for rheumatoid arthritis care
Article first published online: 30 JUL 2008
Copyright © 2008 by the American College of Rheumatology
Arthritis Care & Research
Volume 59, Issue 8, pages 1171–1183, 15 August 2008
How to Cite
Li, L. C., Badley, E. M., MacKay, C., Mosher, D., Jamal, S., Jones, A. and Bombardier, C. (2008), An evidence-informed, integrated framework for rheumatoid arthritis care. Arthritis & Rheumatism, 59: 1171–1183. doi: 10.1002/art.23931
- Issue published online: 30 JUL 2008
- Article first published online: 30 JUL 2008
- Manuscript Accepted: 22 APR 2008
- Manuscript Received: 27 DEC 2007
Providing adequate care for persons with rheumatoid arthritis (RA) is an ongoing challenge. Although the current evidence supports the use of disease-modifying antirheumatic drugs (DMARDs) within the first 3 months of symptoms appearing (1–3), delay in DMARD use and other gaps in care have been reported across communities (4–9). The situation has worsened due to the shortage of specialists (10).
The process of seeking medical treatment begins with the person's recognition of the symptoms and the action of visiting a family physician (FP) (Figure 1, levels A and B). The FP then performs the appropriate investigations, and if RA is suspected, the FP refers the person to a rheumatologist (levels B and C) who then conducts further tests, provides a diagnosis, and prescribes DMARDs and other appropriate medications (level D). Next, the person may be referred to the available community resources and/or rehabilitation programs that enable self-management (levels E1–E4), and will be periodically assessed by a rheumatologist (level F). Successful delivery of these interventions is largely dependent on the availability of local programs and the coordination among the rheumatologist, the FP, and other health professionals. In the case of severe joint damage, the person is referred for an orthopedic consultation and surgery may be considered (levels G1–G4).
Moving from one level to the next involves a potential wait period, which may be caused by, for example, delays in patients' and health professionals' recognition of RA symptoms, delays in referral to rheumatologists, lack of access to specialist care or community resources, or patients' own choices. Delays may occur at any of the following periods (Figure 1): Wait 1: the time between a person's development and awareness of the seriousness of the symptoms and the first visit with an FP; Wait 2: the time between the first visit with an FP and the first visit with a rheumatologist; Wait 3: from the first rheumatology visit to the date the patient starts the appropriate therapy; Wait 4: from a patient starting medication to the date when he or she has access to adequate resources that enable self-management; and Wait 5: from the decision date for an orthopedic consultation to the date of the patient's first visit with a surgeon and, subsequently, the date of surgery.
The delay between symptom onset and DMARD prescription for individuals with RA is a problem across countries (Waits 1–3), with a median lag time ranging from 6.5 to 19 months (5–9). A few studies have attempted to estimate the length of Wait 1, but the findings are inconsistent. Two studies, a retrospective cohort from the US (11) and a prospective study from Norway (12), estimated a median delay of 4 weeks for the first FP visit. However, more recent research from the UK estimated 12 weeks (13), with 38% of people waiting more than 3 months before seeing an FP (14).
The lag time from FP visit to rheumatologist consultation is believed to be a major source of the delay (Wait 2). In a UK study, 44% waited more than 3 months for a specialist referral (14). Recent research from Canada also found a median lag time of 79 days between the FP visit and the first rheumatologist visit (15). In contrast, the median time between the first rheumatologist visit and DMARD use was only 1 month or less (Wait 3) (7–9).
We found no published data on the wait time to comprehensive monitoring and access to self-management resources (Wait 4); however, there is evidence that these treatments fail to reach people with RA. Although nonpharmacologic treatments such as exercise and education play an adjunctive role in medical management (16), 42% of patients in a US study did not obtain needed mental health services and 39% did not obtain needed rehabilitation (17). A Canadian survey also found that only 30% of patients participated in an exercise program supervised by a health professional (18). Patients in general have a significant need for information and welcome full disclosure about treatment options and risks (19, 20), but only 32% in the Canadian survey had attended education programs such as the Arthritis Self-Management Program (18). In general, use of nonpharmacologic treatment by individuals with RA is far from adequate.
The wait time for surgical interventions, especially in total hip and knee replacement surgeries, is well documented (Wait 5) (21, 22). Several expert panels have recommended that the latter should be less than 6 months (23, 24); however, between 2000 and 2001, fewer than 50% of patients in Ontario, Canada underwent their scheduled surgery within this timeframe (25).
Overall, current RA care is a loosely coordinated effort with multiple possibilities for bottlenecks. Data from across countries have revealed the long delays in care prior to diagnosis; however, the availability of health human resources “upstream” is relatively scarce. To address the disparity in RA care, the clinical and research communities have developed a variety of strategies to increase capacity within the health care system. The purpose of this report is to synthesize the research of interventions that improve the delivery of health services to people with RA, and to propose an integrated service delivery framework based on the evidence.
In 2005, the Alliance for the Canadian Arthritis Program (www.arthritisalliance.com) hosted the Summit on Standards for Arthritis Prevention and Care to develop evidence-based, practical standards for government, health care providers, and patients (26). A subgroup reviewed the literature on innovative interventions for improving arthritis care (The Manpower and Model of Care Theme; co-leaders: Drs. Elizabeth Badley, David Hawkins, Linda Li, and Dianne Mosher; members: Drs. Claire Bombardier, Michel Brazeau, Ciaran Duffy, and Michel Zummer, and Ms Mary Kim, Sydney Lineker, and Crystal MacKay; consultant: Dr. Carter Thorne). Articles were initially identified from subgroup members' own collections and an updated literature search was conducted in 2007. Eligible articles were identified using Medline (1950–2007; search terms are listed in Appendix A, available at the Arthritis Care & Research Web site at http://www.interscience.wiley.com/jpages/0004-3591:1/suppmat/index.html), EMBase (1980–2007), and CINAHL (1982–2007). We included all original, English-language studies that evaluated an intervention(s) for improving the delivery of health services to people with RA. Two reviewers (LCL and AJ) screened all titles and abstracts. In addition, we identified articles that evaluated health service interventions in other musculoskeletal conditions that can be adapted for RA management. The literature was synthesized by one of the authors (LCL) and was subsequently used to develop a framework of RA care (Figure 1).
First, we believe that expanding the role of rehabilitation, nursing, and pharmacy professionals in the early stages of RA will help to accelerate the recognition of symptoms and facilitate access to further investigations, thereby shortening the delay at Waits 1 and 2 (Figure 1). Second, we assume that the level of care is flexible and relates to the patient's need. For example, while patients with an acute episode would benefit from intensive team care, those with a well-controlled disease might only need to see the FP, a nurse specialist, or an arthritis-trained rehabilitation professional for followup. This is likely a close reflection of how individuals manage their health in the community. Third, the proposed framework has been developed from a Canadian perspective, which may or may not be applicable to other health care systems. For example, whereas most generalists in Canada are trained in family medicine, many in the US are general internists who may have greater expertise in RA. Therefore, the framework may not reflect the provision of care across countries.
The literature search identified 3,321 citations; of those, 39 met the eligibility criteria (27–65) (Figure 2). In addition, we found 9 articles on other musculoskeletal conditions, including osteoarthritis (OA) and low back pain (66–74) (Table 1). The majority of articles are observational or quasi-experimental studies (n = 33). The findings were synthesized within the RA care framework (Figure 1, boxes i–viii; examples of interventions are listed in Table 2).
|Lead author||Year||Country||Study design||Interventions for improving health service delivery†|
|Buchbinder (66–69)||2001, 2004, 2005, 2006||Australia||Nonrandomized, controlled study||Social marketing campaign for low back pain management|
|Marra (70)||2007||Canada||Observational study||Pharmacists administered a simple question to identify people at risk of knee osteoarthritis|
|Primary care level|
|Bowling (27)||1997||UK||Observational study||Shared care model|
|Davis (28)||2001||Canada||Observational study||Shared care with videoconferencing|
|Glazier (29)||2005||Canada||Nonrandomized, controlled study||Getting a Grip on Arthritis education program for FPs and health professionals|
|Gormley (30)||2003||UK||Observational study||Arthritis referrals triaged by FPs or rheumatology nurses|
|Leggett (31)||2001||UK||Observational study||Shared care with videoconferencing|
|O'Cathain (71)||1995||UK||Nonrandomized, controlled study||Specially trained PTs triaged orthopedic referrals at the primary care setting|
|Pal (32)||1999||UK||Observational study||Rheumatology consultation and advisory service; referrals were made by FPs using a standardized e-mailed form|
|Petrella (33)||2007||Canada||Observational study||Joint Adventures education program for FPs|
|Schulpen (34, 35)||2003||Netherlands||Observational study||FP–rheumatologist joint consultation model|
|Walsh (36)||2007||Observational study||BMJ learning module on common rheumatology problems for FPs|
|Secondary care and followup levels|
|Arndt (37)||2007||Germany||Observational study||Administration of a prereferral questionnaire to facilitate scheduling at early arthritis clinics|
|Arvidsson (38)||2006||Sweden||Qualitative study||Nurse-led rheumatology clinic|
|Bell (39)||1998||Canada||RCT||Rehabilitation provided by rheumatology-trained PTs|
|Bond (40)||2000||UK||Nonrandomized, controlled study||Specialist outreach clinics at primary care practices|
|Cosgrove (41)||1988||US||Observational study||Multidisciplinary team care|
|Helewa (42)||1994||Canada||RCT||Rehabilitation provided by rheumatology-trained PTs|
|Hewlett (43, 44)||2000, 2005||UK||RCT||Patient-initiated outpatient followup|
|Hill (45)||1986||UK||Observational study||Nurse-led rheumatology clinic|
|Hill (46)||1997||UK||RCT||Nurse-led rheumatology clinic|
|Hughes (47)||2002||UK||Observational study||Rheumatology helpline run by specialist nurses|
|Jacobsson (48)||1998||Sweden||Observational study||Multidisciplinary day care program|
|Jong (49)||2004||Canada||Nonrandomized, controlled study||Rheumatology outreach services through 1) visiting rheumatologist clinics (control), 2) e-mail access to rheumatologist, or 3) videoconference consult|
|Lambert (50)||1998||UK||RCT||Multidisciplinary day care program|
|Li (51–53)||2005, 2006||Canada||RCT||Rehabilitation provided by a rheumatology-trained primary therapist|
|McCabe (54)||2000||UK||Observational study||Rheumatology telephone helpline|
|Newman (55)||2004||US||Observational study||Patient-centered advanced access model for scheduling rheumatologist appointments|
|Nordmark (56)||2006||Sweden||Observational study||Multidisciplinary team care for vocational support in early RA|
|Pace (57)||2006||UK||Observational study||Self-referral of symptoms followup system|
|Prier (58)||1997||France||Observational study||Multidisciplinary day care program|
|Ryan (59)||2006||UK||RCT||Drug monitoring provided by a clinical nurse specialist|
|Schned (60)||1995||US||RCT||Multidisciplinary team care at an early arthritis clinic|
|Tijhuis (61, 62)||2002, 2003||Netherlands||RCT||Clinical nurse specialist-led care; multidisciplinary inpatient care; multidisciplinary day care|
|Van den Berg (63)||2006||Netherlands||RCT||Web-based program to deliver individualized exercises; PTs follow up by e-mails|
|Van der Horst- Bruinsma (64)||1998||Netherlands||Nonrandomized, controlled study||Early arthritis clinic|
|Hourigan (73, 74)||1994, 1995||UK||Observational study||Orthopedic-specialty-trained PTs assess and triage all cases referred by FPs to a back pain clinic|
|Rymaszewski (65)||2005||UK||Observational study||Team approach for orthopedic triage, involving nurses, PTs, and podiatrists in extended roles|
|Crowe (72)||2003||Canada||RCT||Individualized rehabilitation program before hip or knee surgery for clients with complex needs (comorbid conditions or no social support)|
|Description of level†||Health services innovation‡||Example of interventions||Findings from the literature|
|Services/information received by the person between the symptom onset and the first family physician visit (level A)||Public education to increase awareness of arthritis (box i)||Public education campaign using printed material and the mass media to increase awareness of back pain management (Australia [66–69]) Further testing in RA is needed||Improved beliefs about back pain in the general public (66). The positive effect remained 3 and 4.5 years after the initial campaign (67–69).|
|Community health professionals provide screening for early arthritis symptoms (box i)||Community pharmacists use a simple questionnaire to identify people with OA (Canada ) Further testing in RA is needed||The questionnaire identified >80% of people with knee pain who had undiagnosed knee OA (70).|
|Primary care level|
|Services provided by a family physician (level B)||Multifaceted education programs for family physicians (box ii)||Getting a Grip on Arthritis program (Canada ) Joint Adventures Program (Canada )||Improvement in clinicians' knowledge, skill, and confidence in musculoskeletal examination, awareness of community resources, communication with patients and other clinicians, and overall disease management (29, 33).|
|Shared care involving family physicians and rheumatologists (box iii)||A rheumatologist provides consultation at a family physician's office a few hours a week (Sweden , The Netherlands [35, 83])||Two regions and 17 counties in Sweden initially adopted the model. No formal evaluation was done. Nine regions abolished shared care after 5 years due to health care restructuring and rheumatic cases were no longer a priority (82).|
|A rheumatologist provides consultations through teleconference/video conference with the patient at the family physician's office (UK )||In The Netherlands, shared care decreased inappropriate referrals, resulting in a 62% reduction in waiting list in rheumatology clinics (35, 83).|
|In the UK, the diagnostic accuracy of the videoconference sessions was 97% compared with the face-to-face rheumatologist consultation; 90% of patients and 99% of family physicians were satisfied with the intervention (31).|
|Specialized nurses or rehabilitation therapists triage rheumatology referrals (box iv)||Nurses triage rheumatology referrals using standardized guidelines (UK )||Positive predictive value = 88% when compared with the rheumatologist's assessment (30).|
|Appropriate referrals increased from 50% to 90% 2 years after the intervention was implemented (30).|
|Specially trained PTs screen and assess orthopedic referrals (UK ) Further testing in rheumatology triage is needed||Compared with the traditional model in which family physicians referred directly to the hospital departments, the screening model reduced referral to orthopedic departments by 17% and to rheumatology departments by 8% (71).|
|Rheumatology care level|
|Services provided by a rheumatologist and other specially trained health care professionals (levels C, D)||EACs (box v)||Rheumatology clinics for patients with early inflammatory arthritis usually include a rheumatologist(s), a nurse specialist(s), and/or rehabilitation professionals (Europe , North America )||In The Netherlands, EACs reduced the wait time for the first rheumatologist visit by 3 months compared with the routine secondary care referral in the outpatient setting (64). In Canada, a Toronto-based EAC had a median delay of 6.5 months between symptom onset and the 1st rheumatologist visit, compared with 11.5 months in the general rheumatology clinics (8).|
|Once diagnosed, nurse specialists or specially trained rehabilitation professionals provide tailored education and nonpharmacologic treatment as needed (box v)||Clinical nurse specialists or nurse practitioners assume extended roles such as performing MSK examination, monitoring, and recommending changes of medication (Europe [46, 61, 62, 91, 92])||In the UK, clinical nurse specialist care, in addition to the usual rheumatology care, resulted in less pain, better knowledge, and greater patient satisfaction compared with usual care alone (46) or care provided by a junior hospital doctor (92).|
|Compared with the junior doctors, the nurse group also showed lower fatigue (92) and better function.|
|In The Netherlands, clinical nurse specialist care resulted in similar health outcomes and was less expensive compared with team care (61, 62, 91).|
|Specially trained PTs provide traditional physical therapy treatment for people with RA (Canada [39, 42])||Compared with the traditional PT/OT model, patients treated by a primary therapist were almost 4 times more likely to meet the clinical response criteria (52). The model was also found to be a cost-effective alternative (53).|
|Primary therapists provide comprehensive education and cross-disciplinary, nonpharmacologic treatment (Canada [52, 53])|
|PT/OT practitioners provide treatments within and beyond the traditional roles. The latter roles may include counseling on medication and ordering investigative tests (Canada [97, 98, 107])||Hospital for Sick Children in Toronto has trained PT/OT practitioners (97). Compared with the physician-led clinics, patient satisfaction in PT practitioner-led clinics was equally high (average rating of 4 out of 5 on the Group Health Association of America's Consumer Satisfaction Survey) (98).|
|The ACPAC program has trained PT and OT practitioners to assume advanced practice roles. Evaluation is underway (107).|
|Services provided to enable self-management after the person is diagnosed (level E)||Comprehensive arthritis care||Comprehensive team care (41, 56, 58, 108, 110)||A 1997 systematic review found that inpatient team care was more effective than regular rheumatology outpatient care (108).|
|The rheumatologist assesses the patient periodically to monitor health status and adverse events from medications (level F)||Arthritis-trained nurses, PTs, or OTs facilitate patient access to a rheumatologist and other health professionals when needed (box vi)||The benefit between outpatient team care and regular outpatient care is less marked (108). Further evaluation of comprehensive team care is underway in Canada (109) and Europe (110).|
|Patient-initiated care, involving a central helpline staffed by a nurse specialist to provide advice about symptom management and referral to other services (UK [43, 44])||Compared with the routine followup group, the patient-initiated care group had less pain, a smaller increase in pain, and greater self-efficacy over 2 years, and used 33.5% less resources (43).|
|At 6 years, the intervention group had similar health status as the routine followup group, while having one-third fewer medical visits (44).|
|Advanced practice nurses, PTs, and OTs provide followup (see description in the rheumatology care level) PTs provide distance supervision on physical activities using e-mails (The Netherlands )||The proportion of the physically active patients was significantly higher in the e-mail supervised group than the nonsupervised controlled group at 6 and 9 months (63).|
|Orthopedic consultation level|
|Consultation with an orthopedic surgeon for possible surgical interventions (levels G1, G2)||Rehabilitation professionals triage orthopedic referrals (box vii)||Expert PT conducts a standardized assessment to determine if the patient should be managed by PT, referred for orthopedic consultation, or requires no treatment (Canada )||In Canada, programs have been established to evaluate the effectiveness of this model (111).|
|In the UK, the team triage approach reduced the outpatient orthopedic clinic waiting time from 182 days to 90 days, despite the doubling of referrals in a period of 4 years (65).|
|A team approach, involving nurses, PTs, and podiatrists in extended roles to triage orthopedic referrals (UK )|
|Services designed and provided prior to the scheduled surgical intervention (level G3)||Prehabilitation (box viii)||Education and exercise by a trained PT and/or OT (72, 103)||A Cochrane review concluded that preoperation education can lower patients' anxiety while waiting for surgery (103).|
|A Canadian study found that tailor education was beneficial when targeting those who are disabled or have limited access to social support (72).|
Recognition of the seriousness of symptoms may not be straightforward for people with early RA, because the onset is sometimes insidious. At this stage, people who have some awareness of arthritis or who know someone with the disease may be more likely to seek help early (75). The literature, however, suggests that the lay public is poorly informed about the nature and treatment of arthritis (76, 77). Although information technologies can be used to increase awareness (77), the quality of arthritis-related Web sites is inconsistent (78, 79). From the experience of public awareness campaigns about acute and subacute low back pain (66–69), it appears that well-coordinated social marketing strategies may have the potential to improve awareness of arthritis symptoms, but further evaluation will be needed to determine if they actually shorten the lag time for people to initiate medical consultation.
Another strategy is to involve other health professionals in symptom detection. Community rehabilitation professionals, nurses, and pharmacists are often the first point of contact with the health care system, and so they are in a unique position to identify people who may require medical consultation. In a recent study, community pharmacists were asked to administer a simple OA questionnaire to people who had undiagnosed knee pain (70). The intervention was able to identify >80% of eligible participants with undiagnosed OA. This has not been tested in RA, but screening in the community may be possible by applying existing criteria (80) or new tools as they are being developed (81) (Figure 1, box i).
Primary care level.
FPs are gatekeepers of specialist care and therefore need to have the skills to accurately identify individuals who require a rheumatology referral. One strategy to improve detection of RA by FPs is to use multifaceted education programs such as Getting a Grip on Arthritis (29) and Joint Adventures (33) (Figure 1, box ii). These programs, which use outreach workshops and information toolkits, have demonstrated potential to improve FPs' knowledge, skills, and confidence in musculoskeletal examination, awareness of community resources, communication with patients and other health professionals, and overall disease management (29, 33).
Another strategy is the shared care model (Figure 1, box iii). This was initially adopted by Sweden in the 1980s, with rheumatologists providing consultations in FPs' offices 2–3 hours a week. New patients were assessed jointly by the rheumatologist and the FP, sometimes in the presence of a rehabilitation therapist. This was followed by a meeting with patients and their caregivers to develop a treatment program. In between visits, rheumatologists and FPs maintained contact through educational workshops and telephone consultations (82). This model was later modified and used in The Netherlands and was successful in shortening the waiting list in rheumatology clinics (35, 83). Furthermore, shared care could be implemented in remote regions using videoconferencing equipment and e-mail (28, 31, 32), with high satisfaction from patients and physicians (28, 31).
Finally, the transition from primary to secondary care can be improved by instituting a referral triage system (30) (Figure 1, box iv). This model was tested with FPs and rheumatology nurses and had high positive predictive values (FPs: 88%; nurses: 91.5%) when compared with the rheumatologist's decision (30). In addition, appropriate referrals increased from 50% to ∼90% 2 years later. O'Cathain and colleagues also evaluated a model in which FPs referred orthopedic cases to an affiliated physical therapy practice for triage assessment, instead of directly to the hospital orthopedic or rheumatology departments (71). The results showed a 17% decrease in referral to orthopedics departments and an 8% decrease in referral to rheumatology departments compared with the traditional referral model, although the study did not assess the appropriateness of the referrals. It should be noted that there was baseline imbalance in the outcome measure, which could undermine the postintervention differences.
Secondary care level.
At the rheumatology care level, the goals are to make an optimal diagnosis, to initiate medication and education, and to provide appropriate nonpharmacologic treatments in a timely manner (84). A number of early arthritis clinics (EACs) have subsequently been established in Europe and North America (84–86). EACs may include a rheumatologist, a nurse specialist, and rehabilitation professionals (84, 85); however, it is unclear if multidisciplinary team management is superior to physician-only care (rheumatologist and FP) at this stage (60). A recent study on an EAC in The Netherlands found a 3-month reduction in wait time for the first rheumatologist visit compared with the traditional referral process (64). Furthermore, rheumatologists were able to make a diagnosis within 2 weeks of the initial visit in 70% of patients based on the American College of Rheumatology (formerly the American Rheumatism Association) criteria (87). Approximately 89% of patients with definite RA remained the same, whereas 51% with probable RA switched to definite RA within 1 year. The use of a structured referral questionnaire may be helpful for EAC staff to plan appointments (37) (Figure 1, box v).
After starting medications, individuals may require additional nonpharmacologic treatment to ameliorate symptoms. Rheumatology-trained rehabilitation professionals and nurses can play a role during this stage. Augmented roles for nonphysicians has been shown to be an effective strategy in the management of chronic diseases (88). Nurses began to assume new roles in the US in the 1960s and in Canada in the 1970s (89, 90). Titles such as clinical nurse specialist (CNS) and nurse practitioner (NP) have been used, although there is considerable debate around the definition of roles (89). In Europe, some CNS/NPs provide supplementary services to rheumatologist care (38, 61, 62, 91), while others assume extended roles, such as performing musculoskeletal examination, monitoring and recommending changes in medication (59), and referring to other health professionals (46, 92).
Physical therapists (PTs) and occupational therapists (OTs) are also expanding their roles. For example, The Arthritis Society (Ontario Division, Canada) employs primary therapists who have completed a program on inflammatory arthritis assessment (93, 94). Under the primary therapist model, PTs and OTs function as multiskilled workers, assuming the roles of both case managers and health care providers (95, 96). Because primary therapists have physical therapy and occupational therapy skills in arthritis care, they are able to provide comprehensive rehabilitation treatment (51–53).
Some rehabilitation therapists are working beyond the traditional scope of practice of their professions after intensive rheumatology training offered by university-affiliated hospitals. For example, physical therapy and occupational therapy practitioners may independently assess patients, order investigative tests, and monitor medications under the supervision of a rheumatologist during followup visits (97, 98). However, further research is needed to assess the effectiveness of the model in improving patient outcomes.
RA is a chronic disease and patients often require ongoing reviews by rheumatologists. The frequency of followup visits varies, but most people are booked in advance every 3–6 months as the course of the disease and its treatments become established. It has been estimated that planned followup visits account for up to 75% of the average rheumatologist's caseload (99). Consequently, rheumatology clinics have very little room to schedule in new patients or urgent cases that need an immediate review. This means that some patients may be seen at a time when no help is required, whereas others may not be able to access the rheumatologist when needed.
To address the inefficiency in followup scheduling, Newman et al developed a patient-centered advanced access scheduling model in which a portion of the rheumatologist's schedule was reserved for patients requiring same-day appointments (55). Hewlett et al also tested a model of patient-initiated care, which involves a central helpline staffed by a specialist nurse who is trained to provide advice about symptom management (43). If the patient requires a medical review or other interventions, an appointment is scheduled within 10 working days. Results from a 6-year followup showed that this model was effective and resulted in fewer medical appointments as compared with the traditional followup model with routinely scheduled rheumatology visits (44). The Hewlett et al model also has the potential to improve access for patients who require a review of their exercise program or other nonpharmacologic treatments (Figure 1, box vi).
Orthopedic consultation and presurgical level.
Experience from back pain management suggests that some patients who are referred to orthopedic consultation do not actually require surgery and can be treated through conservative interventions such as physical therapy (73, 74). Orthopedic surgeons can potentially spend more time performing surgery if their consultation time focuses mainly on patients who are surgical candidates. This has given rise to the orthopedic triage model by specially trained PTs. When receiving a referral, the expert therapist can conduct a standardized assessment to determine if the individual should be managed by physical therapy and other conservative interventions, referred for orthopedic consultation, or considered to require no further treatment. This model has been found effective in reducing unnecessary orthopedic referrals without compromising outcomes in patients with back pain (73, 74) and general orthopedic problems (71). However, the new role may create professional stress due to concerns of misclassification of patients and, at times, patient dissatisfaction (100). The effectiveness of the triage model for hip and knee surgery referrals is unclear, but, judging from the other orthopedic conditions that use this model, it appears to be promising (Figure 1, box vii).
Finally, patients may benefit from “prehabilitation” while waiting for surgery. In some facilities, patients may receive preoperation education and exercise (101). A recent review by Solway and MacKay provides a comprehensive summary of evidence in this area (102). In brief, preoperation education can significantly decrease patients' anxiety while waiting for surgery, although it has little effect on pain, function, and the length of hospital stay (103). Tailored education is particularly beneficial when targeting those who are disabled or have limited access to social support (72). However, preoperative physical therapy appears to have little effect in improving outcomes after total knee replacement, and the effect on the outcome after total hip replacement is inconclusive (104). Based on the evidence, health professionals may consider offering tailored prehabilitation to patients who require additional support while awaiting surgery (Figure 1, box viii).
Recommendations for Future Research
We recognize that the available evidence is limited and insufficient for building a definitive service delivery pathway, but we see it as a starting point to develop solutions that facilitate timely RA care. Although further research is required to refine the RA care framework, we also need to address the fundamental gaps in research and education. There is a need to better understand the factors that contribute to the delay in care at the early stage of the disease. To this end, we recommend studies to develop and test databases that systematically collect information about the early phase of help seeking (patient's perspective) and service delivery (clinician's and health system's perspective). Another challenge is to improve collaboration between primary care and rheumatology so that FPs can become more effective gatekeepers. This is one area where expertise in knowledge translation will be useful in developing interventions to facilitate communication and improve the quality of care.
Finally, we need to ensure that sufficient rheumatology training is available for entry-level and practicing allied health professionals. A recent survey in the UK found that nursing, physical therapy, and occupational therapy programs only offered 5–10 hours of rheumatology and that nursing students received the least time (105). Further research will be needed to assess whether new graduates are properly equipped to work with people with arthritis or to undertake new roles in arthritis care. In addition, we need to understand the current practice of health professionals in order to streamline continuing education programs on arthritis.
In summary, we have introduced a new framework of RA care that focuses on the collaboration between primary care and rheumatology, and on the extended roles of nursing, pharmacy, and rehabilitation professionals. We believe that this framework can serve to guide future research on health service delivery in RA. This framework is in line with other musculoskeletal service models, such as that recently developed in the UK (106) in which the focus is to improve the dissemination of information at the community level, support shared care, and expand the roles of nursing and allied health professionals in service delivery. We would encourage comments and discussions about the framework, and the development of similar frameworks in other chronic conditions.
Dr. Li had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study design. Li, Badley, MacKay, Mosher, Walji, Bombardier.
Acquisition of data. Li, Jones, Bombardier.
Analysis and interpretation of data. Li, Bombardier.
Manuscript preparation. Li, Badley, MacKay, Mosher, Walji, Bombardier.
Background research and needs assessment. Walji.
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