Background/Purpose:

Current guidelines for the optimal care of rheumatoid arthritis (RA) recommend prompt referral to a rheumatologist. In the province of Ontario, Canada all 13 million residents are covered by universal public health insurance. However, almost 2 million residents do no have a regular family physician. Previous research has shown that sustained continuity of primary care plays a positive role in patient health outcomes for other chronic diseases. However, the impact of sustained continuity of primary care on access to rheumatologists remains unstudied. This is particularly concerning since family physicians function as gatekeepers for access to rheumatologists. Our objective was to estimate the percent of incident RA patients who see a rheumatologist within 1 year of diagnosis, and to identify determinants of contact with a rheumatologist within 1 year of RA diagnosis. 

Methods:

We assembled an incident RA cohort aged >65 years from Ontario health administrative data across 1997-2008.  We used a validated algorithm to identify 27,127 seniors with early RA. We followed patients for 1 year, assessing if they had a visit to a rheumatologist. We assessed secular trends and differences for patients who saw a rheumatologist versus those who had not. We performed multilevel logistic regression analyses to determine whether receipt of rheumatology care was associated with: patient characteristics, primary care physician characteristics and provider continuity, and geographic characteristics.

Results:

Overall, 17830 (66%) seniors with early RA identified over 1997-2008 saw a rheumatologist within 1 year of diagnosis. This increased from 50% in 1997 to 78% in 2008. The majority of patients (67%) were female. Few patients (16%) resided in rural areas. Factors associated with a rheumatologist encounter included increasing continuity of primary care, [adjusted Odds Ratio (aOR)=1.30 95% CI 1.11, 1.53], patients of highest socioeconomic status (SES) [aOR=1.24 95% CI 1.13-1.36], and having more rheumatologists in the area (Rheumatology supply per 100,000 adults aOR=1.20 95% CI 1.16, 1.24).  Less contact with rheumatologists occurred among patients with increasing age (aOR= 0.97 95% CI 0.97, 0.98), patients who had male primary care physicians (aOR=0.73 95% CI 0.66, 0.80), residing in a rural area (aOR=0.74 95% CI  0.68, 0.81) and at a remote distance (≥100 km) to the closest rheumatologist (aOR=0.37 95% CI  0.31, 0.44).

Conclusion:

Improvements in access to rheumatologists for RA care have occurred over time but more efforts are needed.  Potential barriers that limit timely access to rheumatologists include increasing age, lower SES, and having a male primary care physician. Measures of poor access (poor continuity of primary care, density and proximity to rheumatologists) negatively impacted rates of encounters with a rheumatologist. Proactive, tailored approaches are needed to provide rheumatology care to such populations. 

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/potential-barriers-that-limit-access-to-rheumatologists-among-patients-with-early-rheumatoid-arthritis-in-a-universal-access-health-care-system/