Background/Purpose:

Despite guidelines and evidence indicating that early diagnosis and treatment of PsA is critical, few studies have described referral and care-management patterns in a real-world setting. This study estimated the prevalence and incidence of PsA in the Sutter Health system, a large integrated U.S. health delivery network, and explored referral patterns and associated care-management practices within this population.

Methods: This was a retrospective review of electronic medical records and medical claims data of patients (age ≥18yrs) diagnosed with PsA (ICD-9-code 696.x) from 2011-2013. Medical chart review by a rheumatologist and/or registered nurse of a sample of prevalent and incident PsA patients was utilized to confirm the diagnosis. Prevalence and incidence rates (defined as no PsA report 2 years before the index PsA record) were estimated annually/100,000 patients. Care management included ascertainment of the physician type recording the first PsA diagnosis and/or treating the patient (specialist vs. non-specialist). Referral patterns ascertained the physician type making the first referral to a specialist.

Results:

Among 1,362,288 adults (≥18 yrs, 59% female) in the health plan, 2,029 were identified as diagnosed with PsA. The average 1-year period prevalence was 161/100,000; incidence: 43/100,000.  Mean age at incident diagnosis was 53 years (s=14.3) for women and 51 years (s=13.6) for men. Chart review revealed low rates for misclassification (5%) of PsA diagnosis. Approximately 54% of all PsA-related encounters were with rheumatologists. The majority of care was provided by rheumatology, primary care, and dermatology, accounting for 54%, 21%, and 19% encounters, respectively. Rheumatologists were first to diagnose PsA in 61% patients followed by primary care physicians (PCP): 24%, dermatologists: 10%, and others: 5%. Of those referred to a rheumatologist, 65% were referred by a PCP, followed by dermatologists: 6%, other rheumatologists: 4%, orthopedists: 3%, podiatrists: 2%, others: 3% and self/ no record: 18%.  Overall, in sampled patients, non-rheumatologist providers were less likely to perform a joint exam or document joint abnormalities, and no providers documented a disease activity score. Of 1665 prevalent cases with a documented encounter with a rheumatologist within the system, 557 (33%) were prescribed biologic agents, 851 (51%) DMARDs, and 359 (22%) steroids.  Among 2029 prevalent cases, 346 (17%) had no documented encounter with a Sutter Health rheumatologist; 30% were prescribed biologics and 26% DMARDs. Chart review revealed that most of these patients had had contact with specialists outside the network.

Conclusion:

Estimated prevalence of PsA in the Sutter Health System was similar to U.S. estimates: between 0.02 and 0.25%. Although rheumatologists provided the majority of care, many patients did not have a record of a rheumatology encounter. Further research is needed to better understand gaps in PsA health care in real world settings.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/characterization-of-psoriatic-arthritis-psa-in-a-large-integrated-health-plan-demographics-referral-patterns-and-care-management/