Background/Purpose:

Effective communication is essential in caring for medically complex patients with rheumatoid arthritis (RA). Communication between clinicians becomes even more crucial when a patient gets admitted to the hospital. Our study aims to investigate how often communication gaps occur at our institution, focusing primarily on RA patients, and subsequent consequences.

Methods:

This is a retrospective cohort study of RA patients admitted to our institution from July 1, 2015 to June 30, 2016. All patients were seen by a rheumatologist at least twice within a 14-month period prior to the admission date. Data gathered include: admission type based on principal diagnosis (infection, cardiac, surgical, other), baseline glucocorticoid and immunosuppressive therapy, rheumatology service notification of a patient’s current or upcoming admission and communication mode (inpatient consult, clinic visit, telephone encounter, discharge instructions or summary), flare up and/or glucocorticoid dose increase up to 3 months after discharge, appropriate preoperative C-spine xray, appropriate medication continuation or discontinuation, and appropriate re-initiation of discontinued medications.  

Results:

Two hundred twenty-nine admissions were included. Rheumatology was notified 57.6% of the time across all admission types. Medications (immunosuppressive and/or glucocorticoid) were appropriately held 36.4% of the time. Medications were rightfully continued for 73% of our patient cohort. Nineteen percent of our patients developed a flare within 3 months after discharge. Only 11% of our patients admitted for surgery had a preoperative C-spine xray. Among our surgical patients, 4 developed non-life-threatening infection and 1 patient had wound healing issues within 3 months after surgery.  

Conclusion:

Our retrospective study highlights both gaps in communication between rheumatology and admitting services, and in the care of RA patients admitted to the hospital. To our knowledge, this is the first study to investigate these gaps, and subsequent consequences, among RA patients followed in a large integrated healthcare system. One potential intervention to address the problem in communication is integrating an automated notification system within our electronic record to inform rheumatology clinicians when one of our RA patients is scheduled for an elective surgery, or gets admitted to the hospital. To bridge gaps in patient care, we are exploring ways to increase our rates of appropriate preoperative C-spine xrays, as well as appropriate medication continuation or discontinuation among our RA patients. This will be done through collaboration with our surgeons to establish a standardized evidence-based approach to the perioperative management of patients with RA.  

Table 1. Summary data of hospital admissions, Rheumatology notification, and patient outcomes