Background/Purpose

Specialist visits are a contributing factor to the rising cost of healthcare and payment models increasingly encourage decreased outpatient specialty visits.

Due to monitoring of methotrexate, sulfasalazine, or leflunamide, many rheumatologists see patients with stable Rheumatoid Arthritis (RA) every 3 months for routine follow up.  We hypothesized that decrease in utilization and cost of outpatient specialty services can be achieved without compromising patient care or safety by seeing these patients every 6 months, with a lab check every 3 months.

Methods

Patients with RA on either methotrexate or sulfasalazine in stable remission or low disease activity were offered visits every 6 months instead of every 3 months, with labwork done at 3 months.  This was part of a Quality Improvement initiative to decrease healthcare costs. 

Outcomes included number of eligible patients for two full time providers over a 6 month period, percent of total established RA patients for these providers deemed appropriate for inclusion, percent of patients who had their labs done, percent of patients with new cytopenia or liver function test (LFT) abnormality, percent of patients who had problems requiring a follow up visit during the 6 month interval, and estimated cost savings.

Results

Over 6 months, 21 eligible patients were identified.  Clinical features are noted in Table 1.  Overall, 14/21 patients were seropositive, either for RF or CCP antibodies, and 12 were positive for both.  10 patients were on combination therapy with a biologic.  The 21 RA patients were out of 184 established RA patients seen for followup visits by two full time providers (11.4%) during the study period (Table 2).  14 of 21 patients (66.7%) had their labs drawn at 3 months.  There were no new cytopenias or LFT abnormalities.  No patients required additional follow up for RA.  One patient required a follow up visit during the 6 month interval for new diagnosis of Giant Cell Arteritis.  Each saved visit equaled an estimated cost savings of between $92 and $356, depending on the insuror, with an average of $161 saved per visit and $362 per patient annually.

Conclusion

Patients with RA in stable remission or low disease activity can safely and cost effectively be seen at 6 month intervals with labs drawn at 3 months.  There were no new RA issues between visits, and no new laboratory abnormalities.  Patient compliance was good, but could be improved.  This intervention saved an average of $362 per patient annually.

Table 1: Clinical Characteristics

Age	56.8
Gender (female)	82.3%
Ethnicity
White	15
Hispanic	6
RF+	13
CCP +	10
Erosive disease	10
Disease duration (years)	8.8
On MTX	24
On SSZ	5
On Leflunamide	1
On Plaquenil	2
On prednisone	1
On biologic (in combination)	10
Etanercept	5
Adalimumab	3
Golimumab	1
Abatacept	1

Table 2: Outcomes

Total Established RA Patient Visits	184
Eligible RA patients	21 (11.4%)
Labs done	14/21 (66.7%)
New Cytopenias	0
New LFT abnormalities	0
Interval Visits	1

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/rheumatoid-arthritis-stable-follow-up-visits-3-month-versus-6-month-intervals/