Background/Purpose: Access to rheumatology is critical for timely treatment of new onset inflammatory arthritis (IA). Barriers to timely care include patient characteristics, the need for a referral from another physician (usually a primary care physician (PCP)), and the availability of a rheumatologist to be referred to.  Treating patients with IA also needs to be balanced against the role of rheumatologists as the medical specialist with expertise in arthritis in general.  There is a shortage of rheumatologist as well are large area variations in their availability. The objectives of this population-based study is to examine access to rheumatologists for IA and arthritis overall (AO) taking into account access to PCP, availability of rheumatologists, and population characteristics.

Methods: A population-based multilevel study of individuals aged 18+ living in 105 residential areas in Ontario, Canada (total population about 13 million) which has a publicly funded health care system covering all physician visits. The physician billing database was used to identify the number of patients seeing rheumatologists for IA and AO and to derive a measure of PCP availability by residential area.  Census data were used to calculate indicators of socio-economic status (SES), population age and rurality. Data from a survey of rheumatologists gave postal code for practice locations and the number of clinic hours per week.  Geographic Information System analysis was used to calculate a weighted measure of rheumatologist availability taking into account amount of clinic hours and distance to rheumatologist locations for each residential area. Multilevel Poisson regression was used to estimate rate ratios for visits to rheumatologists for IA and AO by rheumatologist availability, PCP access, and SES.

Results: 142,600 patients made at least one visit to rheumatologists (13.4 per 1000 population): only 47.7% of visits were for IA, with a seven-fold variation across residential areas.  Comparing the highest to lowest quintile, rate of visits for IA were higher in areas of high SES (RR 1.3 95%CI:1.1-1.6) and areas with high PCP access (RR 1.2 95%CI:1.0-1.5).  There was no association with rheumatologist availability.  However higher rheumatologist availability was associated with visits for AO (RR 1.2: 95% CI 1.0:1.4), as were high SES (RR 1.4 95%CI:1.2-1.6) and high PCP access (RR 1.4 95%CI:1.2-1.7). 

Conclusion: The lack of association with area-level rheumatologist availability for IA suggests that priority is given to these patients.  The association of higher rheumatologist availability with patients seen with AO, raises questions of where these patients go for care when no rheumatologist is available. For both IA and AO, lack of PCP access may be a barrier to referral.  This study also indicates that residents of high SES areas are more likely to see rheumatologists, suggesting inequalities in access to care. Models of care that incorporate the location and amount of rheumatologist and PCP resources are crucial to improve access to care for people with all types of arthritis particularly in areas of low SES.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/use-of-rheumatology-services-for-arthritis-the-role-of-ses-and-geographic-availability-of-rheumatologists-and-primary-care-physicians/