Results: Within a 12-month window, 568 patients had 8,686 outpatient encounters with the healthcare system with a mean of 3.41 unique providers per patient associated with a mean of five primary care and six rheumatologist visits. Half did not see a primary care physician and 20% did not see a rheumatologist during six-month periods, despite their use of potentially toxic drugs, a mean of four comorbidities, and progressive RA. Over the course of 24 months, 29% of patients changed their primary care provider, and 15% changed their rheumatologist. Patients were moderately impaired with mean SF-12 physical component score 37 (standard deviation, 9).
Conclusion: Patients with RA have frequent encounters with multiple providers and also frequent discontinuity of care. Recognizing the complexity of the care of patients with a chronic disease across multiple dimensions provides an opportunity to better understand challenges and opportunities in delivering high-quality care.
Commentary
Making decisions on follow-up appointments, asking for consultations, returning patient telephone calls, communicating with primary care physicians, and transferring medical records to other providers are part of the mechanics of clinical practice. Although most of us live it on a daily basis, rarely do we step back and consider how these efforts fit into the overall pattern of patient care. This study attempts to do just that in a survey of healthcare use by 568 patients with RA.
In a prodigious effort of patient interviews and medical record reviews conducted in 2001, the investigators cataloged the type and frequency of contacts these patients had with healthcare providers during one year.
Some findings were not surprising. Patients with RA are frequent users of healthcare, although the annual number of visits among patients in this study (mean of 4.5 visits to a primary care provider and 5.5 visits to a rheumatologist) was slightly lower than those of past studies. Eighty-six percent of patients saw a rheumatologist during the year before the survey, and 69% did so during the three months before the survey. This frequency was not likely skewed by the study’s source population or recruitment strategy, as most subjects were identified from insurance claims or laboratory databases, and only 15% were recruited from rheumatology practices.
Other findings are more interesting. More than 20% of patients had at least one appointment cancellation or no-show (to any provider, not necessarily to rheumatologists). Only about 20% had at least one visit with a physician assistant or nurse practitioner. These observations suggest opportunities to improve the efficiency of care. In contrast, 37% of patients had a visit that was classified as unscheduled, urgent, or emergent.
