WAIT TIMES TO RHEUMATOLOGY AND REHABILITATION SERVICES: IS RHEUMATOID ARTHRITIS PRIORITIZED?

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1 WAIT TIMES TO RHEUMATOLOGY AND REHABILITATION SERVICES: IS RHEUMATOID ARTHRITIS PRIORITIZED? Ashley Delaurier PT M.Sc. Candidate Biomedical Sciences University of Montreal In collaboration with Debbie Ehrmann Feldman PT PhD (University of Montreal) Sasha Bernatsky MD PhD (McGill University Health Centre) Murray Baron MD (McGill University Health Centre) Marie-Hélène Raymond OT (University of Montreal)

2 INTRODUCTION Arthritis is one of the most prevalent chronic health conditions in Canada and is the leading cause of pain and disability. Persons with arthritis should be seen by healthcare professionals early to begin appropriate treatment and improve health outcomes. Canadian Standards for Arthritis require that patients with suspected inflammatory arthritis obtain definitive diagnoses and treatment within 4 weeks of presentation to medical care. Generally, this requires rheumatology consultation. Canadian rheumatologists report that once they are aware of an urgent referral, they will see this referral within 2 weeks. However, what happens in reality is unknown.

3 INTRODUCTION Physical rehabilitation services such as Physical Therapy (PT) and Occupational Therapy (OT) are a mainstay of treatment in chronic osteoarthritis (OA) and are also beneficial in inflammatory arthritis such as rheumatoid arthritis (RA) Early PT or OT intervention may prevent deformity, decrease pain, improve function and promote participation for persons with arthritis. Previous research suggests that there are problems with access to these services in the public system.

4 CARE TRAJECTORY FOR PATIENTS WITH ARTHRITIS

5 OBJECTIVES 1. Describe wait times from referral by primary care to rheumatology consultation in the public system for persons with RA and OA; 2. Describe wait times from referral to consultation in rehabilitation services (PT or OT) in the public system for persons with RA and OA; 3. Explore factors associated with these wait times.

6 Cross-sectional study design. METHODS We contacted all publicly accessible rheumatology and rehabilitation (PT and OT) service providers in the province of Quebec. Appointments were requested by phone using case scenarios developed by a group of experts. Wait times were evaluated as the time between the initial request and the appointment date provided. We examined wait times in relation to diagnosis, service provider and geographic area using descriptive statistics, bivariate analysis, and logistic regressions.

7 SCENARIOS Rheumatology Rehabilitation Presumed RA 55 year old female with bilateral swollen and tender wrists and MCPs. Morning stiffness of 1 hour. ESR: 22, CRP: 30, RF: 68. Please R/O RA. Possible RA 55 year old female with 3 month history of severe pain and swelling of hands and feet. Unable to work secondary to the pain. NSAIDS not helping. Possible RA. Please assess and treat. Dx: RA 55 year old female diagnosed with RA suffering from severe pain and swelling of hands and feet. Morning stiffness of 1 hour. ESR: 22, CRP: 30, RF: 68. Dx: OA 55 year old female with chronic pain right knee x 5 yrs, no swelling. Dx: OA. Please assess. Presumed OA 55 year old female with pain right knee x 5 yrs, no swelling. X-Ray: early OA? Please assess.

8 RHEUMATOLOGY SAMPLE RHEUMATOLOGY SERVICES Academic Hospital 12 Community Hospital 12 Group Practice 10 Solo Practice 37 Total (n) 71

9 RHEUMATOLOGY WAIT TIMES IN QUEBEC

10 RHEUMATOLOGY RESULTS Factor OR 95% CI Type of Office (Academic vs non) ; 3.68 Region (Montreal vs other) ;10.76

11 REHABILITATION SAMPLE REHABILITATION SERVICES Academic Hospital Department 12 Community Hospital Department 74 Rehabilitation Centre 14 Total (n) 100

12 REHABILITATION WAIT TIMES IN QUEBEC

13 REHABILITATION RESULTS Reasons for refusals included: Only accepting patients referred by their institution (36%) Only accepting post-operative or trauma patients (27%) Not accepting persons with a diagnosis of RA or OA (18%) Only accepting patients 65 years old and older (9%) Not accepting new patients at time the request was made (5%) Upon refusal or when a long wait time was given, the receptionist would suggest seeking private PT or OT services. Evaluation appointments (presumably to determine urgency) were provided in 10% of departments in academic cities vs. 36% in those areas that did not have a university program in rehabilitation (p=0.006).

14 DISCUSSION Focused on one component of the wait time (from referral until consultation) yet it still suggests that many persons with newonset RA in Quebec are not receiving prompt care. Problems with access to public services for both rheumatology and rehabilitation in terms of long wait times and unavailability: 34 % of all rheumatology centres and 22 % of all rehabilitation service provider refused services. Substantial variability exists for wait times between the centres and there appears to be no consistent process for the provision of appointments.

15 DISCUSSION Possible reasons for delays include inadequate or nonexistent triage or insufficient manpower. Strategies for triage are needed to prioritize patients appropriately for services, including prevention of disability at different levels of disease. For rehabilitation services, wait times were based primarily on the patient s level of function rather than their diagnosis. 28% of services providers requested a functional screening evaluation prior to the provision of appointments.

16 LIMITATION A limitation of our study was the inability to provide the personal details required by some offices, which could have expedited the initial consultation and provided us with more accurate wait times for each scenario.

17 CONCLUSION RA is prioritized over OA when obtaining an appointment to a rheumatologist in the province of Quebec. However, the majority of persons with RA are still not receiving an appointment to a rheumatologist in a timely manner. Persons with arthritis in the province of Quebec are not receiving publicly accessible PT or OT intervention in a timely manner. Better methods for triage and increased resource allocation are needed.

18 IMPLICATIONS Important information for clinicians and decision makers regarding wait times in the public system of Quebec for person with arthritis. Increasing patient and family physician awareness regarding the importance of early access to rheumatology care is vital for persons with arthritis. The excessive wait times for rehabilitation services reflect a need for re-evaluation of the supply and demand as well as the role of therapists as first line health care providers. A focus is needed on developing strategies so that the referrals are completed and appointments are obtained in a standard and prompt fashion for both rheumatology and rehabilitation services.

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