An advanced clinician practitioner in arthritis care can improve access to rheumatology care in community-based practice

Vandana Ahluwalia,¹ Tiffany L H Larsen,² Carol A Kennedy,³ Taucha Inrig,³ Katie Lundon<sup>4

1</sup>Division of Rheumatology, Department of Internal Medicine, William Osler Health System, Brampton, ON, Canada; ²Department of Physiotherapy, Headwaters Health Care Center, Orangeville, ON, Canada; ³Musculoskeletal Health and Outcomes Research, St. Michael’s Hospital, Toronto, ON, Canada; ⁴Office of Continuing Professional Development and the Department of Medicine, Faculty of Medicine, University of Toronto, ON, Canada

Objective: To facilitate access and improve wait times to a rheumatologist’s consultation, this study aimed to 1) determine the ability of an advanced clinician practitioner in arthritis care (ACPAC)-trained extended role practitioner (ERP) to triage patients with suspected inflammatory arthritis (IA) for priority assessment by a rheumatologist and 2) determine the impact of an ERP on access-to-care as measured by time-to-rheumatologist-assessment and time-to-treatment-decision.
Materials and methods: A community-based ACPAC-trained ERP triaged new referrals for suspected IA. Patients with suspected IA were booked to see the rheumatologist on a priority basis. Diagnostic accuracy of the ERP to correctly identify priority patients; the level of agreement between ERP and rheumatologist (Kappa coefficient and percent agreement); and the time-to-treatment-decision for confirmed cases of IA were investigated. Retrospective chart review then compared time-to-rheumatologist-assessment and time-to-treatment-decision in the solo-rheumatologist versus the ERP-triage model.
Results: One hundred twenty-one patients were triaged. The ERP designated 54 patients for priority assessment. The rheumatologist confirmed IA in 49/54 (90.7% positive predictive value [PPV]). Of the 121 patients, 67 patients were designated as nonpriority by the ERP, and none were determined to have IA by the rheumatologist (100% negative predictive value [NPV]). Excellent agreement was found between the ERP and the rheumatologist (Kappa coefficient 0.92, 95% CI: 0.84–0.99). In the ERP-triage model, time-from-referral-to-treatment-decision for patients with IA was 73.7 days (SD 40.4, range 12–183) compared with 124.6 days (SD 61.7, range 26–359) in the solo-rheumatologist model (40% reduction in time-to-treatment-decision).
Conclusion: A well-trained and experienced ERP can shorten the time-to-Rheumatologist-assessment and time-to-treatment-decision for patients with suspected IA.

Keywords: rheumatology, health services accessibility, interprofessional relations, community health services, integrated delivery systems