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A study in has identified gaps in ongoing care and treatment for people with rheumatoid arthritis (RA).

Researchers assessed patients for the five years following diagnosis, ultimately including 50,883 patients with RA (26.1% aged 66 years and older). More than half (57.7%) visited a rheumatologist annually for all five years. Steep declines in the percentage of those who made annual visits occurred for each subsequent year after diagnosis. For individuals aged 66 years or older (n=13,293), 82.1% of those who visited their rheumatologist in all five years after diagnosis received a DMARD prescription annually, compared with 31.0% of those who did not. Older age, male sex, lower socioeconomic status, higher comorbidity score, and having an older rheumatologist all decreased the odds of remaining under rheumatology care.

The study's first author, Claire Barber, MD, PhD, is a rheumatologist-researcher with the University of Calgary Cumming School of Medicine. Here she discusses the study and its findings with the Reading Room. The exchange has been edited for length and clarity.

What key question was this study intended to address, and why was this an important area to evaluate?

Barber: We developed some system-level performance measures to evaluate quality of care. These measures primarily address access to care, ongoing care, and treatment. For the present study, the objective was to evaluate existing performance measures at a provincial level in Ontario, Canada.

The first measure we evaluated looked at whether individuals with RA were seen by rheumatologists at least once a year, which is a minimum standard of care. The second measure captures whether they were treated with DMARD therapies.

How would you characterize what you found?

Barber: Over half of the patients saw a rheumatologist yearly for all five years. Although there tended to be sharp declines in annual visits with each subsequent year after diagnosis, we did see a trend toward significant improvement in performance, which was somewhat encouraging.

What this signals is that if you're being seen by rheumatologists on a regular basis, you're much more likely to receive appropriate therapy over time. We also found a variety of factors that affected whether patients were retained in a rheumatologist's care: age, male sex, and economic status.

Were there any surprises in the findings?

Barber: I think probably the thing that might be surprising is that a rheumatologist's age seems to impact the odds of continuous care. We found that having an older rheumatologist actually decreased the odds of remaining under rheumatology care.

Although further study needs to be done, we hypothesized that this may be because of changes in practice that may come closer to retirement.

This could be due to older physicians transitioning to retirement and discharging more stable patients to primary care or limiting follow-up visits. It is also possible that older rheumatologists may have different practice patterns that may be less concordant with current treat-to-target guidelines, which endorse more frequent follow-up visits.

You had some interesting findings around patients and socioeconomic status. Could you say more about what you found in that area?

Barber: Canada has a universal health care system, and yet, despite this, we did see a socioeconomic gradient that affected continuous rheumatology care.

For example, going to a clinic may be costly for patients, especially once you factor in things like paying for transportation or parking. People may be unable to take time off from work. And there could be other factors related to things like health literacy that we were not able to capture in the study.

So I think it's important to think about these determinants of health because they do affect care and access to care, even in Canada.

What are the bottom-line takeaway messages for rheumatology practices?

Barber: I think rheumatologists may not be aware day-to-day of how many patients may be getting follow-up. I think this remains a significant challenge. So practices would do well to set up strategies to ensure that patients who need to be seen continue to be seen.

This may involve reviewing rosters to ensure that patients either have an annual follow-up to check in or are developing other alternative models of care.

During the pandemic, we saw an increase in virtual care. I think virtual personal care and a way of connecting with patients may help with addressing these barriers and access to care.

Clinical implications

• Gaps exist in rheumatology care for people with RA over the five years following diagnosis, with significant declines in annual visits occurring over time.
• The odds of consistently remaining under a rheumatologist's care decreased among older patients, males, those in a lower socioeconomic status, and those with more comorbidities.
• Practices can check rosters to ensure follow-up visits or explore new models of care, such as virtual visits.

Read the study here and expert commentary on the clinical implications here.