Spring 2022 (Volume 32, Number 1)

Characterization of the Rheumatologist-Extended Role Practitioner Model of Care in an Inpatient Tertiary Care Network

Lena Nguyen; Marie-Andree Brosseau, PT; Nancy Granger, MScPT, MSc; Julia Ma, MPH; Andrew Chow, MD, FRCPC; and Stephanie Tom, MD, FRCPC

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Introduction:
Models of care (MOC) have become crucial to address rheumatologist workforce shortages and increasingly complex patient needs. In Canada, leveraging the involvement of extended role practitioners (ERP) in outpatient rheumatology settings has been shown to decrease wait times.^1-2 The first Canadian rheumatologist (MD)-ERP MOC for inpatients was introduced at Trillium Health Partners (THP) in 2015. Our ERPs are physiotherapists who completed the Advanced Clinician Practitioner in Arthritis Care (ACPAC) program.

Methods:
We undertook a retrospective, cross-sectional chart review of all patients referred to the rheumatology inpatient consultation service at THP, which includes the Mississauga Hospital (MH) and Credit Valley Hospital (CVH) sites, to characterize the modern inpatient rheumatology consultation service where they were assessed by the ERPMD team from January 1, 2015 to December 31, 2019. A retrospective chart review was conducted using the hospital’s electronic medical records system and descriptive analyses performed.

Results:
A total of 2,361 patients were seen by the MD-ERP team between January 2015 and December 2019. The overall cohort had a median age of 72 and included more females (59%) than males (41%). The majority of rheumatology referrals (96%) came from wards (hospitalist, internal medicine, surgery); only a few were from intensive care or coronary care units (3%). Most consults were new patients with no prior rheumatology contact (69%). The most common reason for hospitalization was a musculoskeletal (MSK) diagnosis (30%), which included possible rheumatologic or orthopedic etiology, followed by neurologic (19%) and infectious (16%) admission diagnoses (Table 1).

The most common rheumatologic diagnoses were crystal disease (28%) followed by osteoarthritis (OA)/MSK-related pain (27%). Less common were systemic autoimmune rheumatic diseases (15%), inflammatory arthritis (14%), vasculitis (12%), and infection (4%). Of the 169 patients with concurrent diagnoses, the most common concomitant diagnoses were crystal disease and OA/MSK-related pain (50%). Nearly all rheumatology consultations required interventions (98%), which included bloodwork (69%), medication (56%), imaging (47%), and/or intraarticular injection (29%), with most requiring more than one intervention (Table 2).

Of all the consulted patients, 42% required outpatient follow-up (Table 2), particularly those with systemic autoimmune rheumatic disease (28%), inflammatory arthritis (27%), and vasculitis (20%) (Supplementary Table A).

Discussion:
With the goals of addressing unmet inpatient needs and sustainability of hospital-affiliated community practice, THP implemented the first Canadian inpatient MD-ERP MOC. Most patients had no previous contact with rheumatology and only required intervention during their hospitalization. The most common rheumatologic diagnoses were crystal disease and OA/MSK-related pain which corresponds to their prevalence in the general population.³

Although it is important to have rheumatologic management in high acuity inpatient situations (i.e. life-threatening vasculitis), the modern rheumatology service also includes OA/MSK-related pain and crystal disease management. Crystal disease was the most common rheumatologic diagnosis, an observation that aligns with studies reporting gout and pseudogout as the main causes of hospitalizations related to crystal arthropathies.^4-6 Notably, several studies draw links between deficits in pre-hospital care^7-9 and lack of urate-lowering therapy among hospitalized patients.^10-12 OA was another common reason for rheumatologic consultation likely due to comorbidity (i.e. the impact of OA on gait safety and discharge planning). Due to many rheumatologists’ practice scope being focused on inflammatory conditions to cope with human resource shortages.¹³ OA/MSK-related issues and crystal disease are typically managed by primary care providers pre-and post-admission.

Conclusion:
With the increasing burden of rheumatic diseases and too few rheumatologists, ERPs are integral to supporting inpatient rheumatology care. Our study provides a benchmark for future implementations of similar MOCs and highlights an opportunity to improve outpatient management of chronic conditions to mitigate future disease burden. More research is required to evaluate the economic impact of rheumatology consultation and inpatient MD-ERP MOC.

Acknowledgements:
Thank you to our patients, their families, and their healthcare provider teams for making this study possible and to Dr. Judith Versloot for her expertise and input on research analysis.

Declaration of Interest Statement:
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. This research was completed for quality improvement purposes to evaluate our current MOC.

Lena Nguyen
Medical student,
Faculty of Medicine
University of Toronto
Toronto, Ontario

Marie-Andree Brosseau, PT
Advanced Practice Physiotherapist,
Trillium Health Partners
Mississauga, Ontario

Nancy Granger, MScPT, MSc
Advanced Practice Physiotherapist,
Trillium Health Partners
Mississauga, Ontario

Julia Ma, MPH
Biostatistician,
Institute for Better Health
Trillium Health Partners
Mississauga, Ontario

Andrew Chow, MD, FRCPC
Rheumatologist,
Trillium Health Partners
Mississauga, Ontario
Lecturer, University of Toronto
Associate Professor, McMaster University
Hamilton, Ontario

Stephanie Tom, MD, FRCPC
Division Head, Rheumatology
Trillium Health Partners
Mississauga, Ontario
Lecturer, University of Toronto,
Toronto, Ontario

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