Health administrative data can be a valuable tool for disease surveillance and research. Few studies have rigorously evaluated the accuracy of administrative databases for identifying rheumatoid arthritis (RA) patients. Our aim was to validate administrative data algorithms to identify RA patients in Ontario, Canada.
We performed a retrospective review of a random sample of 450 patients from 18 rheumatology clinics. Using rheumatologist-reported diagnosis as the reference standard, we tested and validated different combinations of physician billing, hospitalization, and pharmacy data.
One hundred forty-nine rheumatology patients were classified as having RA and 301 were classified as not having RA based on our reference standard definition (study RA prevalence 33%). Overall, algorithms that included physician billings had excellent sensitivity (range 94-100%). Specificity and positive predictive value (PPV) were modest to excellent and increased when algorithms included multiple physician claims or specialist claims. The addition of RA medications did not significantly improve algorithm performance. The algorithm of "(1 hospitalization RA code ever) OR (3 physician RA diagnosis codes [claims] with =1 by a specialist in a 2-year period)" had a sensitivity of 97%, specificity of 85%, PPV of 76%, and negative predictive value of 98%. Most RA patients (84%) had an RA diagnosis code present in the administrative data within ±1 year of a rheumatologist's documented diagnosis date.
We demonstrated that administrative data can be used to identify RA patients with a high degree of accuracy. RA diagnosis date and disease duration are fairly well estimated from administrative data in jurisdictions of universal health care insurance.
To examine patterns of ambulatory physician visits for musculoskeletal disorders (MSD) in Canada.
Physician claims data from 7 provinces were analyzed for ambulatory visits made by adults age >or= 15 years to primary care physicians and specialists (all medical specialists, rheumatologists, internists, all surgical specialists, orthopedic surgeons) for MSD (arthritis and related conditions, bone disorders, back disorders, ill defined symptoms) during fiscal year 1998-99. Person-visit rates and total and mean number of visits to all physicians for MSD were calculated by condition group. The percentages of patients with MSD seeing physicians of different specialties were also calculated. Provincial data were combined to calculate national estimates.
Over 15.5 million physician visits were made for MSD during 1998-99. About 24% of Canadians made at least one physician visit for MSD: 16% for arthritis and related conditions, 2% for bone disorders, 7% for back disorders, and 6% for ill defined symptoms. Person-visit rates for MSD varied by province, were highest among older Canadians, and were greater for women than men. Primary care physicians were commonly seen, particularly for back disorders. Consultation with surgical and medical specialists was less common and varied by province and by condition.
MSD place a significant burden on Canada's ambulatory healthcare system. As the population ages, there will be an escalating demand for care. Careful planning will be required to ensure that those affected have access to the care they require. A limitation in using administrative data to examine health service utilization is that MSD diagnostic codes require validation.
To survey the practice pattern of Canadian rheumatologists (CR) on their management of corticosteroid induced osteoporosis in their premenopausal (PrM) and postmenopausal (PoM) female patients.
The practice pattern was surveyed using a 17 item questionnaire probing the diagnosis, prevention, treatment, and monitoring of osteoporosis in PrM and PoM women receiving longterm oral systemic corticosteroid therapy.
Most CR investigated and treated osteoporosis themselves, 13% referred to other specialists for investigation, and 22% referred for treatment. Eighty-two percent of CR used dual energy x-ray absorptiometry (DEXA) to confirm a diagnosis of osteoporosis. Most CR initiated investigation for osteoporosis at the start or within the first year of starting longterm systemic corticosteroid therapy: PrM 87% and PoM 93%. The most frequently used initial strategy for the prevention of osteoporosis was as follows. PrM: calcium and vitamin D3 (53%); PoM: hormone replacement therapy (HRT) and calcium (29%). The most common initial choice for treatment of established osteoporosis was as follows: PrM: etidronate (53%); PoM: bisphosphonates +/- HRT (53%). Ninety-six percent of CR used only bone mineral density (BMD) measurement to monitor therapy for corticosteroid induced osteoporosis. Most CR monitored BMD every 12 to 24 months for PrM (81%) and PoM (84%). The BMD parameter(s) (T and Z scores as measured by DEXA) used to initiate therapy for corticosteroid induced osteoporosis was variable.
It appears that, while certain trends are evident, there is still considerable variability in the management of corticosteroid induced osteoporosis.
To describe comorbidity in women with FM, and to examine the effects of different types of comorbidity on physician use.
Women (n = 180) with primary FM were evaluated at baseline and 6 months later for self-reported health resource use and covariates. Reported comorbidity was classified into 4 categories: medical, psychiatric, "functional", and unknown. The category for "functional" conditions included disorders that have been classified by previous authors as medically unexplained symptoms such as the irritable bowel and chronic fatigue syndromes. Logistic regression models were developed to examine associations between types of comorbidity and physician use.
Comorbid conditions were reported by over 90% of the sample. Total number of comorbid complaints was associated with high number of physician visits. In logistic regression models (controlling for age, ethnicity, education, disability, pain, and psychological vulnerability) medical comorbidity was a much stronger determinant of high number of physician visits than was "functional" comorbidity.
Comorbidity with other disorders, both functional and medical, was high in this sample. Medical and psychiatric comorbidity were stronger determinants of high physician use than "functional" comorbidity.
Care in rheumatoid arthritis (RA) is optimized by involvement of rheumatologists. We wished to determine whether patients suspected of having new-onset RA in Québec consulted with a rheumatologist, to document any delay in these consultations, and to determine factors associated with prompt consultation.
Physician reimbursement administrative data were obtained for all adults in Québec. Suspected new-onset cases of RA in the year 2000 were defined operationally as a physician visit for RA (based on the International Classification of Diseases, Ninth Revision diagnostic codes), where there had been no prior visit code to any physician for RA in the preceding 3 years. For those patients who were first diagnosed by a nonrheumatologist, Cox regression modeling was used to identify patient and physician characteristics associated with time to consultation with a rheumatologist.
Of the 10,001 persons coded as incident RA by a nonrheumatologist, only 27.3% consulted a rheumatologist within the next 2.5-3.5 years. Of those who consulted, the median time from initial visit to a physician for RA to consultation with a rheumatologist was 79 days. The strongest predictors of shorter time to consultation were female sex, younger age, being in a higher socioeconomic class, and having greater comorbidity.
Our data suggest that the vast majority of patients suspected of having new-onset RA do not receive rheumatology care. Further action should focus on this issue so that outcomes in RA may be optimized.
Optimal care in RA includes early use of DMARDs to prevent joint damage and hopefully decrease the need for costly surgical interventions. Our objective was to determine whether a reduced rate of orthopaedic surgery was evident for persons with RA who saw a rheumatologist early in the disease course.
We studied persons who had a diagnosis of RA based on billing code data in the province of Quebec in 1995, and for whom the initial date of RA diagnosis by a non-rheumatologist could be established before the confirmatory diagnosis by the rheumatologist. We followed these patients until 2007. Patients were classified as early consulters or late consulters depending on whether they were seen by a rheumatologist within or beyond 3 months of being diagnosed with RA by their referring physician. The outcome, orthopaedic surgery, was defined using International Classification of Diseases (ICD) procedure codes ICD9 and ICD10. Multivariate Cox regression with time-dependent covariates estimated the effect of early consultation on the time to orthopaedic surgery.
Our cohort consisted of 1051 persons; mean age at diagnosis was 55.7 years, 68.2% were female and 50.7% were early consulters. Among all patients, 20.5% (215) had an orthopaedic surgery during the observation interval. Early consulters were less likely to undergo orthopaedic surgery during the 12-year follow-up period (adjusted hazard ratio 0.60, 95% CI 0.44, 0.82).
Persons with RA who consult a rheumatologist later in the disease course have a worse outcome in terms of eventual requirement for orthopaedic surgery.
To describe practice patterns for care of Canadian patients with moderate to severe plaque psoriasis.
Online survey of a consumer panel.
Participants were drawn from a population-wide Canadian consumer database.
To be eligible to participate, respondents had to have been diagnosed with plaque psoriasis within the past 5 years, and to have had body surface area involvement of 3% or greater in the past 5 years, or to have psoriasis on a sensitive area of the body (hands, feet, scalp, face, or genitals), or to be currently receiving treatment with systemic agents or phototherapy for psoriasis.
Proportion of respondents with psoriasis managed by FPs and other specialists, psoriasis therapies, comorbidities, and patient satisfaction.
Invitations were sent to 3845 panelists with self-reported psoriasis, of which 514 qualified to complete the survey. Family physicians were reported to be the primary providers for diagnosis and ongoing care of psoriasis in all provinces except Quebec. Overall physician care was reported to be satisfactory by 62% of respondents. Most respondents receiving over-the-counter therapies (55%) or prescribed topical therapies (61%) reported that their psoriasis was managed by FPs. Respondents receiving prescription oral or injectable medications or phototherapy were mainly managed by dermatologists (42%, 74%, and 71% of respondents, respectively). Ongoing management of respondents with body surface area involvement of 10% or greater was mainly split between dermatologists (47%) and FPs (45%), compared with rheumatologists (4%) or other health care professionals (4%). Of those respondents receiving medications for concomitant health conditions, treatment for high blood pressure was most common (92%), followed by treatment for heart disease (75%) and elevated cholesterol and lipid levels (68%).
Patient-reported practice patterns for the diagnosis and management of moderate to severe psoriasis vary among provinces and in primary and secondary care settings.
Cites: Am J Clin Dermatol. 2003;4(12):833-4214640776
Cites: Int J Dermatol. 2010 Dec;49(12):1368-7521155084
The introduction of biological drugs involved a fundamental change in the treatment of rheumatoid arthritis (RA). The extent to which biological drugs are prescribed to RA patients in different regions in Sweden varies greatly. Previous research has indicated that differences in health care practice at the regional level might obscure differences at the individual level. The objective of this study is to explore what influences individual rheumatologists' decisions when prescribing biological drugs.
Semi-structured interviews, utilizing closed- and open-ended questions, were conducted with senior rheumatologists, selected through a mix of random and purposive sampling. The interview questions consisted of two parts, with a "parallel mixed method" approach. In the first and main part, open-ended exploratory questions were posed about factors influencing prescription. In the second part, the rheumatologists were asked to rate predefined factors that might influence their prescription decisions. The Consolidated Framework for Implementation Research (CFIR) was used as a conceptual framework for data collection and analysis.
Twenty-six rheumatologists were interviewed. A constellation of various factors and their interaction influenced rheumatologists' prescribing decisions, including the individual rheumatologist's experiences and perceptions of the evidence, the structure of the department including responsibility for costs, peer pressure, political and administrative influences, and participation in clinical trials. The patient as an actor emerged as an important factor. Hence, factors both at organizational and individual levels influenced the prescribing of biological drugs. The factors should not be seen as individual influences but were described as influencing prescription in an interactive, nonlinear way.
Potential factors explaining differences in prescription practice are experience and perception of the evidence on the individual level and the structure of the department and participation in clinical trials on the organizational level. The influence of patient attitudes and preferences and interpretation of scientific evidence seemed to be somewhat contradictory in the qualitative responses as compared to the quantitative rating, and this needs further exploration. An implication of the present study is that in addition to scientific knowledge, attempts to influence prescription behavior need to be multifactorial and account for interactions of factors between different actors.
To analyze a prospectively maintained pediatric rheumatology clinic disease registry.
A total of 3269 consecutive referrals to the Pediatric Rheumatology Clinic, University of Saskatchewan, during the period 1981-2004 were analyzed.
Among 3269 patients, a diagnosis was established in 2098 (64.2%). Within this group, 72 subjects (3.4%) were determined to be healthy. Of the remaining 2026 diagnosed patients (62.0% of the total population), 1032 (50.9%) had a rheumatic disease and 994 (49.1%) a nonrheumatic disease. A diagnosis was not established in 1171 patients (35.8%). Among the 1032 patients with a rheumatic disease, 326 (31.6%) had juvenile rheumatoid arthritis (JRA), 360 (34.9%) a spondyloarthropathy (SpA), and 225 (21.8%) a collagen vascular/connective tissue rheumatic disease. The remaining 121 patients with a rheumatic disease (11.7%) had a variety of other conditions. Of the 994 nonrheumatic disease patients, 37 (3.7%) with ocular inflammatory conditions had been referred to exclude an associated rheumatic disease. The remaining group of 957 patients comprised 345 (36.1%) with an orthopedic, mechanical or traumatic condition, 231 (24.1%) had an infection, 45 (4.7%) a hematologic or neoplastic disease, and 336 (35.1%) a variety of other conditions. Current clinic point prevalences for JRA, SpA, and collagen vascular diseases are 35.0, 16.9 and 17.7/100,000, respectively. The mean annual clinic referral incidences of JRA, SpA, and collagen vascular/connective tissue diseases were, respectively, 4.7, 5.2, and 1.7/100,000 children.
Disease registries help establish the frequencies and spectrum of childhood rheumatic diseases and the role of pediatric rheumatology programs in evaluating and caring for children with a wide variety of conditions. Longitudinal disease registries aid in characterizing clinical, epidemiologic, and demographic features of childhood rheumatic diseases.
To determine what health area characteristics, in particular local availability of specialists, were associated with the age-sex adjusted ambulatory utilization rate of musculoskeletal (MSK) specialists (i.e., rheumatologists, orthopaedic surgeons and general internists) in an arthritis and rheumatism (A&R) cohort.
The cohort was composed of respondents aged 15+ from the 1996/97 Ontario Health Survey who self-reported A&R and/or had a primary care encounter for A&R during the two years preceding the survey, as determined by their billings in the Ontario Health Insurance Plan. Respondents with prior exposure to MSK specialists were excluded. The outcome of an encounter with a MSK specialist for A&R was determined during the three-year period after the survey.
The A&R cohort was composed of 5,052 respondents, of whom 11% had an A&R encounter with a MSK specialist in the three-year post-survey period. There was area variation in the age-sex adjusted ambulatory utilization rate of MSK specialists in the A&R cohort. The backwards stepping linear regression to examine predictors for seeing MSK specialists found a positive association with local availability of rheumatologists, a negative association with the proportion of high school graduates in the health area and a negative association with the proportion of people aged 65 years and older.
At the health area level, we found that the local availability of rheumatologists was an important factor associated with utilizing MSK specialists for A&R-related conditions in a cohort of respondents who have not been previously exposed to MSK specialists for musculoskeletal-related conditions.