Assessing the Need for Improved Access to Rheumatology Care
Objective: Access to rheumatology care can expedite diagnosis and treatment of rheumatic diseases and reduce disparities. We surveyed community health center (CHC) medical directors to evaluate rheumatology care in underserved areas and potential strategies for improvement.
Methods: We identified 77 Massachusetts CHCs that provide adult medical services and sent a 40-item survey to their physician medical directors. Survey questions assessed the centers' prevalence of rheumatic diseases, prescribing practices of immunosuppressive medications, and possible interventions to improve care. We compared CHC characteristics and rheumatology-specific items and then stratified our data by the response to whether improved access to rheumatology care was needed. Qualitative data were analyzed thematically.
Results: Thirty-six CHC physician medical directors returned surveys (47% response rate). Fifty-five percent indicated a need for better access to rheumatology care. Eighty-six percent of CHC physicians would not start a patient with rheumatoid arthritis on a disease-modifying antirheumatic drug; 94% would not start a patient with systemic lupus erythematosus on an immunosuppressant. When we compared CHCs that reported needing better access to rheumatology care to those that did not, the former described a significantly greater percentage of patients with private insurance or Medicaid who required outside rheumatology referrals (P < 0.05). Language differences and insurance status were highlighted as barriers to obtaining rheumatology care. Sixteen directors (57%) ranked the patient navigator—a layperson to assist with care coordination—as their first-choice intervention.
Conclusions: Community health center medical directors expressed a need for better access to rheumatology services. A patient navigator for rheumatic diseases was proposed to help improve care and reduce health disparities.
Early access to disease-modifying antirheumatic drugs (DMARDs) can dramatically change the course of rheumatoid arthritis (RA). Similarly, consistent monitoring and appropriate use of immunosuppressants for systemic lupus erythematosus (SLE) can reduce morbidities including end-stage renal disease and premature coronary artery disease. Among patients with RA, access to rheumatologists is associated with reduced racial disparities in DMARD use and overall improved quality of care and outcomes. Systemic lupus erythematosus patients in lower socioeconomic status groups are less likely to identify a rheumatologist as their primary SLE provider and travel significantly further for their care. In addition, SLE patients cared for by nonrheumatologists are rarely prescribed hydroxychloroquine, a medication central to disease control. Differences in access to subspecialty care may contribute to the known disparities in SLE morbidity and mortality by income, sex, race, and ethnicity.
We investigated current access to rheumatology subspecialty care for underserved patients with RA and SLE across community health centers (CHCs) in Massachusetts. More than 1100 federally qualified CHCs operate 8100 delivery sites in medically underserved areas in the United States treating nearly 20 million patients each year. In 2011, Massachusetts' federally qualified CHCs provided care to more than 600,000 residents; 66% were at or below 100% of poverty level, 21% were uninsured, 42% were Medicaid beneficiaries, and 9% were enrolled in Medicare. The US Patient Protection and Affordable Care Act of 2010 established the Community Health Center Fund that provides $11 billion over 5 years to CHCs nationwide. A central priority is the development and implementation of innovative, high-value patient care delivery systems such as the patient-centered medical home model, at CHCs to reduce health care disparities. Massachusetts has been a leader in health care reform and in the promotion of the patient-centered medical home to provide coordinated, team-based care. However, the relationship between this model and subspecialty care has yet to be systematically defined. Therefore, a better understanding of the need for access to rheumatology services at CHCs in Massachusetts will aid in the design of innovative strategies to improve health care delivery under the Affordable Care Act.
To conduct a rheumatology care needs assessment, we partnered with a community-based organization in Massachusetts, the Center for Community Health Education Research and Service, Inc. We surveyed physician medical directors of CHCs to better understand barriers to subspecialty care in medically underserved areas. We also inquired about potential community-based interventions that have been implemented for other chronic diseases including a patient navigator (a layperson from the community who provides education and advocacy to help guide a patient through the health care system), telemedicine (with phone or Internet-based contact between primary care providers and subspecialists), and a health "passport" (a booklet of personalized health information and educational material carried by the patient), to improve care for RA and SLE patients. We hypothesized that there would be a significant need for better access to rheumatologists for these medically complex patients and that CHC medical directors would be appropriately positioned to address this important and timely issue.
Abstract and Introduction
Abstract
Objective: Access to rheumatology care can expedite diagnosis and treatment of rheumatic diseases and reduce disparities. We surveyed community health center (CHC) medical directors to evaluate rheumatology care in underserved areas and potential strategies for improvement.
Methods: We identified 77 Massachusetts CHCs that provide adult medical services and sent a 40-item survey to their physician medical directors. Survey questions assessed the centers' prevalence of rheumatic diseases, prescribing practices of immunosuppressive medications, and possible interventions to improve care. We compared CHC characteristics and rheumatology-specific items and then stratified our data by the response to whether improved access to rheumatology care was needed. Qualitative data were analyzed thematically.
Results: Thirty-six CHC physician medical directors returned surveys (47% response rate). Fifty-five percent indicated a need for better access to rheumatology care. Eighty-six percent of CHC physicians would not start a patient with rheumatoid arthritis on a disease-modifying antirheumatic drug; 94% would not start a patient with systemic lupus erythematosus on an immunosuppressant. When we compared CHCs that reported needing better access to rheumatology care to those that did not, the former described a significantly greater percentage of patients with private insurance or Medicaid who required outside rheumatology referrals (P < 0.05). Language differences and insurance status were highlighted as barriers to obtaining rheumatology care. Sixteen directors (57%) ranked the patient navigator—a layperson to assist with care coordination—as their first-choice intervention.
Conclusions: Community health center medical directors expressed a need for better access to rheumatology services. A patient navigator for rheumatic diseases was proposed to help improve care and reduce health disparities.
Introduction
Early access to disease-modifying antirheumatic drugs (DMARDs) can dramatically change the course of rheumatoid arthritis (RA). Similarly, consistent monitoring and appropriate use of immunosuppressants for systemic lupus erythematosus (SLE) can reduce morbidities including end-stage renal disease and premature coronary artery disease. Among patients with RA, access to rheumatologists is associated with reduced racial disparities in DMARD use and overall improved quality of care and outcomes. Systemic lupus erythematosus patients in lower socioeconomic status groups are less likely to identify a rheumatologist as their primary SLE provider and travel significantly further for their care. In addition, SLE patients cared for by nonrheumatologists are rarely prescribed hydroxychloroquine, a medication central to disease control. Differences in access to subspecialty care may contribute to the known disparities in SLE morbidity and mortality by income, sex, race, and ethnicity.
We investigated current access to rheumatology subspecialty care for underserved patients with RA and SLE across community health centers (CHCs) in Massachusetts. More than 1100 federally qualified CHCs operate 8100 delivery sites in medically underserved areas in the United States treating nearly 20 million patients each year. In 2011, Massachusetts' federally qualified CHCs provided care to more than 600,000 residents; 66% were at or below 100% of poverty level, 21% were uninsured, 42% were Medicaid beneficiaries, and 9% were enrolled in Medicare. The US Patient Protection and Affordable Care Act of 2010 established the Community Health Center Fund that provides $11 billion over 5 years to CHCs nationwide. A central priority is the development and implementation of innovative, high-value patient care delivery systems such as the patient-centered medical home model, at CHCs to reduce health care disparities. Massachusetts has been a leader in health care reform and in the promotion of the patient-centered medical home to provide coordinated, team-based care. However, the relationship between this model and subspecialty care has yet to be systematically defined. Therefore, a better understanding of the need for access to rheumatology services at CHCs in Massachusetts will aid in the design of innovative strategies to improve health care delivery under the Affordable Care Act.
To conduct a rheumatology care needs assessment, we partnered with a community-based organization in Massachusetts, the Center for Community Health Education Research and Service, Inc. We surveyed physician medical directors of CHCs to better understand barriers to subspecialty care in medically underserved areas. We also inquired about potential community-based interventions that have been implemented for other chronic diseases including a patient navigator (a layperson from the community who provides education and advocacy to help guide a patient through the health care system), telemedicine (with phone or Internet-based contact between primary care providers and subspecialists), and a health "passport" (a booklet of personalized health information and educational material carried by the patient), to improve care for RA and SLE patients. We hypothesized that there would be a significant need for better access to rheumatologists for these medically complex patients and that CHC medical directors would be appropriately positioned to address this important and timely issue.