At the Thursday Plenary session at the 2015 CRA Meeting, Dr. Diane Lacaille very elegantly presented her research which evaluated the persistence of rheumatologist care over time and its impact on DMARD use in a population-based incident cohort of RA patients.
This was a retrospective cohort study using administrative data. They looked at 9224 RA patients followed by rheumatologists in BC between January 1997 and March 2006 and followed until December 2010. Cases were selected if they had at least two rheumatologist visits with diagnostic code (714) for RA. Rheumatologist care was defined as having at least one rheumatologist visit per year and DMARD use was defined as having one DMARD prescription in the past year.
What they found was that people frequently stopped seeing a rheumatologist over time. By year 3, 24% had stopped seeing a rheumatologist. This increased to 32% in year 4 and 50% in year 6 and continued to increase over time.
They then looked at the impact of seeing a rheumatologist on the use of DMARDs and found that 91% of patients who saw a rheumatologist at least yearly in the prior 5 years were on a DMARD at year 6. By contrast, only 23% of patients who did not see a rheumatologist in the prior 5 years were on a DMARD at year 6. Over all years of follow-up, those who stopped seeing a rheumatologist had decreasing yearly rates of DMARD use while off rheumatologist care, and those who subsequently returned to rheumatologist care had a gradual increase after resuming rheumatologist care.
This data is very important for a number of reasons. We need to explore the reasons why people stop seeing a rheumatologist and subsequently stop taking their DMARDs. Is it due to manpower issues? Fear of medications? Suboptimal communication between the health care provider and the patient? Moving forward, we need to evaluate if patients who stop taking their DMARDs and are no longer followed by a rheumatologist have different outcomes and more disability.
Janet Pope's Comment - Patients with RA (the most common non-crystal inflammatory arthritis) are not treated appropriately if they do not continue to have clinical encounters with their rheumatologist (this may be the most important justification for the specialty of rheumatology). There is also a need for rheumatologists to determine who is lost to follow up and encourage these patients to return. There may also be other co-sharing models of care that promote adherence in this chronic disease, which usually requires lifelong DMARD treatment.
Dr. Jamal is a Clinical Associate Professor at the University of British Columbia and an active staff physician at Vancouver Coastal Health. Her interests include diagnosis and prognosis of early inflammatory arthritis, and timely assessment and access to care for patients with rheumatoid arthritis.View Full Bio