Life with Arthritis in Canada : A personal and public health challenge

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Chapter Eight: Ambulatory care services utilization

Table of Contents

• Introduction
• All physician visits
  • Physician visits by age, sex and type of arthritis
  • Type of physician visits
• Summary

"This journey of meds, surgeries and other treatments has been exhausting, time consuming and discouraging to say the least. However, I continue to be able to look for the positives in the situations and focus on them so that I don't spiral down into the abyss of despair. My health care team has made all the difference. Their diligent work and compassion go a long way in helping me cope with a very challenging situation."

— Person living with ankylosing spondylitis

Introduction

Arthritis is a major cause of long-term disability and pain, resulting in significant demands on the health care system.^{1 2} In Canada, arthritis care is provided mainly in ambulatory or outpatient settings. Primary care physicians play a central role in establishing early diagnosis, co-ordinating the ongoing management and monitoring of the indi- vidual's condition, and facilitating access to other services, such as consultations with specialists and rehabilitation professionals.^{2 3 4}

Best practice recommendations for the management of rheumatoid arthritis (RA), and other types of arthritis with the potential for serious consequences, stress the importance of early referral to a rheuma- tologist.⁴ A rheumatologist can ensure the definitive diagnosis, initiate early treatment and can evaluate an individual's response to treatment and review the treatment plan on an ongoing basis.^{5 6} General internists are also involved in arthritis management, especially in settings where rheumatologists are not available or in cases where they have developed expertise in arthritis care.⁴

Interventions such as joint replacement are widely recognized as cost-effective procedures for the treatment of advanced osteoarthritis (OA) and RA thus, orthopaedic surgeons are often involved when arthritis is unresponsive to first-line therapy over time.^{4 7 8}

This chapter presents ambulatory healthcare utilization through an examination of visits to both primary care physicians and relevant specialists. Physician claims data on arthritis were collected from five Canadian provinces (Alberta, Manitoba, Nova Scotia, Ontario and Quebec) for the fiscal year 2005-2006*. All individuals aged 15 years or more with at least one ambulatory encounter during the fiscal year 2005-2006 for which the physician claim contained an arthritis diagnostic code were included in the analyses.

The following categories were used for this chapter:

• Rheumatoid arthritis (RA);
• Osteoarthritis (OA);
• Other inflammatory arthritis (e.g. systemic lupus erythematosus, scleroderma, gout, psoriatic arthritis, ankylosing spondylitis);
• Other arthritis conditions (e.g. polymyalgia rheumatica, tendonitis, bursitis, synovitis, internal derangement of the knee, other unspecified arthropathies); and
• All arthritis conditions listed above combined.

A Canadian rate (excluding territories) to estimate the total number of arthritis related visits was calculated. The territories were excluded from this estimate due to differences between the territories and provinces with respect to ambulatory care services utilization.

* These provinces participated in a feasibility study on the use of administrative data for arthritis surveillance. Portions of data were made available by the Nova Scotia Department of Health and the Population Health Research Unit (PHRU), Dalhousie University as well as, the Institute for Clinical Evaluation Sciences (ICES) which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). Although this research is based on this data, the observations and opinions expressed are those of the author(s) and do not represent those of the Nova Scotia Department of Health, PHRU, ICES or the Ontario MOHLTC.

All physician visits

In 2005-2006, the total number of arthritis-related visits in Canada, excluding the territories, was estimated to be 8.5 million (Table 8-1). Approximately 14% of Canadians 15 years and older made at least one visit to a physician with a diagnosis of arthritis. On average, 2.3arthritis-related visits per person were made during 2005-2006 and more women than men consulted a physician for arthritis (women to men ratio 1.4:1).

Approximately 5% of the Canadian population made at least one physician visit with a recorded diagnosis of OA (30% of all arthritis visits). This is less than the proportion of the population who reported they had arthritis, reflecting that many people with OA do not visit their physician each year or if they did, another reason for their visit may have been recorded.

Less than one percent of Canadians (0.6%) visited a physician for RA, which is in keeping with published epidemiological estimates (0.6%–0.76% in an adult population).^{11 12} RA is a serious form of arthritis and it is likely that people will visit their physician at least once a year for this condition.

On average, 2.0 visits per person were made for OA and 3.2 visits per person were made for RA during 2005-2006 (Table 8-1). Women visited a physician 1.7 times more often than men for OA and 2.5 times more often than men for RA, which is in line with the higher prevalence of OA and RA among women.

Table 8-1: Visits to all physicians for arthritis and related conditions among adults aged 15 years and older, in Canada, excluding territories (range of results from participating provinces)*, 2005-2006

	Persons visiting per 1,000 population	Women: men	Average number of visits per person	Estimated total number of visits**
Source: Public Health Agency of Canada using provincial physician billing data (AB, MB, ON, QC, NS). * At least one visit to a physician. ** Canadian rate was calculated using data from the participating provinces, and visits for non-participating provinces were estimated by applying this rate to the respective 2005 provincial populations.
All types of arthritis conditions	136.7 (112.5 - 205.5)	1.4:1 (1.4:1 - 1.5:1)	2.3 (2.1 - 2.7)	8,548,588
Osteoarthritis	45.6 (32.1 - 53.8)	1.7:1 (1.5:1 - 1.9:1)	2.0 (1.8 - 2.3)	2,503,078
Rheumatoid arthritis	6.4 (5.2 - 7.8)	2.5:1 (2.3: 1 - 2.9:1)	3.2 (2.5 - 4.6)	564,644
Other inflammatory conditions	8.8 (5.9 - 13.6)	0.8:1 (0.7:1 - 0.9:1)	1.8 (1.7 - 2.2)	441,740
Other arthritis conditions	94.4 (57.2 - 171.8)	1.3:1 (1.3:1 - 1.5:1)	1.9 (1.6 - 2.3)	5,041,705

Table 8-1 - Text Equivalent

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Physicians visits by age, sex and type of arthritis

Overall, person-visit rates i.e., persons visiting per 1,000 of the Canadian population, for all types of arthritis and for OA increased with age (Figures 8-1 and 8-2). Rates among women were greater than among men within all age groups except the youngest age group (i.e. 15-24 years). Person-visit rates for RA increased with age, and then declined in women 75 years and older (Figure 8-3). This may in part be due to the fact that as people age, they are more likely to have co-existing chronic conditions. The physician may have recorded a condition other than arthritis on the billing form as the primary reason for the visit.

Figure 8-1 - Text Equivalent

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Figure 8-2 - Text Equivalent

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Figure 8-3 - Text Equivalent

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Type of physician visits

In 2005-2006, 80% of the individuals who visited a physician with arthritis was listed as the reason for the visit, saw a primary care physician (Figure 8-4). Approximately 19% saw a surgical specialist and fewer (14%) visited a medical specialist. Of all the surgical specialists, orthopaedic surgeons (85%) were the most commonly consulted. This highlights the important role of the primary care physician in the management of arthritis in collaboration with specialists as needed.

Figure 8-4 - Text Equivalent

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Of those who visited a physician for OA, 79% saw a primary care physician (Figure 8-5). A greater percentage of people with OA visited a surgical specialist (20.5%) compared to a medical specialist (11.5 %). Of all

While over half of individuals who visited a physician for RA visited a primary care physician (60%), a large proportion also visited a medical specialist (53%). Of all the medical specialists consulted, rheumatologists were the most commonly consulted (67%), followed by general internists (37%). Fewer individuals with RA visited a surgical specialist (7%) and of those who did, over half consulted an orthopaedic surgeon.

Figure 8-5 - Text Equivalent

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Summary

• Approximately 14% of Canadians over the age of 15 years made at least one visit to a physician in 2005-2006 for any type of arthritis - an estimated total of 8.5 million visits in Canada (excluding the territories).
• About 5% of the Canadian population 15 years and older made at least one physician visit in 2005-2006 with a recorded diagnosis of OA.
• Less than one percent visited a physician for RA (0.6%) and other inflammatory arthritis (0.9%).
• More women than men made arthritis-related visits and the rate of consultation was highest among older people of both sexes.
• Primary care physicians play a prominent role in arthritis management - 80% who visited a physician for any type of arthritis saw a primary care physician.
• Nineteen percent of individuals with at least one visit for arthritis during the year saw a surgical specialist and 14% saw a medical specialist. Of the surgical specialists, orthopaedic surgeons were the most commonly consulted (85%).
• For those with rheumatoid arthritis, many (60%) visited a primary care physician and a large portion also visited a medical specialist (53%). Rheumatologists were more commonly consulted (35%) than a general internist (19%) and few visited a surgical specialist (7%).

 

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¹ Power JD, Perruccio AV, DesMeules M, Lagace C, Badley EM. Ambulatory Physician Care for Musculoskeletal Disorders in Canada. J Rheuma- tol 2006;33:133–9.

² Hootman JM, Helmick CG, Schappert SM. Magnitude and characteristics of arthritis and other rheumatic conditions on ambulatory medical care visits, United States, 1997. Arthritis Rheum 2002;47(6):571–81.

³ van der Waal JM, Bot SD, Terwee CB, van der Windt DA, Schellevis FG, Bouter LM, et al. The incidences of and consultation rate for lower extremity complaints in general practice. Ann Rheum Dis 2006;65(6):809–15.

⁴ Power JD, Glazier RH, Boyle E, Badley EM. Primary and Specialist Care. In: Badley EM, Boyle E, Corrigan L, DeBoer D, Glazier RH, Guan J, et al (Eds), Arthritis and related conditions in Ontario. 2^nd ed. Toronto, ON: Institute for Clinical Evaluative Sciences (ICES), 2004.

⁵ American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines. Guidelines for the management of rheumatoid arthritis: 2002 Update. Arthritis Rheum 2002; 46:328–46.

⁶ Emery P, Breedveld FC, Dougados M, Kalden JR, Schiff MH, Smolen JS. Early referral recommendation for newly diagnosed rheumatoid arthritis: evidence based development of a clinical guide. Ann Rheum Dis 2002;61(4):290–7.

⁷ Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet. 2007;370(9597):1508–19.

⁸ Ward MM. Health services in rheumatology. Curr Opin in Rheumatol 2000;12(2):99–103.

⁹ Lawrence RC, Felson DT, Helmick CG, Arnold LM, Choi H, Deyo RA, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II . Arthritis Rheum 2008; 58(1):26–35.

¹⁰ Kopec JA, Mushfiqur Rahman M, Berthelot JM, Le Petit C, Aghajanian J, Sayre EC, et al. Descriptive Epidemiology of Osteoarthritis in British Columbia. J Rheumatol 2007;34:386–93.

¹¹ Helmick CG, Felson DT, Lawrence RC, Gabriel S, Hirsch R, Kwoh CK, et al. for the National Arthritis Data Workgroup. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States: Part I. Arthritis Rheum 2008;58(1): 15–25.

¹² Lacaille D, Anis AH, Guh DP, Esdaile JM. Gaps in care for rheumatoid arthritis: A population study. Arthritis Rheum 2005:53(2):241–8.

 

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