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Associations With Rheumatology Subspecialty Care

Michael M. Ward, MD, MPH; J. Paul Leigh, PhD; James F. Fries, MD

Arch Intern Med. 1993;153(19):2229-2237.

Abstract
Background
To determine whether patients with rheumatoid arthritis and their physicians make appropriate decisions regarding referral to rheumatologists and the need for continuing rheumatology care, we examined the relationship between the progression of functional disability in these patients and their use of rheumatology subspecialty care over time.

Methods
A cohort of 282 patients with rheumatoid arthritis was followed prospectively for up to 10 years. Participants were categorized into three subgroups based on the pattern of care received from rheumatologists over the study period: patients who were never treated by a rheumatologist; patients treated by a rheumatologist only intermittently; and patients treated by a rheumatologist at least once during each 6-month study period. The outcome was the rate of progression of functional disability, measured using the Health Assessment Questionnaire Disability Index.

Results
Among the 52 patients who had not been referred to a rheumatologist, 30 (58%) had rates of progression of functional disability that were stable or improving over time (rate <0.01 Disability Index units per year), while 22 (42%) had rates that were worsening (rate 0.01 Disability Index units per year). Among patients treated by rheumatologists, the average rate of progression was substantially lower among the 69 patients who were treated regularly by a rheumatologist than among 161 patients treated by rheumatologists intermittently (0.008 Disability Index units per year vs 0.020 Disability Index units per year). This difference was associated with more intensive use of second-line antirheumatic medications, and more frequent joint surgeries, among patients treated by rheumatologists on a regular basis.

Conclusions
Most patients with rheumatoid arthritis in this community cohort were treated by a rheumatologist, but 42% of those not referred had progressively increasing functional disability. Among patients treated by rheumatologists, those who had continuing care from rheumatologists experienced lower rates of progression of functional disability than those who had only intermittent care. These results suggest that use of rheumatology subspecialty care is associated with better health outcomes in rheumatoid arthritis.

(Arch Intern Med. 1993;153:2229-2237)

Author Affiliations
From the Department of Medicine, Palo Alto (Calif) Veterans Affairs Medical Center (Dr Ward); Division of Rheumatology and Immunology, Department of Medicine, Stanford (Calif) University School of Medicine (Drs Leigh and Fries); and Department of Economics, San Jose (Calif) State University (Dr Leigh).

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