Stressed Healthcare Systems: The Impact on the Care of Patients With Rheumatic Diseases

Healthcare systems worldwide face various challenges, including disparities in infrastructure, shortages in healthcare professionals, and inadequate funding.^1,2 These challenges lead to issues such as suboptimal treatment, limited access to essential services, and difficulties in responding to health crises like the coronavirus disease 2019 (COVID-19) pandemic.¹ To address these challenges, countries should consider strengthening medical education programs to produce competent professionals, improving healthcare infrastructure, enhancing funding mechanisms, and using technologies such as big data and artificial intelligence for better monitoring and management of healthcare services.¹

Medical education in general is a crucial aspect in the care of patients with rheumatic diseases (RDs). It is particularly crucial in rheumatology because there continue to be deficiencies worldwide in the knowledge of adult and pediatric rheumatic and musculoskeletal diseases among medical school graduates and primary care physicians.³

Previous studies have suggested that primary care physicians do not feel comfortable diagnosing and managing RDs, with only one-third of providers reporting being very confident in comanaging patients with rheumatoid arthritis (RA), despite the majority of providers treating these patients.⁴ Internal medicine residents report lower self-confidence in rheumatology skills compared to other subspecialties, suggesting the target timing for intervention to increase providers’ confidence levels in rheumatology should be during general residency training.^5,6 Studies highlight the importance of interventions to enhance rheumatology knowledge and skills among internal medicine residents, emphasizing topics like autoimmune serologies and musculoskeletal exams.^5,6

The shortage of rheumatologists is a pressing issue globally, exacerbated by factors such as an aging population, increased demand for services, and workforce demographics. Studies from the US, Europe, and Mexico highlight the projected deficits in the rheumatology workforce due to factors like retirement, part-time work trends, and geographic maldistribution of providers.^7-11

In Latin America, a previous study reported 1 rheumatologist per 106,838 inhabitants on average. The region’s workforce characteristics vary significantly, with the highest rate of rheumatologists per inhabitants in Uruguay (1 per 27,426) and the lowest in Nicaragua (1 per 640,648). Despite the high demand for specialized rheumatology care, the workforce in Latin America faces challenges such as low income levels and disparities in availability, highlighting the need for policies to enhance the rheumatology workforce and improve patient care quality.¹²

In Canada, a survey was conducted in 2020-2021 to update the Canadian rheumatology workforce characteristics, showing the number of full-time equivalent rheumatologists per 75,000 population to be 0.62 nationally and ranging between 0.00 and 0.70 in different provinces/territories.¹¹ Notable efforts have been made in Canada to attract future trainees in rheumatology programs.^7,13

With this shortage of trained physicians in rheumatology, it is not surprising that there are prolonged wait times for specialist appointments for patients with RDs, and they often need to attend other specialties or emergency departments (EDs) when they have an acute medical problem.

In this issue of The Journal of Rheumatology, the article, “Deciding to Attend the Emergency Department: Experiences of Patients With Inflammatory Arthritis,” by Pianarosa et al¹⁴ reports the results of an online survey distributed to Alberta residents in Canada with known inflammatory arthritis conditions who had visited the ED within the previous year. An embedded mixed-methods approach was used to contextualize quantitative data with free-text responses. The study highlights that existing rheumatology ambulatory care models often fail to meet urgent clinical needs, leading to increased ED visits by patients with inflammatory arthritis. Patients reported challenges in accessing timely ambulatory care, resulting in reliance on ED services for urgent concerns. Eighty-two patients with RA (48%), psoriatic arthritis (12%), spondyloarthritis (6%), or gout (34%) participated. The main concerns for attending the ED were arthritis flare (37%), chest pain (15%), injury (12%), and infection (11%). Twenty-nine percent of patients went directly to the ED, 35% attempted ambulatory care first, and 32% were return visits. For arthritis flares, only 9% of patients were aware that the ED provider contacted the rheumatology service for advice. The quality of patient-provider communication and their relationality significantly affect patient experiences in the ED. The authors concluded that improving coordination within the healthcare system and ensuring timely access to rheumatology care can potentially alleviate the burden on ED services.

In this study,¹⁴ conclusions were drawn from a survey that was sent to 6000 people and answered only by 82 patients (response rate of 1.4%). Despite this, the authors mentioned that qualitative research design yields more profound insights and more substantial content compared to other types of studies, and the patterns elucidated in the paper can serve as a valuable guide for informed action. Specific data on the management of EDs in Canada cannot be extrapolated to other healthcare systems, but it is easy to imagine that in any country, patients who visit an ED for rheumatological reasons specifically do not find the appropriate solutions to their problems.

Working on patient education and adherence is one approach to improving rheumatology care in general and reducing unnecessary ED visits. For example, it was shown in another Canadian study that patients with RA with higher continuity of rheumatology care had lower rates of ED visits and hospitalizations compared to those who did not receive continuous rheumatology care during the first 5 years of follow-up.¹⁵

Educating patients with RDs is crucial for empowering them to manage unexpected disease flares effectively. Understanding their condition helps patients identify the early signs of a flare. This awareness can lead to timely interventions, potentially lessening the severity of symptoms and, in many cases, managing the situation effectively without the need to visit an ED.

Modern strategies for patient education in rheumatology leverage digital tools and personalized approaches to enhance patient engagement and self-management. E-learning programs, such as those evaluated in the WebRA study, have demonstrated effectiveness in improving self-efficacy and disease management among patients with RA by providing accessible home-based education, which can be more convenient than traditional face-to-face sessions.¹⁶ Additionally, the implementation of the European Alliance of Associations for Rheumatology recommendations emphasize the importance of providing tailored education, incorporating patient feedback, and using group education sessions to address individual patient needs and improve the applicability of educational interventions.¹⁷

Improving the management of patients with RDs hinges on a multifaceted approach. Unfortunately, disparities in healthcare systems significantly affect the care of patients. Addressing these issues requires systemic changes in healthcare policy, increased awareness and education among healthcare providers, and targeted interventions to ensure equitable access to high-quality care for all patients. As doctors responsible for patients with RDs, perhaps the most effective things we can do within our reach are to emphasize building a strong doctor-patient relationship, facilitate communication between patients and their healthcare providers, and educate patients about how to handle common symptoms that may occur.

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