Dr. Roberts et al reply

To the Editor:

We thank Dr. Steiman and colleagues¹ for their interest and correspondence regarding our recent publication exploring the feasibility of physiotherapy-led rheumatology triage using a standardized triage algorithm.² The algorithm used in this study relied on the referring providers’ physical examination, laboratory results, and radiographic results, as well as patient-reported questionnaire scores. Those referrals that reached a prespecified threshold score based on this algorithm, without in-person assessment, were triaged as urgent and assessed in clinic by a rheumatologist. This differs from the face-to-face triage performed by extended role practitioners (ERPs) in several other studies that have been highlighted.^3-7 By design, the type of standardized triage algorithm or primary screening used in our study does not require advanced practice training, nor an advanced skill set, to perform.

Neither of the physiotherapists involved in this project received formal training through the Advanced Clinician Practitioner in Arthritis Care (ACPAC) training program. Regrettably, we have no ACPAC-trained ERPs in the province of Nova Scotia and note that, since the training program’s inception, there has been only 1 graduate from Atlantic Canada.⁸ The benefits of having allied health professionals (AHPs) pursue standardized competency-based education is indisputable; however, access to such training is not equitable across Canada. Such programs are delivered, at least partially, in person at large urban centers; this requires travel and a significant economic investment to participate, particularly for those living outside of the provinces where these programs are offered. Barriers to pursing such formalized training in Canada have been previously identified and include personal and geographic barriers, as well as financial and remuneration concerns.⁹

Although this project² did not require the advanced skill set of an ACPAC-trained professional, we recognize how such a trained individual could be optimally used, not only in other triage models but also in the delivery of rheumatology care on a broader scale to improve quality of care and health outcomes for people with rheumatic diseases.

Just as the Canadian Rheumatology Association explores innovative ways to promote the equitable distribution of rheumatologists across Canada, we would argue the same is needed for ERPs. Given the shortage of rheumatologists in Nova Scotia, we are acutely aware of the benefits of investing in our AHPs and we welcome innovative ideas on how we can encourage and facilitate standardized training of these individuals equitably across Canada. Until then, we believe it is important to engage with and incorporate AHPs into rheumatology practice within their existing skill set and despite the absence of formalized rheumatology training. We hope that fostering such collaborations will serve as a stepping stone toward bolstering advanced practice training in our province.

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