Implementation of the Appointments by Choice Model for Rheumatoid Arthritis: A Patient-Initiated Follow-Up Pilot Study

Objectives This study aimed to understand the barriers and facilitators to implementing the “Appointments By Choice” (ABC) patient-initiated follow-up model of care in rheumatoid arthritis (RA).[1] Objectives were to evaluate preliminary data on reach, adoption, and implementation of ABC.

Methods The 1-arm non-randomized ABC implementation pilot study began in January 2024 at a multipractice rheumatology clinic in Alberta. People with (1) established RA, (2) well-controlled disease, (3) no major medication changes, and (4) no other active complex conditions were invited to participate in ABC1. Primary implementation outcomes, informed by the RE-AIM framework,[2] included reach, adoption, and implementation. Secondary outcomes were safety and effectiveness. Quantitative data from surveys and chart reviews were summarized using descriptive statistics. Qualitative data from weekly meetings and interviews were analyzed using thematic analysis, with mapping to CFIR,[3] domains within each RE-AIM category (Table 1).

Results Reach: Over 18 months, 76/140 (54.3%) of eligible individuals consented to participate in ABC. The most common reason for declining was a “preference for usual care” (14/64, 21.9%). Participant altruistic motivation to free-up physician time for those in-need was a facilitator, whereas lack of physician time to discuss ABC was a barrier. Adoption: 5/7 rheumatologists approached participated in ABC, representing over 1/3 of the clinic. The phased rollout of ABC and tension for change were adoption facilitators. Meanwhile, limited early leadership support was a barrier. Implementation: Facilitators included adapting recruitment workflows to rheumatologist preferences, improved integration of ABC processes in the EMR, and clear contact lists for clinical and research teams. Barriers included limited ABC understanding among clinic staff, incomplete transfer of care communication, and participant confusion about ABC due to inconsistent information provided at baseline. Safety/Effectiveness: 68/76 (89.5%) ABC participants remained on ABC, with 2 withdrawing and 6 returning to usual care due to flares, infection and medication change. 31 participants contacted the flare clinic (0.4 calls/week) for support with flares, lab tests, imaging results, and other minor concerns. Overall, 1,520 minutes of rheumatologist time was saved due to reduced appointment frequency, equivalent to 38 new patient consults. Safety and effectiveness facilitators included limited flares and positive participant experiences with flare clinic support. Barriers were mixed rheumatologist perspectives on the value of ABC and limited usefulness of the self-report flare questionnaire.

Conclusion Early insights show promise of ABC for improving the efficiency and patient-centeredness in rheumatology care. For expanded implementation, adaptations are required to address barriers faced during our pilot study.

References [1.] Ester M. BMC Rheumatol 2025;9:31. [2.] Glasgow RE. Front Public Health 2019;7:64. [3.] Damschroder LJ. Implement Sci 2022;17:75. Supported by a CIORA grant