Chapter 8: Life with arthritis in Canada: a personal and public health challenge – Ambulatory care services utilization

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

Introduction

Arthritis is a major cause of long-term disability and pain, resulting in significant demands on the health care system.^{Footnote 1 Footnote 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.^{Footnote 2 Footnote 3 Footnote 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.^{Footnote 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.^{Footnote 5 Footnote 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.^{Footnote 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.^{Footnote 4 Footnote 7 Footnote 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^{Footnote 1a *}. 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.

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).^{Footnote 11 Footnote 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.

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.

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.

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.

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%).