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The status of private rheumatology is known, but there is no information on the kind of patients seen. This study describes the experience over a 3-year period in a private rheumatology practice in the Autonomous Community of Madrid. We collected demographic and descriptive data. Of 706 patients seen, almost half (46%) were there for their first visit, and 12% of patients who had asked for an appointment did not attend. The majority of patients were women (72.4%) with a median age of 44.3 years old (range 3-93). The most frequent diagnoses were osteoarthritis (20.9%), osteopenia/osteoporosis (16.8%), arthralgia (13.4%) and soft tissue disorder (9.6%). The majority of the patients had private insurance with Spanish companies, such as MAPFRE, Adeslas and Asisa. At least one quarter of ancillary tests ordered in the first visit were not revised on a second visit., (Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología. All rights reserved.)

Objective: To describe the variability of the day care hospital units (DCHUs) of Rheumatology in Spain, in terms of structural resources and operating processes., Material and Methods: Multicenter descriptive study with data from a self-completed questionnaire of DCHUs self-assessment based on DCHUs quality standards of the Spanish Society of Rheumatology. Structural resources and operating processes were analyzed and stratified by hospital complexity (regional, general, major and complex). Variability was determined using the coefficient of variation (CV) of the variable with clinical relevance that presented statistically significant differences when was compared by centers., Results: A total of 89 hospitals (16 autonomous regions and Melilla) were included in the analysis. 11.2% of hospitals are regional, 22,5% general, 27%, major and 39,3% complex. A total of 92% of DCHUs were polyvalent. The number of treatments applied, the coordination between DCHUs and hospital pharmacy and the post graduate training process were the variables that showed statistically significant differences depending on the complexity of hospital. The highest rate of rheumatologic treatments was found in complex hospitals (2.97 per 1,000 population), and the lowest in general hospitals (2.01 per 1,000 population). The CV was 0.88 in major hospitals; 0.86 in regional; 0.76 in general, and 0.72 in the complex., Conclusions: there was variability in the number of treatments delivered in DCHUs, being greater in major hospitals and then in regional centers. Nonetheless, the variability in terms of structure and function does not seem due to differences in center complexity., (Copyright © 2016 Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología. All rights reserved.)

Outpatient rheumatologic treatment in Germany is managed by rheumatologists in private practice (n = 557), by authorized rheumatism outpatient centers (n = 116), by rheumatism centers according to §116b (n = 43) and by university outpatient departments. A total number of 975 rheumatologists were registered by the end of 2012 of whom approximately 830 were active in outpatient care. With this number of rheumatologists Germany is in the middle range in comparison to eight industrial nations including the USA. This number is not sufficient to provide adequate medical care and the consequences are too long waiting times for an appointment with a rheumatologist. Statistical data of the Kassenärztliche Bundesvereinigung (KBV, National Association of Statutory Health Insurance Physicians) showed 688,000 general insurance patients with rheumatoid arthritis (RA). As some 68.9 % of the population are in this insurance scheme there are some 770,000 RA patients in Germany (almost 1 % of the population). One way to improve rheumatology care in spite of the lack of rheumatologists could be special agreements with the general health insurance providers to improve cooperation and division of responsibilities between rheumatologists and general practitioners, to implement patient education, tighter control and treat to target in rheumatology care. Another way could be a new treatment level called "ambulant specialist care", with no budget for medical care and no budget for the number of patients treated and therefore the chance for rheumatologists to treat more patients and have a better income. To achieve that more young doctors receive approval as a specialist in rheumatology, more chairs of rheumatology at universities and a nationwide stipendium for training assistants are needed.

Health services research in rheumatology investigates the healthcare needs, the quality of care and trends in healthcare for patients with musculoskeletal disorders. Using rheumatoid arthritis (RA) as an example, key results of health services research during the last 25 years are summarized. There are currently approximately 540,000 persons with RA in Germany of which some two thirds are regularly seen by rheumatologists. The data from the national database of the German collaborative arthritis centres show that patients are now seen earlier and to a greater extent. The intensity of drug treatment with synthetic or biological disease-modifying antirheumatic drugs (DMARDs) has increased continuously. At the same time, the mean disease activity (DAS28) has decreased from 4.7 to 3.3 and approximately 50 % of patients treated early achieve remission. Physician-rated disease severity has considerably improved and fewer patients suffer from erosive disease. This corresponds with improvements in functional capacity and work participation. Health services research impressively shows the advances in rheumatological care. Further improvements at the population level are limited by the low numbers of rheumatologists in outpatient care.

Aim: the aim of this study was to give an update on outpatient healthcare structures in rheumatology in Germany., Methods: a survey among the members of the German Association of Rheumatologists was carried out via a self-developed questionnaire, followed by a detailed descriptive and explorative statistical analysis. Contents of the questionnaire focussed on data concerning the practice, structure of the patients with regard to different indications and therapies, structure and quality of healthcare services provided, quality assurance and the economic situation of the practice as well as a subjective assessment of the outpatient healthcare environment. This approach is similar to the first survey conducted in 2005., Results: compared to the findings from the first survey in 2005 no significant changes could be found in many areas. As this may intuitively sound disappointing it must be stated that high positive levels maintained in some areas, which cannot be taken for granted, can also be counted as success. With respect to the structure of services provided and medical therapies, a further upward trend could be observed. Topics which were assessed for the first time dealt with communication with healthcare insurers and teaching of rheumatology as a discipline in hospitals., Conclusions: rheumatologists in Germany offer a broad spectrum of different services and actively make use of quality assurance measures in the daily practice. The communication with general practitioners and the training of new rheumatologists in the future remain an area of concern and need to be addressed.

Objective: To examine patterns of ambulatory physician visits for musculoskeletal disorders (MSD) in Canada., Methods: Physician claims data from 7 provinces were analyzed for ambulatory visits made by adults age >or= 15 years to primary care physicians and specialists (all medical specialists, rheumatologists, internists, all surgical specialists, orthopedic surgeons) for MSD (arthritis and related conditions, bone disorders, back disorders, ill defined symptoms) during fiscal year 1998-99. Person-visit rates and total and mean number of visits to all physicians for MSD were calculated by condition group. The percentages of patients with MSD seeing physicians of different specialties were also calculated. Provincial data were combined to calculate national estimates., Results: Over 15.5 million physician visits were made for MSD during 1998-99. About 24% of Canadians made at least one physician visit for MSD: 16% for arthritis and related conditions, 2% for bone disorders, 7% for back disorders, and 6% for ill defined symptoms. Person-visit rates for MSD varied by province, were highest among older Canadians, and were greater for women than men. Primary care physicians were commonly seen, particularly for back disorders. Consultation with surgical and medical specialists was less common and varied by province and by condition., Conclusion: MSD place a significant burden on Canada's ambulatory healthcare system. As the population ages, there will be an escalating demand for care. Careful planning will be required to ensure that those affected have access to the care they require. A limitation in using administrative data to examine health service utilization is that MSD diagnostic codes require validation.

Objective: Current treatment of rheumatoid arthritis (RA) emphasizes the early and consistent use of disease modifying antirheumatic drugs (DMARD). We studied how often these medications were used to treat patients with RA, and whether use of these medications has increased over time., Methods: We used the National Ambulatory Medical Care Surveys to determine national probability estimates of the use of DMARD [hydroxychloroquine, intramuscular gold, auranofin, methotrexate (MTX), sulfasalazine, azathioprine, D-penicillamine, and cyclosporine] by patients with RA. The National Ambulatory Medical Care Surveys record information about treatments provided in outpatient settings by a nationally representative cross sectional sample of physicians. Estimates of the use of DMARD were based on the treatments reported on 502 visits by patients with RA in 1980-81, 339 visits by patients with RA in 1985, 386 visits by patients with RA in 1989-91, and 383 visits by patients with RA in 1993-95., Results: DMARD were used in 30.3% of visits in 1980-81, 36.3% of visits in 1985, 24.9% of visits in 1989-91, and 43.6% of visits in 1993-95 (p for trend < 0.0001). Increased use of MTX accounted for most of the increased prevalence of DMARD use; MTX was used in 27.3% of visits in 1993-95. Use of DMARD increased in 1993-95 in all age, sex, and racial subgroups, and among visits reported by rheumatologists, but did not increase over time among visits reported by physicians other than rheumatologists., Conclusion: Use of DMARD in RA has increased in the recent past, but DMARD are currently used by fewer than 44% of patients with RA. Use of DMARD has not increased over time among patients of physicians other than rheumatologists.

Objective: To compare influenza vaccination billing rates for patients seen by physiatrists with those of four other specialties: neurology, rheumatology, family practice, and internal medicine., Design: Retrospective cohort analysis using Medicare billing data., Patients: 234,164 Medicare outpatients seen in Washington state between September 1 and December 31, 1994., Results: Based on Medicare's billing data, only 6 of 99 physiatrists ordered vaccinations, and they immunized only 159 (6%) of the patients seen. An additional 1,109 (42%) patients seen by physiatrists were vaccinated by other physicians. Physiatric patients were less likely to have been vaccinated than those seen by internists, family practitioners, or rheumatologists (p < .002), but equally likely as those seen by neurologists (p = .07). A significantly smaller percentage of physiatrists ordered vaccinations than all other specialties (p < .04). Utilizing pre-existing survey data, the misclassification rate (those immunized but not billed) was estimated at 22% of our original cohort. Thus, approximately 800 patients, one third of those seeing physiatrists, may not have been immunized. We estimated the increase in hospitalization costs to be $117 per nonvaccinated patient (total >$90,000)., Conclusions: Missed opportunities for vaccination by physiatrists appear to be more frequent than in other specialties and have potentially large health and economic costs.

Objective: To assess the extent to which quantitative clinical measurement is performed by rheumatologists in the longitudinal followup of patients with rheumatoid arthritis (RA), osteoarthritis (OA), ankylosing spondylitis (AS), and fibromyalgia (FM) in routine outpatient practice in Canada., Methods: A cross sectional postal survey was conducted using an 18 item self-administered questionnaire sent to Canadian Rheumatology Association members., Results: Rheumatologists (response rate 85%) were more likely to longitudinally follow patients with RA and AS than those with OA or FM. There was a high degree of variability in the methods used to monitor patients longitudinally. Many measures used in clinical research were used infrequently in routine clinical practice. In general, the major health status measures surveyed were not used in clinical monitoring. There was a high level of agreement (>80%) that the characteristics required of an outcome measure for use in clinical practice should include simplicity, brevity, ease of scoring, reliability, validity, and sensitivity to change., Conclusion: The majority of Canadian rheumatologists perform outcome measurement during the longitudinal followup of their outpatients with RA, AS, OA, and FM. However, the process lacks standardization. High performance health status measures, developed for clinical research, have not been widely adopted in rheumatology practices. There is agreement on the characteristics required by Canadian rheumatologists for measurement procedures used in routine clinical care. Quantitative measurement in clinical practice using standardized procedures is an attainable, but as yet, unrealized opportunity.

A cohort of 392 patients referred to six outpatient clinics by general practitioners during 1987 with diagnoses of rheumatoid arthritis, osteoarthritis, peripheral vascular disease, psoriasis or eczema, were studied from the time of their first attendance until up to two years later. Six consultant clinics were studied in the three specialties: rheumatology, vascular surgery and dermatology. For each specialty a clinic in both a teaching hospital and a district general hospital were included. The cohort members were predominantly middle-aged or elderly people, with a greater proportion of women, except at the vascular surgery clinic where 65% of patients were men. The 392 patients made a total of 936 visits (median two, range one-eight) during the study period; 91 patients were still attending up to two years after the first visit. Patients referred by their general practitioner for therapy were less likely to be discharged than those referred for other reasons. The principal reason for continuing attendance as perceived by patients, general practitioners and hospital doctors was the necessity for consultant supervision, although agreement was far from complete in individual cases. Junior staff tended to see a higher proportion of patients at follow-up visits than did consultants, and were found to have lower discharge rates than consultants. Analyses of data showed that at the first visit, diagnosis, disease severity and the grade of doctor seeing the patient in the clinic was significantly associated with patient discharge at the P < 0.05 level of significance. Patients considered that their visits had produced improvement in their condition in 38% of cases.(ABSTRACT TRUNCATED AT 250 WORDS)