Changes in the Workforce Characteristics of Providers Who Care for Adult Patients With Rheumatologic and Musculoskeletal Disease in the United States.

OBJECTIVE: The aim of this study was to describe the adult rheumatology workforce in the United States, assess change in rheumatology providers over time, and identify variation in rheumatology practice characteristics. METHODS: Using national Medicare claims data from 2006 to 2020, clinically active rheumatology physicians and advanced practice providers (APPs) were identified. Each calendar year was used for inclusion, exclusion, and analysis, and providers were determined to be entering, exiting, or stable based upon presence or absence in the prior or subsequent years of data. Characteristics (age, gender, practice type, rural, and region) of rheumatologists were determined for 2019 and in mutually exclusive study periods from 2009 to 2011, 2012 to 2015, and 2016 to 2019. The location of rheumatology practice was determined by billing tax identification and mapped. Demographics of physicians exiting or entering the rheumatology workforce were compared separately to those stable by logistic regression. RESULTS: The clinically active adult rheumatology workforce identified in US Medicare in 2019 was 5,667 rheumatologists and 379 APPs. From 2009 to 2020, the number of rheumatologists increased 23% and the number of APPs increased 141%. There was an increase in female rheumatologists over time, rising to 43% in 2019. Women and those employed by a health care system were more likely to exit, and those in a small practice or in the South were less likely to exit. CONCLUSION: The overall number of clinically active rheumatology providers grew more than 20% over the last decade to a high of 6,036 in 2020, although this rate of growth appears to be flattening off in later years.

2015 American College of Rheumatology Workforce Study and Demand Projections of Pediatric Rheumatology Workforce, 2015-2030.

OBJECTIVE: To describe the character and composition of the 2015 pediatric rheumatology workforce in the US, evaluate current workforce trends, and project future supply and demand of the pediatric rheumatology workforce through 2030. METHODS: The American College of Rheumatology created the workforce study group to study the rheumatology workforce. The workforce study group used primary and secondary data to create a representative workforce model. Pediatric rheumatology supply and demand was projected through 2030 using an integrated data-driven framework to capture a more realistic clinical full-time equivalent (FTE) and produce a better picture of access to care issues in pediatric rheumatology. RESULTS: The 2015 pediatric rheumatology workforce was estimated at 287 FTEs (300 providers), while the estimated excess demand was 95 (33%). The projected demand will continue to increase to almost 100% (n = 230) by 2030 if no changes occur in succession planning, new graduate entrants into the profession, and other factors associated with the workforce. CONCLUSION: This study projects that the pediatric rheumatology workforce gap will continue to worsen significantly from the 2015 baseline, and by 2030 the demand for pediatric rheumatologists will be twice the supply. Innovative strategies are needed to increase the workforce supply and to improve access to care.

Addressing the rheumatology workforce shortage: A multifaceted approach.

A significant challenge facing the field of rheumatology is the projected gap between the growing demand for rheumatologists and the available workforce. In order to improve access to care, augmenting the rheumatology workforce is required. Herein we discuss potential solutions to the anticipated workforce shortage, including 1) expanding the training of rheumatology physicians; 2) increasing nurse practitioner, physician assistant and pharmacist utilization in rheumatology practice; 3) growing the use of telemedicine; and 4) reducing burnout in order to retain practicing rheumatologists. Building on the existing literature in these areas, we propose a multifaceted approach to addressing the rheumatology workforce shortage.

Factors impacting referral of JIA patients to a tertiary level pediatric rheumatology center in North India: a retrospective cohort study.

BACKGROUND: JIA studies demonstrate that there is a "window of opportunity" early in the disease course during which appropriate management improves outcomes. No data is available regarding patients' pathway, before first pediatric rheumatology (PR) evaluation in India, a country where health-care costs are self- paid by patients and where a significant shortage of pediatric rheumatologists (PRsts) is known. This study aimed to describe time from onset of symptoms to first PR visit of JIA patients to a tertiary center in India and factors that impact this. METHODS: This retrospective study is from data collected at the PR center, Sir Ganga Ram Hospital (SGRH) in New Delhi. JIA patients fulfilling ILAR 2004 criteria and seen at least twice from 1st October 2013 to 30th September 2018 were included. Data collected were: demographic details, history of disease, referral practitioner, clinical and laboratory features, treatments. Mann-Whitney U-test, Chi square and logistic regression were used as appropriate to study factors that determined time to first PR visit. RESULTS: Five hundred and twenty patients were included: 396 were diagnosed at this PR center (group A), 124 were previously diagnosed as JIA and managed by non PRsts before first PR visit (group B). Median time from symptom onset to first PR visit was 4.1 months and median distance travelled 119.5 km. Despite ongoing treatment, group B patients had more aggressive disease and resided further away as compared to Group A patients. On univariate analysis, factors that predicted PR visit within 3 months were private patients, short distance to travel, family history of inflammatory disease, history of fever, history of acute uveitis or high ESR. On multivariate analysis all these factors were significant except high ESR and acute uveitis. CONCLUSION: Time to first PR assessment at this center was comparable to that seen in western countries. Cost of care and long distance to the center delayed consultation; acuity of complaints and family history of rheumatologic condition hastened referral. Possible solutions to improve referral to PR centers would be to increase the number of PRsts and to improve medical insurance coverage.

Rheumatology capacity building: implementing a rheumatology curriculum for Liberian health-care providers in 2016.

INTRODUCTION: Liberia has no rheumatology providers for the nation's 4.7 million people. We proposed a short course format rheumatology curriculum to educate Liberian providers as an initial step in providing graduate medical education in musculoskeletal health. METHOD: A 1-week training curriculum in rheumatology encompassing introduction to musculoskeletal exam and approach to rheumatology diagnosis and management was designed. The curriculum used multiple education methods including interactive lectures, bedside training, and hands-on learning. RESULTS: A 1-week rheumatology training curriculum for 24 local physicians was feasible. The execution of the designed rheumatology curriculum in Liberia relied upon a mixed method format that was both didactic and case-based. A survey of the Liberian trainees revealed that the curriculum was salient to care of patients and barriers to optimal learning such as time and space limitations were identified. CONCLUSIONS: A 1-week rheumatology training education program is possible and relevant to local providers, but training length and setting may need to be optimized. Future training will aim to minimize barriers to education and expand the cohort of providers with rheumatologic knowledge in Liberia.Key Points• Liberia, like many nations in sub-Saharan Africa, has no trained rheumatologists to serve the nation's population.• Education and capacity building for rheumatologic care in short course format are relevant and feasible to local health-care providers.• Further efforts are needed to develop and evaluate continuing rheumatology education in Liberia.

Rheumatology in Ukraine.

Rheumatology in Ukraine is based on established research and clinical infrastructure that enable the integration with regional and global societies. This article overviews current state of Ukrainian rheumatology, important steps toward expanding clinical settings, and opportunities for strengthening cooperation of local rheumatologists and patients with rheumatic diseases with related international societies. The main achievements and some challenges encountered by the Association of Rheumatologists of Ukraine are outlined. The Association supports continuing medical education of local specialists and explores options for advancing research and publishing in rheumatology. One of the main challenges still remains the creation of registries of patients with rheumatic diseases and expansion of activities of public societies with interest in combating rheumatic diseases. The issue of inadequate access to immunobiological therapies is also highlighted.

Medical education in pediatric rheumatology-unique challenges and opportunities.

Pediatric rheumatology faces workforce shortages in both developed and developing regions of the world resulting in suboptimal care of children with chronic rheumatic diseases. In addition to outlining the structure of formal rheumatology training programs in North America and Europe, we attempt to summarize various strategies being implemented with success in several parts of the world to help close the gap via innovative learning strategies. We discuss the important role of professional organizations in leading this effort.

Lupus education for physicians and patients in a resource-limited setting.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a wide range of manifestations and potential to affect several organ systems. Complications arise from both disease and medications especially glucocorticoids, significantly contributing to overall morbidity and mortality. SLE predominantly affects patients during their prime productive years resulting in substantial economic burden on the patient, caregivers, and society due to direct, indirect, and intangible costs. This illness burden is compounded in developing countries with limited resources due to various disparities in healthcare delivery. Physician education and practical referral and endorsement guidelines adapted to the local setting reinforce continuity and coordinated care. Likewise, patient education, self-help programs, and shared decision-making are essential best practice in the clinics. Both physician education and patient education improve overall outcomes in chronic diseases like SLE. As a developing country with very few rheumatologists and/or lupus specialists, efficient healthcare delivery for most Filipino lupus patients remains elusive. We describe our experience in confronting these challenges through development of strategies which focus on physician and patient education. KEY POINTS: • Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a highly variable course, requiring specialized, individualized, and coordinated care by a healthcare team. • Health disparities and limited resources significantly contribute to illness burden on the patient, family, and society. • Physician education on SLE must commence at undergraduate medical school, be integrated in Internal Medicine and Pediatrics, and reinforced through specialized training in Rheumatology and related specialties. • Patient education and empowerment are integral to improving healthcare outcomes especially in a resource-limited setting.

A survey of the New Zealand rheumatology workforce.

AIM: To characterise the demographics, size and distribution of the New Zealand rheumatology workforce. METHOD: An online survey was sent to New Zealand rheumatologists in February 2018. RESULTS: The survey was completed by 63 of 64 practising New Zealand rheumatologists (response rate 98%). In public practice, the number of half-day clinics per FTE was five (R2 linear 0.87), so a half-day session in private practice was counted as 0.2 FTE. There were 28.71 FTE in the public sector, 14.97 in private and 43.68 total FTE. By district health board (DHB), public FTE per capita ranged from 0.20 FTE per 100,000 population in Nelson-Marlborough DHB to 0.96 in Whanganui DHB. None of the 20 DHBs met the Royal College of Physicians guideline of 1.16 FTE per 100,000 population in the public sector, and only four DHBs reached this level when private FTE were included. Rheumatologists under the age of 50 years were predominantly female (62% female), and older rheumatologists predominantly male (7.7% female, p<0.001). In the next five years 6.58 FTE public rheumatologists intended to retire, (94% male). 23/53 (43%) of public hospital rheumatologists offer appointments for non-inflammatory conditions, compared to 30/31 (97%) of private practice rheumatologists. Between 1999 and 2011, the FTE per 100,000 population increased by 35.4%, but the rate of improvement slowed in the interval between 2011 and 2018, increasing by 3.0%. CONCLUSION: The New Zealand rheumatologist workforce is becoming more gender-balanced but is below recommended FTE levels, is unevenly distributed, and previously documented improvements in overall FTE have now reached a plateau.

Rheumatology in Poland.

The aim of this article is to present the current state of rheumatology in Poland, including the scientific and clinical activity and essential aspects of Polish rheumatic patients' treatment. PubMed, Scopus and Web of Science databases were searched for main keywords: "rheumat*" and affiliation with Poland. Statistical data were obtained from the Central Statistical Office, the National Health Fund and the Polish Chamber of Physicians and Dentists, while the public information from the Polish Society for Rheumatology, the Ministry of Health and the Ministry of Science and Higher Education. Databases of the World Health Organization, the Organization for Economic Co-operation and Development and the European Statistical Office (Eurostat) were used. Most Polish rheumatologists work in large urban agglomerations in the Mazovian, Malopolskie and Silesian Voivodeships. The rheumatologic infrastructure includes 1713 working rheumatologists (> 30% exceeding the age of 60 years), 2301 hospital beds, 2279 outpatient clinics and 955 private practices. Poland's state funding is relatively limited, this problem being addressed by health officials with special treatment programs for biological drugs. The Eurostat data indicate, that in Poland, like in the majority of EU Member States, there's a tendency of specialist/general practitioner ratio rising. The number of scientific publications by Polish rheumatologists has steadily increased in recent years. Poland's rheumatology has made an enormous progress at all levels of functioning in recent decades. The EULAR recommendations are mostly incorporated into the Polish health system, leaving still room for its further improvement in the fields of financing, therapy and education.

Workforce Trends in Rheumatology.

The United States is facing a rheumatology provider shortage over the next decade, which will negatively affect care for patients with rheumatic disease across the nation if this deficit is not thoughtfully addressed. The increasing numbers of retiring rheumatology specialists, women entering the workforce, and rheumatology graduates seeking part-time employment were identified as the most significant factors driving the projected decline in supply of providers. The major factors driving the projected increase in demand include an aging and growing population and improved treatment options, both of which increase disease prevalence and the challenge of managing chronic rheumatologic diseases.

The incidence rate and the early management of rheumatoid arthritis in Slovenia.

Epidemiological data for rheumatoid arthritis (RA) differ according to ethnicity and geographical region. Moreover, despite of clear RA management guidelines, the implementation of treat-to-target (T2T) strategy often remains incomplete. Our objectives were to determine the incidence rate of RA, the clinical characteristics, and the level of adherence to the T2T guidelines in Slovenia. We analyzed prospectively the collected data of adult patients diagnosed with RA from 2014 through 2016 at the Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia. The department provides rheumatology services to a well-defined region with a population of 704,000 adult residents. During the 3-year observation, we identified 341 incipient cases of RA (75% females, median (IQR) aged 64 (52.0-75.4) years), resulting in an annual incidence rate of 16.1 per 100,000 adults (95% CI 14.5-17.9). The incidence rate peaked in the 70-79-year age interval. The median time from the onset of symptoms suggestive of RA to rheumatology consultation was 12.9 (4.4-26.1) weeks, and the median time from referral to consultation was 1 (1-3) day. Within 12 weeks of symptom onset, 161 (47.2%) incipient RA patients were examined by a rheumatologist, and 123 (36.1%) were started on DMARD therapy. The estimated incidence rate was in line with the available epidemiological data. Our early interventional clinic enabled us to identify and manage a substantial portion of RA patients within the recommended time frame.

2015 American College of Rheumatology Workforce Study: Supply and Demand Projections of Adult Rheumatology Workforce, 2015-2030.

OBJECTIVE: To describe the character and composition of the 2015 US adult rheumatology workforce, evaluate workforce trends, and project supply and demand for clinical rheumatology care for 2015-2030. METHODS: The 2015 Workforce Study of Rheumatology Specialists in the US used primary and secondary data sources to estimate the baseline adult rheumatology workforce and determine demographic and geographic factors relevant to workforce modeling. Supply and demand was projected through 2030, utilizing data-driven estimations regarding the proportion and clinical full-time equivalent (FTE) of academic versus nonacademic practitioners. RESULTS: The 2015 adult workforce (physicians, nurse practitioners, and physician assistants) was estimated to be 6,013 providers (5,415 clinical FTE). At baseline, the estimated demand exceeded the supply of clinical FTE by 700 (12.9%). By 2030, the supply of rheumatology clinical providers is projected to fall to 4,882 providers, or 4,051 clinical FTE (a 25.2% decrease in supply from 2015 baseline levels). Demand in 2030 is projected to exceed supply by 4,133 clinical FTE (102%). CONCLUSION: The adult rheumatology workforce projections reflect a major demographic and geographic shift that will significantly impact the supply of the future workforce by 2030. These shifts include baby-boomer retirements, a millennial predominance, and an increase of female and part-time providers, in parallel with an increased demand for adult rheumatology care due to the growing and aging US population. Regional and innovative strategies will be necessary to manage access to care and reduce barriers to care for rheumatology patients.

Defining Quality of Rheumatolgic Care: Argentina.

Health care system in Argentina is highly fragmented and disconnected. Argentina's health system is divided into 3 major nonintegrated subsystems as follows: public subsystem, financed through taxes; the social security subsystem, financed through obligatory insurance schemes; and the private subsystem, financed through voluntary insurance. There are approximately 800 rheumatologists in Argentina, serving a population of approximately 40 million people, representing approximately 1.8 rheumatologists per 100.000 inhabitants; however, most of them are concentrated in large cities, and patients need to travel several hours to reach a specialist. Although the health care system in Argentina is highly fragmented and disconnected, health coverage is universal, accessible, and of good quality. Quality or value assessment of care and use of electronic medical records are not part of the system in Argentina, and there does not appear they would be in the near future.

[Memorandum of the German Society for Rheumatology on the quality of treatment in rheumatology - Update 2016]. / Memorandum der Deutschen Gesellschaft für Rheumatologie zur Versorgungsqualität in der Rheumatologie ­ Update 2016.

On behalf of the Steering Committee of the German Society for Rheumatology, in 2016 the Interdisciplinary Commission on Healthcare Quality updated the 2008 memorandum on rheumatological healthcare in Germany. The update considers changes in therapeutic strategies, treatment targets as well as current structures in healthcare and the political framework. It concentrates on examination of the need for rheumatologists with a background in internal medicine and determines the gap between needs and supply. The internist rheumatologist is responsible for the care of patients with inflammatory rheumatic diseases and contributes to the care of patients with severe forms of other musculoskeletal diseases. At least 2 internist rheumatologists are needed for the outpatient care of 100,000 adult inhabitants, equivalent to 1350 rheumatologists in Germany. With currently 776 rheumatologists, we have little more than half of what we need. The German Society for Rheumatology calls for specific requirements planning for rheumatologists in outpatient care in order to decrease the deficit. In acute inpatient care we need specialized hospitals and wards that ensure a high quality of treatment for patients with complex diseases. We need up to 50 beds per 1 million inhabitants. At least 2 full-time internist rheumatologists and 3 further physicians are needed per 30 beds. In inpatient and outpatient rehabilitation we need 40 beds or outpatient places per 1 million inhabitants with at least 1 full-time rheumatologist and 1 further physician. In order to reduce the existing deficits and to cover the increasing future need for rheumatologists, more emphasis has to be laid on primary and secondary education. Chairs for internal rheumatology are needed at each medical university and more positions for postgraduate training in rheumatology should be provided. In all segments of healthcare the treatment aims should be jointly defined between patients and physicians. The patients should be treated in an interdisciplinary network, comprising other medical specialties, health professionals as well as patient organizations.

Pediatric rheumatology consultant workforce in Australia and New Zealand: the current state of play and challenges for the future.

AIM: There have been no formal assessments of current levels of the pediatric rheumatology workforce in Australia and New Zealand. Despite this it is felt that we fall well behind international guidelines placing children and adolescents with rheumatic diseases at risk of suboptimal care. Overcoming this shortfall in specialist pediatric rheumatology care requires documentation and recognition of the shortfall and a commitment from the health system to support improvements to supplement the current specialist workforce. The purpose of this survey was to assess the current state of play of the pediatric rheumatology workforce in Australia and New Zealand. METHODS: The Australian Paediatric Rheumatology Group (APRG) conducted a survey, which examined the current pediatric rheumatology workforce in Australia and New Zealand. The survey was sent via email link to a survey hosted by Zoomerang™ to 49 physicians known to treat patients with pediatric rheumatic diseases and they were asked to forward the survey to any others who they knew saw children with rheumatic disease. RESULTS: Currently there is a shortfall in the pediatric rheumatology workforce of 68% based on minimum requirements and a shortfall of 225% based on an ideal scenario. CONCLUSION: Currently in Australia and New Zealand we fail to provide the level of care to children with pediatric rheumatic diseases comparable to other developed health economies worldwide. The current deficiency requires an increase in resource allocation to clinical service and speciality training to overcome this disparity and ensure children in Australia and New Zealand receive internationally recognized standards of care.