48. Rheumatology Out-Patient Services Over the Past Two Decades in Bristol

Abstract

Background: Accurate information about local referral patterns, case mix, treatment needs and capacity of current services is key to improve and develop rheumatology services particularly in the current commissioning landscape. Methods: A survey of all out-patient visits during November 2012 at the 2 trusts in Bristol (catchment population 900,000) collecting data on case mix, waiting times and clinic visit outcomes. These were compared with previous surveys carried out in 1994 and 2000 as part of a regional audit. Results: Of the 243 new referrals (113 centre A, 130 centre B), 42.4% were diagnosed with inflammatory arthritis, 9.9% with OA, 11.1% with soft tissue conditions; 4.9% with back problems; 2.5% with PMR; 4.5% with other arthritis; 16.5% with other diseases and 8.2% with osteoporosis. Compared with 1994 there was a 24% increase in new patients, mainly inflammatory arthritis and osteoporosis with a reduction in OA and soft tissue conditions. Of the 1146 follow-ups (478 centre A, 668 centre B) 136 patients (11.8%) were seen by allied health professionals and 83.8% had inflammatory arthritis. Compared with 1994 there was a 58.7% increase in follow-up patients almost entirely due to inflammatory arthritis. Compared with previous surveys there has been a significant drop in waiting times for new referrals. Over 95% of new referrals were seen within 18 weeks. The overall follow-up to new ratio was 4:1. The follow-up to new ratio for RA was 21:1, for seronegative arthritis and CTDs 5:1 and for non-inflammatory arthritis 1:1. Following the clinic visit, 30% of new referrals and 5% of follow-ups were discharged while 15% were given open appointments. Interesting differences in follow-up trends were observed. At the centre operating the traditional appointments model the majority of follow-up appointments were booked at 26 and 52 weeks. At the centre running the direct access, follow-up appointments peaked at 12 and 26 weeks, while the remaining patients were followed up on the direct access system. Conclusion: At these centres, the number of patients referred, and especially the number with inflammatory polyarthritis continues to increase. The great majority of follow-up appointments are for inflammatory arthritis. The overall follow-up to new ratio is a poor measure in rheumatology and should be interpreted in relation to case mix. Centres have adopted two strategies for follow-up appointments- direct access and long appointment times-to help manage long term care of inflammatory arthritis. Rheumatology services need to adapt and seek innovative sustainable ideas which improve productivity and efficiency while reducing inequality and dependency. These changes need to be specific to local circumstances and address the whole patient journey and long-term follow-up.