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Pre-appointment consults effectively triage patients with rheumatic disease
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Pre-appointment consult screenings are effective in helping physicians identify patients who have an autoimmune or inflammatory rheumatic disease, enabling the patients with the greatest need to quickly access care as well as generating increased revenue for the practice, according to findings published in Arthritis Care and Research.
“Hospital leadership is very interested in making sure that all patients have access to specialty care in a timely manner,” Sterling G. West, MD, MACP, MACR, of the University of Colorado Denver, told Healio Rheumatology. “However, there are not enough rheumatologists to see all patients with rheumatic complaints and this deficit is likely to get worse.”
Noting that rheumatologists at the University of Colorado have, for the past 15 years, used a consult triage system specifically designed to schedule timely appointments for patients with autoimmune and rheumatic diseases, the researchers evaluated the effectiveness of the system in identifying appropriate patients. They also aimed to determine the consult system’s effect on revenue.
West and colleagues reviewed data from the electronic medical records of all new outpatient rheumatology consults seen during a 9-month period from April through December. They noted final diagnoses and revenue generation for routine outpatient care for each patient for 1 year following their consult. In all, 961 patients received consults and pre-appointment triage during the 9-month period. Of those, 673 patients were approved for autoimmune or rheumatic disease evaluation, while 288 were declined to be seen.
According to the researchers, patients were seen by a rheumatologist an average of 13 days after their consult review. Among the 673 approved consults, 597 patients arrived for evaluation, of whom 357 received a diagnosis for an autoimmune or inflammatory rheumatic disease. A total of 240 patients were diagnosed with something other than an autoimmune or inflammatory rheumatic disease. Among the declined consults, 128 had 1-year follow-up data, of whom six patients were eventually diagnosed with an autoimmune or inflammatory rheumatic disease. This corresponds to a consult triage sensitivity of 98%, and a positive predictive value of 60%, the researchers wrote.
In addition, revenue data demonstrated that care of patients with autoimmune or inflammatory rheumatic disease generated 44 times more revenue compared with patients without autoimmune or inflammatory rheumatic diseases (P < .001).
“Although all patients with a rheumatic complaint would likely benefit from a rheumatology consultation, it is clear that timely access to rheumatologic care is most beneficial for patients with inflammatory rheumatic diseases to prevent future morbidity and disability,” West said. “Our consult triage protocol appears to be an effective method to assure that patients with inflammatory rheumatic diseases get expedited access to appropriate rheumatologic care. Using conservative measures, caring for patients with inflammatory rheumatic diseases results in significantly more revenue generation.” – by Jason Laday
Disclosure: West reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Cathy Patty-Resk, MSN, RN, CPNP-PC
As a member of a two-provider pediatric rheumatology academic practice in a large urban city, I can appreciate the dual purpose of this study and the multifactorial implications for rheumatology as a whole. The goals of getting the patient to the appropriate specialist with the appropriate screening in a timely fashion while being fiscally responsible with health care dollars are ones we are all challenged by daily.
The pre-appointment consult triage protocol proposed by West and colleagues may be the best thing since advanced practice providers for the rheumatology service line. Be that as it may, the referring providers are unwittingly getting small bits of rheumatology education each time the rheumatology provider offers them suggestions regarding further testing, explaining how the problem does not meet criteria for the suspected rheumatology diagnosis and recommending referral to a different specialist (such as, orthopedics, infectious disease or ophthalmology) altogether.
One can only predict that, over time, the referring providers are better able to correctly identify patients who are most likely to have a rheumatologic disorder, what testing to do before they get to the rheumatologist and what testing to stop performing so routinely — namely, antinuclear antibody tests for anyone with joint pain. Just as important, the referring providers may take more of an interest in rheumatology and participate in more rheumatology CME activities, ultimately providing better primary care to our rheumatology patients.
I have referred patients to other specialties that require pre-appointment triage before an appointment can be obtained and, generally speaking, patients either get an appointment or they do not. I have never really understood this practice until now because we seem to manage to get our new pediatric rheumatology patients seen somehow without lengthy delays. However, I cannot recall ever getting any feedback or guidance on whether any other testing should be done or other diagnoses be considered. This would certainly be helpful in routing the excluded patients to the most appropriate specialty care while conserving health care dollars at the same time, as West and colleagues have demonstrated. The concept of giving feedback — the “consult” part of the pre-appointment consult triage system — is pivotal to maintaining a quality service line.
I must admit I was intrigued by the profound fiscal changes that occurred with this practice protocol; albeit, it would impact large health care systems the most by yielding the greatest downstream effect on net revenue. The individual private practice provider should consider using this protocol as well, particularly those with on-site infusion suites. Pre-appointment consult triage is a home run for all the players.
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