Better ambulatory care can help reduce ED visits by patients with inflammatory arthritis

Rheumatology ambulatory care must adequately respond to the need of patients with inflammatory arthritis (IA) to reduce their visits to the emergency department (ED), suggests a study.

"Persons with IA conditions turn to the ED for urgent concerns when their care needs are not met in ambulatory care settings,” the researchers said. “Their expectations for quality acute healthcare interactions were discordant with their reported experiences.”

In this study that employed an embedded mixed-methods approach, researchers contextualized quantitative data with associated free-text responses from an online survey given to residents of Alberta, Canada, with a known IA condition and an ED attendance.

Eighty-two individuals (aged 16–55 years, 48 percent female, 50 percent urban residents) completed the survey. Of these, 48 percent had rheumatoid arthritis, 12 percent had psoriatic arthritis, 6 percent had spondyloarthritis, and 34 percent had gout. [J Rheumatol 2024;51:1015-1022]

Arthritis flare (37 percent) was the most common concern presented by patients with IA, followed by chest pain (15 percent), injury (12 percent), and infection (11 percent). Of all visits, 29 percent went directly to the ED, 35 percent attempted to access ambulatory care initially, and 32 percent arrived for a return visit.

Notably, patients presenting with arthritis flare were aware of the rheumatology service being contacted by the ED provider for advice in 9 percent of events.

“Challenges in healthcare system coordination ... resulted in patients requiring ED attendance to assess their concern,” the researchers said. “The quality of communication and relationality developed between patients with IA and healthcare providers informed experiences of ED care.”

The gap in care coordination between acute and ambulatory services, in which patients were unable to access appropriate care after being discharged from the ED, may result in a return visit to the ED for the same health concern, according to the researchers.

"Whereas some ED use by patients with IA is necessary and inevitable, we present ... recommendations to develop systems and procedures to reduce the need for ED use by patients with IA for concerns that could be addressed in ambulatory care settings,” they added.

ED volume

To ease the volume of ED visits, several approaches have been suggested in previous studies, including having direct applicability to rheumatology care providers. [Health Policy 2016;120:1337-1349; Can J Health Technol 2023;3]

“Education and self-management support would encourage reduced presentations to the ED,” the researchers said. “Patients confident in managing their own health have 32 percent fewer ED visits and 38 percent fewer emergency hospital admissions.” [https://www.health.org.uk/publications/reducing-emergency-admissions-unlocking-the-potential-of-people-to-better-manage-their-long-term-conditions]

One strategy to help patients manage their own health is by providing evidence-based sources of information to develop a self-management plan for flares, which has succeeded in reducing ED use for other chronic conditions (eg, asthma). Such action plan developed with the healthcare provider reduced ED use by as much as 20 percent. [NPJ Prim Care Respir Med 2022;32:34]

“There is a clear indication to increase rheumatology care capacity,” the researchers said.