title: The complexity of care for patients with rheumatoid arthritis: metrics for better understanding chronic disease care.
abstract: BACKGROUND
  Patients with rheumatoid arthritis (RA) provide an important opportunity for understanding care of patients with a serious chronic condition.
  
  
  OBJECTIVE
  We sought to characterize the complexity of care for patients with RA, including metrics describing the patient, the disease, and use of the health care system across time and place.
  
  
  METHODS
  We undertook a prospective cohort study of 568 community-dwelling patients with RA by using observational data from clinically detailed telephone interviews at baseline and 2 years later in addition to medical record abstraction. Health status, comorbidity, use of disease-modifying antirheumatic drugs, visits, providers, provider types, encounter settings, and the discontinuity between patients and providers were studied.
  
  
  RESULTS
  Within a 12-month window, 568 patients had 8686 outpatient encounters with the health care system with a mean of 3.41 unique providers per patient associated with a mean of 5 primary care and 6 rheumatologist visits. Half did not see a primary care physician, and 20% did not see a rheumatologist during 6-month periods despite their use of potentially toxic drugs, a mean of 4 comorbidities and progressive RA. Over the course of 24 months, 29% of patients changed their primary care provider, and 15% changed their rheumatologist. Patients were moderately impaired with mean SF-12 physical component score 37 (SD, 9).
  
  
  CONCLUSIONS
  Patients with RA have frequent encounters with multiple providers and also frequent discontinuity of care. Recognizing the complexity of the care of patients with a chronic disease across multiple dimensions provides an opportunity to better understand challenges and opportunities in delivering high quality care.
authors.affiliation: University of California at Los Angeles, Greater Los Angeles VA Healthcare System, Los Angeles, California 90095-1736, USA. kkahn@mednet.ucla.edu
authors.forename: Katherine L
authors.initials: KL
authors.lastname: Kahn
authors.forename: Catherine H
authors.initials: CH
authors.lastname: MacLean
authors.forename: Honghu
authors.initials: H
authors.lastname: Liu
authors.forename: Laurence Z
authors.initials: LZ
authors.lastname: Rubenstein
authors.forename: Andrew L
authors.initials: AL
authors.lastname: Wong
authors.forename: Judith O
authors.initials: JO
authors.lastname: Harker
authors.forename: Wen-Pin
authors.initials: WP
authors.lastname: Chen
authors.forename: Diane M
authors.initials: DM
authors.lastname: Fitzpatrick
authors.forename: Ken J
authors.initials: KJ
authors.lastname: Bulpitt
authors.forename: Shana B
authors.initials: SB
authors.lastname: Traina
authors.forename: Brian S
authors.initials: BS
authors.lastname: Mittman
authors.forename: Bevra H
authors.initials: BH
authors.lastname: Hahn
authors.forename: Harold E
authors.initials: HE
authors.lastname: Paulus
mesh_terms: D000328:Adult; D000368:Aged; D001172:Arthritis, Rheumatoid / Q000145:classification / Q000175:diagnosis / Q000628:therapy*; D015331:Cohort Studies; D015897:Comorbidity; D005260:Female; D006801:Humans; D008297:Male; D008499:Medical Records; D008511:Medicine / Q000706:statistics & numerical data; D008875:Middle Aged; D010548:Personal Health Services / Q000706:statistics & numerical data*; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D012720:Severity of Illness Index; D013038:Specialization