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Rheumatology is a medical specialty dedicated to the assessment and management of acute and chronic rheumatic diseases. Rheumatologists are trained to provide expert medical care for people with inflammatory arthritides, like psoriatic and rheumatoid arthritis, and systemic immune diseases, such as systemic lupus erythematosus and vasculitis. The management of these rheumatic diseases is often complex, and care for people with active disease requires frequent review, with defined patient-care goals and ideally a multidisciplinary approach.[[1]] Rheumatic diseases also have potential for significant morbidity, and even mortality, highlighting the need for specialist care.[[2,3]]

There are many guidelines that describe the evidence-based components of care for people with different rheumatic diseases aiming to achieve optimal health outcomes. These address many aspects of care including diagnosis and pharmacologic management, frequency and type of clinical care events, and the contribution of specific healthcare professionals (HCP) such as nurses, occupational therapists, psychologists and physiotherapists.[[4–10]] These guidelines could inform essential requirements of an evidence-based rheumatology service that provides care to optimise health outcomes for people with rheumatic disease.

In Aotearoa New Zealand (AoNZ), most rheumatology care is provided in the public health system, delivered in district health boards (DHBs), although there is a significant contribution from private practice.[[11]] Over the last 20 years, the reported number of full-time equivalent rheumatologists in public and private practice has been well below recommendations.[[11, 12]] There is also significant variation in the rheumatologists per capita between DHBs.[[11, 12]] Other aspects of rheumatology services provision, such as access to other HCPs, what services are provided by the HCP, and how these are organised, has not been reported. In addition, there are not yet agreed or recommended service benchmarks for what a rheumatology service should provide in DHBs. Benchmarks might include types of HCPs available, what types of care should be provided by these HCP, and how often.

The aim of this study was to identify consensus from rheumatologists on components of a best practice rheumatology service in DHBs in AoNZ, using an online Delphi consensus approach.

Methods

Setting and sample

Potential participants were members from the Fellow of the Royal Australasian College of Physicians (or equivalent), practicing under the scope of “rheumatologist”, who were members of the New Zealand Rheumatology Association (NZRA) as of December 2020. These rheumatologists were considered the clinical experts in comprehensive care of people with rheumatic disease.

Identification of statements from literature

The first iteration of the Delphi exercise was an ideas generation survey, to determine statements for consensus voting. The National Institute of Health and Care Excellence (NICE) guideline for the management of rheumatoid arthritis in adults 2019,[[13]] and the NICE quality standard for rheumatoid arthritis in over 16’s 2020,[[14]] were the primary sources for statements describing components of care in an optimally delivered service for care of people with rheumatoid arthritis, the most common form of autoimmune inflammatory arthritis. NICE is part of the Department of Health in the United Kingdom and develops quality stands and performance metrics for the commissioning and provision of healthcare.[[15]]

Additional statements were sourced from a recent systematic review of quality measures for inflammatory arthritis[[16]] generated by the researchers, or adapted from guidelines found in searches of major international rheumatology guideline groups pertaining to different aspects of delivery of evidence-based care in rheumatology.[[17,18,19]] The wordings of the statements were adapted slightly for consistency. Two additional statements were added to address the principles of the Treaty of Waitangi/Te Tiriti o Waitangi and addressing the aim to achieving equitable health outcomes for Māori.

Data collection

An invitation email was sent, independently of the researchers, to NZRA members in December 2020. This contained a link to an initial online survey using Qualtrics that included all the statements describing components of a best practice rheumatology service. For each statement, participants could offer free text comments. Participants were also asked for free text offering additional statements to be included in the consensus rounds. The two authors reviewed feedback, refined initial statements, and added suggested statements. The finalised list of statements was included in a consensus survey tool for the Delphi exercise.

The consensus survey link was emailed to NZRA members, independently of the researchers. Baseline, non-identifying demographic data were collected from each participant. Participants were asked to rate their agreement with each statement as it applies to the delivery of a rheumatology service in a “small DHB” and a “large DHB”. A seven-point Likert scale was used for each statement (Anchors 1 = strongly agree, 7 = strongly disagree), as well as an “I don’t know” option. A small DHB was defined as having a catchment population of less than 250,000 people, and a large DHB, a catchment population of greater than 250,000 people (Supplementary Table 1).[[20]]

The consensus survey had three rounds. After the first round only participants who had responded in full were invited to round two. For second and third rounds, only statements that had not yet met consensus were rated. Participants were provided a table summarising the distribution of the group’s ratings from the previous round and asked to re-rate each remaining statement. A reminder email was sent to non-responding participants after a week, and a further week was given to complete the survey round. Participants remained anonymous to each other throughout.

Data analysis

A statement was determined to have met consensus when ≥80% of respondent’s votes were within one of three pre-determined categories:

A. Either 1 (strongly agree), or 2 (agree)—consensus met to be considered as an essential component of rheumatology service delivery

B. Either 3 (somewhat agree), or 4 (neither agree nor disagree)—consensus met to be considered as a potentially desirable, but non-essential component of rheumatology service delivery

C. Either 5 (slightly disagree), 6 (disagree), or 7 (strongly disagree)—consensus met to be considered as a component to be avoided in rheumatology service delivery.  

The ≥80% level for consensus is consistent with previous definitions of consensus in Delphi exercises.[[21]] Ratings of “I don’t know” were excluded from the denominator. The median rating and an accompanying interquartile range (IQR), which is equal to the difference between the 25th and 75th percentiles, were calculated for each of the statements when they met consensus, or at the end of the final round of the survey.

Ethics

The study protocol was approved by the University of Otago Human Ethics Committee (D20/0257). Consent was obtained electronically before participation in the initial survey and first round of Delphi survey.

Results

The NZRA invited 76 potential participants. There were ten respondents to the initial survey of the proposed 19 statements. Four statements (statements 2, 3, 16, 19) were refined or amended on the basis of feedback received (Supplementary Table 2), and three were added (statements 20, 21, 22) leading to a total of 22 statements the consensus survey (Table 1).

The first round of the consensus survey had 30 responses, with four responses excluded as the survey was incomplete (n=3), or the respondent was not rheumatologist (n=1). The characteristics of the 26 respondents are in Table 2. Almost 2/3 (16/26, 61.5%) of participants were employed by a large DHB. Five participants in the first round did not provide an email address for participation in rounds two and three. All remaining 21 participants completed rounds two and three.

View Tables 1 & 2.

In the first consensus round, consensus was reached for nine statements (9/22, 40.9%) as essential service components for a small DHB rheumatology service, and fourteen statements (14/22, 63.6%) as essential service components for a large DHB rheumatology service. In the second round, seven further statements met consensus to be considered as essential for a small DHB service, and a further two statements for a large DHB service. In the third and final round, one further statement gained consensus to be considered as potentially desirable, but non-essential, for a large DHB service. After three rounds, the same 16 statements (16/22, 72.1%) describing best practice components of a rheumatology service had met consensus to be considered essential for both small and large services (statements 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 19, 21). One statement had met consensus to be considered potentially desirable, but non-essential, for a large DHB service but not for a small DHB service (statement 15). Of these 17 statements, 13 were derived or adapted from guidelines in the literature. The remaining five statements failed to reach consensus for any of the pre-determined agreement categories (statements 4, 17, 18, 20, 22). There were no statements that met consensus to be avoided in rheumatology service delivery.

Discussion

In this Delphi consensus exercise rheumatologists in AoNZ agreed on 16 statements describing components of a best practice rheumatology service to be considered as essential in both large and small DHB rheumatology services. One statement met consensus to be considered as potentially desirable, but non-essential, for a large DHB rheumatology service only. Most of the statements that met consensus (13/17, 75%) were sourced or adapted from existing rheumatology service recommendations.[[13, 14, 22–26]] Only one statement derived from guidelines, relating to receiving advice within one working day of contacting a rheumatology service (statement 4), failed to reach consensus. Three researcher/rheumatologist-generated statements also reached consensus as essential (14, 19, and 21). These attempted to encapsulate typical aspects of a rheumatology service that were not described in the literature and one related to the Treaty of Waitangi/Te Tiriti o Waitangi and equitable health outcomes for Māori (statement 19). Statement 19 met consensus to be considered an essential component of a rheumatology service in round two. This is of particular importance, given there is known inequity in health outcomes for some chronic rheumatologic conditions, for example gout, amongst Māori and Pacific communities in AoNZ.[[27]]

Three of the statements that failed to meet the ≥80% agreement required for consensus for any of the pre-determined categories (statements 4, 18, 20) were rated 1, 2, 3 or 4 on the seven-point Likert scale by >90% of participants, indicating the majority of rheumatologists deemed these services to be of at least “neutral” importance. Further understanding of the circumstances in which, and for whom, these service elements are important is required. For example, statement 20 related to the use of Telehealth in rheumatology, which has become more relevant during the COVID-19 related restrictions on health service delivery. While there are limited empiric data evaluating the use of telemedicine in rheumatology,[[28]] it has been adopted in emergency situations in AoNZ and provided adequate rheumatology service delivery, at least in the short term.[[29]] Since Telehealth has been proposed as a mechanism to expand reach of a limited rheumatology workforce, the implementation of Telehealth in rheumatology services, where clinically appropriate, probably warrants further consideration, even if not considered essential at this time.[[30]]

Some statements may have not reached consensus due to differences in views on scope of DHB rheumatology services in AoNZ. Statement 17, relating to provision of assessment for non-inflammatory conditions, did not reach consensus. This is consistent with previous report that only 43% of public practice rheumatologists in AoNZ accepted referrals for non-inflammatory conditions such as fibromyalgia.[[11]] In contrast, 97% of rheumatologists in private practice accepted referrals for non-inflammatory conditions. This might suggest that lack of consensus relates to differences in views on scope of DHB rheumatology services in the setting of resource constraint, rather than scope of rheumatology practice per se. There was also no consensus to consider discharging clinically stable patients with chronic rheumatic disease to primary care (statement 22) as either potentially desirable or essential. This may capture the tension between the best practice of longitudinal care of people with inflammatory rheumatic disease in specialist clinics, and the limited capacity of these services. The model of “shared-care” arrangements with primary care and rheumatology has been considered previously in the United Kingdom for stable patients with inflammatory arthritis.[[31]] Such models may require further refinements in models of collaboration between primary and secondary care in AoNZ, which are not yet adequately established.

Almost all statements of best practice care that reached consensus as essential did so for both large and small DHB rheumatology services. The only exception was statement 15, relating to the combined specialist clinics, which was not deemed essential for a small DHB service. This likely reflects the challenges of combining clinics in DHB with overall fewer specialists, perhaps also with more general scope of practice, or absence of a smaller specialties in small DHBs. It also highlights that rheumatologists expect that people of AoNZ should get access to a similar quality and scope of rheumatology care whether they reside in the catchment of West Coast DHB (~32,000 catchment population) or of Waitematā DHB (~630,000 catchment population).[[20]] These views are consistent with the vision for the New Zealand health system reforms in which excellence in care delivery includes “consistent high-quality care everywhere”.[[32]] Studies similar to this one may assist in describing what excellent care for the people of AoNZ requires.

This study has some limitations. About 1/3 (26/76, 34%) of eligible rheumatologists in AoNZ participated, so findings may not represent of the views of all rheumatologists in AoNZ. However, the response rate is in the acceptable sample size for a Delphi exercise.[[33, 34]] Furthermore, the majority of participating rheumatologists (61.5%) practiced in large DHBs, who may not fully understand the contexts for small DHBs. This study also collected the views of only one stakeholder in rheumatology service delivery, the rheumatologist. It would be important in future research to elicit views of other stakeholders, particularly users of rheumatology clinics, the patients.

In conclusion, this study has identified that 16 best practice components of a rheumatology service are considered essential in DHB rheumatology services by rheumatologists, regardless of size of DHB catchment population. These recommendations could be used to inform the development of services in Health New Zealand when this is established in July 2022 and developed into benchmarking standards for rheumatology services. The views of users of rheumatology services in DHB in AoNZ on these best practice components and other aspects of care that are important to them also need to be explored.

View Supplementary Tables 1 & 2.

Summary

Abstract

Aim

To identify consensus of rheumatologists on components of best practice rheumatology service in district health boards (DHB) in Aotearoa New Zealand (AoNZ).

Method

A consensus survey of rheumatologists in AoNZ was informed by an initial survey inviting modifications to statements about best practice rheumatology from international literature and requested additional statements. The three-round consensus email exercise asked rheumatologists to indicate their level of agreement with each statement for a DHB serving a small or large population. Consensus for each statement was achieved when ≥80% of participants’ votes were within a pre-determined category (essential, potentially desirable, to be avoided).

Results

Ten rheumatologists reviewed the 19 initial statements with three additional statements offered—the consensus survey had 22 statements. Twenty-six rheumatologists responded in the first consensus round, with 21/26 (81%) responding in rounds two and three. After three rounds, 16 statements met consensus as essential for both small and large DHB rheumatology services. One statement met consensus as potentially desirable for a large rheumatology service. Five statements did not reach consensus.

Conclusion

The component statements identified by consensus can inform policy and implementation of rheumatology services in the AoNZ health system reforms and be used for benchmarking.

Author Information

Hamish Nigel Gibbs: Physician and Rheumatologist, Hawke's Bay District Health Board, Hastings. Rebecca Grainger: Department of Medicine, University of Otago Wellington, Wellington; Rheumatologist, Hutt Valley District Health Board.

Acknowledgements

The authors thank Associate Professor William Taylor for support in survey distribution to members of the New Zealand Rheumatology Association. We also thank Professor Nicola Dalbeth for feedback on the survey instrument and all the rheumatologists who participated in the Delphi.

Correspondence

Rebecca Grainger: Professor, Department of Medicine University of Otago Wellington, PO Box 7343, 23a Mein St, Newtown, Wellington South 6242 New Zealand, +64 4385 5541.

Correspondence Email

rebecca.grainger@otago.ac.nz

Competing Interests

The authors declare that we are both employees of District Health Boards in New Zealand. Rebecca Granger is a rheumatologist. Hamish Gibbs did this study when he was an advanced trainee in Rheumatology. He is now a Physician employed at Hawke's Bay DHB. The authors do not believe these are potential or actual competing interests.

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2) Arthritis New Zealand. The economic cost of arthritis in New Zealand in 2018. Published August 2018. Accessed October 15, 2021. https://www.arthritis.org.nz/wp-content/uploads/Economic-Cost-of-Arthritis-in-New-Zealand-2018.pdf

3) GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1789–1858. doi:10.1016/S0140-6736(18)32279-7

4) Smolen JS, Landewé RBM, Bijlsma JWJ, Burmester GR, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis. 2020;79:685–6. doi:10.1136/annrheumdis-2019-216655.

5) Singh JA, Guyatt G, Ogdie A, Gladman DD, et al. 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis. Arthritis Rheumatol. 2019;71(1): 5-32. doi:10.1002/art.40726.

6) Ward MM, Deodhar A, Gensler LS, et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2019 Oct;71(10):1599-1613. doi:10.1002/art.41042.

7) Fanouriakis A, Kostopoulou M, Alunno A, Aringer M, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019 Jun;78(6):736-745. doi:10.1136/annrheumdis-2019-215089.

8) Mackie SL, Dejaco C, Appenzeller S, Camellino D, et al. British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis: executive summary. Rheumatology (Oxford). 2020;59:487-494. doi:10.1093/rheumatology/kez664.

9) Bech B, Primdahl J, van Tubergen A, Voshaar M, et al. 2018 update of the EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis. Ann Rheum Dis. 2020;79(1):61-68. doi:10.1136/annrheumdis-2019-215458.

10) Rausch Osthoff A-K, Niedermann K, Braun J, Adams J, et al. 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis. Ann Rheum Dis. 2018;77:1251-1260. doi:10.1136/annrheumdis-2018-213585

11) Harrison AA, Tugnet N, Taylor WJ. A survey of the New Zealand rheumatology workforce. N Z Med J. 2019 Dec 13;132(1507):70-76.

12) Harrison A. Provision of rheumatology services in New Zealand. N Z Med J. 2004; 117(1192):846.

13) National Institute for Health and Care Excellence. Rheumatoid arthritis in adults: management. Published July 11 2018. Updated October 12 2020. Accessed August 8 2021. www.nice.org.uk/guidance/ng100

14) National Institute for Health and Care Excellence. Rheumatoid arthritis in over 16’s. Quality Standard. Published date: 28 June 2013 Last updated: 09 January 2020. Accessed August 8 2021. www.nice.org.uk/guidance/qs33

15) National Institute for Health and Care Excellence. What we do. Accessed August 3 2021. NICE.org.uk/about/what-we-do

16) Cooper M, Rouhi A, Barber CEH. A systematic review of quality measures for inflammatory arthritis. J. Rheumatol. 2018;45(2):274-283. doi:10.3899/jrheum.170157

17) European Alliance of Associations for Rheumatology. Recommendations and initiatives. Accessed October 2021. https://www.eular.org/recommendations_home.cfm

18) British Society for Rheumatology. Guidelines. Accessed October 2021. https://www.rheumatology.org.uk/practice-quality/guidelines

19) American College of Rheumatology. Clinical Practice Guidelines. Accessed October 2021. https://www.rheumatology.org/Practice-Quality/Clinical-Support/Clinical-Practice-Guidelines

20) New Zealand Government: Ministry of Health, Manatū Hauora. My DHB. Last updated September 29 2016. Accessed June 2020. www.health.govt.nz/new-zealand-health-system/my-dhb

21) Diamond IR, Grant RC, Feldman BM, Pencharz PB, et al. Defining consensus: A systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol. 2014;67:401-409. doi:10.1016/j.jclinepi.2013.12.002.

22) van Eijk-Hustings Y, van Tubergen A, Boström C, Braychenko E, et al. EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis. Ann Rheum Dis. 2012;71(1):13-9

23) Van Hulst LT et al. Development of quality indicators for monitoring of the disease course in rheumatoid arthritis. Ann Rheum Dis. 2009;68:1805-10. doi:10.1136/annrheumdis-2011-200185

24) Colebatch AN, Edwards CJ, Østergaard M, et al. EULAR recommendations for the use of imaging of the joints in the clinical management of rheumatoid arthritis. Ann Rheum Dis. 2013;72:804-814. doi:10.1136/annrheumdis-2012-203158

25) Geenen R, Overman CL, Christensen R, et al. EULAR recommendations for the health professional’s approach to pain management in inflammatory arthritis and osteoarthritis. Ann Rheum Dis. 2018;77:797-807. doi:10.1136/annrheumdis-2017-212662

26) Royal College of Physicians. Consultant physicians working with patients. The duties, responsibilities and practice of physicians in medicine. Revised 5th edition 2013 (online update). Accessed January 2021. http://www.rcplondon.ac.uk/file/1578/download?token=TH8kJh7r

27) Dalbeth N, Dowell T, Gerard C, Gow P, Jackson G. Gout in Aotearoa New Zealand: the equity crisis continues in plain sight. N Z Med J. 2018;131(1485):8-12.

28) McDougall JA, Ferucci ED, Glover J, Fraenkel L. Telerheumatology: A Systematic Review. Arthritis Care Res (Hoboken). 2017;69(10):1546-1557. doi:10.1002/acr.23153

29) Mair J, Woolley M, Grainger, R. Abrupt change to telephone follow-up clinics in a regional rheumatology service during COVID-19: analysis of treatment decisions. Intern Med J. 2021. 51:960-964. doi:10.1111/imj.15336

30) Miloslavsky EM, Bolster MB. Addressing the rheumatology workforce shortage: A multifaceted approach. Semin Arthritis Rheum. 2020;50(4):791-796. doi:10.1016/j.semarthrit.2020.05.009

31) Lythgoe MP, Abraham S. Good practice in shared care for inflammatory arthritis. Br J Gen Pract. 2016;66(646):275-277. doi:10.3399/bjgp16X685177

32) New Zealand Government: Department of the Prime Minister and Cabinet (DPMC). Our health and disability system: building a stronger health and disability system that delivers for all New Zealanders. April 2021. Accessed October 2021. https://dpmc.govt.nz/sites/default/files/2021-04/heallth-reform-white-paper-summary-apr21.pdf

33) Santaguida P, Dolovich L, Oliver D, Lamarche L, et al. Protocol for a Delphi consensus exercise to identify a core set of criteria for selecting health related outcome measures (HROM) to be used in primary health care. BMC Fam Pract. 2018;19(1):152. doi:10.1186/s12875-018-0831-5

34) Hsu C-C, Sandford BA. The Delphi Technique: Making Sense of Consensus. Pract. Assess. Res. 2007;12(1). doi:10.7275/pdz9-th90

For the PDF of this article,
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Rheumatology is a medical specialty dedicated to the assessment and management of acute and chronic rheumatic diseases. Rheumatologists are trained to provide expert medical care for people with inflammatory arthritides, like psoriatic and rheumatoid arthritis, and systemic immune diseases, such as systemic lupus erythematosus and vasculitis. The management of these rheumatic diseases is often complex, and care for people with active disease requires frequent review, with defined patient-care goals and ideally a multidisciplinary approach.[[1]] Rheumatic diseases also have potential for significant morbidity, and even mortality, highlighting the need for specialist care.[[2,3]]

There are many guidelines that describe the evidence-based components of care for people with different rheumatic diseases aiming to achieve optimal health outcomes. These address many aspects of care including diagnosis and pharmacologic management, frequency and type of clinical care events, and the contribution of specific healthcare professionals (HCP) such as nurses, occupational therapists, psychologists and physiotherapists.[[4–10]] These guidelines could inform essential requirements of an evidence-based rheumatology service that provides care to optimise health outcomes for people with rheumatic disease.

In Aotearoa New Zealand (AoNZ), most rheumatology care is provided in the public health system, delivered in district health boards (DHBs), although there is a significant contribution from private practice.[[11]] Over the last 20 years, the reported number of full-time equivalent rheumatologists in public and private practice has been well below recommendations.[[11, 12]] There is also significant variation in the rheumatologists per capita between DHBs.[[11, 12]] Other aspects of rheumatology services provision, such as access to other HCPs, what services are provided by the HCP, and how these are organised, has not been reported. In addition, there are not yet agreed or recommended service benchmarks for what a rheumatology service should provide in DHBs. Benchmarks might include types of HCPs available, what types of care should be provided by these HCP, and how often.

The aim of this study was to identify consensus from rheumatologists on components of a best practice rheumatology service in DHBs in AoNZ, using an online Delphi consensus approach.

Methods

Setting and sample

Potential participants were members from the Fellow of the Royal Australasian College of Physicians (or equivalent), practicing under the scope of “rheumatologist”, who were members of the New Zealand Rheumatology Association (NZRA) as of December 2020. These rheumatologists were considered the clinical experts in comprehensive care of people with rheumatic disease.

Identification of statements from literature

The first iteration of the Delphi exercise was an ideas generation survey, to determine statements for consensus voting. The National Institute of Health and Care Excellence (NICE) guideline for the management of rheumatoid arthritis in adults 2019,[[13]] and the NICE quality standard for rheumatoid arthritis in over 16’s 2020,[[14]] were the primary sources for statements describing components of care in an optimally delivered service for care of people with rheumatoid arthritis, the most common form of autoimmune inflammatory arthritis. NICE is part of the Department of Health in the United Kingdom and develops quality stands and performance metrics for the commissioning and provision of healthcare.[[15]]

Additional statements were sourced from a recent systematic review of quality measures for inflammatory arthritis[[16]] generated by the researchers, or adapted from guidelines found in searches of major international rheumatology guideline groups pertaining to different aspects of delivery of evidence-based care in rheumatology.[[17,18,19]] The wordings of the statements were adapted slightly for consistency. Two additional statements were added to address the principles of the Treaty of Waitangi/Te Tiriti o Waitangi and addressing the aim to achieving equitable health outcomes for Māori.

Data collection

An invitation email was sent, independently of the researchers, to NZRA members in December 2020. This contained a link to an initial online survey using Qualtrics that included all the statements describing components of a best practice rheumatology service. For each statement, participants could offer free text comments. Participants were also asked for free text offering additional statements to be included in the consensus rounds. The two authors reviewed feedback, refined initial statements, and added suggested statements. The finalised list of statements was included in a consensus survey tool for the Delphi exercise.

The consensus survey link was emailed to NZRA members, independently of the researchers. Baseline, non-identifying demographic data were collected from each participant. Participants were asked to rate their agreement with each statement as it applies to the delivery of a rheumatology service in a “small DHB” and a “large DHB”. A seven-point Likert scale was used for each statement (Anchors 1 = strongly agree, 7 = strongly disagree), as well as an “I don’t know” option. A small DHB was defined as having a catchment population of less than 250,000 people, and a large DHB, a catchment population of greater than 250,000 people (Supplementary Table 1).[[20]]

The consensus survey had three rounds. After the first round only participants who had responded in full were invited to round two. For second and third rounds, only statements that had not yet met consensus were rated. Participants were provided a table summarising the distribution of the group’s ratings from the previous round and asked to re-rate each remaining statement. A reminder email was sent to non-responding participants after a week, and a further week was given to complete the survey round. Participants remained anonymous to each other throughout.

Data analysis

A statement was determined to have met consensus when ≥80% of respondent’s votes were within one of three pre-determined categories:

A. Either 1 (strongly agree), or 2 (agree)—consensus met to be considered as an essential component of rheumatology service delivery

B. Either 3 (somewhat agree), or 4 (neither agree nor disagree)—consensus met to be considered as a potentially desirable, but non-essential component of rheumatology service delivery

C. Either 5 (slightly disagree), 6 (disagree), or 7 (strongly disagree)—consensus met to be considered as a component to be avoided in rheumatology service delivery.  

The ≥80% level for consensus is consistent with previous definitions of consensus in Delphi exercises.[[21]] Ratings of “I don’t know” were excluded from the denominator. The median rating and an accompanying interquartile range (IQR), which is equal to the difference between the 25th and 75th percentiles, were calculated for each of the statements when they met consensus, or at the end of the final round of the survey.

Ethics

The study protocol was approved by the University of Otago Human Ethics Committee (D20/0257). Consent was obtained electronically before participation in the initial survey and first round of Delphi survey.

Results

The NZRA invited 76 potential participants. There were ten respondents to the initial survey of the proposed 19 statements. Four statements (statements 2, 3, 16, 19) were refined or amended on the basis of feedback received (Supplementary Table 2), and three were added (statements 20, 21, 22) leading to a total of 22 statements the consensus survey (Table 1).

The first round of the consensus survey had 30 responses, with four responses excluded as the survey was incomplete (n=3), or the respondent was not rheumatologist (n=1). The characteristics of the 26 respondents are in Table 2. Almost 2/3 (16/26, 61.5%) of participants were employed by a large DHB. Five participants in the first round did not provide an email address for participation in rounds two and three. All remaining 21 participants completed rounds two and three.

View Tables 1 & 2.

In the first consensus round, consensus was reached for nine statements (9/22, 40.9%) as essential service components for a small DHB rheumatology service, and fourteen statements (14/22, 63.6%) as essential service components for a large DHB rheumatology service. In the second round, seven further statements met consensus to be considered as essential for a small DHB service, and a further two statements for a large DHB service. In the third and final round, one further statement gained consensus to be considered as potentially desirable, but non-essential, for a large DHB service. After three rounds, the same 16 statements (16/22, 72.1%) describing best practice components of a rheumatology service had met consensus to be considered essential for both small and large services (statements 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 19, 21). One statement had met consensus to be considered potentially desirable, but non-essential, for a large DHB service but not for a small DHB service (statement 15). Of these 17 statements, 13 were derived or adapted from guidelines in the literature. The remaining five statements failed to reach consensus for any of the pre-determined agreement categories (statements 4, 17, 18, 20, 22). There were no statements that met consensus to be avoided in rheumatology service delivery.

Discussion

In this Delphi consensus exercise rheumatologists in AoNZ agreed on 16 statements describing components of a best practice rheumatology service to be considered as essential in both large and small DHB rheumatology services. One statement met consensus to be considered as potentially desirable, but non-essential, for a large DHB rheumatology service only. Most of the statements that met consensus (13/17, 75%) were sourced or adapted from existing rheumatology service recommendations.[[13, 14, 22–26]] Only one statement derived from guidelines, relating to receiving advice within one working day of contacting a rheumatology service (statement 4), failed to reach consensus. Three researcher/rheumatologist-generated statements also reached consensus as essential (14, 19, and 21). These attempted to encapsulate typical aspects of a rheumatology service that were not described in the literature and one related to the Treaty of Waitangi/Te Tiriti o Waitangi and equitable health outcomes for Māori (statement 19). Statement 19 met consensus to be considered an essential component of a rheumatology service in round two. This is of particular importance, given there is known inequity in health outcomes for some chronic rheumatologic conditions, for example gout, amongst Māori and Pacific communities in AoNZ.[[27]]

Three of the statements that failed to meet the ≥80% agreement required for consensus for any of the pre-determined categories (statements 4, 18, 20) were rated 1, 2, 3 or 4 on the seven-point Likert scale by >90% of participants, indicating the majority of rheumatologists deemed these services to be of at least “neutral” importance. Further understanding of the circumstances in which, and for whom, these service elements are important is required. For example, statement 20 related to the use of Telehealth in rheumatology, which has become more relevant during the COVID-19 related restrictions on health service delivery. While there are limited empiric data evaluating the use of telemedicine in rheumatology,[[28]] it has been adopted in emergency situations in AoNZ and provided adequate rheumatology service delivery, at least in the short term.[[29]] Since Telehealth has been proposed as a mechanism to expand reach of a limited rheumatology workforce, the implementation of Telehealth in rheumatology services, where clinically appropriate, probably warrants further consideration, even if not considered essential at this time.[[30]]

Some statements may have not reached consensus due to differences in views on scope of DHB rheumatology services in AoNZ. Statement 17, relating to provision of assessment for non-inflammatory conditions, did not reach consensus. This is consistent with previous report that only 43% of public practice rheumatologists in AoNZ accepted referrals for non-inflammatory conditions such as fibromyalgia.[[11]] In contrast, 97% of rheumatologists in private practice accepted referrals for non-inflammatory conditions. This might suggest that lack of consensus relates to differences in views on scope of DHB rheumatology services in the setting of resource constraint, rather than scope of rheumatology practice per se. There was also no consensus to consider discharging clinically stable patients with chronic rheumatic disease to primary care (statement 22) as either potentially desirable or essential. This may capture the tension between the best practice of longitudinal care of people with inflammatory rheumatic disease in specialist clinics, and the limited capacity of these services. The model of “shared-care” arrangements with primary care and rheumatology has been considered previously in the United Kingdom for stable patients with inflammatory arthritis.[[31]] Such models may require further refinements in models of collaboration between primary and secondary care in AoNZ, which are not yet adequately established.

Almost all statements of best practice care that reached consensus as essential did so for both large and small DHB rheumatology services. The only exception was statement 15, relating to the combined specialist clinics, which was not deemed essential for a small DHB service. This likely reflects the challenges of combining clinics in DHB with overall fewer specialists, perhaps also with more general scope of practice, or absence of a smaller specialties in small DHBs. It also highlights that rheumatologists expect that people of AoNZ should get access to a similar quality and scope of rheumatology care whether they reside in the catchment of West Coast DHB (~32,000 catchment population) or of Waitematā DHB (~630,000 catchment population).[[20]] These views are consistent with the vision for the New Zealand health system reforms in which excellence in care delivery includes “consistent high-quality care everywhere”.[[32]] Studies similar to this one may assist in describing what excellent care for the people of AoNZ requires.

This study has some limitations. About 1/3 (26/76, 34%) of eligible rheumatologists in AoNZ participated, so findings may not represent of the views of all rheumatologists in AoNZ. However, the response rate is in the acceptable sample size for a Delphi exercise.[[33, 34]] Furthermore, the majority of participating rheumatologists (61.5%) practiced in large DHBs, who may not fully understand the contexts for small DHBs. This study also collected the views of only one stakeholder in rheumatology service delivery, the rheumatologist. It would be important in future research to elicit views of other stakeholders, particularly users of rheumatology clinics, the patients.

In conclusion, this study has identified that 16 best practice components of a rheumatology service are considered essential in DHB rheumatology services by rheumatologists, regardless of size of DHB catchment population. These recommendations could be used to inform the development of services in Health New Zealand when this is established in July 2022 and developed into benchmarking standards for rheumatology services. The views of users of rheumatology services in DHB in AoNZ on these best practice components and other aspects of care that are important to them also need to be explored.

View Supplementary Tables 1 & 2.

Summary

Abstract

Aim

To identify consensus of rheumatologists on components of best practice rheumatology service in district health boards (DHB) in Aotearoa New Zealand (AoNZ).

Method

A consensus survey of rheumatologists in AoNZ was informed by an initial survey inviting modifications to statements about best practice rheumatology from international literature and requested additional statements. The three-round consensus email exercise asked rheumatologists to indicate their level of agreement with each statement for a DHB serving a small or large population. Consensus for each statement was achieved when ≥80% of participants’ votes were within a pre-determined category (essential, potentially desirable, to be avoided).

Results

Ten rheumatologists reviewed the 19 initial statements with three additional statements offered—the consensus survey had 22 statements. Twenty-six rheumatologists responded in the first consensus round, with 21/26 (81%) responding in rounds two and three. After three rounds, 16 statements met consensus as essential for both small and large DHB rheumatology services. One statement met consensus as potentially desirable for a large rheumatology service. Five statements did not reach consensus.

Conclusion

The component statements identified by consensus can inform policy and implementation of rheumatology services in the AoNZ health system reforms and be used for benchmarking.

Author Information

Hamish Nigel Gibbs: Physician and Rheumatologist, Hawke's Bay District Health Board, Hastings. Rebecca Grainger: Department of Medicine, University of Otago Wellington, Wellington; Rheumatologist, Hutt Valley District Health Board.

Acknowledgements

The authors thank Associate Professor William Taylor for support in survey distribution to members of the New Zealand Rheumatology Association. We also thank Professor Nicola Dalbeth for feedback on the survey instrument and all the rheumatologists who participated in the Delphi.

Correspondence

Rebecca Grainger: Professor, Department of Medicine University of Otago Wellington, PO Box 7343, 23a Mein St, Newtown, Wellington South 6242 New Zealand, +64 4385 5541.

Correspondence Email

rebecca.grainger@otago.ac.nz

Competing Interests

The authors declare that we are both employees of District Health Boards in New Zealand. Rebecca Granger is a rheumatologist. Hamish Gibbs did this study when he was an advanced trainee in Rheumatology. He is now a Physician employed at Hawke's Bay DHB. The authors do not believe these are potential or actual competing interests.

1) Woolf AD. What healthcare services do people with musculoskeletal conditions need? The role of rheumatology. Ann Rheum Dis. 2007;66:281–282. doi:10.1136/ard.2007.069443

2) Arthritis New Zealand. The economic cost of arthritis in New Zealand in 2018. Published August 2018. Accessed October 15, 2021. https://www.arthritis.org.nz/wp-content/uploads/Economic-Cost-of-Arthritis-in-New-Zealand-2018.pdf

3) GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1789–1858. doi:10.1016/S0140-6736(18)32279-7

4) Smolen JS, Landewé RBM, Bijlsma JWJ, Burmester GR, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis. 2020;79:685–6. doi:10.1136/annrheumdis-2019-216655.

5) Singh JA, Guyatt G, Ogdie A, Gladman DD, et al. 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis. Arthritis Rheumatol. 2019;71(1): 5-32. doi:10.1002/art.40726.

6) Ward MM, Deodhar A, Gensler LS, et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2019 Oct;71(10):1599-1613. doi:10.1002/art.41042.

7) Fanouriakis A, Kostopoulou M, Alunno A, Aringer M, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019 Jun;78(6):736-745. doi:10.1136/annrheumdis-2019-215089.

8) Mackie SL, Dejaco C, Appenzeller S, Camellino D, et al. British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis: executive summary. Rheumatology (Oxford). 2020;59:487-494. doi:10.1093/rheumatology/kez664.

9) Bech B, Primdahl J, van Tubergen A, Voshaar M, et al. 2018 update of the EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis. Ann Rheum Dis. 2020;79(1):61-68. doi:10.1136/annrheumdis-2019-215458.

10) Rausch Osthoff A-K, Niedermann K, Braun J, Adams J, et al. 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis. Ann Rheum Dis. 2018;77:1251-1260. doi:10.1136/annrheumdis-2018-213585

11) Harrison AA, Tugnet N, Taylor WJ. A survey of the New Zealand rheumatology workforce. N Z Med J. 2019 Dec 13;132(1507):70-76.

12) Harrison A. Provision of rheumatology services in New Zealand. N Z Med J. 2004; 117(1192):846.

13) National Institute for Health and Care Excellence. Rheumatoid arthritis in adults: management. Published July 11 2018. Updated October 12 2020. Accessed August 8 2021. www.nice.org.uk/guidance/ng100

14) National Institute for Health and Care Excellence. Rheumatoid arthritis in over 16’s. Quality Standard. Published date: 28 June 2013 Last updated: 09 January 2020. Accessed August 8 2021. www.nice.org.uk/guidance/qs33

15) National Institute for Health and Care Excellence. What we do. Accessed August 3 2021. NICE.org.uk/about/what-we-do

16) Cooper M, Rouhi A, Barber CEH. A systematic review of quality measures for inflammatory arthritis. J. Rheumatol. 2018;45(2):274-283. doi:10.3899/jrheum.170157

17) European Alliance of Associations for Rheumatology. Recommendations and initiatives. Accessed October 2021. https://www.eular.org/recommendations_home.cfm

18) British Society for Rheumatology. Guidelines. Accessed October 2021. https://www.rheumatology.org.uk/practice-quality/guidelines

19) American College of Rheumatology. Clinical Practice Guidelines. Accessed October 2021. https://www.rheumatology.org/Practice-Quality/Clinical-Support/Clinical-Practice-Guidelines

20) New Zealand Government: Ministry of Health, Manatū Hauora. My DHB. Last updated September 29 2016. Accessed June 2020. www.health.govt.nz/new-zealand-health-system/my-dhb

21) Diamond IR, Grant RC, Feldman BM, Pencharz PB, et al. Defining consensus: A systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol. 2014;67:401-409. doi:10.1016/j.jclinepi.2013.12.002.

22) van Eijk-Hustings Y, van Tubergen A, Boström C, Braychenko E, et al. EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis. Ann Rheum Dis. 2012;71(1):13-9

23) Van Hulst LT et al. Development of quality indicators for monitoring of the disease course in rheumatoid arthritis. Ann Rheum Dis. 2009;68:1805-10. doi:10.1136/annrheumdis-2011-200185

24) Colebatch AN, Edwards CJ, Østergaard M, et al. EULAR recommendations for the use of imaging of the joints in the clinical management of rheumatoid arthritis. Ann Rheum Dis. 2013;72:804-814. doi:10.1136/annrheumdis-2012-203158

25) Geenen R, Overman CL, Christensen R, et al. EULAR recommendations for the health professional’s approach to pain management in inflammatory arthritis and osteoarthritis. Ann Rheum Dis. 2018;77:797-807. doi:10.1136/annrheumdis-2017-212662

26) Royal College of Physicians. Consultant physicians working with patients. The duties, responsibilities and practice of physicians in medicine. Revised 5th edition 2013 (online update). Accessed January 2021. http://www.rcplondon.ac.uk/file/1578/download?token=TH8kJh7r

27) Dalbeth N, Dowell T, Gerard C, Gow P, Jackson G. Gout in Aotearoa New Zealand: the equity crisis continues in plain sight. N Z Med J. 2018;131(1485):8-12.

28) McDougall JA, Ferucci ED, Glover J, Fraenkel L. Telerheumatology: A Systematic Review. Arthritis Care Res (Hoboken). 2017;69(10):1546-1557. doi:10.1002/acr.23153

29) Mair J, Woolley M, Grainger, R. Abrupt change to telephone follow-up clinics in a regional rheumatology service during COVID-19: analysis of treatment decisions. Intern Med J. 2021. 51:960-964. doi:10.1111/imj.15336

30) Miloslavsky EM, Bolster MB. Addressing the rheumatology workforce shortage: A multifaceted approach. Semin Arthritis Rheum. 2020;50(4):791-796. doi:10.1016/j.semarthrit.2020.05.009

31) Lythgoe MP, Abraham S. Good practice in shared care for inflammatory arthritis. Br J Gen Pract. 2016;66(646):275-277. doi:10.3399/bjgp16X685177

32) New Zealand Government: Department of the Prime Minister and Cabinet (DPMC). Our health and disability system: building a stronger health and disability system that delivers for all New Zealanders. April 2021. Accessed October 2021. https://dpmc.govt.nz/sites/default/files/2021-04/heallth-reform-white-paper-summary-apr21.pdf

33) Santaguida P, Dolovich L, Oliver D, Lamarche L, et al. Protocol for a Delphi consensus exercise to identify a core set of criteria for selecting health related outcome measures (HROM) to be used in primary health care. BMC Fam Pract. 2018;19(1):152. doi:10.1186/s12875-018-0831-5

34) Hsu C-C, Sandford BA. The Delphi Technique: Making Sense of Consensus. Pract. Assess. Res. 2007;12(1). doi:10.7275/pdz9-th90

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Rheumatology is a medical specialty dedicated to the assessment and management of acute and chronic rheumatic diseases. Rheumatologists are trained to provide expert medical care for people with inflammatory arthritides, like psoriatic and rheumatoid arthritis, and systemic immune diseases, such as systemic lupus erythematosus and vasculitis. The management of these rheumatic diseases is often complex, and care for people with active disease requires frequent review, with defined patient-care goals and ideally a multidisciplinary approach.[[1]] Rheumatic diseases also have potential for significant morbidity, and even mortality, highlighting the need for specialist care.[[2,3]]

There are many guidelines that describe the evidence-based components of care for people with different rheumatic diseases aiming to achieve optimal health outcomes. These address many aspects of care including diagnosis and pharmacologic management, frequency and type of clinical care events, and the contribution of specific healthcare professionals (HCP) such as nurses, occupational therapists, psychologists and physiotherapists.[[4–10]] These guidelines could inform essential requirements of an evidence-based rheumatology service that provides care to optimise health outcomes for people with rheumatic disease.

In Aotearoa New Zealand (AoNZ), most rheumatology care is provided in the public health system, delivered in district health boards (DHBs), although there is a significant contribution from private practice.[[11]] Over the last 20 years, the reported number of full-time equivalent rheumatologists in public and private practice has been well below recommendations.[[11, 12]] There is also significant variation in the rheumatologists per capita between DHBs.[[11, 12]] Other aspects of rheumatology services provision, such as access to other HCPs, what services are provided by the HCP, and how these are organised, has not been reported. In addition, there are not yet agreed or recommended service benchmarks for what a rheumatology service should provide in DHBs. Benchmarks might include types of HCPs available, what types of care should be provided by these HCP, and how often.

The aim of this study was to identify consensus from rheumatologists on components of a best practice rheumatology service in DHBs in AoNZ, using an online Delphi consensus approach.

Methods

Setting and sample

Potential participants were members from the Fellow of the Royal Australasian College of Physicians (or equivalent), practicing under the scope of “rheumatologist”, who were members of the New Zealand Rheumatology Association (NZRA) as of December 2020. These rheumatologists were considered the clinical experts in comprehensive care of people with rheumatic disease.

Identification of statements from literature

The first iteration of the Delphi exercise was an ideas generation survey, to determine statements for consensus voting. The National Institute of Health and Care Excellence (NICE) guideline for the management of rheumatoid arthritis in adults 2019,[[13]] and the NICE quality standard for rheumatoid arthritis in over 16’s 2020,[[14]] were the primary sources for statements describing components of care in an optimally delivered service for care of people with rheumatoid arthritis, the most common form of autoimmune inflammatory arthritis. NICE is part of the Department of Health in the United Kingdom and develops quality stands and performance metrics for the commissioning and provision of healthcare.[[15]]

Additional statements were sourced from a recent systematic review of quality measures for inflammatory arthritis[[16]] generated by the researchers, or adapted from guidelines found in searches of major international rheumatology guideline groups pertaining to different aspects of delivery of evidence-based care in rheumatology.[[17,18,19]] The wordings of the statements were adapted slightly for consistency. Two additional statements were added to address the principles of the Treaty of Waitangi/Te Tiriti o Waitangi and addressing the aim to achieving equitable health outcomes for Māori.

Data collection

An invitation email was sent, independently of the researchers, to NZRA members in December 2020. This contained a link to an initial online survey using Qualtrics that included all the statements describing components of a best practice rheumatology service. For each statement, participants could offer free text comments. Participants were also asked for free text offering additional statements to be included in the consensus rounds. The two authors reviewed feedback, refined initial statements, and added suggested statements. The finalised list of statements was included in a consensus survey tool for the Delphi exercise.

The consensus survey link was emailed to NZRA members, independently of the researchers. Baseline, non-identifying demographic data were collected from each participant. Participants were asked to rate their agreement with each statement as it applies to the delivery of a rheumatology service in a “small DHB” and a “large DHB”. A seven-point Likert scale was used for each statement (Anchors 1 = strongly agree, 7 = strongly disagree), as well as an “I don’t know” option. A small DHB was defined as having a catchment population of less than 250,000 people, and a large DHB, a catchment population of greater than 250,000 people (Supplementary Table 1).[[20]]

The consensus survey had three rounds. After the first round only participants who had responded in full were invited to round two. For second and third rounds, only statements that had not yet met consensus were rated. Participants were provided a table summarising the distribution of the group’s ratings from the previous round and asked to re-rate each remaining statement. A reminder email was sent to non-responding participants after a week, and a further week was given to complete the survey round. Participants remained anonymous to each other throughout.

Data analysis

A statement was determined to have met consensus when ≥80% of respondent’s votes were within one of three pre-determined categories:

A. Either 1 (strongly agree), or 2 (agree)—consensus met to be considered as an essential component of rheumatology service delivery

B. Either 3 (somewhat agree), or 4 (neither agree nor disagree)—consensus met to be considered as a potentially desirable, but non-essential component of rheumatology service delivery

C. Either 5 (slightly disagree), 6 (disagree), or 7 (strongly disagree)—consensus met to be considered as a component to be avoided in rheumatology service delivery.  

The ≥80% level for consensus is consistent with previous definitions of consensus in Delphi exercises.[[21]] Ratings of “I don’t know” were excluded from the denominator. The median rating and an accompanying interquartile range (IQR), which is equal to the difference between the 25th and 75th percentiles, were calculated for each of the statements when they met consensus, or at the end of the final round of the survey.

Ethics

The study protocol was approved by the University of Otago Human Ethics Committee (D20/0257). Consent was obtained electronically before participation in the initial survey and first round of Delphi survey.

Results

The NZRA invited 76 potential participants. There were ten respondents to the initial survey of the proposed 19 statements. Four statements (statements 2, 3, 16, 19) were refined or amended on the basis of feedback received (Supplementary Table 2), and three were added (statements 20, 21, 22) leading to a total of 22 statements the consensus survey (Table 1).

The first round of the consensus survey had 30 responses, with four responses excluded as the survey was incomplete (n=3), or the respondent was not rheumatologist (n=1). The characteristics of the 26 respondents are in Table 2. Almost 2/3 (16/26, 61.5%) of participants were employed by a large DHB. Five participants in the first round did not provide an email address for participation in rounds two and three. All remaining 21 participants completed rounds two and three.

View Tables 1 & 2.

In the first consensus round, consensus was reached for nine statements (9/22, 40.9%) as essential service components for a small DHB rheumatology service, and fourteen statements (14/22, 63.6%) as essential service components for a large DHB rheumatology service. In the second round, seven further statements met consensus to be considered as essential for a small DHB service, and a further two statements for a large DHB service. In the third and final round, one further statement gained consensus to be considered as potentially desirable, but non-essential, for a large DHB service. After three rounds, the same 16 statements (16/22, 72.1%) describing best practice components of a rheumatology service had met consensus to be considered essential for both small and large services (statements 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 19, 21). One statement had met consensus to be considered potentially desirable, but non-essential, for a large DHB service but not for a small DHB service (statement 15). Of these 17 statements, 13 were derived or adapted from guidelines in the literature. The remaining five statements failed to reach consensus for any of the pre-determined agreement categories (statements 4, 17, 18, 20, 22). There were no statements that met consensus to be avoided in rheumatology service delivery.

Discussion

In this Delphi consensus exercise rheumatologists in AoNZ agreed on 16 statements describing components of a best practice rheumatology service to be considered as essential in both large and small DHB rheumatology services. One statement met consensus to be considered as potentially desirable, but non-essential, for a large DHB rheumatology service only. Most of the statements that met consensus (13/17, 75%) were sourced or adapted from existing rheumatology service recommendations.[[13, 14, 22–26]] Only one statement derived from guidelines, relating to receiving advice within one working day of contacting a rheumatology service (statement 4), failed to reach consensus. Three researcher/rheumatologist-generated statements also reached consensus as essential (14, 19, and 21). These attempted to encapsulate typical aspects of a rheumatology service that were not described in the literature and one related to the Treaty of Waitangi/Te Tiriti o Waitangi and equitable health outcomes for Māori (statement 19). Statement 19 met consensus to be considered an essential component of a rheumatology service in round two. This is of particular importance, given there is known inequity in health outcomes for some chronic rheumatologic conditions, for example gout, amongst Māori and Pacific communities in AoNZ.[[27]]

Three of the statements that failed to meet the ≥80% agreement required for consensus for any of the pre-determined categories (statements 4, 18, 20) were rated 1, 2, 3 or 4 on the seven-point Likert scale by >90% of participants, indicating the majority of rheumatologists deemed these services to be of at least “neutral” importance. Further understanding of the circumstances in which, and for whom, these service elements are important is required. For example, statement 20 related to the use of Telehealth in rheumatology, which has become more relevant during the COVID-19 related restrictions on health service delivery. While there are limited empiric data evaluating the use of telemedicine in rheumatology,[[28]] it has been adopted in emergency situations in AoNZ and provided adequate rheumatology service delivery, at least in the short term.[[29]] Since Telehealth has been proposed as a mechanism to expand reach of a limited rheumatology workforce, the implementation of Telehealth in rheumatology services, where clinically appropriate, probably warrants further consideration, even if not considered essential at this time.[[30]]

Some statements may have not reached consensus due to differences in views on scope of DHB rheumatology services in AoNZ. Statement 17, relating to provision of assessment for non-inflammatory conditions, did not reach consensus. This is consistent with previous report that only 43% of public practice rheumatologists in AoNZ accepted referrals for non-inflammatory conditions such as fibromyalgia.[[11]] In contrast, 97% of rheumatologists in private practice accepted referrals for non-inflammatory conditions. This might suggest that lack of consensus relates to differences in views on scope of DHB rheumatology services in the setting of resource constraint, rather than scope of rheumatology practice per se. There was also no consensus to consider discharging clinically stable patients with chronic rheumatic disease to primary care (statement 22) as either potentially desirable or essential. This may capture the tension between the best practice of longitudinal care of people with inflammatory rheumatic disease in specialist clinics, and the limited capacity of these services. The model of “shared-care” arrangements with primary care and rheumatology has been considered previously in the United Kingdom for stable patients with inflammatory arthritis.[[31]] Such models may require further refinements in models of collaboration between primary and secondary care in AoNZ, which are not yet adequately established.

Almost all statements of best practice care that reached consensus as essential did so for both large and small DHB rheumatology services. The only exception was statement 15, relating to the combined specialist clinics, which was not deemed essential for a small DHB service. This likely reflects the challenges of combining clinics in DHB with overall fewer specialists, perhaps also with more general scope of practice, or absence of a smaller specialties in small DHBs. It also highlights that rheumatologists expect that people of AoNZ should get access to a similar quality and scope of rheumatology care whether they reside in the catchment of West Coast DHB (~32,000 catchment population) or of Waitematā DHB (~630,000 catchment population).[[20]] These views are consistent with the vision for the New Zealand health system reforms in which excellence in care delivery includes “consistent high-quality care everywhere”.[[32]] Studies similar to this one may assist in describing what excellent care for the people of AoNZ requires.

This study has some limitations. About 1/3 (26/76, 34%) of eligible rheumatologists in AoNZ participated, so findings may not represent of the views of all rheumatologists in AoNZ. However, the response rate is in the acceptable sample size for a Delphi exercise.[[33, 34]] Furthermore, the majority of participating rheumatologists (61.5%) practiced in large DHBs, who may not fully understand the contexts for small DHBs. This study also collected the views of only one stakeholder in rheumatology service delivery, the rheumatologist. It would be important in future research to elicit views of other stakeholders, particularly users of rheumatology clinics, the patients.

In conclusion, this study has identified that 16 best practice components of a rheumatology service are considered essential in DHB rheumatology services by rheumatologists, regardless of size of DHB catchment population. These recommendations could be used to inform the development of services in Health New Zealand when this is established in July 2022 and developed into benchmarking standards for rheumatology services. The views of users of rheumatology services in DHB in AoNZ on these best practice components and other aspects of care that are important to them also need to be explored.

View Supplementary Tables 1 & 2.

Summary

Abstract

Aim

To identify consensus of rheumatologists on components of best practice rheumatology service in district health boards (DHB) in Aotearoa New Zealand (AoNZ).

Method

A consensus survey of rheumatologists in AoNZ was informed by an initial survey inviting modifications to statements about best practice rheumatology from international literature and requested additional statements. The three-round consensus email exercise asked rheumatologists to indicate their level of agreement with each statement for a DHB serving a small or large population. Consensus for each statement was achieved when ≥80% of participants’ votes were within a pre-determined category (essential, potentially desirable, to be avoided).

Results

Ten rheumatologists reviewed the 19 initial statements with three additional statements offered—the consensus survey had 22 statements. Twenty-six rheumatologists responded in the first consensus round, with 21/26 (81%) responding in rounds two and three. After three rounds, 16 statements met consensus as essential for both small and large DHB rheumatology services. One statement met consensus as potentially desirable for a large rheumatology service. Five statements did not reach consensus.

Conclusion

The component statements identified by consensus can inform policy and implementation of rheumatology services in the AoNZ health system reforms and be used for benchmarking.

Author Information

Hamish Nigel Gibbs: Physician and Rheumatologist, Hawke's Bay District Health Board, Hastings. Rebecca Grainger: Department of Medicine, University of Otago Wellington, Wellington; Rheumatologist, Hutt Valley District Health Board.

Acknowledgements

The authors thank Associate Professor William Taylor for support in survey distribution to members of the New Zealand Rheumatology Association. We also thank Professor Nicola Dalbeth for feedback on the survey instrument and all the rheumatologists who participated in the Delphi.

Correspondence

Rebecca Grainger: Professor, Department of Medicine University of Otago Wellington, PO Box 7343, 23a Mein St, Newtown, Wellington South 6242 New Zealand, +64 4385 5541.

Correspondence Email

rebecca.grainger@otago.ac.nz

Competing Interests

The authors declare that we are both employees of District Health Boards in New Zealand. Rebecca Granger is a rheumatologist. Hamish Gibbs did this study when he was an advanced trainee in Rheumatology. He is now a Physician employed at Hawke's Bay DHB. The authors do not believe these are potential or actual competing interests.

1) Woolf AD. What healthcare services do people with musculoskeletal conditions need? The role of rheumatology. Ann Rheum Dis. 2007;66:281–282. doi:10.1136/ard.2007.069443

2) Arthritis New Zealand. The economic cost of arthritis in New Zealand in 2018. Published August 2018. Accessed October 15, 2021. https://www.arthritis.org.nz/wp-content/uploads/Economic-Cost-of-Arthritis-in-New-Zealand-2018.pdf

3) GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1789–1858. doi:10.1016/S0140-6736(18)32279-7

4) Smolen JS, Landewé RBM, Bijlsma JWJ, Burmester GR, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis. 2020;79:685–6. doi:10.1136/annrheumdis-2019-216655.

5) Singh JA, Guyatt G, Ogdie A, Gladman DD, et al. 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis. Arthritis Rheumatol. 2019;71(1): 5-32. doi:10.1002/art.40726.

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