The ratio of nurse consultation and physician efficiency index of senior rheumatologists is significantly higher than junior physicians in rheumatology residency training: A new efficiency measure in a cohort, exploratory study

To elucidate the difference between ratios of nurse consultation sought by senior rheumatologists and junior physicians in rheumatology residency training, and also to evaluate physician efficiency index respecting patients with rheumatoid arthritis (RA). Data regarding outpatient visits for RA patients between November 2013 and 2015 were extracted. The mean interval (day) between consultations, the nurse/physician visits ratio, and physician efficiency index (nurse/physician visits ratio × mean interval) for each senior and junior physicians were calculated. Disease Activity Score in 28 joints-C-Reactive Protein (DAS28-CRP) and Health Assessment Questionnaire (HAQ) scores were used to monitor treatment outcome. Therefore, DAS28 and HAQ scores were measured 3 times: firstly at physician consultation, then after nurse consultation, and finally at the third visit, either at a nurse or physician consultation. Of 6046 visits, 3699 visits, planned by 11 physicians (4 specialists and 7 junior physicians), were included. These numbers of visits belonged to 672 RA patients, among which 431 (64.1%) patients were female, the mean age being 64.9 ± 14.1 years, and DAS28 at baseline was 4.5 ± 1.2. The nurse/physician visits ratio (P = .01) and mean efficiency index (P = .04) of senior rheumatologists were significantly higher than that of junior physicians. Regression analysis showed a positive correlation between physician postgraduate experience and physician efficiency index adjusted for DAS28 at baseline and number of patients for each physician (regression coefficient 5.427, 95% confidence interval 1.068–9.787, P = .022). There was a high correlation between physicians’ postgraduate experience (year) and the ratio of nurse/physician visits (r = 0.91, P < .001), and also physician efficiency index (r = 0.94, P < .001). Nurse consultation did not contribute to worsening treatment outcome, since DAS28 and HAQ scores were significantly decreased if physician visits were followed by nurse visits (P = .004 for DAS28 and P = .025 for HAQ). If junior physicians are supervised to refer RA patients with milder and sufficient treatment plan to nurses, the entire department operates more efficiently, leading to prevent additional expenses (due to the differences in yearly salary of physicians and nurses) and human resource waste. Quality of care should be monitored by markers of disease activity and CRP.