Supply factors used in rheumatology workforce studies
| Author, year | Clinical setting42 | Time spent on clinical (rheumatological) care43 | Source of data for estimating of % of patient care in rheumatology* | Tasks delegated to other health professionals in rheumatology (HP)44 | Demographic trends in workforce45 | Entry and exit from the profession46 | Source of information for in- and outflow of medical graduates* | Result presented in number of rheumatologists and/or clinical FTEs47 |
| Ogryzlo, 197526 | Not stated
| Not stated48 | Not stated | Not stated
| Not stated
| Attrition rate of training programme
| Not stated | Number of rheumatologists
|
| Marder et al, 199114 | Ambulatory and hospital (outpatient only)
| ~80%–85% of working time49 | Not stated | Per morbidity indicated the expected number of visits delegated to a non-physician member of the office staff: PsA, RA, SpA, OA, OP 5%–15% of visits
| Retirement and death due to age
| Projected number of new entrants
| Historical trends | Number of rheumatologists
|
| Deal et al, 200715 | Not stated
| ~90% of rheumatologists see patients
| Not stated | About 25% of rheumatologists are working with a NP or PA
| Female and older rheumatologists have less visits, younger doctors tend to work less hours
| Number and fill rate of rheumatology positions, including foreign students
| Council of Graduate Medical Education | Number of rheumatologists
|
| Zummer and Henderson, 200018 | Not stated
| Not stated
| Not stated | Not stated
| Over 50% of rheumatologists are >50, and 15% will retire in next 10 years
| Number of trainees in relation to current vacancies, number of graduated specialists that will practice out of Canada
| Survey by the Economics and Manpower Committee of the Canadian Rheumatology Association | Number of rheumatologists
|
| Edworthy, 200019 | Community, academic, administrator
| 5%–80% of working time50 | Not stated | Not stated
| Not stated
| Attrition rate including illness, emigration (estimated at 10%), number of new graduates entering the market
| Not stated | Number of rheumatologists
|
| Hanly, 200120 | Academic
| ~50%–60% of working time
| Not stated | Not stated
| The ‘greying’ of the physicians, changing lifestyles and expectations of young physicians, increasing proportion of women
| Not stated
| Not stated | Number of rheumatologists and clinical FTE
|
| Raspe, 199522 | Hospital, private practice, centres of excellence (outpatient only)
| 45 hours/week
| Not stated | Primary care specialist51 | Not stated
| Not stated
| Not stated | Number of rheumatologists
|
| German Society for Rheumatology, Committee for Care, 200821 | Outpatient clinic
| 75% of working time52 | Not stated | Not stated
| Not stated
| Not stated
| Not stated | Number of rheumatologists
|
| Làzaro y De Mercado, 201325 | Academic, non-academic, private practice
| 78.4% of working time53 | Survey among rheumatologists | Not stated
| Age and gender of current and future workforce taken into account
| Number of residents that graduates each year
| Not stated | Number of rheumatologists
|
| Committee of Rheumatology, 198823 | General hospital
| Not stated54 | Not stated | Junior medical staff House officer: 0.5 FTE per consultant, secretarial and administrative support 1 FTE per consultant
| Not stated
| Not stated
| Not stated | Number of rheumatologists
|
| Rowe et al, 201324 | Community (rheumatologist, rheumatologist with GIM), academic
| 25%–65%55 | Programmed activities based on British Society of Rheumatology recommendations | Shared care between primary and secondary care necessary but dependent on the existence of intermediate care56 | Not stated
| Not stated
| Not stated | Number of rheumatologists
|
| American College of Rheumatology, 201538 | Academic (80%) and non-academic (20%)
| Academic setting 1 doctor=0.5 clinical FTE Non-academic setting 1 doctor=1 FTE 
| Expert consensus | Include number of NP and PA in the modelling
| Workforce is ageing; women work 7 hours less per week and see 30% less patients. Share of women increasing
| Number and fill rate of rheumatology positions, drop-out, number of those who will practise outside USA
| Survey and data from American Medical Association (AMA) | Number of rheumatologists and clinical FTE
|
| HRSA Health Workforce, 201516 | 7 settings: Emergency rooms, hospitals, provider offices, outpatient departments, home health, nursing homes, residential facilities
| Not stated
| Not stated | Not stated
| Age and gender distribution of the workforce taken into account57 | Number of newly trained doctors entering the market
| AMA Masterfile for physicians, the Association of American Medical Colleges (AAMC) 2012–2013 Graduate Medical Education Census, Physician Assistant Education Association survey | Number of rheumatologists and clinical FTE
|
| German Society for Rheumatology, 20177 | Hospital, private practice, rehabilitation centres
| Of a total of 54 hours/per week, 38 hours patient work58 | Source are given for the definition of the number of working hours/week and the time dedicated to rheumatology care | Not stated
| Rheumatologists are ageing and many will retire soon
| Not stated
| Not stated | Number of rheumatologists and clinical FTE
|
The risk of bias scores: red dot (
)=high risk of bias, indicating that the factor has not been considered or considered in an inadequate way, in workforce prediction model; orange dot ()=moderate risk of bias, when a factor has been considered with limitations; green dot ()=low risk of bias and corresponds to a well-considered factor in sufficient level of detail and based on a reliable evidence. Detailed description of grading system is presented in online supplementary table S7.(1) Considering more than one level of setting for the calculation of workforce supply improves the accuracy of the projections.
(2) Accurate projections require the percentage of time spent on clinical care by making estimations for the number, durations and types of visits, using more than one data source.
(3) Possible task shifting with HP is relevant for workforce calculation and can rely on data or formal expert consensus.
(4) More than one demographic trends like ageing and millennial trend should be considered for forecasting.
(5) The accuracy of the model can be increased by considering more than one entry and exit factor, using more than one data source.
(6) Projected number of rheumatologists and clinical FTEs should be explicit from the calculations.
(7) According to author’s statement calculation adjusted for clinical care, research and teaching; 2000 rheumatologists in USA from which 1700 are practising, 300 are teaching/researchers; same proportions are assumed for Canada.
(8) Authors estimate a ~15%–20% extra number of rheumatologist to compensate for ‘other activities’ including research and education.
(9) Authors assume that community based rheumatologists use 80% of a 55-hour week (=44 hours) for clinical visits, 20% for administrative work and education; academic rheumatologists use 25% of a 60-hour week (=15 hours) for clinical visits and 75% for administration, research and training; administrators use 5% of a 60-hour week (=3 hours) for clinical visits and 95% for administrative work and work with complex medical systems and provincial organisations. A total of 46 working weeks/year is assumed (5-week vacation, 1 week conference).
(10) Authors provide a diagram on patients’ flow from primary to specialist care and vice versa; however, the effect of this diagram on the number of visits/rheumatologists required was not provided.
(11) Authors estimate that out of a 10-hour working day, 7.5 hours will be available for clinical visits.
(12) According to the survey performed the following activities reduce the time for clinical visits: research, teaching, scientific sessions, training, congresses, institutional participation and other activities.
(13) All rheumatologists spend time on development and maintenance of educational programmes for continuing education of general practitioners and colleagues in other specialties and for other health professionals.
(14) Community-based rheumatologist: 55% of working time for clinics, 10% ward work, inpatient referrals, day unit and multidisciplinary team meeting (MDT) support, 10% administrative work, 25% supporting professional activities (teaching, training, appraisal, audit, clinical governance, CPD (continuing professional development), revalidation, research, departmental management and service, development); community-based rheumatologist with general internal medicine: 45% of working time for clinics, 18% for GIM and specialty ward round, inpatient referrals, day unit and MDT support, 9% for patient-related administration, relatives and contact, 9% for peri-take and post-take ward rounds weekdays and weekends, 19% for teaching, training, appraisal, audit, clinical governance, revalidation, research, departmental management and service development; academic rheumatologist: 15% special clinics, 10% inpatient referral and ward work, 50% full academic sessions, 25% supporting professional activities; a 20%–25% reduction of patients per clinic is suggested in case a consultant is involved in teaching junior staff, students or supervising nurse clinics.
(15) Local CATS (intermediate services between primary and secondary care known as Clinical Assessment and Treatment services) and the possibility to involve general practitioners, the introduction of nurse-led clinics, telephone follow-up clinics or electronic advice to general practitioners.
(16) Assumed that current rates of workforce participation will remain stable into the future (2025).
(17) Considered the number of working hours/week and the percentage of rheumatologists who are working in the hospital or as freelancer.
*Risk of bias related to the data source is taken into account in scoring of the respective factor.
CPD, continuing professional development; FTE, full-time equivalent; GIM, general internal medicine; NP, nurse practitioner; OA, osteoarthritis; OP, Osteoporosis; PA, physician assistant; PsA, psoriatic arthritis; RA, Rheumatoid arthritis; SpA, Spondyloarthritis.
