EULAR ‘points to consider’ for the conduction of workforce requirement studies in rheumatology

Background EULAR has developed recommendations for early referral, diagnosis and treatment of rheumatic and musculoskeletal diseases (RMD). These recommendations can only be implemented if sufficient manpower is available. An estimation of how many rheumatologists are needed to meet population needs must be provided in order to counsel health care planners and decision makers. Current methods used for forecasting manpower are disparate, with projections varying by a factor of five between studies. 11/01/2019

Objective/Target population To provide EULAR endorsed ‘points to consider’ for the methodology of future workforce requirement studies for adult rheumatologists. The targeted audiences are health care planners, epidemiologists, health professionals, politicians, rheumatologists, payers and patient organisations. 11/01/2019

Methods/methodological approach EULAR Standardised Operating Procedures were followed. A systematic literature review was conducted to retrieve workforce models in rheumatology and other medical fields. Based on expert opinion informed by the SLR, the task force consisting of 20 experts from 11 EULAR countries and the USA developed recommendations, with consensus obtained through informal voting. The final level of agreement was voted anonymously. 11/01/2019

Stakeholder involvement Stakeholder involvement in workforce studies is essential; however, the perception of which stakeholders are relevant may vary between countries. The task force suggests including representatives from different geographic regions and involving at minimum rheumatologists, patient representatives, politicians and health care planners. Stakeholders have an advisory role in the selection of model and parameters, interpretation, as well as consideration of scenarios for uncertainty analysis. They may serve as interviewees for qualitative (sub-)studies when empiric data are absent. 11/01/2019

Individual Recommendations Reco 1: Workforce models should integrate supply, demand and need of the respective geopolitical entity (e.g. municipality, region, state, country), and should express results as full time equivalents and as number of rheumatologists. Reco 2: Workforce models should provide projections over a period of 5-15 years. Reco 3: Workforce models should not assume a current balance between supply and need. Reco 4: Workforce models should, where possible, rely on several data sources and include uncertainty analyses. 11/01/2019

Individual Recommendations Reco 5: Workforce models should be regularly updated; updates should include an analysis of the actual performance (i.e. prediction validity) of the previous model. Reco 6: Workforce need for patient care should be based on the prevalence and referral rates of diseases managed by rheumatologists as well as on an estimation of time needed per patient. Reco 7: Workforce need for patient care should consider current and future demographics, sociocultural characteristics of the population and disease patterns. 11/01/2019

Individual Recommendations Reco 8: Workforce need and supply should consider work outside rheumatology patient care (e.g. administrative tasks, research, teaching, non-rheumatologic disease management), as well as patient care performed by other health professionals in rheumatology. Reco 9: Workforce supply should account for demographic composition of rheumatologists, the number of rheumatologists entering and leaving the workforce, and generational attitudes of rheumatologists towards scope of practice and work-life balance. Reco 10: Workforce models should consider the effects of medical developments, including new technologies, medications, artificial intelligence and e-health, on demand and supply. 11/01/2019

Summary Table Oxford Level of Evidence None of the studies identified corresponded to any of the categories of Oxford Centre for Evidence-Based Medicine (OCEBM)1. Evidence level (possible range 1-5) was therefore set as “5” (=mechanism- based reasoning), which is the lowest level of evidence, for all points to consider. 1OCEBM Levels of Evidence Working Group. The Oxford 2011 Levels of Evidence. 2011.http://www.cebm.net/index.aspx?o=5653 11/01/2019

Summary of Recommendations No. Statement LoE LoA 1 Workforce models should integrate supply, demand and need of the respective geopolitical entity (e.g. municipality, region, state, country), and should express results as full time equivalents and as number of rheumatologists. 5 9.5 (0.9) 2 Workforce models should provide projections over a period of 5-15 years. 9.1 (1.1) 3 Workforce models should not assume a current balance between supply and need. 9.6 (0.7) 4 Workforce models should, where possible, rely on several data sources and include uncertainty analyses. 9.8 (0.4) Workforce models should be regularly updated; updates should include an analysis of the actual performance (i.e. prediction validity) of the previous model. 9.5 (0.6) 6 Workforce need for patient care should be based on the prevalence and referral rates of diseases managed by rheumatologists as well as on an estimation of time needed per patient. 9.7 (0.7) 7 Workforce need for patient care should consider current and future demographics, sociocultural characteristics of the population and disease patterns. 8 Workforce need and supply should consider work outside rheumatology patient care (e.g. administrative tasks, research, teaching, non-rheumatologic disease management), as well as patient care performed by other health professionals in rheumatology. 9.4 (0.9) 9 Workforce supply should account for demographic composition of rheumatologists, the number of rheumatologists entering and leaving the workforce, and generational attitudes of rheumatologists towards scope of practice and work-life balance. 9.1 (2.3) 10 Workforce models should consider the effects of medical developments, including new technologies, medications, artificial intelligence and e-health, on demand and supply. 9.4 (1.1) Numbers in column ‘LoA’ indicate the mean and SD (in parentheses) of the LoA, as well as the percentage of task force members with an agreement ≥8. LoA, Level of Agreement; LoE, Level of Evidence according to OCEBM 2011 levels of evidence. 11/01/2019

Summary of Recommendations (lay format) Workforce studies are intended to model need/demand for, and supply of rheumatologists to provide manpower targets of rheumatologists. Workforce prediction models should integrate factors related to supply with rheumatologists and those associated with demand/need for rheumatologic care. Predictions should provide projections over a period of 5-15 years and should undergo regular update. A balance of supply with rheumatologists and need for rheumatologic care at baseline should not be assumed. 11/01/2019

Summary of Recommendations (lay format) Projections of workforce requirements should consider all factors relevant for current and future workload in rheumatology in- [e.g. out- patient clinics, night shifts] and outside [e.g. teaching, research, administration] of direct patient care. Forecasts of workforce supply should consider demography and attrition of rheumatologists [e.g. change to another specialty or to another profession], as well as the effects of new developments in health care. Predictions of future need/demand should take demographic, sociocultural and epidemiologic development of the population into account. 11/01/2019

Next steps and research agenda It is anticipated that these PTC will be used as a basis for future workforce studies, which are then translated into political actions. Other medical specialties might use these PTC, as well. It should be studied how to integrate workforce calculation for rheumatologists, other medical disciplines and non-physician HCPs. It should be studied what are the most influential factors to be included in workforce models; how to quantify the relative importance of various items (weighting) included in workforce models. Methods should be developed for the validation of workforce models. 11/01/2019

Task force members Convenors: Christian Dejaco, Frank Buttgereit Methodologist: Sofia Ramiro Fellows: Polina Putrik, Julia Unger Health Care Professional: Tanja Stamm Patients representative: Dieter Wiek  EMEUNET members: Francisca Sivera, Sofia Ramiro, Christian Dejaco Task force members: Daniel Aletaha, Gerolamo Bianchi, Johannes W. Bijlsma, Annelies Boonen, Nada Cikes, Axel Finck, Laure Gossec, Tore K. Kvien, Joao Madruga Dias, Eric L. Matteson, Zoltan Szekanecz, Angela Zink 11/01/2019

Acknowledgements This work was supported by a grant from EULAR (EPI016). We thank Louise Falzon for their help with the literature search and Federico Torres for his support in the communication with Public Affairs section of EULAR. 11/01/2019