Table 1
Description of The Rheumatology-Gastroenterology clinic, Silkeborg Regional Hospital, structured with inspiration from the Template for Intervention Description and Replication (TIDieR) checklist and guide [36].
| 1. Brief name | ReGa – Integrated Rheumatology-Gastroenterology Clinic |
| 2. Why | The rationale for the ReGa clinic is based on the organisational need to create continuity in patient pathways for patients with multiple autoimmune diseases, the clinical need to coordinate treatment for the patient group and the patient’s needs for an individualised person-centred approach. |
| The Danish healthcare system is highly specialised. Systematic challenges arise in particular for patients with multiple chronic diseases, where patients typically are assigned to several distinct departments, with each disease treated separately by different specialists [2]. The presence of one autoimmune disease increases the risk of developing multiple autoimmune diseases, such as in patients with both IBD and IJD. This combination often requires complex treatment with contraindicated medications as a medical challenge [16]. The co-occurrence also affects several aspects of patients’ lives, including challenges in family life, work life and treatment in healthcare [8]. | |
| To address these challenges, several different elements were considered. A multidisciplinary approach with both specialties was chosen to ensure coherence and the right treatment. Furthermore, the clinic was inspired by the person-centred care model, where a human and value-based approach involves the patient as an active part of their care/treatment and in the decision-making process [37]. | |
| The focus is on the patient’s problems and not their diagnoses. | |
| ReGa is thus an attempt to adapt the system to the patients. By doing so, patients’ needs for coordination of care and treatment are accommodated while focusing on the individual rather than the disease. Another assumption is a temporal benefit for both patients and professionals, as care for both conditions is provided simultaneously. | |
| 3. What – materials | A consultation room in the Department of Rheumatology. |
| 4. What – procedures | Patients and any accompanying relatives are met in the waiting area by the clinic’s rheumatologist. The rheumatologist retrieves the patient, allowing for an immediate observation and impression of physical functioning, in particular, how the patient rises from the chair and walks into the consultation room. |
| The gastroenterologist starts by asking questions about the patient’s inflammatory bowel disease. Subsequently, the rheumatologist asks questions about the patient’s inflammatory rheumatic disease and performs joint examinations if necessary. | |
| The consultation flow typically reflect the chronological order in which the patient’s conditions were diagnosed, as most have lived with IBD for many years prior to developing a rheumatic disease. | |
| The doctors occasionally supplement one another, and the consultation unfolds as a shared dialogue all participants. The conversation with the patient typically includes disease status, results from tests or scans, and follow-up or adjustment of medical treatment. Using illustrations of the intestinal and skeletal systems, the doctors provide patient education on their conditions, including how and why their autoimmune diseases develop. The conversations also include discussion of the patient’s work and family life. | |
| 5. Who provided | The resources in ReGa consist of an experienced doctor and a nurse from both gastroenterology and rheumatology departments. Booking and coordinating appointments is managed by a nurse from the rheumatology department. |
| 6. How | The multidisciplinary approach consists of a face-to-face model, where the two doctors see the patients at the same time, in the same room. Occasionally, contact is also made by telephone, either on the patient’s or healthcare professional’s initiative. |
| 7. Where | The ReGa Clinic takes place at the outpatient Department of Rheumatology at Medical Diagnostic Centre, Silkeborg Regional Hospital, Denmark. |
| Patients are primarily referred from the rheumatology and gastroenterology departments at Silkeborg Regional Hospital. Referrals are occasionally also sent from other hospitals within and outside the region, and in some cases, patients request enrolment after learning about the clinic. | |
| 8. When and How much | Newly referred patients are scheduled for one hour, while follow-up visits last half an hour. This allows additional time to conduct thorough examinations within each speciality and develop a joint treatment plan. Based on the first assessment, patients are referred to the gastroenterology or rheumatology department or invited to continue in the ReGa clinic. |
| The clinic is open for patients on a monthly basis. | |
| Patients can reach the specialists by contacting the rheumatology or gastroenterology departments from 8 AM to 4 PM on weekdays. | |
| 9. Tailoring | The number of clinic visits and the duration of treatment depend on the individual patient and the complexity of their diseases. The course of treatment is therefore, based on medical need and specialist assessment. |
| 10. Modifications | During the pilot phase, an increasing need became apparent as referral rates increased. Consequently, the number of appointments was expanded along with the addition of two nurses, and the ReGa clinic now sees patients regularly every month. |
Figure 1
Flowchart of Patient Pathways in the Rheumatology-Gastroenterology clinic, Silkeborg Regional Hospital.
Table 2
Characteristics of patients attending The Rheumatology-Gastroenterology clinic, Silkeborg Regional Hospital n = 54.
| Gender (male), n (%) | 31 (57.4) |
| Age at baseline (years), n (%) | |
| 20–29 | 8 (14.8) |
| 30–39 | 12 (22.2) |
| 40–49 | 15 (27.8) |
| 50–59 | 12 (22.2) |
| 60+ | 7 (13) |
| Number of outpatient visits in ReGa pr. patient, n (%) | |
| 1 | 38 (70.4) |
| 2–4 | 14 (25.9) |
| 5–6 | 2 (3.7) |
| Length of patient pathway in years, n (%) | |
| <1 | 45 (83.3) |
| 1 | 2 (3.7) |
| 2 | 5 (9.3) |
| 3 | 2 (3.7) |
| Total outpatient contacts during the study period, n | 1601 |
| Number of outpatient contacts pr. patient, mean (min-max) | 29.6 (1–67) |
| Contacts related to gastroenterology | 905 (56.5) |
| Contracts related to rheumatology | 696 (43.5) |
| Proportion of patients admitted during study period, n (%) | 15 (27.8) |
| Admissions in total, n | 38 |
| Admissions related to gastroenterology, n (%) | 32 (84) |
| Admissions related to rheumatology, n (%) | 6 (16) |
Table 3
Interview quotes from patients, Rheumatology-Gastroenterology clinic, Silkeborg Regional Hospital.
| MAIN THEMES | PATIENT QUOTES |
|---|---|
| Informational continuity | If you visit different clinics several times, questions can easily be forgotten (..); the thing is that here [in the ReGa Clinic], nothing is lost, nothing is wasted, and as a patient, you get a lot out of it by having them both.
It’s so much easier when they sit and talk about things together. Instead of me having to explain what happened in one place when I got to the other place (…) There are often things that don’t quite come together properly when you’re navigating across systems.
The most important thing is being able to make contact – that there’s a connection, that you can reach a doctor or a nurse, and that’s something I have always experienced (…). For me, the most important thing is that when something has come up, there has been someone at the other end who has helped.
|
| Management continuity | I get that percentage fewer appointments because some of it has been merged (…) I think it works overall, this merging thing, but when you visit almost all departments except fertility or the women’s ward, there could be more of it.
When you have a dual diagnosis, it’s important to get help understanding the connections and challenges involved, and a joint consultation really helps with that. Also, it’s a great help to be able to manage with fewer visits.
I actually have an hour’s drive to get here [the hospital], so it’s also a matter of time. You have to go to the hospital so often when you have these conditions, especially when they keep haunting you. So, for me, it’s really wonderful that they can sit together and discuss it.
|
| Relational continuity | You can have a conversation that is completely down to earth while not being unserious at all; on the contrary, it is a feeling that you are taken seriously while, at the same time, you do not feel that you have entered the rulers of some kingdom you did not know existed, so in that way, I feel very much on the same page with them.
With chronic disorders, you need to feel secure in relation to the treatment you receive, and you achieve this security, by being confident about their decision that you should have it [medication], that it is right, and now that it is two specialists, who have agreed that this is something for me, then of course I experience a special security.
You kind of feel like you get a… not a relationship, but, you know, there’s this sense of knowing each other and talking, and that makes you feel a bit more comfortable with it (…) For me, it’s made a huge difference that it’s the same [healthcare professionals], because we kind of know each other, and they know me and who I am, and I think that means a lot.
|
| IBD: | Inflammatory Bowel Disease |
| IJD: | Inflammatory Joint Disease |
| ReGa: | Rheumatology-Gastroenterology Clinic |