What impacts care complexity in RA? An integrative review of complexity domains and associated patient and health system outcomes

Objective Care complexity represents the intersection of health status and social determinants of health, which can impact patient care and outcomes. People living with rheumatoid arthritis (PlwRA) experiencing care complexity may require longer healthcare appointments or more frequent healthcare visits or services. This review identified RA-related care complexity domains and their associated patient outcomes. Methods An integrative literature review was conducted to identify RA-related care complexity domains and their associated patient, provider, and health system outcomes across diverse study designs. MEDLINE was searched using keywords and MeSH terms for care complexity domains and outcomes from 2000-current. Extracted data were analyzed using the constant comparison method. Results The search yielded 9835 articles, and 181 met the inclusion criteria. The care complexity domains identified included co/multimorbidity and polypharmacy, overweight/obesity, substance use, mental health, chronic pain, difficult-to-treat RA, cognitive impairment, advanced age and/or frailty, race/ethnicity, socioeconomic considerations, social support/connectedness, and healthcare access. The most common outcomes across one or more of the domains were impaired functional status, poor quality of life, elevated mortality risk, high disease activity and/or difficulty achieving remission, and higher healthcare utilization. Intersectionality between domains compounded the impact on outcomes. Evidence was unevenly distributed, with relatively few studies examining outcomes of care complexity at the health system level. Conclusion We identified 12 domains of care complexity and 5 patient outcomes. Our findings will inform the development of a care complexity framework and measurement strategies to tailor care to patient needs.