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There is mounting evidence that early disease modifying treatment improves the outcome in patients with rheumatoid arthritis (RA)1 and that treatment should begin before the disease is established and irreversible damage has occurred.2 This evidence has led to the development of “early synovitis clinics” in many rheumatology units to fast track appropriate patients. Early referral for specialist advice has been shown to be associated with improved health and physical function, with the concept of early treatment of RA shortening observation periods before referral in general practice.3 A shortened observation time is important as Irvine et al showed that 73% of patients waiting more than one year from the onset of symptoms already had radiological evidence of erosive change.4
Despite the improved observation times, there are few published data showing whether referrals to early synovitis clinics are appropriate. We reviewed all referrals (n=156) to our early synovitis clinic at the Royal Victoria Hospital, Belfast, which was established in January 1999, to determine the proportion which were appropriate. Referrals were considered appropriate if they could be classified within a broad based category of inflammatory arthritis. We felt a broad based approach was necessary to identify patients with RA early in the disease course. Referral guidelines to the early synovitis clinic were circulated to all general practitioners in the catchment area of the hospital (population 600 000) every three months. The information was also disseminated by the local medical press and by presentations at general practitioner meetings.
Fifty four per cent (n=84) of the 156 patients were classified as having inflammatory arthritis. Of these patients, 33 were diagnosed as RA and disease modifying treatment was started. The other diagnoses within the inflammatory arthritis group included psoriatic arthritis, reactive arthritis, ankylosing spondylitis, seronegative arthritis, systemic lupus erythematosus, primary Sjögren's syndrome, and crystal arthritis. Despite the educational strategies outlined above, a large percentage of referrals were inappropriate. Forty six per cent (n=72) of patients did not have inflammatory arthritis. Of these patients, 35 had fibromyalgia, 28 had osteoarthritis, and nine had another diagnosis within the category of soft tissue rheumatism.
The median time from symptom onset to referral was eight weeks and the median time from arrival of the referral letter to attendance at the early arthritis clinic was four weeks. These results suggest that although the message about early referral appears to have been successful there were a large number of inappropriate referrals.
Factors contributing to inappropriate referrals include:
The low priority of musculoskeletal disorders in undergraduate training,5 resulting in poor skills in recognising signs and symptoms of inflammatory arthritis
The opportunity for faster access to a specialty with long waiting lists
The broad based referral guidelines which were designed to obtain maximum sensitivity for patients with early RA.
To maximise valuable clinic time for patients with early RA and improve the proportion of appropriate referrals we suggest that increased emphasis should be given to the importance of recognition of inflammatory arthritis in undergraduate and postgraduate medical education. The exploration of new methods of triage in primary care groups by general practitioners with a special interest in rheumatology, or by specialist rheumatology nurses, may also help to improve referrals.
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