Background The delay in referral of patients with suspicion of Undifferentiated Inflammatory Arthritis (UIA), especially the Rheumatoid Arthritis (RA), from the primary care physician (PCP) to the Rheumatologist prevents diagnosing and treatment in a timely manner. Early diagnosis and treatment decreases progression and permanent joint damage. Several strategies have been proposed to improve the time to referral of patients with UIA, however there is none for early RA in specific.
Objectives We present a pilot study for the use of a weighted construct format for the improvement of the time to referral of patients with suspicion of early RA.
Methods Since June 2005, in clinics and hospitals, PCPs were trained for the use of the weighted construct format tool. Adult patients with less than 1year of symptoms were considered for the referral. The criteria for reference of suspicion of early RA are shown in Table 1. The patient referral was made through the counter-reference system, including the complete format and laboratory results. The patient's appointment was given within 15 business days. Once the patients were evaluated and studied in the Department of Rheumatology, they were classified with RA according to 2010 ACR/EULAR criteria when was available this criteria classification. For the demographic variables, we used descriptive and inferential statistics and for the format validation we verified the reliability, and validity of the construct and criterion tool.
Results Between July 2005 and July 2015, 298 patients were referred to our clinic. The average referral time in the first year (2005–2006) was 34.3±20.4 days, maintaining an average of 32.1±16.8 days until 2015. There was a reduction of 74% of referral time compared to a historical reference (mean time of referral was 127.4±51.8 days, in 122 patients). 182 (62%) patients filled out the 2010 ACR/EULAR criteria. The referral format for early RA had a Cronbach alpha of 0.49, Sensitivity 85.1%, Specificity 93.5% and PPV 92.2%. The correlation between patients with early RA and the 2010 ACR/EULAR criteria was 0.765 with a p<0.000.
Conclusions In this pilot study, we observed that the construct had a suitable sensitivity, specificity and PPV for a referral format. Therefore, on suspicion of early RA the referral format could be useful as a simple clinical tool for the timely referral to the Rheumatologist. On the other hand, the program implementation allowed the reduction in the referral time substantially. To implement the use of this tool in the daily clinical practice it needs to be validated with an open population and an adequate sample size
Emery P,Breedveld F C,Dougados M,Kalden J R,Schiff M H,Smolen J S. Early referral recommendation for newly diagnosed rheumatoid arthritis:evidence based development of a clinical guide. Ann Rheum Dis 2002;61:290–297.
Villeneuve E,Nam JL,Bell MJ,Deighton CM,Felson DT, Et al, A systematic literature review of strategies promoting early referral and reducing delays in the diagnosis and management of inflammatory arthritis. Ann Rheum Dis 2013;72:13–22.
Deane KD,Striebich CC,Goldstein BL, et al. Identification of undiagnosed inflammatory arthritis in a community health fair screen. Arthritis Rheum 2009;61:1642–9.
Disclosure of Interest None declared