Statistics from Altmetric.com
The benefit of early treatment of inflammatory joint disease (IJD) with disease modifying drugs (DMARDs) to avoid progressive irreversible joint damage is well established. The time delay from onset of symptoms to starting a DMARD is determined by a number of factors, and early synovitis clinics have been developed to facilitate speedy referral and initiation of DMARD treatment. The efficiency of these clinics is dependent on appropriate referral.1 Diagnosing early IJD is not easy; even specialists have been shown to disagree when tested.2 Therefore an effective screening tool could be used to maximise identification of patients likely to have IJD and minimise unnecessary use of urgent appointments.
A simple eight point questionnaire (box 1) was devised to separate patients with and without IJD. It uses well recognised diagnostic criteria for rheumatoid arthritis (morning stiffness, rheumatoid factor, and erosions) but also includes more general markers of inflammation (erythrocyte sedimentation rate (ESR)), benefit from non-steroidal anti-inflammatory drugs (NSAIDs)/steroids, synovitis, and family history.
1 Box 1 Questionnaire.
The presence or absence of the following items was recorded.
Early morning stiffness >1 hour
Characteristic distribution for IJD
First degree relative with IJD
Clinical evidence of synovitis
ESR ⩾20 mm/1st h (men), ⩾30 mm/1st h (women)
Positive rheumatoid factor (⩾1/80)
Erosions on hands or feet x ray
Benefit from NSAID or steroids
We prospectively studied 100 consecutive patients whom their general practitioner (GP) suspected might have IJD and had referred to one consultant for early assessment over a 10 month period. GP letters were initially screened by the consultant and then passed to the nurse practitioner who applied the questionnaire (box 1) to all patients before the consultant’s assessment.
Characteristic distribution for IJD was positive if more than one joint was affected by pain or stiffness, but negative if the pattern affected predominately the distal interphalangeal joints of the hands or the base of the thumbs. Synovitis was defined as the affected joint being tender and swollen. The most recent ESR was used, radiographs of hands and feet were used for assessment of erosions, and benefit from NSAID/steroids was taken as a reported patient global assessment. The diagnosis was taken as that made by the consultant at the first assessment. In cases where there was some doubt, it was taken as the most likely diagnosis at the subsequent review appointment. Seventy six women and 24 men not known to have IJD were included with mean ages of 55 years (women) and 50 years (men). The consultant diagnosed 31 as having IJD, of whom 30 scored 3 or more on the questionnaire (27 rheumatoid arthritis, 2 psoriatic arthritis, 1 palindromic arthritis). Sixty nine patients were diagnosed as having non-IJD, of whom 31 scored 3 or more on the questionnaire and 38 scored less than 3. For a score of 3 or more the questionnaire diagnosed IJD with a sensitivity of 97% (30/31), a specificity of 55% (38/69), a positive predictive value of 49% (30/61) and a negative predictive value of 97% (38/39).
Given both its accuracy in identifying patients with non-IJD and high sensitivity in identifying patients with IJD, the questionnaire appears to offer a means of differentiating urgent referrals from routine cases. Further studies are necessary to establish reproducibility of the tool when used by other medical and nursing staff, in the hope that GPs could use this tool to determine the urgency of referral—using three or more positive answers as criteria for prompt action. This will potentially reduce delay from onset of symptoms to initiation of DMARD treatment in patients with IJD.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.