Strategies for identification and referral of patients with inflammatory arthritis
| Strategies for early identification and referral — from patients at symptom onset to primary care | |||
|---|---|---|---|
| Reference | Country of origin | Type of strategy/description | Reported outcomes |
| 1) Community case finding strategies | |||
| Deane22 | USA | Health Fair – CSQ+antibody testing (Ab) (RF and anti-CCP); 601 subjects: Reason for participation • Joint symptoms 51% • General health interests 28% • Relatives with RA 21% | IA (≥1 swollen joint on examination) n=84 (14%). New RA (1987 RA classification criteria) n=9 (1.5%). • CSQ≥1 and Ab* tests done at the same time: sensitivity 95.3%, specificity 32.4%, ppv 18.8%, npv 97.7%. • CSQ≥4 then Ab testing: sensitivity 11.8%, specificity 99.2%, ppv 71.4%, npv 87.2% RF or anti-CCP+but no synovitis n=42 (6.1%) |
| Eberhardt24 | Sweden | Self-administered hand test (firm handshake, a four-finger grip around a pencil and pincer grip of a sheet of paper) | 5262 patients screened: • 873 Unable to perform the test requiring clinical review • 48 Individuals with suspected previously undiagnosed inflammatory disease underwent further evaluation. • 12 (0.2%) Diagnosed with new RA |
| Arthritis foundation screening programme25 (http://njtoday.net/2010/06/18/foundation-launches-new-rheumatoid-arthritis-screening-program/) | USA | Community screening | – |
| Dr Lloyd's arthritis screening and workshop26 (http://lloydchiro.com/?p=844) | USA | Community screening/outreach programme | – |
| 2) Public awareness programmes | |||
| Machold, Austria27 | Austria | A large bus (Rheuma-Bus), positioned at a number of easily accessible public places, was adapted for informal medical counselling regarding any kind of MSK conditions. The initiative was accompanied by countrywide information through broadcasts and newspapers. | RA was considered for the first time in 1.1% of patients who were subsequently referred to a rheumatology unit for assessment. |
| 3) Internet and website information | |||
| About.com28 http://arthritis.about.com/od/rheumatoidarthritis/l/blrheumarthquiz.htm | Web | Internet | - |
| Hwang29 | Web | Internet | Accurate information, but reading level too high for average reader. Poor in terms of differential diagnosis, prioritising the possibilities. None provide an algorithm of action. |
| De Leonardis EULAR30 | Web | Internet | 9.2% sponsored by rheumatologists/rheumatology associations. 12.8% created by patient associations. 74.2% clearly showed banners or links to one or more commercial sponsors. |
| Strategies for early identification and referral – from primary care to rheumatology referral | |||
|---|---|---|---|
| 1) PCP and health professions education programmes | |||
| Schulpen31 | Sweden | Joint consultation of PCP and rheumatologist every 6/52 | Patients referred by participating PCPs reduced by 62% per year; referral rate for non-participating PCPs unchanged. The decrease in referral can lead to a reduction in waiting lists. |
| Boonen32 | The Netherlands | Joint consultation between PCP and rheumatologist for 2–3 h/week | Reduced number of referrals to specialist clinics |
| Glazier33 | Canada | 2-day workshop and follow-up reinforcement activities for healthcare providers and a toolkit of written materials | Reported improved knowledge and communication with community services |
| Ledue ACR34 | USA | Maine arthritis partnership. Distribution of a MAP guide (educational handbook, joint pain evaluation form, diagnostic algorithm for IA identification, current national practice guidelines, physician resource information and printed brochures for patients) | 50% of participants found that it improved the quality of the referral process but did not affect the number of referrals |
| Bingham ACR35 | USA | RAPID continuing medical Education Programme. CME initiative to educate PCPs on the benefits of screening/diagnosing patients with suspected RA and co-managing these patients with a specialist (workshops, mobile Epocrates activities and journal supplements) | Increase in short-term knowledge. Referral of patients with RA to rheumatologists increased from 37.4% to 41.8% |
| Fautrel, ACR38 | France | Early arthritis: early act. Community-based knowledge-transfer programme using EULAR screening recommendation to help GP detect IA | Resulted in increased awareness of importance of early detection, increased knowledge and ability to detect IA |
| Lineker39 | Canada | The Getting a Grip on Arthritis programme: based on clinical practice guidelines adapted for primary care and consists of an accredited interprofessional workshop and 6 months of activities to reinforce the learning | Using 3 standardised case scenarios, decision to refer of patient with early RA to a rheumatology increased from 43.2% (117) to 54.6% (148) (p<0.05) |
| Boyle, Survey36 | USA | Tele-Clinic. PCPs presents patients via phone or webcam. In 2009: 216 cases presented, 100 clinicians participated | – |
| http://www.arhp.org/professional-education/programs/rheumatoid-arthritis37 | Web | Improving early diagnosis and treatment of RA' – education programme for healthcare providers | – |
| 2) Self administered questionnaires | |||
| Bell ACR40 44 | Canada | 11 Question self-administered EIA detection tool, including history of joint pain and symmetry, pain or swelling of wrists or hands, EMS and duration, ability to make a fist, functional ability, history and family history of RA, history of psoriasis | Tested in 143 patients on the waiting lists of two rheumatologists (30 subsequently diagnosed with IA): cut-off score of 7 of 12 (0.58): AUC 0.77, sensitivity 0.87 and specificity 0.52 for the detection of early IA. |
| Maksymowych ACR41 45 | Canada | ERASE web based screening tool for early RA. Weighted score (four for any MCP involvement)+(two for any wrist involvement)+ (two for duration weeks/months)+(−3 for any 2/4 of jaw pain, IBS, chronic fatigue, daily headaches). | Tested in 124 patients newly referred to a rheumatologist, 21 subsequently diagnosed with RA: cut-off score of 2.5: AUC 0.93; sensitivity 98%; specificity 95%. |
| Khraishi EULAR42 | Canada | RASQ – self administered RA screening questionnaire. Seven weighted questions+a diagram. One point deducted for a history of psoriasis. | Tested in 116 patients newly referred to rheumatology (61 with RA according to the 1987 ACR classification criteria). Cut-off score 11.5/ 15: Sensitivity 67.2%; specificity 60.4%. Cut-off score 9.5/ 15: sensitivity 85.2%; specificity 34% |
| Callahan43 | USA | Ratio of patient pain VAS score divided by the score from a questionnaire on difficulties in ADLs | 75 RA patients compared with 75 patients with non-IA diffuse MSK pain (clinical fibromyalgia), P-VAS: D-ADL Ratio ≥ 3: sensitivity 72%; specificity 67% (RA vs non – inflammatory diffuse MSK pain) |
| 3) Other potential PCP tools | |||
| Beattie48 | Canada | GALS MSK screening examination used to detect RA | Sensitivity 50–77%, specificity 75–100% when used by physiotherapists. |
| Singh49 | India | Computer based questionnaire with nine items to assist GPs to diagnose arthritis | – |
| 4) Referral guidelines | |||
| Emery50 | Europe | Referral guideline: ≥3 Swollen joints. MTP/MCP involvement (squeeze test positive). EMS ≥ 30 min | – |
| Barts and The London EAC http://www.bartsandthelondon.nhs.uk/docs/early_arthritis_clinic_guidelines.pdf51 | UK | Referral guideline: clinical evidence of IA. Disease duration 3–12 months from symptom onset. ≥1 swollen joint. | – |
| Brighton and Hove http://www.brightonandhove.nhs.uk/healthprofessionals/clinical-areas/documents/EACreferral1.doc52 | UK | EAC referral algorithm & form: criteria for referral: persistent joint inflammation ≥ 4 weeks and inflammation affecting at least three joint areas; and at least one of the following: Involvement of MCP and/or MTP joints. EMS ≥30 min. Raised inflammatory markers (ESR or CRP). | – |
| Hulsemann53 | Austria | Referral criteria – also printed on the referral form: recent onset (<2 years) and 1 of the following: EMS ≥ 30 min Elevated inflammatory markers (ESR or CRP) | – |
| Strategies for identification and early referral – from rheumatology referral to assessment | |||
|---|---|---|---|
| 1) Triage of referrals | |||
| Sathi54 | UK | ABC grade*: A (IA suspected and warranted a clinical appointment in 2/52); B (established RA and new patients that needed to be seen within 8/52); C (low clinical priority to be seen within current guidelines of 13/52) (n=102). Class A vs. B+C: sensitivity 93.1%, specificity 87.7%, ppv 75%, npv 96.7%. | |
| Graydon55 | Canada | A+ to D grade; A+ (urgent cases seen within 24–48 h); A (includes new IA; seen within 2–4 weeks); B (includes established IA and undiagnosed or subacute or probable IA); C (includes possible IA but not deemed highly likely and seen within 6–12 months); D (problems best assessed by another healthcare provider and appointment not given) (n=206). Grade A versus B–D: sensitivity 59.1%, specificity 87.7%, ppv 56.5%, npv 88.7%. | |
| Madan58 | UK | ABC grade*+anti-CCP (n=28 RF+patients) | Graded A: 5 referrals; all anti-CCP+Graded B: 10 referrals; eight anti-CCP – and two borderline results; no IA on follow-up; Grade C: 13 referrals; all CCP – Class A versus B+C: sensitivity 100%, ppv 100%. |
| Barbour56 | UK | Eight items: EMS >1 h Characteristic distribution for IA First degree relative with IA Clinical evidence of synovitis ESR >20 mm/1st h (men), >30 mm/1st h (women) Positive RF (>1/80) Erosions on hands or feet x-ray Benefit from NSAID or steroids (n=100) | ≥3/8=positive; Sensitivity 97%, specificity 55%, ppv 49%, npv 97% |
| Harrington 200157 | USA | Preappointment management (n=279) | Only 59% of referrals considered requiring an appointment; 30/164 (18%) diagnosed with IA; 1- 3/52 access time for initial appointment versus. 2–10 days for an appointment after review of records |
| 2) Referral forms | |||
| Arndt59 | Germany | Questionnaire including patient and doctor directed questions (n= 220 cf. n=125 before administration of questionnaires) | Rates of monthly referral remained the same; Increased use of NSAIDs (52% vs 64%, p=03) and steroids (12.2% vs 24.9%, p=0.004) |
| Fitzgerald60 | Canada | Non–diagnosis-dependent priority referral score (PRS) comprising eight criteria, one of which focuses on early inflammatory arthritis; Developed by a group of 10 rheumatologists and PCPs based on 32 case scenarios and tested by an independent group of 24 rheumatologists and PCPs. | Independent rheumatologists: interrater time 1 (n=14) 0.8; time 2 (n=14) 0.8; Intrarater: 0.83 PCPs: interrater time 1 (n=10) 0.81; time 2(n=8) 0.76; Intrarater: 0.82. |
| 4)Triage with referral forms | |||
| Thompson ACR61 | Canada | Grade 1–4 based on the CART form (Grade 1=emergency, 2=urgent, 3=semiurgent, 4=elective) (n=469). | Sensitivity 76.9%; specificity 75.4% |
| Hazlewood62 | Canada | Common referral form screened by a nurse clinician (n=9182 cf. n=485 prior to use of the referral form) | 57% of cases referred for possible IA; Reduction in wait time (Mean (SD) days): routine appointment: 155 (88) versus 143 (59) (p<0.01); Moderate: 110 (57) versus 77 (53) (<0.01); Urgent: 29 (46) versus 18 (17) (p=0.04) |
| Triage clinics | |||
| Gormley63 | Ireland | PCP/rheumatology nurse (RN) | Comparison of appropriateness of referrals between GP and RN versus rheumatologist respectively: sensitivity 89.9 and 87.1%; specificity 87.2 and 91.5%; ppv 88 and 91.5%; npv 89 and 87.1% |
| Bain64 | Canada | The Arthritis Program (TAP), Southlake Regional Centre; Triage of paper referrals; Assessment by AHP; EAC within TAP; Model is now being disseminated through a training programme. | |
| 4) Rapid access services | |||
| Newman65 | USA | 4 phases: Eliminated backlog; Same day access for patients; New appointment system; Protocols for primary care colleagues. | Third available rheumatology appointment fell from 60 days to <2 days; Increase of 49.8% of new referrals and 50% of new RA referrals; Cancellations fell from 40% to 18%; Financial performance and patient satisfaction also improved. |
| Maddison66 | UK | Early access to MSK programme developed | Wait time for rheumatology fell from 35 weeks to 5 weeks. 116% increase in total referrals. |
| Pflugbeil EULAR67 | Austria | Rapid access clinic – New patients seen within 24 h of contacting the department and briefly assessed and then either entered into the regular OPC or provided with further recommendation. | Wait time decreased from 6–10 weeks to 24 h; 2.5% had early arthritis of <3 months disease duration; 42% had inflammatory arthritis. |
| Gärtner69 | Austria | Immediate access clinic (IAC) – Patients referred by their PCP, another specialist or who are self-referred receive a brief assessment by an experienced rheumatologist who decides on further diagnostic or therapeutic management. | Wait time between referral and rheumatology assessment reduced: median (IQR) 8.0 (4.0–13.25) days versus frequently >4 months in 2007; 21.5% seen before 3 months' symptom duration; At follow-up, >75% of the diagnoses of inflammatory rheumatic diseases initially suspected at the IAC were correct. |
| Smith70 | UK | Rapid access services for patients who present with acute problems including IA | – |
| Edwards EULAR71 | UK | – | |
| Magnusson68 | Canada | – | |
| 6) EAC | |||
| Speyer72 | The Netherlands | Leiden EAC (1993–1994) (n=113 (EAC) versus. n=99 (OPC)) | Time from symptom onset to PCP (weeks); EAC versus OPC: 6.4 versus 17.3; Time from symptom onset to clinic (weeks); EAC versus OPC: 14.1 versus 37; Definitive diagnosis in 68% of patients at 2/52. |
| Van der Horst-Brunsma73 | The Netherlands | Leiden EAC (1993–1996) entry criteria: at least two of joint pain, joint swelling or ROM: duration of symptoms <2 years; First referral for this problem (n= 233 (EAC) vs n=241(OPC) fulfilling the EAC criteria) | Median time from symptom onset to clinic (weeks) EAC versus OPC: 4.4 (range 0.1–87) vs 17 (range 0.1–104); Time from symptom onset to EAC versus OPC for patients with RA: 104 versus 164 days (p=0.095). |
↵* Same grading system in both groups.
Ab, antibody; ABC grade*: A (IA suspected and warranted a clinical appointment in 2/52); B (established RA and new patients that needed to be seen within 8/52); C (low clinical priority to be seen within current guidelines of 13/52); ACR, American College of Rheumatology; ADLs, activities of daily living; anti-CCP, anticyclic citrullinated peptide antibody; AHP, allied health professional; AUC, area under the curve; CME, continuing medical education; CRP, C reactive protein; CSQ, connective diseases screening questionnaire; EAC, early arthritis clinic; EIA, early inflammatory arthritis; EMS, early morning stiffness; ESR, erythrocyte sedimentation rate; EULAR, European League Against Rheumatism; GALS, gait, arms, legs and spine; GP, general practitioner; IA, inflammatory arthritis; IBS, irritable bowel syndrome; MCP, metacarpophalangeal; MSK, musculoskeletal; MTP, metatarsophalangeal; npv, negative predictive value; NSAID, non-steroidal anti-inflammatory drug; OPC, outpatient clinic; PCP, primary care provider; ppv, positive predictive value; RA, rheumatoid arthritis; RF, rheumatoid factor; RN, rheumatology nurse; VAS, visual analogue scale.