Table 1

Strategies for identification and referral of patients with inflammatory arthritis

Strategies for early identification and referral — from patients at symptom onset to primary care
ReferenceCountry of originType of strategy/descriptionReported outcomes
1) Community case finding strategies
Deane22USAHealth 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%)
Eberhardt24SwedenSelf-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 ( screening
Dr Lloyd's arthritis screening and workshop26 ( screening/outreach programme
2) Public awareness programmes
Machold, Austria27AustriaA 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
Hwang29WebInternetAccurate 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 EULAR30WebInternet9.2% 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
Schulpen31SwedenJoint consultation of PCP and rheumatologist every 6/52Patients 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.
Boonen32The NetherlandsJoint consultation between PCP and rheumatologist for 2–3 h/weekReduced number of referrals to specialist clinics
Glazier33Canada2-day workshop and follow-up reinforcement activities for healthcare providers and a toolkit of written materialsReported improved knowledge and communication with community services
Ledue ACR34USAMaine 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 ACR35USARAPID 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, ACR38FranceEarly arthritis: early act. Community-based knowledge-transfer programme using EULAR screening recommendation to help GP detect IAResulted in increased awareness of importance of early detection, increased knowledge and ability to detect IA
Lineker39CanadaThe 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 learningUsing 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, Survey36USATele-Clinic. PCPs presents patients via phone or webcam. In 2009: 216 cases presented, 100 clinicians participated early diagnosis and treatment of RA' – education programme for healthcare providers
2) Self administered questionnaires
Bell ACR40 44Canada11 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 psoriasisTested 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 45CanadaERASE 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 EULAR42CanadaRASQ – 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%
Callahan43USARatio of patient pain VAS score divided by the score from a questionnaire on difficulties in ADLs75 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
Beattie48CanadaGALS MSK screening examination used to detect RASensitivity 50–77%, specificity 75–100% when used by physiotherapists.
Singh49IndiaComputer based questionnaire with nine items to assist GPs to diagnose arthritis
4) Referral guidelines
Emery50EuropeReferral guideline: ≥3 Swollen joints. MTP/MCP involvement (squeeze test positive). EMS ≥ 30 min
Barts and The London EAC guideline: clinical evidence of IA. Disease duration 3–12 months from symptom onset. ≥1 swollen joint.
Brighton and Hove 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).
Hulsemann53AustriaReferral 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
Sathi54UKABC 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%.
Graydon55CanadaA+ 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%.
Madan58UKABC 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%.
Barbour56UKEight 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
≥3/8=positive; Sensitivity 97%, specificity 55%, ppv 49%, npv 97%
Harrington 200157USAPreappointment 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
Arndt59GermanyQuestionnaire 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)
Fitzgerald60CanadaNon–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 ACR61CanadaGrade 1–4 based on the CART form (Grade 1=emergency, 2=urgent, 3=semiurgent, 4=elective) (n=469).Sensitivity 76.9%; specificity 75.4%
Hazlewood62CanadaCommon 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
Gormley63IrelandPCP/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%
Bain64CanadaThe 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
Newman65USA4 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.
Maddison66UKEarly access to MSK programme developedWait time for rheumatology fell from 35 weeks to 5 weeks. 116% increase in total referrals.
Pflugbeil EULAR67AustriaRapid 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.
Gärtner69AustriaImmediate 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.
Smith70UKRapid access services for patients who present with acute problems including IA
Edwards EULAR71UK
6) EAC
Speyer72The NetherlandsLeiden 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-Brunsma73The NetherlandsLeiden 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.