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Diagnostic Agreement Among General Practitioners, Residents, and Senior Rheumatologists for Rheumatic Diseases. J Clin Rheumatol 2022; 28:293-299. [PMID: 35660703 DOI: 10.1097/rhu.0000000000001854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the concordance of the diagnoses made by senior rheumatologists and those made by residents in rheumatology and by general practitioners (GPs). METHODS In this cohort, 497 patients referred by GPs from August 1, 2018 to December 16, 2019 were evaluated first by a second-year resident in rheumatology. After clinical rounds, the diagnoses by senior rheumatologists were assumed as the criterion standard and defined the prevalence of the rheumatic diseases, divided into 5 groups: rheumatoid arthritis, spondyloarthritis, other connective tissue diseases and vasculitis, nonautoimmune rheumatic diseases, and nonrheumatic diseases. The follow-up ended on November 30, 2020. We calculated sensibility, specificity, positive predictive value, negative predictive value, and κ coefficient of the diagnosis by GPs and residents. RESULTS The diagnoses were changed for 58% of the referral letters. Diseases of low complexity, such as fibromyalgia and osteoarthritis, accounted for 50% of the diagnoses. Compared with senior rheumatologists, residents in rheumatology had κ > 0.6 for all the groups, whereas GPs had κ < 0.5, with the worst performance for nonautoimmune rheumatic disease (κ = -0.18) and nonrheumatic disease (κ = 0.15). In terms of level of complexity, 46% of the letters were inappropriate. CONCLUSIONS We found a poor level of diagnostic agreement between GPs and the rheumatology team. General practitioners had difficulties diagnosing and treating rheumatic diseases, referring patients that should be treated in the primary level of health care. One year of training in rheumatology made residents' skills comparable to those of senior rheumatologists.
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Development of a Multidimensional Additive Points System for Determining Access to Rheumatology Services. J Clin Rheumatol 2016. [PMID: 26203827 DOI: 10.1097/rhu.0000000000000274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE In many countries, including New Zealand, the demand for rheumatology services exceeds their supply, resulting in some patients experiencing long delays or being denied access. The principal aim of this work was to create a validated, transparent, and fair system for determining access to rheumatology services. METHODS A panel of 5 rheumatologists, 6 primary care physicians, and 4 nurse specialists ranked a series of 25 clinical scenarios in order of priority to see a rheumatologist. Important determining factors were weighted in an iterative process to generate a multidimensional additive point score to determine access to rheumatology service. RESULTS The score comprises 6 domains of 2 to 4 items weighted to give a total score out of 100. The effect of the problem on the patient's life and role, the presence of an inflammatory rheumatic disease, appropriateness of current treatment, and the ability of the rheumatologist to influence the current symptoms and future prognosis were felt to be critical factors in determining access to the service. The score showed a strong correlation with the rankings agreed by the clinical panel, and the overall intraclass correlation coefficient for the rheumatologists was 0.698. CONCLUSIONS Our score has face validity, is easy to perform, and has been assessed by an independent panel of rheumatologists as providing a fair system for determining access to rheumatology services. The system is acceptable to primary care physicians and has been adopted by our local primary care organizations.
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Thompson AE, Haig SL, LeRiche NGH, Rohekar G, Rohekar S, Pope JE. Comprehensive arthritis referral study -- phase 2: analysis of the comprehensive arthritis referral tool. J Rheumatol 2014; 41:1980-9. [PMID: 25179851 DOI: 10.3899/jrheum.140167] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Rheumatologists triage referrals to assess those patients who may benefit from early intervention. We describe a referral tool and formally evaluate its sensitivity for urgent and early inflammatory arthritis (EIA) referrals. METHODS All referrals received on a standardized referral tool were reviewed by a rheumatologist and, based on the information conferred, assigned a triage grade using a previously described triage system. Each referral was also dichotomized as suspected EIA or not. After the initial rheumatologic assessment, the diagnosis was recorded and a consultation grade, blinded to referral grade, was assigned to each case. Agreement between referral and consultation grades was assessed. A regression analysis was performed to determine factors that predicted truly urgent referrals including EIA. RESULTS We evaluated 696 referrals. A total of 210 (30.2%) were categorized as urgent at the time of consultation. The referral tool was able to successfully detect 169 of these referrals (sensitivity 80.5%, specificity 79.4%). EIA occurred in 95 (13.6%); of those referrals, 86 were correctly classified as urgent at the time of triage (sensitivity 90.5%, specificity 69.6%). Items that helped correctly discriminate urgent or EIA referrals included patient age < 60, duration of disease, morning stiffness, patient-reported joint swelling, a personal or family history of psoriasis, urgency as rated by referring physician, prior assessment by a rheumatologist, elevated C-reactive protein, and a positive rheumatoid factor. CONCLUSION A 1-page referral tool that includes parts completed by the referring physician and patient has good sensitivity to detect urgent referrals including EIA.
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Affiliation(s)
- Andrew E Thompson
- From the Department of Medicine, Division of Rheumatology, Western University, London, Ontario, Canada.A.E. Thompson, BSc, MD, FRCPC, Associate Professor of Medicine; N.G.H. LeRiche, MD, Associate Professor of Medicine; G. Rohekar, MD, Assistant Professor of Medicine; S. Rohekar, MD, Assistant Professor of Medicine; J. Pope, MD, Professor of Medicine, Western University, Rheumatology Centre, St. Joseph's Hospital; S.L. Haig, MD, Resident in Internal Medicine, Western University.
| | - Sara L Haig
- From the Department of Medicine, Division of Rheumatology, Western University, London, Ontario, Canada.A.E. Thompson, BSc, MD, FRCPC, Associate Professor of Medicine; N.G.H. LeRiche, MD, Associate Professor of Medicine; G. Rohekar, MD, Assistant Professor of Medicine; S. Rohekar, MD, Assistant Professor of Medicine; J. Pope, MD, Professor of Medicine, Western University, Rheumatology Centre, St. Joseph's Hospital; S.L. Haig, MD, Resident in Internal Medicine, Western University
| | - Nicole G H LeRiche
- From the Department of Medicine, Division of Rheumatology, Western University, London, Ontario, Canada.A.E. Thompson, BSc, MD, FRCPC, Associate Professor of Medicine; N.G.H. LeRiche, MD, Associate Professor of Medicine; G. Rohekar, MD, Assistant Professor of Medicine; S. Rohekar, MD, Assistant Professor of Medicine; J. Pope, MD, Professor of Medicine, Western University, Rheumatology Centre, St. Joseph's Hospital; S.L. Haig, MD, Resident in Internal Medicine, Western University
| | - Gina Rohekar
- From the Department of Medicine, Division of Rheumatology, Western University, London, Ontario, Canada.A.E. Thompson, BSc, MD, FRCPC, Associate Professor of Medicine; N.G.H. LeRiche, MD, Associate Professor of Medicine; G. Rohekar, MD, Assistant Professor of Medicine; S. Rohekar, MD, Assistant Professor of Medicine; J. Pope, MD, Professor of Medicine, Western University, Rheumatology Centre, St. Joseph's Hospital; S.L. Haig, MD, Resident in Internal Medicine, Western University
| | - Sherry Rohekar
- From the Department of Medicine, Division of Rheumatology, Western University, London, Ontario, Canada.A.E. Thompson, BSc, MD, FRCPC, Associate Professor of Medicine; N.G.H. LeRiche, MD, Associate Professor of Medicine; G. Rohekar, MD, Assistant Professor of Medicine; S. Rohekar, MD, Assistant Professor of Medicine; J. Pope, MD, Professor of Medicine, Western University, Rheumatology Centre, St. Joseph's Hospital; S.L. Haig, MD, Resident in Internal Medicine, Western University
| | - Janet E Pope
- From the Department of Medicine, Division of Rheumatology, Western University, London, Ontario, Canada.A.E. Thompson, BSc, MD, FRCPC, Associate Professor of Medicine; N.G.H. LeRiche, MD, Associate Professor of Medicine; G. Rohekar, MD, Assistant Professor of Medicine; S. Rohekar, MD, Assistant Professor of Medicine; J. Pope, MD, Professor of Medicine, Western University, Rheumatology Centre, St. Joseph's Hospital; S.L. Haig, MD, Resident in Internal Medicine, Western University
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Xibillé-Friedmann D, Mondragón-Flores V, de la Rosa CH. [Criterios utilizados por médicos de atención primaria para el diagnóstico y derivación al reumatólogo del paciente con artritis reumatoide]. ACTA ACUST UNITED AC 2006; 2:235-8. [PMID: 21794335 DOI: 10.1016/s1699-258x(06)73053-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2005] [Accepted: 04/23/2006] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Rheumatoid arthritis (RA), an important cause of disability, affects 1% of the population. Early diagnosis and referral to a rheumatologist are positive prognostic factor but diagnosis in many cases is in the hands of primary care physicians (PCP). OBJECTIVE To determine the criteria used by PCP for diagnosis of RA and referral of these patients to a rheumatologist; to evaluate how many cases can be classified as RA according to the ACR. METHODS Retrospective study of 530 patients referred by PCP and seen as outpatients at a rheumatology clinic in 2002. Patients with referral diagnosis of RA were identified and symptoms, signs, functional capacity and ACR criteria for RA were evaluated by 2 rheumatologists. RESULTS 302 patients had a referral diagnosis of RA, 33 male (10.9%) and 269 female (89.1%), median age 50.5 years, with a median time since diagnosis of 45.2 months. 57.9% had FC stage II. 100% of cases had "generalized" joint pain, 67.5% arthritis of 3 or more joints and 51.7% arthritis of hand joints. Arthritis was symmetrical in 58.9% and 77.2% of the patients had morning stiffness (> 30 min). 49.7% of the cases had positive rheumatoid factor, 19.2% had a negative RF and 31.1% had none reported. In 2% ESR was measured. X-ray erosions were reported in 6.6% of cases. When using the ACR criteria, 17.8% of patients had 1, 28.7% had 2 and 53.5% had 3 or more criteria. In only 59 cases (20%) did the rheumatologist agree with the referral diagnosis of RA. CONCLUSIONS 80% of PCP referrals of RA to the rheumatologist were another disease. A poor clinical evaluation and little support from laboratory and x-rays was noticed. The delay in diagnosis and referral was 3 years, worsening prognosis. A vigorous effort in educating PCP is needed to achieve early diagnosis and referral of RA cases.
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Affiliation(s)
- Daniel Xibillé-Friedmann
- Departamento de Reumatología. Hospital General de Cuernavaca Dr. José G. Parres. Secretaría de Salud. Cuernavaca. Morelos. México
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Branch VK, Graves G, Hanczyc M, Lipsky PE. The utility of trained arthritis patient educators in the evaluation and improvement of musculoskeletal examination skills of physicians in training. ARTHRITIS CARE AND RESEARCH : THE OFFICIAL JOURNAL OF THE ARTHRITIS HEALTH PROFESSIONS ASSOCIATION 1999; 12:61-9. [PMID: 10513492 DOI: 10.1002/1529-0131(199902)12:1<61::aid-art10>3.0.co;2-g] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To determine the level of examination skills of internal medicine residents and to assess whether an intervention by trained persons with arthritis could have a greater impact on their examination skills than participation in an ambulatory care training experience. METHODS Twenty-seven residents attended a 6-week ambulatory care rotation that included didactic teaching as well as attendance at an outpatient arthritis clinic with supervision by rheumatologists. Sixteen residents were randomly assigned to have a training encounter with an arthritis educator along with the standard experience in the arthritis clinic, whereas 11 residents received training in the arthritis clinic only. Arthritis educators evaluated the musculoskeletal examination skills of each resident during the first week of the rotation. The 16 residents in the intervention group received instruction on joint examination techniques by the arthritis educator immediately following their evaluation. At the end of the 6-week rotation, the groups were re-evaluated by a different arthritis educator. A group of 21 rheumatologists was also asked to perform a comprehensive musculoskeletal examination on individual arthritis educators. The arthritis educators assessed the examination of the rheumatologists using the same evaluation instrument that was used to assess the residents. RESULTS Initially, internal medicine residents carried out the musculoskeletal examination poorly (34.2 +/- 0.09% correct, n = 27). By contrast, the rheumatologists carried out a significantly greater amount of the examination correctly (54.5 +/- 0.05%). The musculoskeletal examination skills of the residents who received additional training from an arthritis educator were significantly greater at the end of the rotation than the group who did not receive this intervention (50.5 +/- 0.10% versus 41.9 +/- 0.14% correct, P = 2.15 x 10(-5). CONCLUSION Internal medicine residents carried out the musculoskeletal examination poorly. However, an intervention by arthritis educators improved the musculoskeletal examination skills of internal medicine residents significantly and more effectively than the standard clinical teaching in a rheumatology outpatient clinic. The impact of the arthritis educator intervention persisted for at least 5 weeks.
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Affiliation(s)
- V K Branch
- Rheumatic Diseases Division, University of Texas, Southwestern Medical Center at Dallas 75235-8884, USA
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Abstract
During a 6-month period in 1994-1995, 0.7% of patient visits (51 visits of 47 patients) at the emergency unit of the Department of Medicine, Helsinki University Central Hospital, were due to joint symptoms. Infection seemed to play an important role as the etiologic factor for the joint complaints. Acute joint exacerbation in pre-existing arthritis was the reason for 11.7%, and suspected Baker's cyst for 3.9% of the visits. Confirmed (12.8%) or suspected reactive arthritis (10.6%), septic arthritis/spondylitis (6.4%), arthritis with inflammatory bowel disease (6.4%), and gout (14.9%) were the most common final diagnoses for the patients. In a quarter of the patients, the etiology for joint symptoms could not be confirmed. In conclusion, joint symptoms very seldom lead to visits to an emergency unit. In such cases, infection seems to be an important contributing factor. Patients with chronic rheumatic diseases only occasionally have to seek help at an emergency unit.
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Affiliation(s)
- M Sharma
- Department of Medicine, Helsinki University Central Hospital, Finland
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