Session Information
Session Type: ACR Poster Session C
Session Time: 9:00AM-11:00AM
Background/Purpose: Primary care physicians (PCP) often play a central
role in the early detection and referral for patients with rheumatic diseases. Our
aim was to characterize referrals from PCPs to rheumatologists and investigate
diagnostic and treatment patterns of PCPs prior to rheumatologist consultation.
Methods: We performed a retrospective chart review and an
analysis of structured and semi-structured data within the primary care Electronic
Medical Record Administrative data Linked Database (EMRALD), representing
comprehensive EMR data from 168 PCPs across Ontario, Canada. We identified patients
with first-time rheumatology referrals. Using a standardized data abstraction tool, PCP and
rheumatology consultation records were reviewed to identify diagnoses and
treatments associated with each referral. Referrals were characterized in terms
of patient demographics, provisional diagnoses/clinical impressions, laboratory diagnostic tests and treatment
initiated by PCPs, and other specialists seen for the complaint prior to
rheumatology referral.
Results: Among 2430 patients referred
to rheumatologists, 69% were female and the mean (SD) age at time of referral was 53 (16)
years. Reasons for referrals included:
mechanical/degenerative conditions
(787; 32%), systemic
inflammatory rheumatic diseases (745; 31%), regional MSK conditions
(395; 16%), chronic pain conditions (346; 14%), osteoporosis/osteopenia (45;
2%), and other (e.g., abnormal labs, 112; 5%). Systemic inflammatory rheumatic disease referrals included inflammatory
arthritis (287; 38%), connective tissue diseases and other systemic autoimmune rheumatic diseases (e.g., lupus, scleroderma, Sjogren’s, Raynaud’s) (131; 18%),
gout/crystal arthropathies
(122; 16%), spondyloarthropathies (120; 16%), polymyalgia rheumatica (66; 9%), and vasculitis (19; 3%). Laboratory testing done within the 3 months prior to referral is as noted in Table 1. Among the 745 systemic inflammatory
patients, 22% were also seen in the emergency room for their complaint prior to seeing the rheumatologist, and 61% received treatment by their PCP (48% received NSAIDs/COXIBs,
and 20% received corticosteroids). For patients diagnosed with rheumatoid
arthritis, 72% received treatment by their PCP (53% received NSAIDs/COXIBs, 27%
received corticosteroids, and 6% received DMARDs). The time from 1st
PCP visit for the rheumatic disease complaint to date of referral exceeded 100
days for each type of systemic inflammatory rheumatic disease, except vasculitis (table).
Conclusion: We present
novel data on PCP management
of patients prior to rheumatology referral. Approximately
1 in 3 PCP referrals to
rheumatologists were referred for a systemic inflammatory rheumatic
disease. Understanding the
referral patterns of PCPs can identify opportunities to improve PCP management of patients prior to rheumatology
referral.
Table:
|
All Patients
|
Systemic Inflammatory Rheumatic Diseases n=745
|
|||||||||
|
n=2430 |
All n=745 |
RA n=120 |
IA n=167 |
PsA n=44 |
CTDs n=131 |
AS/SpA n=76 |
Crystal n=122 |
PMR n=66 |
Vasculitis n=19 |
|
|
Age, mean (SD) years |
53 (16)
|
53 (17)
|
55 (16) |
51 (16) |
53 (13) |
45 (14) |
42 (15) |
61 (15) |
71 (9) |
53 (24) |
|
Female |
69%
|
57%
|
70% |
57% |
59% |
82% |
41% |
27% |
62% |
52% |
|
Diagnostic Tests1 |
|
|
|
|
|
|
|
|
|
|
|
ESR done |
30%
|
45%
|
52% |
52% |
36% |
47% |
43% |
23% |
59% |
58% |
|
ESR abnormal |
29%
|
38%
|
47% |
29% |
38% |
34% |
24% |
29% |
67% |
# |
|
CRP done |
36%
|
53%
|
63% |
56% |
34% |
50% |
50% |
36% |
77% |
53% |
|
CRP abnormal |
19%
|
30%
|
35% |
30% |
# |
14% |
24% |
36% |
44% |
# |
|
RF Done |
41%
|
58%
|
76% |
68% |
50% |
57% |
51% |
40% |
50% |
26% |
|
RF positive |
24%
|
30%
|
66% |
30% |
# |
18% |
# |
18% |
# |
# |
|
ANA Done |
20%
|
42%
|
46% |
49% |
36% |
53% |
38% |
21% |
47% |
# |
|
ANA positive |
11%
|
15%
|
9% |
10% |
# |
35% |
# |
# |
# |
# |
|
PCP Initiated Treatment |
49%
|
61%
|
72% |
63% |
64% |
35% |
46% |
79% |
79% |
47% |
|
NSAID/COXIB |
38%
|
48%
|
53% |
54% |
61% |
24% |
43% |
62% |
44% |
# |
|
Corticosteroid |
10%
|
20%
|
27% |
16% |
# |
8% |
# |
18% |
59% |
42% |
|
DMARD |
1%
|
2%
|
6% |
# |
# |
# |
# |
# |
0 |
0 |
|
Time from 1st PCP visit for the complaint to Referral, median (IQR) days |
310 (13-324)
|
156 (12-168)
|
115 (14-128) |
125 (11-136) |
513 (15-528) |
181 (7-188) |
174 (7-181) |
353 (20-378) |
123 (15-138) |
73 (7-188) |
|
Abbreviations: RA: Rheumatoid Arthritis; IA: Inflammatory Arthritis – other (e.g., undifferentiated); PsA: Psoriatic Arthritis; CTDs: Connective Tissue Diseases and other systemic autoimmune rheumatic diseases (e.g., lupus, scleroderma, Sjogren’s, Raynaud’s); AS/SpA: Ankylosing Spondylitis and other spondyloarthropathies; Crystal: Gout and other crystal arthropathies; PMR: Polymyalgia Rheumatica; ESR: erythrocyte sedimentation rate; CRP: c-reactive protein; RF: rheumatoid factor; ANA: antinuclear antibody; 1denominator for abnormal tests reflects those with tests done; # not reported due low count |
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To cite this abstract in AMA style:
Widdifield J, Thorne JC, Tu K, Butt D, Ivers N, Bombardier C, Jaakkimainen RL, Ahluwalia V, Paterson JM, Bernatsky S. Primary Care Management of Patients with Rheumatic Diseases Prior to Rheumatologist Consultation [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). https://acrabstracts.org/abstract/primary-care-management-of-patients-with-rheumatic-diseases-prior-to-rheumatologist-consultation/. Accessed .« Back to 2015 ACR/ARHP Annual Meeting
ACR Meeting Abstracts - https://acrabstracts.org/abstract/primary-care-management-of-patients-with-rheumatic-diseases-prior-to-rheumatologist-consultation/