The ACR/EULAR joint task force identified four steps that can involve delay: the gap between the first symptoms and the patient visiting a GP; the gap between the first visit to the GP and a referral to a rheumatologist; the gap between the referral and actually seeing a rheumatologist; and the gap between seeing the rheumatologist and starting disease-modifying antirheumatic drug therapy.1
Community awareness programs are one way to shorten the time it takes for patients to seek medical help once they notice symptoms. Such programs include screening questionnaires and the “Rheuma Bus” that’s been used in Germany. In general, such programs aren’t very effective, Dr. Fautrel said. “You need to reach many, many people with only a few people at risk,” he said.
Options for reducing the time between a GP visit and referral to a rheumatologist include joint consultations between the GP and the specialist, and easy-to-use tools for GPs to decide whether to make a referral.
Joint consultations can be too time consuming to be worthwhile, although they have been done with some success in the United Kingdom. Referral tools, though, are useful.
Dr. Fautrel said joint consultations can be too time consuming to be worthwhile, although they have been done with some success in the United Kingdom. Referral tools, though, are useful, he said. They include assessing whether certain tasks with the hand are painful or making a referral if certain clinical signs are present.
Professional education programs also have proved effective, including France’s Acting Early campaign, an education effort done over the phone in which 1,500 GPs were trained in six months.
Early arthritis clinics—used in the U.S. and Europe—have not shown greater capture of arthritis patients than more traditional healthcare channels and might not be worth the expense and effort involved, Dr. Fautrel said.
Development of triage procedures to quickly get patients to a rheumatologist can be very worthwhile, he said. A grading system in London, Ontario, Canada, that assigns a letter grade to patients based on the urgency with which they need treatment has proved effective, Dr. Fautrel said. And in Wales, a joint organization by four rheumatology departments has successfully channeled patients to the proper caregivers, speeding care and eliminating unnecessary referrals.
These kinds of approaches “should be implemented more and more largely,” Dr. Fautrel said.
Why Patients Wait
Karim Raza, BMBCh, PhD, professor of clinical rheumatology at the University of Birmingham in the United Kingdom, has studied why it is that patients wait so long before they see a GP about symptoms that could be an indication of a inflammatory arthritis. What he has found is that patients tend to wait to seek help until their symptoms “get really bad” or interfere with their normal activities, new symptoms arise or they feel they can no longer control the symptoms on their own.