Delay in seeing a rheumatologist and getting treatment for rheumatic diseases can make a huge difference in outcomes, and experts at the Annual European Congress of Rheumatology (EULAR 2014) in June discussed ways to speed up the process.
Musculoskeletal problems, for example, are top reasons patients see a primary care provider, but only a small portion need to be seen by a rheumatologist. Back pain is a common symptom, Dr. Mallen said, but most GPs will come across one ankylosing spondylitis patient every two or three years, he said.
“The symptoms are common, but pathology is rare in general practice,” Dr. Mallen said. “As such, it’s very challenging for the GP to untangle this to get the right person to rheumatology.” He often feels like he’s “trying to find the needle in the haystack.”
An approach that might be worthwhile is for patients to be fast-tracked for “red flag” symptoms. He said he has seen good results from rheumatologists seeing patients along with GPs. Another good practice is giving patients clear, detailed discharge plans, with a clear management plan and descriptions of the roles of a patient’s various providers, Dr. Mallen said.
GPs have an important role in the care of rheumatic patients even after they’re referred to a specialist—by helping treat comorbidities and helping patients navigate work and benefits issues, he said. Plus, they can help coordinate care that often ends up involving many specialists, he said.
“Coordinating that takes time, it takes knowledge,” he said. “And I think primary care probably is the best place for that to be happening.”
Options for Shortening Delay
There are a lot of options for shortening delays in patients getting access to rheumatologists and to the therapies they need, but some are more worthwhile than others, said Bruno Fautrel, MD, PhD, professor of rheumatology at Pitié Salpêtrière Hospital in Paris.
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.
Many studies have found that patients tend to take a wait-and-see approach and think their symptoms will just go away.
Having heard or read that it’s important to act quickly is one of the least common reasons patients see a doctor, Dr. Raza said. “People aren’t aware of rheumatoid arthritis; they aren’t aware of what their symptoms might mean.”
Patients’ poor evaluation of their own symptoms is probably the factor that can be most manipulated in order to prompt patients to seek help more quickly, he said. One potential solution would be a public health campaign regarding inflammatory arthritis, but there are significant challenges associated with that. It’s not as simple as telling patients to visit the doctor for joint pain; given how common musculoskeletal symptoms are that could inundate GPs’ offices, he said. Deciding what to tell patients to look for requires more research to identify the constellation of symptoms with the best ability to identify those patients with, or at risk of, RA and to separate them from those with other less urgent musculoskeletal conditions, Dr. Raza said.
“Getting patients with new onset RA to consult quickly is a key challenge that we must rise to,” Dr. Raza said. “A public health campaign may well help, but its content should be informed by evidence—what set of symptoms are we going to tell people that they should be looking out for?—and its impact should be formally assessed in the context of carefully designed pilots.”
Beyond broad public awareness campaigns—which might be of questionable value—there are specific opportunities to help patients assess their own symptoms better. Before people actually see a doctor, research has shown they often visit the pharmacy to get over-the-counter drugs and research their symptoms on the Web. Therefore, Dr. Raza said, easy availability of helpful information at the pharmacy might be a useful step, along with sharpening the delivery of information on commonly visited websites.
Thomas R. Collins is a freelance medical writer based in Florida.
