Aims Urate‐lowering therapy (ULT) is effective in gout, but suboptimal management with wide variability in dose escalation remains widespread. We protocolized dose escalation of ULT to improve gout management. The aim was to reduce time to achieve target serum urate (SU) <360 µmol/L. Methods Process improvement tools were used to identify underlying causes of prolonged time to target SU. We designed a nurse‐led telemedicine intervention for dose escalation of ULT. Patients with gout with SU ≥360 µmol/L meeting indications for ULT at a single institution were recruited. Exclusion criteria were estimated glomerular filtration rate <30 mL/min, pregnancy, cognitive impairment and poor mobility. A nurse‐led telemedicine clinic was set up to perform patient education, monitoring of adverse events and drug escalation. We partnered with primary healthcare centers for routine blood tests. Results From July 2016 to December 2017, 127 patients were recruited. Median time to target SU was 19.0 weeks (interquartile range [IQR] 11.0‐31.0). Median dose of allopurinol was 300 mg/d (IQR 200‐400) in normal renal function and lower in renal impairment. Median telemedicine calls required to achieve target SU was 2 (IQR 1‐3). No patient was hospitalized for gout flares. Two patients had adverse drug reactions, one required cessation of allopurinol for rash with eosinophilia, the other had self‐resolving ulcers and allopurinol was continued. Lower baseline SU and number of gout flares were associated with attainment of target SU. Conclusion A nurse‐led telemedicine for gout care is effective and safe. Our results affirm the utility of telemedicine in increasing access to care and lower healthcare utilization.

The aim of this study is to identify factors from referral information predictive of patients with inflammatory arthritis (IA) requiring early review. Four hundred twenty-six consecutive rheumatologist-triaged referrals from February to June 2012 were retrospectively reviewed to identify patients with rheumatologist-diagnosed IA correctly triaged for review within 2 weeks from referral date. Information from referral was analyzed descriptively followed by univariate logistic regression adjusted for age and sex to identify predictors of IA. Of the 108 patients with rheumatologist-confirmed diagnoses seen within 2 weeks, 76 patients (70.4%) were correctly triaged with 44.7% having rheumatoid arthritis (RA); 9.2%, psoriatic arthritis; 9.2%, spondyloarthritis; and 18.4%, undifferentiated inflammatory arthritis. The majority were females (63.2%), with median age of 52.8 years (Q1; Q3 38.4; 61.3) with referrers indicating presence of morning stiffness in 71.4% and symmetrical distribution in 74.6%. Five or more joints were involved in 65.7% with suspected metacarpophalangeal joint (MCPJ) (44.7%) or proximal interphalangeal joint (PIPJ) (59.6%) involvement. Of the referrals with laboratory results, erythrocyte sedimentation rate (ESR) was raised with median 43.5 mm/h (Q1; Q3 24.8; 77.5) and normal median uric acid of 312.5 μmol/L (Q1; Q3 249.5; 363.5). Univariate analysis revealed that presence of ≥5 joints affected (p = 0.001), symmetrical distribution (p = 0.006), MCPJ (p = 0.003), PIPJ (p = 0.003), and elevated ESR (p = 0.001) were predictive of IA after adjustment for age and sex. Specific information including number, pattern, and location of joint involvement with relevant laboratory investigations should be included in referral letters to assist with effective triaging of patients with IA.

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Background The management of patients with inflammatory arthritis relies on the principle that patients are referred to and reviewed by rheumatologists as soon as possible. Success of this depends upon accurate and thorough information being provided in the letter of referral as well as the rheumatologist themselves, in the interpretation of this information. Important components of an informative referral letter to rheumatologists have not been evaluated in an Asian setting. Objectives To identify factors from referral information predictive of patients with inflammatory arthritis requiring early review. Methods 426 consecutive rheumatologist-triaged referrals from February to June 2012 were retrospectively reviewed to identify patients with confirmed inflammatory arthritis after rheumatologist review, correctly triaged initially for review within 2 weeks from referral date. Appropriate early review was defined as patients with rheumatologist-diagnosed inflammatory arthritis (excluding crystal arthritis) reviewed within 2 weeks from referral. Data on provisional and final diagnoses, time to review and appropriateness of early review were collected. Information from the referral letters including age, gender, morning stiffness, number of joints involved, pattern of joint involvement, laboratory results such as rheumatoid factor, erythrocyte sedimentation rate (ESR) and uric acid (if available), were analysed descriptively followed by univariate logistic regression adjusted for age and gender to identify predictors of inflammatory arthritis diagnosis in referral letters. Results 76 patients with inflammatory arthritis were correctly triaged with 45% having rheumatoid arthritis, 9% psoriatic arthritis, 9% spondyloarthritis and 18% with undifferentiated inflammatory arthritis. 63% were females, with median age 53 years (Q1; Q3 38; 61) with referrers indicating presence of morning stiffness in 71% and symmetrical distribution of joint involvement in 74%. More than 5 joints were involved in 66%, with suspected metacarpophalangeal joint (MCPJ) in 45% or proximal interphalangeal joint (PIPJ) involvement in 60%. Of the referrals with laboratory results, ESR was raised with median 43.5 mm/hr (Q1; Q3 24.8; 77.5) and normal median uric acid of 313 mmol/L (Q1; Q3 250; 364). Univariate analysis revealed that involvement of > 5 joints (p=0.008), MCPJ (p=0.003), PIPJ (p=0.003), symmetrical distribution (p=0.005), positive rheumatoid factor (p=0.029) and elevated ESR (p=0.001) predicted inflammatory arthritis after adjustment of age and gender. Conclusions Referral letters to rheumatologists for an opinion of inflammatory arthritis should contain the factors relevant to a diagnosis of inflammatory arthritis as identified. It is possible that letters that do not contain all available information lead to patients being inappropriately triaged and having a delayed diagnosis. A standardized referral template would help improve waiting times for patients with inflammatory arthritis. Disclosure of Interest None Declared