Can diagnostic triage by general practitioners or rheumatology nurses improve the positive predictive value of referrals to early arthritis clinics?

Abstract

Diagnostic triage by GPs or RNs improved the positive predictive value of referrals to an EAC with a degree of accuracy approaching that of a group of experienced rheumatologists.

Improving Appropriate Access to Care With Central Referral and Triage in Rheumatology

“…Evidence supports the integration of alternate care providers in the care of patients with rheumatic diseases as it frees the specialist physician's time for care of more complex patients [19,20]. In particular, previous studies have shown that clinical triage by rheumatology nurses have high positive predictive values when compared with the rheumatologist's decision [21]. In our study, triage by the nurse clinician was found to be effective and accurate, with 90% of referrals assigned to the correct triage category as judged by rheumatologists.…”

System Integration and Clinical Utilization of the Advanced Clinician Practitioner in Arthritis Care (ACPAC) Program–Trained Extended Role Practitioners in Ontario: A Two-Year, System-Level Evaluation

“…Past research has identified that often both GPs and specialists are dissatisfied with the referral process 22,62 . Deficiencies of the referral process from primary care provider to rheumatologist have been documented elsewhere [63][64][65][66] . Most authors agree that high frequency, inappropriateness and delays in referrals contribute to increased waiting times and compromise the quality of health care 66,67 .…”

“…The median time between symptom onset to DMARD initiation was over six months with delays in the identification of inflammatory arthritis and referral to a rheumatologist being a key contributor. Several studies have highlighted potential solutions to ensuring timely care, including, the improved communication between GPs and specialists 66 , joint consultation between GPs and rheumatologists to influence the referral behaviour of GPs to decrease referral and potentially lead to a reduction of waiting lists 67 , and diagnostic triage by GPs, Registered Nurses, or other appropriately trained health professionals have been posed as ways to regulate frequency and appropriateness of referrals 72 .…”

“…As the population ages and the demand for rheumatology services continues to increase, while physician human resource shortages will ultimately limit the ability of Canadians to seek care 27 , long waiting times 22,32 , referral problems 33,34 , and geographic misdistribution 17,35 will compound the problem further. Not only are individuals having difficulty accessing care 36 , but younger rheumatologists are spending less time in patient care 22 and, as reported in the United States, are working shorter hours 37 .…”

Dr. Harrington replies

“…Referral of patients to a musculoskeletal screening clinic is one of the intriguing redesigns referenced by Graydon and Thompson, and that might rapidly improve referral performance 8 , but it would require cooperation among primary physicians, orthopedic surgeons, and rheumatologists at the health system or regional level.…”