Dr. Kevin Deane of the University of Colorado in Aurora and his colleagues have conducted community health fairs to detect undiagnosed inflammatory arthritis. In one, 601 individuals were screened with a connective tissue–screening questionnaire and were tested for rheumatoid factor and anti–cyclic citrullinated protein [anti-CCP] antibodies. Of these, 9 people had inflammatory arthritis; screening found they met four or more of the seven ACR criteria for RA but had no prior diagnosis. Another 15 had inflammatory arthritis and were rheumatoid factor and/or anti-CCP positive, suggesting early RA (Arthritis Rheum. 2009;61:1642-9). Most of us are not going to go out and organize health fairs, but this is potentially a way to identify patients very early.
Also out of the University of Colorado, investigators are screening relatives of probands with RA to identify those with symptoms of early disease (Arthritis Rheum. 2009;61:1735-42).
Other strategies being investigated include the use of self-administered questionnaires, including a recent one comprised of 11 questions deemed to be predictive of early disease (BMC Musculoskelet. Disord. 2010 March 17 [doi:10.1186/1471-2474-11-50]), Internet-based case identification (J. Clin. Rheumatol. 2009;15:218-22), and primary care education, including continuing medical education programs that teach the benefits of screening and early diagnosis of patients. In addition, wide dissemination of and frequent reminders about early referral guidelines have been being investigated. One such set was authored by Dr. Paul Emery, professor of rheumatology and head of the academic unit of musculoskeletal medicine at the University of Leeds in England and his colleagues. These guidelines advise rapid referral to a rheumatologist for patients with three or more swollen joints, metatarsophalangeal/MCP involvement, and morning stiffness lasting 30 minutes or more (Ann. Rheum. Dis. 2002;61:290-7).
Q: How can triage systems be implemented to streamline time to treatment?
Dr. Bykerk: Triage refers to prescreening patients before referral. It depends in large part on the information that’s provided to the rheumatologist from the patient and the primary care provider. Many rheumatologists have tried to use referral forms, which can be effective, but primary care providers in general don’t like them because they get them from all directions – cardiology, endocrinology, pulmonology – and completing them all can be time consuming. As a result, triage efforts can be hampered by the lack of basic history, examination, and lab markers that would be needed to appropriately triage urgent cases.
Rapid triage, which I like to fondly call "speed dating," seems to be promising. In this model, patients with early disease attend a triage clinic where they come in for a few minutes and are seen by a rheumatologist or allied health professional; they may get a questionnaire to fill out, and are rapidly identified as having early inflammatory arthritis or not. This approach has been shown to reduce wait times dramatically in early studies. The limitation is that patients must be aware that they can get to these clinics.
Similarly, early arthritis clinics, which have popped up all over the world, have reduced patient wait times, as we’ve seen in the Canadian ArThritis CoHort (CATCH) multicenter research project (www.earlyarthritis.com). The hypothesis is that increased awareness of these clinics will eventually lead physicians to making earlier and earlier referrals.
Q: Where should rheumatologists focus their energies in order to identify and treat inflammatory arthritis patients as early as possible?
Dr. Bykerk: Overcoming delays for patients requires interventions at many levels: the symptomatic level, potentially through community initiatives; the primary care level, including referral guidelines and other methods to comanage patient care with primary care colleagues; and the rheumatology level, where we need to make a concerted effort to triage appropriately and, with the new criteria, diagnose and start treatment earlier. At all of these levels, we need to promote our evidence-based solutions, and they have to be health care specific. We should also consider promoting the idea of value-based incentives for referring patients with early arthritis to specialty care and removing disincentives for doing so.
Dr. Bykerk is a staff physician in the division of rheumatology, allergy, and immunology at Brigham and Women’s Hospital, Harvard Medical School, Boston. She disclosed financial relationships with Abbott, Amgen, BMS, Hoffmann-La Roche, Pfizer, Sanofi-Aventis, Schering-Plough, UCB, and Wyeth.
This interview was conducted by Diana Mahoney.