Sternhall Lane Practice, 12 Sternhall Lane, London SE15 4NT and
1 Department of Rheumatology, King's College Hospital, London SE5 9RS, UK
SIR, Although referral for specialist advice in secondary care rheumatology departments is a key determinant of clinical activity within the speciality, this has not been comprehensively or systematically studied. Isolated reports from the UK and Ireland [18], continental Europe [9, 10] and North America [11] suggest there is wide diversity in the pattern of referral. Although local factors may be especially important in determining which patients are referred and the reasons why, there have been no comparisons of the management of musculoskeletal diseases between primary and secondary care in one or more areas. We therefore compared rheumatology referrals to one specialist unit with cases with rheumatic disorders seen at a nearby general practice where one general practitioner (GP) had a specific interest in rheumatology. We also reviewed experience at other UK specialist rheumatology centres. Our aims were to define the patterns of specialist rheumatology referrals and to suggest how these are likely to affect the future development of the speciality.
Two hundred and five consecutive new cases referred to our rheumatology outpatient clinic were studied in spring 1995; 153 attended, 12 cancelled and 40 did not attend. Case notes were reviewed after discharge for patients seen once and after the first follow-up visit for those who re-attended.
Hospital case notes were available for 138 of the 153 attenders (92%). One hundred and thirty consecutive cases with a musculoskeletal problem were seen in a single general practice where one of the principals had a specific interest in rheumatology. They were prospectively studied in spring 1996; all had GP records available. Using structured questionnaires, data were collected on age, sex and source of referral (in hospital cases) and the main rheumatological diagnoses.
The 138 clinic cases comprised 89 (64%) females and 51 (36%) males of median age 52 yr (range 1198 yr); 123 (88%) were referred from general practice, 13 (11%) from other hospital clinics and two (1%) from the Accident and Emergency Unit. The 130 cases seen in primary care comprised 91 (67%) females and 41 (32%) males of median age 45 yr (range 1581 yr).
There were differences in diagnostic categories of patients seen in primary and secondary care (Table 1). In primary care there were eight (6%) patients with inflammatory arthritis, 36 (28%) patients with osteoarthritis, 76 (58%) patients with back pain and soft tissue disease and 10 (8%) patients with other disorders. In secondary care there were 18 (13%) patients with inflammatory arthritis, 20 (14%) patients with osteoarthritis, 80 (58%) patients with back pain and soft tissue disease and 20 (14%) patients with other disorders. These differences were significant (
2 = 11.6; DF = 3; P = 0.009) and were mainly due to a preponderance of osteoarthritis cases in primary care (
2 = 5.7; DF = 1; P = 0.017) and a small excess of cases with inflammatory synovitis seen in secondary care.
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A Medline search with referral, outpatient and rheumatology as search terms identified seven reports of experience in the UK and four of experience in European or North American settings. Four reports gave data in a similar format to our own, and this information has been included in Table 1. Overall experience, based on 2459 cases, is that 25% of new referrals are for rheumatoid arthritis or another inflammatory arthritis, 24% are for osteoarthritis, 36% are for back pain and soft tissue rheumatism and 15% for other conditions. Interestingly, the number of patients with inflammatory arthritis fell from 43% in the southwest, at a time when there were relatively few rheumatologists to 1113% in London, where there is not an under-provision of rheumatologists.
Within London, where the numbers of rheumatologists approaches 1/100 000 of the population, the majority of new referrals have back pain or soft tissue rheumatism (5160% of cases in the three centres studied). The relative proportions of cases with back pain and soft tissue rheumatism seen in primary care and in secondary care are very similar, suggesting that there is no specific distillation of patients with these conditions towards secondary care. The relatively large number of patients referred in London with back pain and soft tissue disorders can be interpreted in two ways. One explanation is that most of these cases need referral and that, if there were an adequate number of rheumatologists in other parts of the UK, the numbers of cases referred with these disorders would rise to London levels. An alternative view is that there are too many rheumatologists in London and that they are unnecessarily seeing patients with back pain and soft tissue rheumatism. Our study does not differentiate between these two alternatives.
Finally, there may be differences between patients who attend with musculoskeletal problems in primary care and those with significant musculoskeletal disease who do not seek medical advice. It is likely that there are many people with significant arthritis, especially among the elderly, who are disabled by their musculoskeletal disease but who do not seek medical care from their GP. We found the average age of patients seen in primary and secondary care was below 55 yr, and this suggests that the elderly may be reluctant to seek medical advice for arthritis. The impact of this reluctance on the provision of medical services needs further evaluation.
We are grateful for the support of the Arthritis Research Campaign through an ICAC grant.
Notes
Correspondence to: D. L. Scott, Department of Rheumatology, King's College Hospital (Dulwich), East Dulwich Grove, London SE22 8PT, UK.
References