Can a rheumatologist accurately prioritize patients on the basis of information in the general practitioner referral letter?

N. Sathi, E. Whitehead1 and D. Grennan

Wrightington Hospital, Rheumatology, Wigan and 1United Hospital, Rheumatology, Co. Antrim, Northern Ireland, UK

Correspondence to: D. Grennan, Wrightington Hospital, Hall Lane, Appley Bridge, WN6 9EP, UK. E-mail: nsathi{at}doctors.org.uk

SIR, It is widely recognized that certain rheumatological problems, such as patients suffering from active rheumatoid arthritis, are mostly effectively treated if diagnosed and treated early in the course of their illness [1]. Kirwan’s latest audit [2] highlighted a number of problems related to increasing workload, waiting times, and referrals of soft-tissue rheumatism and back problems. It was felt that the increased resources given to the South West regional rheumatology services had only helped in coping with the increased rheumatology clinic referrals. This was thought to be insufficient for improving service provision for individual patients [2].

In this situation it seems essential that patients be prioritized appropriately, so that those suffering from potentially reversible forms of inflammatory joint disease are seen promptly in early synovitis clinics [3] before irreversible changes to their joints have occurred. By contrast, for the majority of referrals of non-urgent rheumatological problems a wait of 13 weeks has been shown to have no adverse influence on the outcome [4]. These patients may safely be seen in non-urgent, routine clinics. In this study we examined the accuracy with which a consultant rheumatologist prioritizes patients using a simple prioritization system with three grades (A, B and C), based on the information supplied in the referral letter from the general practitioner (GP). Priorities made on the basis of the referral letter (paper priority) were compared with the clinical priorities made after the patient had been assessed clinically in the rheumatology out-patient clinic by the same consultant rheumatologist.

We examined priorities in 102 consecutive new GP referrals over a 10-week period (re-referrals were excluded). When the referral letters were received by the consultant rheumatologist, a ‘paper’ priority was assigned to the patient and recorded on the back of the referral letter, where it would not be seen by the consultant rheumatologist when the patient was subsequently seen in the out-patient clinic. Criteria for each priority were as follows:

Priority A. Patients suspected of suffering from (rheumatoid arthritis or other) forms of inflammatory joint disease of less than 2 yr duration; patients with suspected polymyalgia rheumatica or temporal arteritis; patients with suspected connective tissue disease or suspected vasculitis.

Priority B. Patients with established (rheumatoid arthritis or established forms of other) inflammatory joint disease of more than 2 yr duration; patients with undiagnosed rheumatic problems; patients with osteoarthritis and symptoms sufficient to cause major disturbance of life style.

Priority C. Other patients, including patients referred with simple neck or simple low back pain; patients with fibromyalgia; patients with occupation-related rheumatic disease and re-referrals of patients with osteoarthritis or soft-tissue rheumatism.

Priority A patients were seen within 2 weeks, priority B within 8 weeks and priority C within 13 weeks.

Clinical priorities were assigned when the patient had been assessed clinically by the same consultant rheumatologist without looking at the paper priority. Agreement between paper and clinical priorities was analysed using the {kappa} score for inter-rater agreement [5].

One hundred and two patients were assessed. On receipt of their referral letters, 36 were assigned paper priority A, 49 paper priority B and 17 paper priority C.

Of the 36 patients with paper priority A, 27 were assigned to clinical priority A, 8 to clinical priority B and 1 to clinical priority C. Of the 49 patients with paper priority B, 2 were assigned to clinical priority A, 44 to clinical priority B and 3 to clinical priority C (after being seen in clinic). Of the 17 patients with paper priority C, 0 were assigned to clinical priority A, 4 to clinical priority B and 13 to clinical priority C (after being seen in clinic). Overall, 6 of the paper priorities were upgraded and 12 of the paper priorities were downgraded clinical priorities. The overall {kappa} score was 0.71, which represents good agreement [5].

This study showed good agreement between paper priorities made by the consultant on receipt of the GP’s letter and clinical priorities made after seeing the patient in the out-patient clinic. It could be argued that this study was biased in favour of good agreement as the same consultant carried out both the paper and the clinical prioritization. The main aim of this study was to ensure that patients with urgent conditions that might benefit from being seen early were not kept waiting on any routine waiting list. However, paper diagnoses were upgraded in only six instances, when the patient was actually seen in clinic. Thus, at least in our patients in Lancashire, we are able to obtain acceptable prioritization of patients for a rapid-access clinic on the basis of information supplied in the GP’s referral letter. This prioritization system may help our colleagues deal with their workloads and the demands made by the NHS plan [6].

We are grateful to M. Joshi (Department of Statistics, Lancaster University) for statistical advice.

References

  1. Emery P, Salmon M. Early rheumatoid arthritis: time to aim for remission. Ann Rheum Dis 1995;54:944–7[ISI][Medline]
  2. Kirwan JR, Averns H, Creamer P et al. Changes in rheumatology outpatient workload over 12 years in the South West of England. Rheumatology 2003;42:175–9[Free Full Text]
  3. Courtney PA, Wright GD. Referrals to an ‘early synovitis clinic’: are they appropriate? Ann Rheum Dis 2001;60:991–2[Free Full Text]
  4. Hurst NP, Lambert CM, Forbes J, Lochhead A, Major K, Lock P. Does waiting matter? A randomised controlled trial of new non-urgent rheumatology outpatient referrals. Rheumatology 2000;39:369–76[Abstract/Free Full Text]
  5. Altman AG. Practical statistics for medical research. London: Chapman & Hall, 1991
  6. Cutting waiting time for treatment. In: Department of Health. The NHS plan. London: Department of Health, 2001
Accepted 26 February 2003





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