Research ArticleArticle

Comprehensive Arthritis Referral Study — Phase 2: Analysis of the Comprehensive Arthritis Referral Tool

Andrew E. Thompson, Sara L. Haig, Nicole G.H. LeRiche, Gina Rohekar, Sherry Rohekar and Janet E. Pope
The Journal of Rheumatology October 2014, 41 (10) 1980-1989; DOI: https://doi.org/10.3899/jrheum.140167

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  • Table 1.

    Baseline demographics based on grade at consultation (%).

    CharacteristicsOverall, n = 696Urgent, n = 210Non-urgent, n = 486EIA, n = 95Non-EIA, n = 601
    Age, yrs< 2034 (4.9)12 (5.7)22 (4.5)6 (6.3)28 (4.8)
    20–40137 (19.7)42 (20)95 (19.5)20 (21.1)117 (19.4)
    41–60310 (44.5)96 (45.7)214 (44)42 (44.2)268 (44.6)
    > 60215 (30.9)60 (28.6)155 (32)27 (28.4)188 (31.2)
    SexFemale475 (68.2)129 (61.4)346 (71.2)50 (52.6)425 (70.7)
    Male221 (31.8)81 (38.6)140 (28.8)45 (47.4)176 (29.3)
    Duration, mos> 12423 (60.8)102 (48.6)321 (66)17 (17.9)406 (67.6)
    < 12273 (39.2)108 (51.4)165 (34)78 (82.1)195 (32.4)
    Morning stiffness, min> 60313 (45.0)106 (50.5)207 (42.6)55 (57.9)258 (42.9)
    < 60383 (55.0)104 (49.5)279 (57.4)40 (42.1)343 (57.1)
    Prior rheumatologic assessmentYes224 (32.2)76 (36.2)148 (30.5)8 (8.4)216 (35.9)
    No449 (64.5)128 (61.0)321 (66.0)85 (89.5)364 (60.6)
    Not sure23 (3.3)6 (2.9)17 (3.5)2 (2.1)21 (3.5)
    Patient reports swollen jointsYes439 (63.1)160 (76.2)279 (57.4)82 (86.3)357 (59.4)
    No171(24.6)28 (13.3)143 (29.4)4 (4.2)167 (27.8)
    Not sure86 (12.4)22 (10.5)64 (13.2)9 (9.5)77 (12.8)
    Referring physician reports swollen jointsYes341 (49.0)138 (65.7)203 (41.8)73 (76.8)268 (44.6)
    No255 (36.6)42 (20.0)213 (43.8)10 (10.5)245 (40.8)
    Not sure100 (14.4)30 (14.3)70 (14.4)12 (12.6)88 (14.6)
    Difficulty with simple ADLYes435 (62.5)150 (71.4)285 (58.6)72 (75.8)363 (60.4)
    No261 (37.5)60 (28.6)201 (41.4)23 (24.2)238 (39.6)
    Missed or stopped workingYes279 (40.1)94 (44.8)185 (38.1)39 (41.1)240 (39.9)
    No417 (59.9)116 (55.2)301 (61.9)56 (58.9)361 (60.1)
    Personal or family history of psoriasisYes123 (17.7)47 (22.4)76 (15.6)21 (22.1)102 (17.0)
    No573 (82.3)163 (77.6)410 (84.4)74 (77.9)499 (83.0)
    Strong family history of RAYes262 (37.6)68 (32.4)194 (39.9)32 (33.7)230 (38.3)
    No434 (62.4)142 (67.6)292 (60.1)63 (66.3)371 (61.7)
    ESRElevated192 (27.6)90 (42.9)102 (21.0)47 (49.5)145 (24.1)
    Normal or no blood work504 (72.4)120 (57.1)384 (79.0)48 (50.5)456 (75.9)
    CRPElevated138 (19.8)73 (34.8)65 (13.4)40 (42.1)98 (16.3)
    Normal or no blood work551 (79.2)137 (65.2)421 (86.6)55 (57.9)503 (83.7)
    RFPositive156 (22.4)81 (38.6)75 (15.4)39 (41.1)117 (19.5)
    Negative or no blood work540 (77.6)129 (61.4)411 (84.6)56 (58.9)484 (80.5)
    ANAPositive168 (24.1)65 (31.0)103 (21.2)29 (30.5)139 (23.1)
    Negative or no blood work528 (75.9)145 (69.0)383 (78.8)66 (69.5)462 (76.9)

    • ADL: activities of daily life; RA: rheumatoid arthritis; ESR: erythrocyte sedimentation rate; CRP: C-reactive protein; RF: rheumatoid factor; ANA: antinuclear antibody.

  • Table 2.

    Urgent versus non-urgent referrals at triage versus consultation.

    Consultation GradeTotal
    UrgentNon-urgent
    Triage GradeUrgent169100269
    Non-urgent41386427
    Total210486696
  • Table 3.

    Triage urgency grading versus consultation EIA grading.

    Consultation GradeTotal
    EIANot EIA
    Triage GradeUrgent86183269
    Non-urgent9418427
    Total95601696

    • EIA: early inflammatory arthritis.

  • Table 4.

    Predictors of urgent versus non-urgent referrals.

    VariableOR95% CIp
    1. Positive RF2.621.70–4.04< 0.001
    2. Referring physician rating the referral as urgent2.051.33–3.15< 0.001
    3. Elevated CRP1.971.23–3.150.005
    4. Patient has seen a rheumatologist before1.801.17–2.770.007
    5. Patient reports a history of joint swelling1.771.09–2.530.021
    6. Duration more than 12 mos1.671.01–2.530.016
    7. Patient reports a personal or family history of psoriasis1.651.03–2.650.037
    8. Family history of RA*0.620.42–0.930.022

    • ↵* Protective, less likelihood of an urgent referral. RF: rheumatoid factor; CRP: C-reactive protein; RA: rheumatoid arthritis.

  • Table 5.

    Predictors of early inflammatory arthritis.

    VariableOR95% CIp
    1. Duration less than 12 mos6.163.21–11.84< 0.001
    2. Patient-reported joint swelling3.801.70–8.540.001
    3. Referring physician classifies diagnosis as inflammatory2.481.10–5.610.0293
    4. Referring physician reported referral as urgent2.211.23–3.960.008
    5. Positive RF1.881.01–3.480.046
    6. Morning stiffness > 60 min1.791.02–3.140.044
    7. Patient > 60 yrs of age*0.250.07–0.930.038
    8. Patient previously assessed by a rheumatologist*0.240.10–0.550.001

    • ↵* Protective, less likelihood of early inflammatory arthritis. RF: rheumatoid factor.

  • APPENDIX 2.

    Triage grading system.

    CategoryDescriptionExamples
    A+For patients who require assessment and treatment on an urgent basis within 24–48 h. Reserved for patients whose physicians personally contact the rheumatologist to outline clinical details.

    • Septic arthritis

    • Giant cell arteritis

    • CTD with major organ decompensation

    AFor patients who require assessment and treatment on an emergent basis within 2–4 weeks. Reserved for patients with a recent onset inflammatory arthritis where early intervention is critical to a successful outcome.

    • New onset IA

    • Severe IA with impact on ADL

    • CTD

    • Vasculitis

    • PMR

    BFor patients who require assessment and treatment on an elective basis within 2–4 mos. Reserved for patients with information that suggests an inflammatory syndrome where immediate intervention is not necessarily as important, but treatment is necessary.

    • Established IA

    • Undiagnosed or subacute or probable IA

    • Crystalline arthritis

    • Severe OA with a major impact on ADL

    CFor patients who require assessment and treatment on an elective basis within the next 6–12 mos. Reserved for patients with stable treated inflammatory disorders or non-inflammatory disorders.

    • Previously diagnosed rheumatic disease (stable) referred for diagnostic re-evaluation or review of treatment

    • FM not previously seen by rheumatologist

    • Possible IA, but not deemed highly likely

    • OA which may benefit from consultation

    DFor patients with a problem which is best assessed by another healthcare provider. Appointments are not given unless discussed with referring physician. Reserved for patients with established chronic pain conditions who would be better treated by specialists in orthopedics, chronic pain, or rehabilitation.

    • Diagnosed FM

    • Chronic MBP

    • Soft tissue pain

    • CTD: connective tissue disease; IA: inflammatory arthritis; PMR: polymyalgia rheumatica; ADL: activities of daily living; OA: osteoarthritis; FM: fibromyalgia; MBP: mechanical back pain. From: Graydon SL, Thompson AE. J Rheumatol 2008;35:1378–83.

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Keywords

ARTHRITIS
TRIAGE
REFERRAL
EARLY INFLAMMATORY ARTHRITIS

Keywords