Rheumatology Advance Access originally published online on November 15, 2005
Rheumatology 2006 45(2):201-203; doi:10.1093/rheumatology/kei122
© The Author 2005. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Self-referral of symptoms (SOS) follow-up system of appointments for patients with uncertain diagnoses in rheumatology out-patients
A. V. Pace,
C. M. Dowson and
P. T. Dawes
Staffordshire Rheumatology Centre, The Haywood Hospital, High Lane, Burslem, Stoke-on-Trent ST6 7AG, UK.
Correspondence to: P. T. Dawes, Staffordshire Rheumatology Centre, The Haywood Hospital, High Lane, Burslem, Stoke-on-Trent ST6 7AG, UK. E-mail: PT.Dawes{at}uhns.nhs.uk
 |
Abstract
|
|---|
Objective. Clinical features in rheumatological conditions often
fluctuate with time and this may cause difficulty when evaluating
patients whose symptoms or signs do not coincide with their
initial rheumatology visit. The aim of this study was to evaluate
the outcome of a follow-up system whereby patients with uncertain
rheumatological diagnoses at their initial assessment are given
easy and rapid access to a rheumatology review.
Method. We studied the outcome of SOS (self-referral of symptoms) appointments offered to patients over a 44-month period in one consultant's clinic at the Staffordshire Rheumatology Centre. The reattendance rates and diagnoses at the initial and subsequent visits were evaluated over a mean period of 26.3 months (range 7–64 months).
Results. Thirty-seven patients (23 males, 14 females) were offered SOS appointments during the period studied. At the initial assessment, a provisional diagnosis was recorded for 29 patients (78.4%), whereas the diagnosis was unclear for the other eight patients. At the end of the study period, 10 patients (27%) had requested specialist review via the SOS system after a mean period of 6.8 months (1–19 months). The diagnosis remained unchanged in 8 of the 10 reattenders, whereas the diagnosis was revised in two patients. None of these patients, however, developed an inflammatory arthritis.
Conclusion. We suggest that an SOS system of appointments may be a feasible and practical method to follow up patients who have uncertain rheumatological diagnoses at their initial visit. This follow-up system may not easily fit into the current out-patient reforms being implemented in the National Health Service, yet this form of specialist follow-up seems clinically essential for some forms of disease management. The requirements necessary to operate such a system as well as the envisaged pros and cons for the patient and for the rheumatologist are discussed.
KEY WORDS: Self-referral, Musculoskeletal diseases, Accessibility of health-care
|
Introduction
|
|---|
The natural history and progression of musculoskeletal conditions
varies, with a pattern of clinical symptoms and signs that change
in severity over time. Some red-flag conditions, such as malignancy,
are severe and progressive. Others, such as gout, are episodic,
fluctuating or self-limiting. The severity of symptoms and signs
may not always coincide with the initial or subsequent visit
to a rheumatologist and hence the attending physician relies
on an accurate account of symptoms as described by the patient.
Symptoms such as joint swelling can be misleading as subjective,
rather than objective, swelling is unlikely to represent significant
pathology. Various patient factors, such as intellect, memory
and communication skills, will influence the description of
symptoms and may affect the ability of the clinician to reach
an accurate diagnosis. These difficulties may be overcome by
offering patients the opportunity to be assessed at the time
when their symptoms are present or severe. Patients prefer a
health system which facilitates rapid access to a specialist
assessment and this appears to increase the satisfaction and
confidence in that rheumatology department [
1,
3]. Some rheumatology
centres have adopted patient self-referral to a rheumatologist
when their symptoms are severe, usually in patients with known
rheumatoid arthritis [
1–3]. Its use for patients with
other rheumatological conditions or for patients with an uncertain
clinical diagnosis has not been studied previously. The aim
of this study was to evaluate the outcome of acute self-referral
appointments of patients with an uncertain diagnosis (self-referral
of symptoms, SOS). We describe the outcome of a pilot study
to evaluate this type of access.
|
Method
|
|---|
The study included all patients attending a consultant clinic
at the Staffordshire Rheumatology Centre over a 44-month period
from April 2000 to December 2003. Patients were given SOS appointments,
rather than a routine follow-up appointment, if there was an
absence of signs despite symptoms suggestive of pathology and
where there was diagnostic uncertainty. Patients were given
a slip of paper with a secretary's direct telephone number.
Secretaries were able to access letters from the patients’
initial appointment via the departmental information technology.
If the secretary was unavailable, they were asked to use the
patients’ telephone helpline and state that they required
an SOS appointment because their symptoms (e.g. joint swelling)
were now present.
We evaluated whether patients given SOS access contacted the department as described or attended the hospital through a different referral route. Details of their reattendance at the centre were recorded up until July 2004. The diagnoses in reattenders were evaluated. A comparison was made between the provisional diagnoses given at the initial visit and those made on reattending the centre. Whether patients had developed evidence of inflammatory arthritis was of particular interest.
|
Results
|
|---|
Thirty-seven patients (23 males, 14 females) were given SOS
appointments during the period from April 2000 to December 2003.
Their ages ranged from 12 to 80 yr, with a mean of 46.2 yr (39.6
yr for females, 50.1 yr for males). Most patients (78.3%) were
given an SOS appointment after only one initial clinic visit.
Duration of their symptoms ranged from 6 weeks to more than
10 yr (mean 38.5 months). The mode of presentation was evenly
distributed between monoarticular (38%), oligoarticular (30%)
and generalized (32%) symptoms. Knee pain featured in the symptomatology
of 21 (56.8%) patients. At the initial assessment, a provisional
diagnosis was recorded for 29 patients (78.4%), whereas the
diagnosis was unclear for the other eight patients. By the end
of July 2004, the follow-up period for the patients studied
potentially ranged from 7 to 64 months (mean 26.3 months).
A total of 10 patients (27%) reattended the centre. The SOS appointments were requested by patients after a mean of 6.8 months (range 1–19 months) following their last routine visit. No correlation was found between gender, mode of presentation or provisional diagnosis between the reattenders and the non-attenders. The majority of the reattenders used the designated contact numbers but two returned to their general practitioner in order to regain access for a specialist assessment. All 10 patients were seen by a specialist within 2 days, irrespective of contact method.
At the reassessment visit, the diagnosis remained unchanged for 8 of the 10 reattenders. The diagnosis was revised for two patients. None of these patients were considered to have developed an inflammatory arthritis. Five of the 10 patients were discharged again after one reassessment visit. Four patients required further out-patient visits before being discharged, because of diagnostic difficulty or severity of symptoms. Ongoing follow-up visits were required for only one patient (Table 1).
|
Discussion
|
|---|
This SOS appointment system provides symptomatic patients with
timely access to a rheumatologist, and may be a more appropriate
and efficient way of managing acute problems in patients suspected
of having conditions such as crystal arthropathies and soft
tissue problems. A considerable number of clinic appointments
would have been required if all the patients originally seen
were given routine follow-up appointments after their initial
assessment. The practice of arranging SOS appointments in appropriate
cases saves clinic time and releases appointment slots for patients
who are more in need of frequent follow-up visits. This method
of ensuring appropriate timely follow-up for some patients may
not be in accordance with planned National Health Service reforms
on out-patient booking, but it is hoped that local flexibility
can be maintained to ensure that novel and efficient services
are not compromised.
Patient acceptance of such a self-referral system is likely to be high as it provides them with quick access to specialist assessment at the time when they have symptoms. Their time is not wasted attending routine appointments when they are asymptomatic. For patients without significant pathology, the avoidance of frequent or regular follow-up appointments may help to provide reassurance that their condition is not serious and may also empower them in the management of their symptoms. Similarly, SOS appointments are highly likely to be welcomed by rheumatologists because assessing clinical features in patients who are symptomatic increases the positive yield from investigations and increases diagnostic accuracy. The envisaged advantages and disadvantages of this system are outlined in Table 2.
Selection of patients suitable for SOS access needs careful
consideration to ensure the system is used appropriately. SOS
appointments should be offered to patients in situations in
which there is diagnostic uncertainty because of paucity of
clinical features at the initial assessment. Similarly, confirmation
of a suspected diagnosis is facilitated in conditions that follow
an episodic course, such as gout or palindromic rheumatism.
In patients who are suspected of having self-limiting conditions
at their initial assessment, an SOS system provides the rheumatologist
with the advantages of discharging the patient whilst also reassuring
the patient of early review when and if necessary (
Table 3).
One of our concerns was that this process of self-referral may
be abused; however, our experience indicates that this will
not be the case. Our results were reassuring in that no patients
suspected of preclinical or very early inflammatory arthritis
actually developed sustained inflammatory disease. This system
may also be extended to patients who have an established diagnosis,
e.g. rheumatoid arthritis or systemic lupus erythematosus, and
have been taught to use the system when significant symptoms
related to their condition occur. In the longer term, this may
allow the interval between routine out-patient appointments
to be lengthened [
3].
An SOS appointment system requires the presence of supporting
services. A 24 h contact system needs to be available to allow
reporting of symptoms. A 24 h telephone helpline, the use of
secretaries’ direct numbers and contact telephone numbers
of a designated ward are all means which may be readily available
to patients to order to report their symptoms. Trained personnel
handling such calls will then organize an assessment with a
rheumatologist within 24 h. An on-call rheumatology service
is therefore required to ensure assessment of patients preferably
within this period, and complements the needs of patients with
other rheumatological emergencies. Clinic facilities and access
to patients’ medical notes or electronic patient records
should be available to allow rapid and efficient assessment
of patients utilising the SOS system (
Table 4).
The demand of rheumatological emergencies on acute services
has often been ignored. However, this has changed in recent
years and expertise is required because of factors such as demography,
increased patient awareness of rheumatological conditions, the
need for early assessment of inflammatory arthritis and potential
problems arising from the use of biological treatments. The
workload generated from patients with rheumatological conditions
requires reorganization of services [
4]. Adopting a practice
of SOS appointments for new patients may contribute to this.
Our study suggests that this is a feasible approach to managing
out-patient workload and, when used for selected patients and
with the appropriate support, may be extended for use in a wider
range of conditions.
The authors have declared no conflicts of interest.
|
References
|
|---|
- Hewlett S, Mitchell K, Haynes J, Paine T, Korendowych E, Kirwan JR. Patient-initiated hospital follow-up for rheumatoid arthritis. Rheumatology 2000;39:990–7.[Abstract/Free Full Text]
- Kirwan JR, Mitchell K, Hewlett S et al. Clinical and psychological outcome from a randomized controlled trial of patient-initiated direct-access hospital follow-up for rheumatoid arthritis extended to 4 years. Rheumatology 2003;42:422–6.[Abstract/Free Full Text]
- Hewlett S, Kirwan J, Pollock J et al. Patient initiated outpatient follow up in rheumatoid arthritis: six year randomised controlled trial. BMJ 2005;330:171–5.[Abstract/Free Full Text]
- Kirwan JR. New modes of practice. Curr Opin Rheumatol 2004;16:125–9.[Medline]
Submitted 5 July 2005;
revised version accepted 12 August 2005.
CiteULike 
Connotea 
Del.icio.us What's this?
Top
Abstract
Introduction