Rheumatology Advance Access originally published online on October 19, 2007
Rheumatology 2007 46(12):1859-1860; doi:10.1093/rheumatology/kem255
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LETTERS TO THE EDITOR |
Specialist interventions at the rheumatology outpatient clinic
1Rheumatology Department, Musgrave Park Hospital, 2Rheumatology Department, Royal Victoria Hospital, Belfast, UK
Correspondence to: M. Wray, Musgrave Park Hospital, Stockman's Lane, Belfast, BT9 7JB, UK. E-mail: mwray{at}doctors.org.uk
SIR, As rheumatologists we are under significant pressure to reduce the waiting times for new patients in the outpatient clinic. As there is restricted clinic time available for new and review patients, it has been suggested that ‘stable’ review patients should be discharged to primary care. We believe there exists a perception that review patients with rheumatic disease require little intervention or adjustment to treatment and do not need to continue to re-attend the outpatient clinic on a long-term basis. We collected data on specialist interventions required by patients with chronic rheumatic disease over a 6-week period on 253 consecutive patients who had been attending the rheumatology outpatient clinic for >12 months. A record was made of their diagnosis, current disease-modifying-drugs (DMARDs) and all interventions that had been undertaken in the clinic in the preceding 12 months. Anti-rheumatic ethical approval and informed patient consent was not required for this case-review-based study as confirmed by the trust research office.
The majority of patients had a chronic inflammatory arthritis; the largest subgroup being rheumatoid arthritis (47%) with psoriatic arthritis the next biggest group (14%), followed by osteoarthritis (13%), systemic lupus erythematosis (6%), ankylosing spondylitis (4.5%), seronegative arthritis (3%), polymyalgia rheumatica (2%), fibromyalgia syndrome (1.5%), juvenile idiopathic arthritis (1%) and others (8%).
In the previous 12 months, 90% of patients had required at least one specialist intervention including the following:
- Thirty percent of the patients had received an intra-articular or soft-tissue steroid injection.
- Thirty percent of the patients had required a dose adjustment or change of DMARD.
- Twenty-six percent had a change or new prescription of an analgesic or anti-inflammatory drug.
- Thirty-two percent of patients had a radiological investigation, five percent had diagnostic musculoskeletal ultrasound performed at the clinic.
- Twenty percent were referred to another member of the multidisciplinary team or medical specialty.
- Other interventions included adjustment of oral steroids (11%), adjustment of other rheumatological treatments (10%), blood testing other than for routine monitoring (11%), pulse of methylprednisolone (10%), admission to day ward or inpatient ward (10%).
Only 25 patients (10%) had no interventions in the preceding 12 months. Ninety percent of patients had one intervention, 31% had two, 23% had three, 10% had four, 4% had five, 2% had six and one patient (<1%) had seven interventions. The median number of investigations per patient was 2, with a mean of 2.07 interventions per patient. Of the 25 patients who had no intervention, 22 had a chronic inflammatory arthritis, and 15 were maintained on DMARD therapy.
This study was conducted in a general rheumatology outpatient clinic in a teaching hospital. The staff involved were Consultant, Specialist Registrar (SpR), Senior House Officer (SHO) and Nurse Specialist. The review patients are largely seen every 6–8 months during a 15 minute appointment. There were no complex connective tissue disease/vasculitis patients and few patients on biological therapies as they are seen in separate clinics. The patients at this clinic could therefore be considered to be a ‘stable’, less ill population and yet 90% of them required a specialist intervention in a 12 month period, 64% requiring between two and four interventions. Even the majority of those who had no intervention had chronic inflammatory disease and most were on DMARDs.
These results suggest that very few of our review patients could be discharged without the need for further ongoing care. In this practice, the consultant already receives on average 2–3 re-referrals per week as well as 3–4 letters or phone calls per week from GPs seeking advice.
It appears that those involved in these management decisions consider the surgical ‘one stop shop’ model of care to be appropriate, suggesting a fundamental lack of understanding of the management of chronic disease.
In the era of biological therapies, early aggressive treatment, ‘tight control’ of inflammatory disease [1], cardiovascular risk assessment, etc., we are now able to influence the natural history of rheumatic disease more than ever. It is likely, therefore, that patients will require more frequent review by trained specialists rather than less.
In our view, the care of review patients cannot be sacrificed to free up clinic time for new patients who may in turn become review patients. This study has highlighted the need for long-term specialist care for all patients with chronic rheumatological disease.
Disclosure statement: The authors have declared no conflicts of interest.
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- Grigor C, Capell H, Stirling A, et al. Effect of a treatment strategy of tight control for rheumatoid arthritis (the TICORA study): a single blind randomised controlled trial. Lancet 2004:17–23. 364:263–9.
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