The British Journal of Rheumatology, Vol 37, 1215-1219, Copyright © 1998 by British Society for Rheumatology
JI Gamez-Nava, L Gonzalez-Lopez, P Davis and ME Suarez-Almazor
OBJECTIVE: To describe primary care patterns of referral and diagnoses of
patients with rheumatic diseases referred to rheumatologists. METHODS: The
medical records of all consecutive patients referred in 1994 by >300
primary care physicians to two rheumatologists at an academic centre were
reviewed. The referring physician diagnosis was compared with the
rheumatologist's diagnosis. Sensitivity, specificity and predictive values
of primary care diagnoses were estimated using the rheumatologist diagnosis
as the 'gold standard'. SETTING: University-based rheumatology out-patient
clinic. RESULTS: Over half of the patients referred had a rheumatologist
diagnosis of soft-tissue rheumatism or a spinal pain syndrome. Three
hundred and forty-seven patients (49%) had a primary care diagnosis of a
defined rheumatic disease. Of these, 142 (41%) of the primary care
diagnoses were subsequently modified by the rheumatologist. The highest
agreement between primary care physician and rheumatologist was observed
for crystal-induced arthritis (kappa = 0.86), and the lowest agreement for
polymyalgia rheumatica (kappa = 0.39) and systemic lupus (kappa = 0.46).
Sensitivity was lowest for a primary care diagnosis of fibromyalgia (48%)
and highest for ankylosing spondylitis (94%). Positive predictive values
were generally low, in particular for systemic lupus erythematosus (33%)
and polymyalgia rheumatica (30%). CONCLUSION: Most patients referred to an
academic rheumatology centre had soft-tissue rheumatism or other pain
syndromes. In general, diagnostic agreement between rheumatologists and
primary care physicians was low. Increased emphasis on musculoskeletal
disorders should be encouraged in medical education to increase the
efficiency of rheumatology referrals.
ORIGINAL PAPERS
Referral and diagnosis of common rheumatic diseases by primary care physicians
Department of Public Health Sciences, Faculty of Medicine and Oral Health Sciences, University of Alberta, Edmonton, Canada.
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