Abstract and Introduction
Abstract
Objective and Methods In order to facilitate access and shorten waiting times to rheumatologist assessment, an immediate access clinic (IAC) was established. Patients were assessed at presentation in the clinic and after 6–12 months, either in the clinic or by telephone. Data regarding diagnostic accuracy, pain levels and care were analysed.
Results From February to December 2009, 1036 patients were assessed. 223 (21.5%) patients had symptoms for 3 months or less. 660 were available for re-assessment after 6–12 months. Initial tentative diagnoses were confirmed in over 75% of patients suspected of having rheumatoid arthritis (RA), spondylarthropathy and osteoarthritis. Men suspected of having spondylarthropathy had a significantly longer symptom duration than women (median (IQR) 54.0 (18.0–120.0) vs 24.0 (6.0–66.0) months; p=0.0082). There was no significant gender difference regarding pain. At follow-up, the visual analogue scale for pain in RA patients admitted to further care in the clinic (n=61) had significantly decreased by a median (IQR) of 37.5 mm (10.5–50.5), whereas this improvement was only 6 mm (−26–33.5) in the 22 RA patients followed outside the clinic (p=0.0083).
Conclusions The IAC resulted in considerable waiting time reduction for rheumatology assessment. A substantial minority was seen before 3 months' symptom duration. 'Positive predictive correctness' of the assessing rheumatologists regarding the presence of inflammatory rheumatic conditions was over 75%. Patients with RA cared for in the clinic had substantially lower pain levels after 6–12 months' follow-up than patients treated elsewhere.
Introduction
Rheumatic diseases constitute major health and societal burdens. Rheumatoid arthritis (RA) with an estimated prevalence of 0.5–1% affects approximately 5–10 million individuals in industrialised countries, more than 150 million have osteoarthritis or any other form of arthritis, approximately 50 million have osteoporosis and more than 350 million have spine problems. The societal burden is underscored by the fact that after 5 years 22% of patients with RA were unable to work or by the significant excess mortality in patients with osteoporosis.
RA, the most common chronic inflammatory rheumatic disease, is a destructive progressive immune-mediated disorder leading to joint erosions in 60% of patients within 1 year. Ten per cent of those presenting early (median of 8 weeks from first symptoms) have joint erosions at the first visit. It was postulated that early application of disease-modifying antirheumatic drugs (DMARD) improves the outcome of RA. Furthermore, it was shown that there is a 'window of opportunity' especially within the first 3 months.
The delay from symptom onset to the first visit with a rheumatologist or start of therapy ranges from several months up to more than 1 year. This delay has several reasons: neglect or negation of rheumatic diseases in general, lack of information, lack of knowledge about available therapies, limited availability and (geographical) proximity of specialists, or a mix thereof. As early and easy access to rheumatology assessment and treatment is regarded as mandatory, early arthritis clinics have been established in many countries such as The Netherlands, Germany, the UK, Austria and North America.
As a result of the lack of rheumatologists, however, waiting times frequently exceed by far the desired and recommended period of maximally 3 months from the onset of symptoms, thus precluding the start of therapy within the 'window of opportunity'. Therefore, we decided to establish an 'easy access' clinic, the so-called immediate access clinic (IAC; German: 'Akutbegutachtungsambulanz'), in which patients are seen usually within 1 day to 2 weeks from referral by other physicians or upon patients' self-referral, but only for a brief encounter and evaluation.
In the present study we describe the spectrum of patients' diagnoses and clinical characteristics at presentation and after 6–12 months. The aims of this study were: (1) to describe the characteristics of the patients evaluated in the IAC with respect to demographic data and initially suspected diagnoses; (2) to evaluate the accuracy of the initial diagnostic categorisations when compared with the 'final' diagnoses after 6–12 months; (3) to analyse differences between diagnostic categories with respect to disease duration, gender and pain levels; (4) to compare outcomes after 6–12 months with respect to pain levels and treatments between patients who continued to be cared for in our clinic and those cared for at other facilities.