A systematic literature review of strategies promoting early referral and reducing delays in the diagnosis and management of inflammatory arthritis.

BACKGROUND: Despite the importance of timely management of patients with inflammatory arthritis (IA), delays exist in its diagnosis and treatment. OBJECTIVE: To perform a systematic literature review to identify strategies addressing these delays to inform an American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) taskforce. METHODS: The authors searched literature published between January 1985 and November 2010, and ACR and EULAR abstracts between 2007-2010. Additional information was obtained through a grey literature search, a survey conducted through ACR and EULAR, and a hand search of the literature. RESULTS: (1) From symptom onset to primary care, community case-finding strategies, including the use of a questionnaire and autoantibody testing, have been designed to identify patients with early IA. Several websites provided information on IA but were of varying quality and insufficient to aid early referral. (2) At a primary care level, education programmes and patient self-administered questionnaires identified patients with potential IA for referral to rheumatology. Many guidelines emphasised the need for early referral with one providing specific referral criteria. (3) Once referred, early arthritis clinics provided a point of early access for rheumatology assessment. Triage systems, including triage clinics, helped prioritise clinic appointments for patients with IA. Use of referral forms standardised information required, further optimising the triage process. Wait times for patients with acute IA were also reduced with development of rapid access systems. CONCLUSIONS: This review identified three main areas of delay to care for patients with IA and potential solutions for each. A co-ordinated effort will be required by the rheumatology and primary care community to address these effectively.

A systematic literature review of strategies promoting early referral and reducing delays in the diagnosis and management of inflammatory arthritis.

BACKGROUND: Despite the importance of timely management of patients with inflammatory arthritis (IA), delays exist in its diagnosis and treatment. OBJECTIVE: To perform a systematic literature review to identify strategies addressing these delays to inform an American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) taskforce. METHODS: The authors searched literature published between January 1985 and November 2010, and ACR and EULAR abstracts between 2007-2010. Additional information was obtained through a grey literature search, a survey conducted through ACR and EULAR, and a hand search of the literature. RESULTS: (1) From symptom onset to primary care, community case-finding strategies, including the use of a questionnaire and autoantibody testing, have been designed to identify patients with early IA. Several websites provided information on IA but were of varying quality and insufficient to aid early referral. (2) At a primary care level, education programmes and patient self-administered questionnaires identified patients with potential IA for referral to rheumatology. Many guidelines emphasised the need for early referral with one providing specific referral criteria. (3) Once referred, early arthritis clinics provided a point of early access for rheumatology assessment. Triage systems, including triage clinics, helped prioritise clinic appointments for patients with IA. Use of referral forms standardised information required, further optimising the triage process. Wait times for patients with acute IA were also reduced with development of rapid access systems. CONCLUSIONS: This review identified three main areas of delay to care for patients with IA and potential solutions for each. A co-ordinated effort will be required by the rheumatology and primary care community to address these effectively.

Design and validation of 2 objective structured clinical examination stations to assess core undergraduate examination skills of the hand and knee.

OBJECTIVE: To evaluate the development, validity, and reliability of 2 undergraduate Objective Structured Clinical Examination (OSCE) stations for core hand and knee examination skills. METHODS: Two OSCE stations for hand and knee based on core skills were developed, and qualitatively assessed for face and content validity by an expert consensus panel. Construct validity was evaluated by comparing the performance of third- (n = 21) and fifth-year (n = 50) medical students with 6 specialist registrars (SpR) in rheumatology. Concurrent validity was evaluated by correlating the scores of the fifth-year students with their eventual final examination scores. The fifth-year data were used to calculate the interrater and intrarater reliabilities of 2 examiners. Intrarater reliability analyzed repeat scores using videotapes of the examinations. RESULTS: Both stations were deemed to fulfil face and content validity criteria by the expert consensus panel. There was no significant difference in the mean scores of the third- and fifth-years. There were significant differences in the mean scores between both student groups and the SpR in both stations consistent with a valid construct theory. The fifth-year hand OSCE results correlated moderately with other indices of clinical skills, but not knowledge, and satisfied concurrent validity. Inter- and intrarater reliability for both stations was high. CONCLUSION: These OSCE stations are valid and reliable tools for testing competency in core hand and knee examination skills. They can be used in educational research as outcome measures of specific teaching interventions and can also be used as an early feedback tool when teaching joint examination.