Improving Appropriate Access to Care With Central Referral and Triage in Rheumatology.

OBJECTIVE: To evaluate the short-term and long-term impact of a centralized system for the intake and triage of rheumatology referrals on access to care and referral quality. METHODS: An innovative central referral process, the Central Referral and Triage in Rheumatology (CReATe Rheum) program, was implemented in 2006, serving a referral base of 2 million people. Referrals are received in a central office, triaged by trained nurses, and assigned to the next available appointment on a prioritized basis. To evaluate the short-term impact, we compared wait times, duplicate referrals, and no-shows from a pre-implementation practice audit to a 2-year post-implementation evaluation (January 2007 to December 2008). Rheumatologists also assessed the quality and completeness of the referral information and accuracy of the urgency category assigned during triage. We evaluated the long-term impact by tracking referral volume, wait times, and rheumatologist manpower each year until December, 2013. RESULTS: During the first 2 years, wait-time variability between rheumatologists decreased, and wait times were reduced for moderate and urgent referrals. CReATe Rheum improved the quality of referral information and eliminated duplicate referrals. The urgency of the referral was assigned correctly in 90% of referrals. Over the long term, CReATe Rheum maintained short wait times for more urgent patients despite a growing number of referrals and a stable number of rheumatologists. CONCLUSION: A centralized system for the intake and triage of rheumatology referrals improved referral quality, reduced system inefficiencies, and effectively managed wait times on a prioritized basis for a large referral population.

Clinical and serological analysis of patients with positive anticyclic citrullinated Peptide antibodies referred through a Rheumatology Central Triage System.

OBJECTIVE: Anticitrullinated protein antibodies (ACPA) are a highly specific and sensitive biomarker for the diagnosis of rheumatoid arthritis (RA). Some patients who were found to have a positive ACPA test were referred to our Rheumatology Central Triage (CT; Calgary, Alberta, Canada) for assessment by a rheumatologist. The objectives of our study were to determine the clinical accuracy of ACPA in establishing a diagnosis of RA in a real-time clinical setting. METHODS: Cases that met 3 criteria were included in the study: (1) referred to the CT over 3 calendar years (n = 20,389), (2) reason for referral was a positive ACPA test (n = 568), and (3) evaluated by a certified rheumatologist (n = 314). An administrative serological database was used to retrieve specific ACPA results. RESULTS: Of patients referred through our CT for evaluation of a positive ACPA test, 57.6% received a diagnosis of RA; the remainder had a variety of other diagnoses, some of which might be considered early RA (9%). The predictive values of ACPA for the diagnosis of RA were increased when rheumatoid factor (RF) results were included in the analysis. When definite and possible RA were combined and the prevalence of moderate/high ACPA was compared to all other individuals, the positive and negative predictive values for moderate/high ACPA for RA were 74.3% and 68.4%, respectively. CONCLUSION: About 58% of patients with a positive ACPA referred through a triage system for a rheumatologist opinion received a diagnosis of RA at their first visit. RF provides additional useful information to guide the diagnosis and urgency of referral.