Rheumatic diseases comprise a constellation of more than 100 discrete disorders primarily affecting the joints and connective tissues, and is a leading cause of work disability and activity limitation in the United States. The Centers for Disease Control and Prevention reported that 52.5 million US adults were affected by arthritis in 2013, a statistic projected to reach 67 million by 2030.1,2 The clinical effects of the inflammatory arthritic conditions have far-reaching systemic manifestations and can significantly shorten life expectancy.3,4 The healthcare cost associated with rheumatic disease is staggering and has been estimated at $127.8 billion in 2008, nearly 25% more than the $104 billion associated with the cost of cancer care.4
Patients with joint or muscular-related pain generally first present to their primary care physician (PCP), who must make a determination for referral to a rheumatologist. The aging US population and the increasing challenge to meet the demand for rheumatologists, as demonstrated in the Workforce Study of Rheumatologists Report,5,6 have resulted in delays to rheumatologist referral and has increasingly shifted the role of the PCP from “gatekeeper” to a greater role in diagnosis and treatment.
Inflammatory arthritic diseases can progress rapidly to significant joint deformity if not promptly diagnosed and aggressively treated. Guidelines recommend early and aggressive treatment with disease-modifying antirheumatic drugs (DMARDs) initiated during the “window of opportunity” and implementation of a “treat-to-target” approach.7
A key question is how well PCPs perform to guideline recommendations compared with their rheumatologist colleagues. This question has been investigated indirectly and directly by surveys, which collectively show that PCPs and nonrheumatologists are less likely to prescribe DMARDs8,9 and more likely to delay initiation of a systemic therapy, including biologic agents.10 These findings are not unique to the United States, as demonstrated in several studies conducted in Europe that show differences in treatment patterns between general practitioners (GPs) and rheumatologists. Specifically, studies conducted in Italy, France, and the United Kingdom consistently show that GPs are more likely than rheumatologists to prescribe no treatment, complementary therapy, or nonsteroidal anti-inflammatory drugs (NSAIDs) for the treatment of arthritic conditions and less likely to prescribe DMARDs or systemic therapy.11-13
Delay in diagnosing degenerative arthritic diseases is a key obstacle to initiating prompt treatment and can result in long-term harm.14 Conducting key laboratory tests and initiating preliminary therapeutic interventions in the primary care setting before referral to a rheumatologist may be a strategy to expedite diagnosis and treatment. This approach may also promote a more collaborative approach to patient care between the PCP and the rheumatologist.
This is an interesting concept that has been evaluated in a study conducted in Austria by Puchner and colleagues, involving 1229 GPs and 110 rheumatologists managing cases of arthritis or suspected inflammatory back pain.15 The study compared pre-referral recommendations by GPs and rheumatologists for specific tests and treatment that should be initiated by the GP. Overall, the majority of GPs (100%) and rheumatologists (92%) were in agreement that key laboratory tests should be done by the GP; however, there were differences in the recommended tests. Significantly more GPs than rheumatologists recommended testing for rheumatoid factor (P<.001), antinuclear antibodies (P<0.001), and uric acid (P=.001).
In contrast, more rheumatologists than GPs recommended testing for alanine transaminase (P<.001) and creatinine (P=.035). In suspected cases of inflammatory back pain, significantly more GPs than rheumatologists (94% vs 71%, respectively; P<0.001) recommended that radiographic imaging should be performed by the GP before referral to the rheumatologist. GPs and rheumatologists were also in agreement that synthetic DMARDs should be initiated only by specialists, although biologic DMARDs can also be administered by GPs.
However, there were significant differences in opinion with regard to initiation of glucocorticoids (GC). Although rheumatologists generally discourage the initial use of GC to avoid masking of symptoms potentially leading to underdiagnosis or misdiagnosis, significantly more GPs (43%) than rheumatologists (11%) recommended initiating GC before referral (P<.001). There were also differences between GPs and rheumatologists in the recommended course of action for worsening disease or treatment adverse effects, with more rheumatologists (51%) than GPs (12%) recommending immediate referral to a specialist (P<.001).
Before evaluating the clinical relevance of this study, it is important to highlight some of the study limitations. The authors acknowledge that the study was limited to Austrian healthcare practitioners and primarily included GPs from the more rural setting who see relatively few cases of RA (an average of 0.4 cases a year). Therefore, how representative the study findings are, especially in other healthcare settings outside Austria, including the United States, is questionable. However, the study provides some useful insight and data that may be used as a starting point for further studies.
Summary and Clinical Applicability
Rheumatic inflammatory disease is progressive. The current delay in diagnosis and failure to initiate DMARD early results in progression, poor patient outcomes, and escalating healthcare cost. Initial studies suggest the potential benefit of coordinated care between PCPs and rheumatologists, where essential tests can be initiated by the PCP prior to referral to a rheumatologist. This approach may reduce the time to diagnosis and treatment initiation, may improve cooperative care between PCPs and rheumatologists, and may ultimately lower healthcare cost.
- American College of Rheumatology. Prevalence Statistics. Overall Prevalence of Arthritis and Rheumatic Diseases. Available at: http://www.rheumatology.org/Learning-Center/Statistics/Prevalence-Statistics. Accessed January 26, 2016.
- University of Rochester Medical Center. Arthritis and Other Rheumatic Diseases Statistics. Available at: https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=85&ContentID=P00068. Accessed January 26, 2016.
- Center for Disease Control and Prevention. Rheumatoid arthritis (RA). Available at: http://www.cdc.gov/arthritis/basics/rheumatoid.htm. Accessed January 26, 2016.
- American College of Rheumatology. Rheumatic diseases in America: The problem, the impact, and the answers. Available at: http://www.bu.edu/enact/files/2012/10/ACR_Whitepaper_SinglePg.pdf. Accessed January 26, 2016.
- US Census Bureau 2014. Persons 65 years and over. Available
http://quickfacts.census.gov/qfd/states/00000.html. Accessed January 26, 2016.
- Hogan PF, Bouchery E. The Lewin Group. Workforce Study of Rheumatologists. Final Report. Prepared for: The American College of Rheumatology. Published 2006. Available at: http://www.rheumatology.org/Portals/0/Files/LewinReport.pdf. Accessed January 26, 2016.
- Smolen JS. Treat-to-target: Rationale and strategies. Clin Exp Rheumatol. 2012;30:S2-S6.
- Poulin Y, Wasel N, Chan D, et al. Evaluating practice patterns for managing moderate to severe plaque psoriasis: role of the family physician. Can Fam Physician. 2012;58(7):e390-e400.
- Garneau KL, Iversen MD, Tsao H, Solomon DH. Primary care physicians’ perspectives towards managing rheumatoid arthritis: room for improvement. Arthritis Res Ther. 2011;13(6):R189.
- Adnot-Desanlis L, Brochot P, Eschard JP, Bernard P, Reguiaï Z. Treatment of psoriasis with biologics: a survey of dermatological and rheumatological practice at Reims University Hospital. Ann Dermatol Venereol. 2012;139(5):355-362.
- Scarpa R, Sarzi-Puttini P, Cimmino MA, et al. Analysis of pharmacologic and nonpharmacologic prescription patterns of general practitioners and specialists in the AMICA study. Semin Arthritis Rheum. 2005;35(1 Suppl 1):24-30.
- Richette P, Hilliquin P, Bertin P, Carni P, Berger V, Marty M. Comparison of general practitioners and rheumatologists’ prescription patterns for patients with knee osteoarthritis. BMC Musculoskelet Disord. 2011;12:72.
- Chard J, Dickson J, Tallon D, Dieppe P. A comparison of the view of rheumatologists, general general practitioners and patients on the treatment of osteoarthritis. Rheumatology (Oxford). 2002;41(10):1208-1210.
- Bykerk V, Emery P. Delay in receiving rheumatology care leads to long-term harm. Arthritis Rheum. 2010;62(12):3519-3521.
- Puchner R, Edlinger M, Mur E, et al. Interface Management between General Practitioners and Rheumatologists-Results of a Survey Defining a Concept for Future Joint Recommendations. PLoS One. 2016 Jan 7;11(1):e0146149.