Supporting primary care to refer suspected early inflammatory arthritis patients appropriately is vital to ensure prompt diagnosis and treatment. The rheumatology team at Lancashire and South Cumbria NHS Foundation Trust identified issues around referral following antibody test results, using the National Early Inflammatory Arthritis Audit (NEIAA). It's worked closely with primary care colleagues to tackle the issue and improve referrals. To find out more, we speak to Dr Lizzy MacPhie.
Identifying the problem
When the National Early Inflammatory Arthritis Audit first launched, we investigated our referrals to see whether the right patients were being referred to our clinic in a timely manner. We used audit data to show that some patients were taking longer to be referred than others; specifically sero-negative patients.
We found that GPs were referring a lot of patients to the service based on positive antibody results. Those with negative results weren’t being referred as promptly despite symptoms. What primary care colleagues didn’t realise is that a negative result doesn’t exclude rheumatoid arthritis (RA), nor does a positive result equate to a diagnosis.
We reviewed the wording on the antibody reports going to GPs and realised they were inferring that a positive antibody test was consistent with sero-positive RA, which would invariably result in patients being referred to us.
For many patients with a negative result, result misinterpretation meant a delay in being referred. Matters were compounded by the rheumatoid factor being referred to as a rheumatoid screen. Throughout the primary care pathway, the wording was inconsistent, leading to lots of confusion.
Bringing colleagues together
We sat down with members of the immunology department at the hospital performing the tests and producing the reports, and also involved GPs. Wording changes were agreed by all; we changed what's requested by primary care from a ‘rheumatoid screen’ to ‘rheumatoid factor’.
We simplified report wording to help result interpretation incorporating the following wording for both positive and negative results: “Patients with a suspected inflammatory arthritis e.g., RA, should be referred to rheumatology without delay. A negative result does not exclude RA nor does a positive test equate to a diagnosis.”
We incorporated the same advice into the GP electronic requesting system prompts (ICE), so that primary care colleagues are advised to still refer if they suspect inflammatory arthritis, rather than relying on antibody tests. Importantly, we’ve made the wording consistent at every stage to avoid confusion and aligned this to the Choosing Wisely recommendation.
Since the wording change we’ve not seen as many inappropriate referrals. At triage, we can tell that primary care colleagues are utilising antibody testing more appropriately and understanding the issue much better.
In primary care, more and more patients are being assessed by nurse practitioners, first contact practitioners and pharmacists, so we need to make sure we support all healthcare professionals to understand the nuances of antibody testing. We’ve also applied the same principles to other antibody tests relating to autoimmune connective tissue diseases.
Advice to other units
It’s worth reviewing immunology reports that go back to primary care from hospitals and check they're worded appropriately to support colleagues to interpret them. Consider whether you can include prompts at the point of requesting investigations; it may just be subtle changes you need to make to help guide and support primary care colleagues.
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