Early referral in rheumatoid arthritis

Rheumatoid arthritis affects 1% of adults and is associated with progressive joint damage and disability and increased mortality. Treatment with disease modifying anti-rheumatic drugs (DMARDs), such as methotrexate, has been shown to reduce the progression of radiologically evident joint damage and improve long term disability. A shift towards starting DMARD treatment as early as possible has therefore occurred.

Guidelines recommend that patients should be referred early, ideally within six weeks of the onset of symptoms, and that DMARDs should be started within 12 weeks of onset.

However, a recent survey found that only 50% of patients were assessed by a rheumatologist within this time. Patients with suspected rheumatoid arthritis should be referred to rheumatology as soon after first presentation as possible.

The very recent PROMPT trial compared methotrexate and placebo in 110 patients with undifferentiated polyarthritis (not yet fulfilling criteria for established rheumatoid arthritis). The median disease duration was nine months. The trial concluded that treatment with methotrexate delayed the onset of rheumatoid arthritis and slowed joint damage in patients with undifferentiated polyarthritis. The results were most pronounced in patients positive for anti-cyclic citrullinated peptide antibodies, a highly specific antibody for rheumatoid arthritis.

Evidence is accumulating that very early rheumatoid arthritis (within the first 12 weeks) may be an immunopathologically distinct phase of disease. Thus, a "window of opportunity" may exist within the first 12 weeks of disease, during which introducing DMARDs may have different effects than treatment at a later date, including prevention of erosions and possibly complete switching off of the disease.

Only half of all patients with rheumatoid arthritis are first seen by a rheumatologist within three months.

A large proportion of this delay undoubtedly occurs before the patient even seeks primary care. However, once contact is made, the challenge for all doctors is recognising early rheumatoid arthritis, for which no specific diagnostic criteria exist.

In patients with a suspected inflammatory arthritis (persistent joint swelling in more than one joint, early morning stiffness over 30 minutes, or involvement of metacarpophalangeal or metatarsophalangeal joints), urgent referral (ideally within six weeks of symptom onset) to rheumatology should be made with a clear indication that inflammatory arthritis (or rheumatoid arthritis) is suspected.

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Hospital league tables don’t work (so far)

Publicly rating the performance of hospitals, doctors, and other healthcare providers should, in theory, motivate them to improve their quality of service, attract more patients, and treat them better. But a systematic review of 45 studies has found little evidence that it works.

The results were a mixed bag except for fairly consistent evidence that publishing performance data stimulates quality improvement activity in hospitals, and probably influences patients’ choice of health plan. Whether the reports help make hospitals or doctors more effective is still unclear, and few data are available on the effect of public reporting on patient safety.

Public reporting is expensive and this review suggests it may not be paying off. Perhaps the underlying theory is wrong, says an editorial. Or perhaps the information in the reports is simply too inaccessible for people to use when choosing where to go for treatment.

Patients may also define quality differently from the academics who devise and publish performance reports. The idea behind public reporting is probably sound, says the editorial. It’s the execution that needs work.

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NICE advises commissioners

The National Institute for Health and Clinical Excellence (NICE) has published six new evidence based guides on commissioning services. This more than doubles the number of topics in such guidance for NHS staff who are responsible for costing and arranging new or improved services.

The new topics are memory assessment, hysterectomy, endometrial ablation, female urinary incontinence, intrauterine devices, bariatric surgery, and the intrauterine system for contraception and for the management of heavy menstrual bleeding. The guides offer a way of implementing the recommendations on evidence based care found in NICE’s clinical guidelines.

Each guide answers a series of questions, the first of which is "Why commission this service?" This first section highlights the main benefits of the service, identifies national targets and standards, and should help the user make a case for setting up the service.

The second question explores the range of service elements that need to be considered, including referral criteria, accessibility, and what is to be provided.

The third and fourth questions ask what level of service will be needed locally and, therefore, what resources will be needed.

For example, the guide on setting up a memory assessment service for the early identification and care of people with dementia says: "New referrals into a memory assessment service [will be] 0.19 per cent, or 190 per 100,000 population per year. For a standard primary care trust population of 250,000 the average number of people requiring referral to a memory assessment service would be 475 per year.

For an average practice with a list size of 10,000, the average number of people requiring referral would be 19 per year."

The guides conclude by asking, "What mechanisms are available for quality and corporate assurance?" This section includes suggestions for audit and monitoring arrangements.

The "commissioning tool" incorporated into each guide is an online interactive resource for estimating the level of service needed and the cost of commissioning decisions.

NICE aims to produce up to 10 new guides a year. Future topics will include faecal incontinence and cognitive behaviour therapy.

Gillian Leng, director of NICE Implementation Systems, said, "I would like to encourage individuals involved in the commissioning of healthcare services in England to contact us with topic suggestions so that we can continue to help NHS organisations make a real change."

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