As part of a larger body of work to develop a rheumatology priority referral score, a literature review was conducted. The objective of the literature review was to identify preexisting priority-setting, triage, and refe...As part of a larger body of work to develop a rheumatology priority referral score, a literature review was conducted. The objective of the literature review was to identify preexisting priority-setting, triage, and referral tools/scales developed to guide referrals from primary care to specialist care/consultation usually provided by a rheumatologist. Using a combination of database, citation, Internet, and hand-searching, 20 papers were identified that related to referral prioritization in three areas: rheumatoid arthritis (RA; 5), musculoskeletal (MSK) diseases other than RA (3), and MSK diseases in general (12). No single set of priority-setting criteria was identified for rheumatologic disorders across the spectrum of patients who may be referred from primary care providers (PCPs) to rheumatologists. There appears to be more congruence on conditions at either end of the urgency spectrum with conditions such as suspected cranial arteritis or systemic vasculitis deemed to be emergency referrals and fibromyalgia and other soft-tissue syndromes deemed to be more routine referrals. Between these two extremes, there is a divergence of opinion about urgency and few papers on the issue. The exception to this is referral for early RA for which several criteria have been established. Despite the inherent complexities in developing a tool to prioritize patients referred by PCPs to rheumatologists, there are compelling reasons to proceed. With the aging of the population, the number of patients being referred to rheumatologists is expected to increase. With pharmaceutical advances, there are demonstrable benefits in early referral for some conditions. These trends have led to increased pressure on scarce rheumatological human resources. A tool to prioritize referrals is a critical component of improving access and the referral process.
Best Pract Res Clin Rheumatol
· 2008 Jun · PMID 18519103
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The development and deployment of physician assistants (PAs) and nurse practitioners (NPs) began in the late 1960s. This has been a social phenomenon that has spread to a number of countries. The original intention was t...The development and deployment of physician assistants (PAs) and nurse practitioners (NPs) began in the late 1960s. This has been a social phenomenon that has spread to a number of countries. The original intention was to extend the role of the busy general/family practitioner in providing access and offloading some of the workload in primary care. Within a few years, PAs and NPs were to be found not only in primary care but dispersed through many medical and surgical subspecialties. Rheumatology is one such discipline where PAs and NPs are employed and have been so for 30 years. A survey by the American College of Rheumatology in 2003 found that more than one fifth of the responders employed a PA or NP in their practice. While their deployment in rheumatology may be more prevalent in the US, England has led in documenting their role. A role delineation of PAs in the US finds them working closely with rheumatologists and often providing similar care; the question of how efficient they are in these roles provides opportunities for further research. Understanding the various components of the health workforce is paramount in making estimates of future care needs. This chapter examines PAs and NPs in rheumatology settings to understand what they do and how they are utilized.
Best Pract Res Clin Rheumatol
· 2007 Oct · PMID 17870030
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Rheumatoid arthritis is a chronic inflammatory disease with a major impact on physical and psychological health. It can cause severe disability and reduce health-related quality of life, aspects that are important to pat...Rheumatoid arthritis is a chronic inflammatory disease with a major impact on physical and psychological health. It can cause severe disability and reduce health-related quality of life, aspects that are important to patients. Thus, it is important to measure disability and health-related quality of life in clinical practice and in clinical trials. This article presents an overview of the most important measures of outcome concerning disability and health-related quality of life, including different forms of the Health Assessment Questionnaire (HAQ, MHAQ, MDHAQ, HAQ II), visual analogue scales for fatigue and function, SF-36, Arthritis Impact Measurement Scales (AIMS/AIMS2), the Rheumatoid Arthritis Quality of Life (RAQoL) questionnaire, Nottingham Health Profile, Sickness Impact Profile and the utility instruments 15D, EQ-5D, SF-6D and Health Utilities Index (HUI) 2 and 3.
Best Pract Res Clin Rheumatol
· 2007 Aug · PMID 17678834
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The American College of Rheumatology Core Data Set for rheumatoid arthritis (RA) includes 3 measures which are found on a patient self-report questionnaire, physical function, pain, and patient estimate of global status....The American College of Rheumatology Core Data Set for rheumatoid arthritis (RA) includes 3 measures which are found on a patient self-report questionnaire, physical function, pain, and patient estimate of global status. These measures are included in all clinical trials, but not assessed at most encounters in standard rheumatology care. Rheumatologists may have experience with lengthy research questionnaires in clinical trials and other clinical research, which (appropriately) are regarded as relatively cumbersome research tools and do not contribute to clinical care. A format of a questionnaire known as the multidimensional health assessment questionnaire (MDHAQ) has been developed for standard rheumatology care to contribute to rheumatology clinical care in daily practice. The 3 scores for physical function, pain, and global status can be "eyeballed" in a second or two and formally scored into a composite index known as rheumatology assessment patient index data (RAPID) in about 10 seconds. This chapter provides a brief tutorial designed to instruct rheumatologists and their staffs regarding how to use and score the MDHAQ and RAPID in standard clinical care.
Best Pract Res Clin Rheumatol
· 2007 Aug · PMID 17678831
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Ankylosing spondylitis (AS) is a chronic inflammatory disease requiring regular medical care and monitoring to alleviate symptoms, maintain function, identify disease progression and initiate appropriate, timely therapie...Ankylosing spondylitis (AS) is a chronic inflammatory disease requiring regular medical care and monitoring to alleviate symptoms, maintain function, identify disease progression and initiate appropriate, timely therapies. Monitoring of the AS patient in clinical daily practice should not only include general history taking and physical examination, but also incorporate specific concepts, pertaining to the disease, which will aid in the detection of disease progression, the requirement of therapeutic intervention and the response to therapy. The Assessments in AS (ASAS) international working group has defined a core set of disease concepts that should be a part of everyday clinical record-keeping in AS, and has identified and validated measurement instruments corresponding to these health concepts, which can easily be incorporated into clinical practice. The group has also developed recommendations for management and a consensus statement for the use of biological therapies in AS, which includes recommendations for the monitoring of AS patients receiving these therapies. This chapter reviews the recommendations for monitoring AS patients in daily clinical practice, with particular regard to those receiving biological treatments.
Best Pract Res Clin Rheumatol
· 2007 Aug · PMID 17678827
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Patient questionnaires are a valuable method of monitoring the health status of patients with musculoskeletal conditions as part of daily clinical practice. Quantitative clinical monitoring improves the physician's abili...Patient questionnaires are a valuable method of monitoring the health status of patients with musculoskeletal conditions as part of daily clinical practice. Quantitative clinical monitoring improves the physician's ability to detect and document changes in patients' health conditions and thus leads to greater precision in clinical decisions. Furthermore, routine data collection on consecutive patients facilitates the analysis of groups of patients, providing more information than can be obtained from randomized clinical trials.
Best Pract Res Clin Rheumatol
· 2007 Jun · PMID 17602994
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Chronic musculoskeletal pain has biological, psychological and social components. This review deals with the biological factors, with emphasis on the fibromyalgia syndrome (FMS). Studies on central sensitization of pain-...Chronic musculoskeletal pain has biological, psychological and social components. This review deals with the biological factors, with emphasis on the fibromyalgia syndrome (FMS). Studies on central sensitization of pain-transmitting neurons, changes in endogenous pain modulation that give rise to pain disinhibition, referred pain, pain-related decrease in muscle strength and endurance, and pain generators in deep tissues are reviewed. In FMS there is strong scientific support for the statement that the biological part of the syndrome is a longstanding or permanent change in the function of the nociceptive nervous system that can be equated with a disease. Further research is necessary in order to determine which methods are best for diagnosis of the pain hypersensitivity in clinical practice. FMS may be the far end of a continuum that starts with chronic localized/regional musculoskeletal pain and ends with widespread chronic disabling pain.
Best Pract Res Clin Rheumatol
· 2007 Jun · PMID 17602990
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Chronic pain is very common in all European countries, with musculoskeletal problems predominating. About 1% of the adult population develops a syndrome of chronic muscle pain, fibromyalgia (FMS), characterized by multip...Chronic pain is very common in all European countries, with musculoskeletal problems predominating. About 1% of the adult population develops a syndrome of chronic muscle pain, fibromyalgia (FMS), characterized by multiple tender points, back or neck pain, and a number of associated problems from other organs, including a high frequency of fatigue. Evidence points to central sensitization as an important neurophysiological aberration in the development of FMS. Importantly, these neurological changes may result from inadequately treated chronic focal pain problems such as osteoarthritis or myofascial pain. It is important for health professionals to be aware of this syndrome and to diagnose the patients to avoid a steady increase in diagnostic tests. On the other hand, patients with chronic widespread pain have an increased risk of developing malignancies, and new or changed symptoms should be diagnosed even in FMS. In rheumatology practice it is especially important to be aware of the existence of FMS in association with immune inflammatory diseases, most commonly lupus and rheumatoid arthritis. Differential diagnoses are other causes of chronic pain, e.g. thyroid disease. The costs of this syndrome are substantial due to loss of working capability and direct expenses of medication and health-system usage. Fibromyalgia patients need recognition of their pain syndrome if they are to comply with treatment. Lack of empathy and understanding by healthcare professionals often leads to patient frustration and inappropriate illness behavior, often associated with some exaggeration of symptoms in an effort to gain some legitimacy for their problem. FMS is multifaceted, and treatment consists of both medical interventions, with emphasis on agents acting on the central nervous system, and physical exercises.
There is an international focus on improving the quality of care for people with chronic conditions, including those with chronic rheumatic conditions such as osteoarthritis (OA). A number of evidence-based clinical prac...There is an international focus on improving the quality of care for people with chronic conditions, including those with chronic rheumatic conditions such as osteoarthritis (OA). A number of evidence-based clinical practice guidelines exist to guide clinician management of OA of the hip and knee. However, gaps and delays in the integration of these recommendations into practice still remain. This paper reviews the role of clinical practice guidelines within the contemporary discourse and practice of information translation. This discussion paper uses an OA quality improvement case study to illustrate how evidence for effective implementation strategies can be used in conjunction with a practical implementation model to plan and implement quality improvement projects.
Best Pract Res Clin Rheumatol
· 2007 Feb · PMID 17350553
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This chapter focuses on how strategies to reduce the burden of musculoskeletal disease might be used to inform the development of best clinical practice, public behaviour and health policy. We review what is known about...This chapter focuses on how strategies to reduce the burden of musculoskeletal disease might be used to inform the development of best clinical practice, public behaviour and health policy. We review what is known about how to modify clinical practice and public behaviour and the effectiveness of a range of interventions that seek to achieve change. From a health policy perspective we examine how those who produce evidence can be linked with decision-makers and how evidence can be used to answer key questions that are pertinent to policy-makers. We argue that implementation strategies need to be targeted to meet the particular contextual constraints and opportunities found within the specific clinical field, policy domain or public setting, but that research is needed to establish the cost and clinical effectiveness of more complex implementation strategies and the financial impact of changing public policy.
Best Pract Res Clin Rheumatol
· 2006 Aug · PMID 16979538
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Sjogren's syndrome is an autoimmune exocrinopathy that predominantly affects salivary and lachrymal glands, leading to dry eyes and mouth. The most common clinical problems faced by the rheumatologist are those of dry ey...Sjogren's syndrome is an autoimmune exocrinopathy that predominantly affects salivary and lachrymal glands, leading to dry eyes and mouth. The most common clinical problems faced by the rheumatologist are those of dry eyes and mouth, parotid swelling, fatigue and extraglandular manifestations. The first stage in management is to make an accurate diagnosis based on the American/European consensus criteria. The most frequent differential diagnoses are dry eyes and mouth symptoms, a variant of chronic fatigue syndrome and fibromyalgia, and sialosis, which causes a non-inflammatory enlargement of the parotid glands. The mainstay of treatment for the sicca symptoms is local therapy, and that for the milder systemic symptoms is hydroxychloroquine. Steroids and immunosuppressive drugs are reserved for more severe extraglandular disease. In spite of intensive research in other systemic treatments including biologic therapies, there is limited evidence to support their use in routine clinical practice.
Best Pract Res Clin Rheumatol
· 2006 Aug · PMID 16979533
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Osteoporotic fractures are emerging as a major public health problem in the aging population. Fractures result in increased morbidity, mortality and health expenditures. This article reviews current evidence for the mana...Osteoporotic fractures are emerging as a major public health problem in the aging population. Fractures result in increased morbidity, mortality and health expenditures. This article reviews current evidence for the management of common issues following osteoporotic fractures in older adults including: (1) thromboembolism prevention; (2) delirium prevention; (3) pain management; (4) rehabilitation; (5) assessing the cause of fracture; and (6) prevention of subsequent fractures. Areas for practice improvement and further research are highlighted.
Best Pract Res Clin Rheumatol
· 2006 Jun · PMID 16777580
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Assessment of disease status and response to therapy in ankylosing spondylitis is a rapidly expanding area of research. The assessment in ankylosing spondylitis international working group has contributed greatly to this...Assessment of disease status and response to therapy in ankylosing spondylitis is a rapidly expanding area of research. The assessment in ankylosing spondylitis international working group has contributed greatly to this development, defining core sets of health domains for use in daily practice and in clinical trials, developing and validating measurement instruments corresponding to these health domains, and developing response and remission criteria for use in clinical trials. This chapter reviews available measures of three major areas of disease impact in ankylosing spondylitis (disease activity, structural damage and functioning), and discusses which measures are relevant for use in clinical practice.
Glucocorticoids are the most common cause of drug-related osteoporosis. We reviewed current evidence on risk factors for glucocorticoid-induced osteoporosis (GIOP) and prevention and treatment of GIOP-related fractures....Glucocorticoids are the most common cause of drug-related osteoporosis. We reviewed current evidence on risk factors for glucocorticoid-induced osteoporosis (GIOP) and prevention and treatment of GIOP-related fractures. Guidelines for GIOP management published since 2000 were also reviewed. Significant bone loss and increased fracture risk is seen with daily prednisone doses as low as 5 mg. Alternate-day glucocorticoid therapy can lead to similar bone loss. No conclusive evidence exists for a safe minimum dose or duration of glucocorticoid exposure. Physicians should consider risk factors for involutional osteoporosis such as older age, postmenopausal status, and baseline bone density measurements as they assess patients for prevention or treatment of GIOP. Bisphosphonates were reported to reduce GIOP-related vertebral fractures, but inconclusive data exist for hip fractures associated with glucocorticoid use. Hormone replacement therapy and parathyroid hormone analogs are effective in preserving bone density in GIOP. The risk of osteoporosis and fractures should be routinely assessed in patients receiving glucocorticoid therapy. Effective prevention and treatment options are available and can result in meaningful reduction of GIOP-related morbidity and mortality. Current guidelines for GIOP management recommend bisphosphonates, especially alendronate and risedronate, as first-line agents for GIOP, and these guidelines propose the preventive use of bisphosphonates early in the course of glucocorticoid therapy in high-risk patient subgroups.
Best Pract Res Clin Rheumatol
· 2006 Apr · PMID 16546057
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The goal of juvenile idiopathic arthritis (JIA) treatment is to achieve remission of disease. The absence of a full understanding of the disease pathogenesis for JIA hinders the development of truly effective treatment a...The goal of juvenile idiopathic arthritis (JIA) treatment is to achieve remission of disease. The absence of a full understanding of the disease pathogenesis for JIA hinders the development of truly effective treatment approaches. Further, the lack of clear knowledge regarding the mechanisms of action of rheumatologic medications and the existence of few randomized controlled trials leaves clinicians with very little evidence upon which to base decisions regarding the best timing, dosages or combinations of medications to be used for fully effective treatment of JIA. There is now a shift in treatment focus from that of chasing failure (gradual add-on approach to the use of medications) to one of early aggressive combination treatment. This chapter will discuss the current approaches to medical management of JIA and the medications currently available for use. JIA treatment is a vast, rich area in need of research.
Best Pract Res Clin Rheumatol
· 2006 Apr · PMID 16546055
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Musculoskeletal (MSK) complaints in children and adolescents are common. The differential diagnosis is broad and based predominantly on clinical assessment. The skills both for eliciting history and for examination requi...Musculoskeletal (MSK) complaints in children and adolescents are common. The differential diagnosis is broad and based predominantly on clinical assessment. The skills both for eliciting history and for examination require understanding of the child/young person's specific emotional and cognitive developmental stage; interpretation of the findings requires knowledge of normal (and abnormal) motor and musculoskeletal growth and development. We specifically describe the different approach, unique skills and knowledge required by all clinicians who assess children and adolescents with MSK complaints; children and adolescents are not 'just little adults'. We emphasize the importance of clinical competence in ensuring that patients with juvenile idiopathic arthritis are diagnosed early and referral to specialist centres is not delayed with consequential suboptimal management and outcome. There is evidence that physician clinical skills in MSK assessment are inadequate, probably as a result of systemic deficiencies in the education process. Current and proposed solutions are discussed.
Best Pract Res Clin Rheumatol
· 2006 Feb · PMID 16483914
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Prior to the need for arthroplasty, there are numerous surgical options for management of osteoarthritis. This chapter is aimed at addressing the current state of knowledge and practice regarding: (1) arthroscopic lavage...Prior to the need for arthroplasty, there are numerous surgical options for management of osteoarthritis. This chapter is aimed at addressing the current state of knowledge and practice regarding: (1) arthroscopic lavage and debridement; (2) articular surface stimulation by means of penetration or microfracture; (3) high tibial osteotomies; (4) preventative ligament stabilization and joint distraction; and (5) transplantation of soft tissue, osteochondral, chondrocyte and matrix implantation as well as use of growth factors. Evidence is reviewed regarding the outcomes and indications for each of these operations, and where evidence is lacking, needs for further research are indicated. Future directions building upon promising early results of articular surface regeneration are also described.
Best Pract Res Clin Rheumatol
· 2006 Feb · PMID 16483908
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It is possible to use biomarkers in cohort studies and in clinical trials to increase our understanding of disease, to elucidate disease mechanisms, and to bolster a clinical impression of the disease state of osteoarthr...It is possible to use biomarkers in cohort studies and in clinical trials to increase our understanding of disease, to elucidate disease mechanisms, and to bolster a clinical impression of the disease state of osteoarthritis. Whether it will be possible to utilize biomarkers meaningfully to characterize the disease state in an individual patient remains to be seen. Major concepts related to the use of biomarkers for research and clinical practice, and factors influencing biomarker concentrations, are described in this review in order to address the potential role of biomarkers in osteoarthritis diagnosis, prognosis, and treatment.
Best Pract Res Clin Rheumatol
· 2006 Feb · PMID 16483906
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Based upon published data, the different methods of imaging the knee joint are evaluated with respect to the radiographic procedure and anatomical structures recorded in: (1) images from radiographs of the tibiofemoral j...Based upon published data, the different methods of imaging the knee joint are evaluated with respect to the radiographic procedure and anatomical structures recorded in: (1) images from radiographs of the tibiofemoral joint that have been obtained from the non-weight-bearing and weight-bearing extended knee views and the standardized knee flexion positions using fluoroscopy (semi-flexed and Lyon Schuss views) and non-fluoroscopic methods (MTP and fixed flexion); and (2) images from radiographs of the patellofemoral joint obtained from the lateral and the different axial views of the joint. Non-weight-bearing and weight-bearing radiographs of the knee in extension were found to be of limited value in assessing disease status, whereas all standing flexed knee positions reliably imaged joint space width and bone changes in the tibiofemoral joint. Fluoroscopic positioning of the joint is more demanding on equipment and personnel than non-fluoroscopic methods. Skyline rather than lateral views of the patellofemoral joint were better at detecting joint changes in osteoarthritis. It is concluded that for both clinical practice and research purposes the non-fluoroscopic MTP and fixed flexion methods are recommended for imaging the tibiofemoral compartment, and the standing skyline view is recommended for the patellofemoral joint.