British Journal of Rheumatology 1992;31:209-214
LETTERS TO THE EDITOR
Rheumatology/General Practitioner Interface. Proceedings of a meeting held between general practitioners and rheumatologists
TABLE I GP EXPECTATION OF RHEUMATOLOGY FOLLOW-UP
Follow-up Nil or once Inflammatory polyarthritis Degenerative disease Chronic low back pain Acute low back pain Crystal arthritis Septic arthritis Soft tissue lesions
Until resolve or stable Long term
1 13 11 12 10 15 16
15 7 8 11 12 6 6
10 1 1 0 0 0 0
they most valued about their rheumatology service, speed came out as a clear leader followed by diagnostic acumen and technical expertise. Of the rheumatologists present, four had both metrologist and a nurse specialist, seven had a nurse specialist only and four a metrologist only. Almost half had neither. Eighteen general practitioners had open access to physiotherapy, 11 to occupational therapy and only two to appliances. All but one wished to have open access to physiotherapy, all but two open access to occupational therapy, all but three open access to appliances. The desire of general practitioners to have open access to physiotherapy was only exceeded by the desire of rheumatologists for them to have such access (i.e. 100%). Rheumatologists were less certain about occupational therapy where 68% wished them to have open access and even less certain about appliances, where only 40% wished them to have such access. When questioned about their judgement of the usefulness of physiotherapy, the difference became apparent between general practitioners and rheumatologists, with the general practitioners being more optimistic about what physiotherapy could do for their patients. When asked, to which alternative practitioners they would refer patients if they could do so on the NHS, the group as a whole ranked them in the following order: (1) acupuncturist; (2) chiropractor; ( 3 = ) osteopath, dietary exclusion advice; (4) faith healers; (5) herbalists; (6) homeopathists. Finally, when questioned about the impact of the changes in the Health Service relating to the White Paper, 24% of rheumatologists thought they would be receiving more referrals than before the changes, 36% thought they would be receiving the same number and 39% thought they would be receiving fewer referrals. The vast majority TABLE II WHAT DO YOU THINK SHOULD BE CHARGED FOR PATIENTS WHO DID NOT ATTEND? (%)
No charge Small charge to cover costs Standard charge Larger 'deterrent' charge 209
Rheumatologists
General practitioners
7% 40% 40% 13%
59% 27% 9% 5%
Downloaded from http://rheumatology.oxfordjournals.org/ at New York University on April 29, 2015
SIR—In June of 1991 a meeting was held in Dublin to explore the interface between rheumatology and general practice. Thirty-three rheumatologists and 26 general practitioners were present, the rheumatologists representing single specialty rheumatology; rheumatology and rehabilitation; and rheumatology and general medicine and came from both teaching hospitals and district general hospitals. The general practitioners represented large group practices of eight partners down to singlehanded practices and included both fund holders and nonfund holders. We were able to explore current attitudes and opinions on matters of mutual interest using a press button system that was then able to give an immediate read-out of the results. The group as a whole were asked whether they valued good communication with the patient or good communication with the general practitioner and voted by a majority of 2:1 in favour of good communication with the patient. When the rheumatologists were asked what information was most irritatingly left out of referral letters, they ranked them in the following order: lack of (1) adequate description of the problem; (2) current drug therapy; ( 3 = ) investigations already performed, presence of concomitant disease and urgency. Lack of social circumstances, previous referral to hospital and general practitioner diagnosis were thought less important. When asked what they found irritatingly left out of replies from the hospital, general practitioners ranked them in the following order: (1) prognosis; (2) anticipated follow-up; ( 3 = ) diagnosis and current therapy. The exact nature of investigations and review of other conditions were thought less important. When asked which conditions were appropriately referred to rheumatologists, the general practitioners ranked inflammatory polyarthritis; seronegative spondarthritis; crystal-associated disease and septic arthritis as being important in that order. Acute and chronic low back pain; degenerative joint disease and soft tissue injury were thought less appropriate. The rheumatologists broadly agreed with inflammatory polyarthritis; septic arthritis and seronegative spondarthritis being thought most appropriate, with crystal associated disease following behind. Some respondents felt that, in principle, all referrals were equally appropriate. If a general practitioner wanted a specialist opinion then referral was appropriate. The general practitioners' views on appropriate follow-up for different conditions are shown in Table I. Only for inflammatory polyarthritis did a substantial number of respondents think that long term follow-up was appropriate but even then the majority thought it should be followed up only until the condition was stable. The majority was in favour of single or no follow-up in degenerative disease, septic arthritis and soft tissue lesions. When asked what most influenced the decision to refer to hospital general practitioners put diagnostic uncertainty at the top, followed by the severity of the condition and patient pressure. Social, economic and other circumstances were not thought important. When asked what
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of general practitioners thought they would be sending the same number (65%) with a few expecting to refer more and less (17% each). There was, therefore, a very good agreement between general practitioners and rheumatologists on professional and communication aspects of the service, with a few minor exceptions (e.g. expectation of physiotherapy) and a suggestion that general practitioners should describe the patient problems better and rheumatologists should outline a prognosis and speed up their service. In contrast, when it came down to money, and participants were asked what they thought should be the charge for patients who did not attend, differences became apparent (Table II). Money may be the driving force of the new NHS but it can also be divisive. This meeting was sponsored by Ciba Geigy.
Psoriatic Arthritis (PA): a Harmless Disease? SIR—We have read with much interest the recent article by Torre Alonso and colleagues [1] about their experience on psoriatic arthritis (PA) in Spain. In spite of their gratifying confirmation of the majority of our data we believe that some issues deserve to be clarified. The distal interphalangeal (DIP) joint arthritis described by Wright [2] is one of the five clinical patterns of PA. It is considered a 'classic' form of the disease occurring as an oligoarthritis, commonly related to nail changes. Since Torre Alonso and colleagues have observed DIP involvement in each of the other four arthritis subgroups, they deduce that the exclusive DIP involvement may not be a distinct clinical entity. We believe that this conclusion depends on the limited
R. SCARPA, G . DELLA VALLE, E . LUBRANO, C. DI GIROLAMO, A. DEL PUENTE, P. ORIENTE
Rheumatology Unit, Department of Internal Medicine and Metabolic Diseases, 2nd Medical School, University of Naples, via S. Pansini 5, Italy Accepted 5 November 1991 1. Torre Alonso JC, Rodriguez Perez JM, ArribasCastrilloJM, Ballina Garcia J, Riestra Noriega JL, Lopez Larrea C. Pso-
TABLEI (A) CLINICAL FINDINGS IN 50 UNSELECTED PATIENTS WITH PSORIATIC POLYARTHRITIS (PP) AND 45 UNSELECTED WITH RHEUMATOID ARTHRITIS ( R A ) (CHI-SQUARE TEST)
Number Sex (F/M) Age (mean) Malaise Fever Vasculitis (skin) Lung involvement Kidney involvement Eye involvement Heart involvement Lymphoadenopathy
PP
RA
Chi-square
50 29/21 46.70 3/50 4/50 0/50 0/50 0/50 2/50 0/50 3/50
45 37/8 44.70 10/45 18/45 17/45 12/45 3/45 12/45 6/45 5/45
5.28 9.67 18.44 15.26 3.44 9.68 5.04 0.28
0.04 0.004
LETTERS TO THE EDITOR
Rheumatology/General Practitioner Interface. Proceedings of a meeting held between general practitioners and rheumatologists
TABLE I GP EXPECTATION OF RHEUMATOLOGY FOLLOW-UP
Follow-up Nil or once Inflammatory polyarthritis Degenerative disease Chronic low back pain Acute low back pain Crystal arthritis Septic arthritis Soft tissue lesions
Until resolve or stable Long term
1 13 11 12 10 15 16
15 7 8 11 12 6 6
10 1 1 0 0 0 0
they most valued about their rheumatology service, speed came out as a clear leader followed by diagnostic acumen and technical expertise. Of the rheumatologists present, four had both metrologist and a nurse specialist, seven had a nurse specialist only and four a metrologist only. Almost half had neither. Eighteen general practitioners had open access to physiotherapy, 11 to occupational therapy and only two to appliances. All but one wished to have open access to physiotherapy, all but two open access to occupational therapy, all but three open access to appliances. The desire of general practitioners to have open access to physiotherapy was only exceeded by the desire of rheumatologists for them to have such access (i.e. 100%). Rheumatologists were less certain about occupational therapy where 68% wished them to have open access and even less certain about appliances, where only 40% wished them to have such access. When questioned about their judgement of the usefulness of physiotherapy, the difference became apparent between general practitioners and rheumatologists, with the general practitioners being more optimistic about what physiotherapy could do for their patients. When asked, to which alternative practitioners they would refer patients if they could do so on the NHS, the group as a whole ranked them in the following order: (1) acupuncturist; (2) chiropractor; ( 3 = ) osteopath, dietary exclusion advice; (4) faith healers; (5) herbalists; (6) homeopathists. Finally, when questioned about the impact of the changes in the Health Service relating to the White Paper, 24% of rheumatologists thought they would be receiving more referrals than before the changes, 36% thought they would be receiving the same number and 39% thought they would be receiving fewer referrals. The vast majority TABLE II WHAT DO YOU THINK SHOULD BE CHARGED FOR PATIENTS WHO DID NOT ATTEND? (%)
No charge Small charge to cover costs Standard charge Larger 'deterrent' charge 209
Rheumatologists
General practitioners
7% 40% 40% 13%
59% 27% 9% 5%
Downloaded from http://rheumatology.oxfordjournals.org/ at New York University on April 29, 2015
SIR—In June of 1991 a meeting was held in Dublin to explore the interface between rheumatology and general practice. Thirty-three rheumatologists and 26 general practitioners were present, the rheumatologists representing single specialty rheumatology; rheumatology and rehabilitation; and rheumatology and general medicine and came from both teaching hospitals and district general hospitals. The general practitioners represented large group practices of eight partners down to singlehanded practices and included both fund holders and nonfund holders. We were able to explore current attitudes and opinions on matters of mutual interest using a press button system that was then able to give an immediate read-out of the results. The group as a whole were asked whether they valued good communication with the patient or good communication with the general practitioner and voted by a majority of 2:1 in favour of good communication with the patient. When the rheumatologists were asked what information was most irritatingly left out of referral letters, they ranked them in the following order: lack of (1) adequate description of the problem; (2) current drug therapy; ( 3 = ) investigations already performed, presence of concomitant disease and urgency. Lack of social circumstances, previous referral to hospital and general practitioner diagnosis were thought less important. When asked what they found irritatingly left out of replies from the hospital, general practitioners ranked them in the following order: (1) prognosis; (2) anticipated follow-up; ( 3 = ) diagnosis and current therapy. The exact nature of investigations and review of other conditions were thought less important. When asked which conditions were appropriately referred to rheumatologists, the general practitioners ranked inflammatory polyarthritis; seronegative spondarthritis; crystal-associated disease and septic arthritis as being important in that order. Acute and chronic low back pain; degenerative joint disease and soft tissue injury were thought less appropriate. The rheumatologists broadly agreed with inflammatory polyarthritis; septic arthritis and seronegative spondarthritis being thought most appropriate, with crystal associated disease following behind. Some respondents felt that, in principle, all referrals were equally appropriate. If a general practitioner wanted a specialist opinion then referral was appropriate. The general practitioners' views on appropriate follow-up for different conditions are shown in Table I. Only for inflammatory polyarthritis did a substantial number of respondents think that long term follow-up was appropriate but even then the majority thought it should be followed up only until the condition was stable. The majority was in favour of single or no follow-up in degenerative disease, septic arthritis and soft tissue lesions. When asked what most influenced the decision to refer to hospital general practitioners put diagnostic uncertainty at the top, followed by the severity of the condition and patient pressure. Social, economic and other circumstances were not thought important. When asked what
BRITISH JOURNAL OF RHEUMATOLOGY VOL. XXXI NO. 3
210
of general practitioners thought they would be sending the same number (65%) with a few expecting to refer more and less (17% each). There was, therefore, a very good agreement between general practitioners and rheumatologists on professional and communication aspects of the service, with a few minor exceptions (e.g. expectation of physiotherapy) and a suggestion that general practitioners should describe the patient problems better and rheumatologists should outline a prognosis and speed up their service. In contrast, when it came down to money, and participants were asked what they thought should be the charge for patients who did not attend, differences became apparent (Table II). Money may be the driving force of the new NHS but it can also be divisive. This meeting was sponsored by Ciba Geigy.
Psoriatic Arthritis (PA): a Harmless Disease? SIR—We have read with much interest the recent article by Torre Alonso and colleagues [1] about their experience on psoriatic arthritis (PA) in Spain. In spite of their gratifying confirmation of the majority of our data we believe that some issues deserve to be clarified. The distal interphalangeal (DIP) joint arthritis described by Wright [2] is one of the five clinical patterns of PA. It is considered a 'classic' form of the disease occurring as an oligoarthritis, commonly related to nail changes. Since Torre Alonso and colleagues have observed DIP involvement in each of the other four arthritis subgroups, they deduce that the exclusive DIP involvement may not be a distinct clinical entity. We believe that this conclusion depends on the limited
R. SCARPA, G . DELLA VALLE, E . LUBRANO, C. DI GIROLAMO, A. DEL PUENTE, P. ORIENTE
Rheumatology Unit, Department of Internal Medicine and Metabolic Diseases, 2nd Medical School, University of Naples, via S. Pansini 5, Italy Accepted 5 November 1991 1. Torre Alonso JC, Rodriguez Perez JM, ArribasCastrilloJM, Ballina Garcia J, Riestra Noriega JL, Lopez Larrea C. Pso-
TABLEI (A) CLINICAL FINDINGS IN 50 UNSELECTED PATIENTS WITH PSORIATIC POLYARTHRITIS (PP) AND 45 UNSELECTED WITH RHEUMATOID ARTHRITIS ( R A ) (CHI-SQUARE TEST)
Number Sex (F/M) Age (mean) Malaise Fever Vasculitis (skin) Lung involvement Kidney involvement Eye involvement Heart involvement Lymphoadenopathy
PP
RA
Chi-square
50 29/21 46.70 3/50 4/50 0/50 0/50 0/50 2/50 0/50 3/50
45 37/8 44.70 10/45 18/45 17/45 12/45 3/45 12/45 6/45 5/45
5.28 9.67 18.44 15.26 3.44 9.68 5.04 0.28
0.04 0.004
