ABC of Rheumatology

Ade Adebajo, Lisa Dunkley, Ade Adebajo, Lisa Dunkley

• Publisher: BMJ Books
• Year: 2018
• ISBN:
  9781118793206
• Edition: 5
• Topic: Medicine
• Subtopic: Rheumatology, Orthopedics & Prosthetics

ABC of Rheumatology continues to be a practical and informative guide to the assessment, treatment and management of common rheumatic and musculoskeletal conditions within primary care.

Fully updated to reflect developments in this fast growing field, the fifth edition covers overviews of all key areas of rheumatology, and includes new chapters on radiology and immunology, as well as expanded coverage on metabolic bone disease, chronic widespread pain, and complex regional pain syndrome.

Featuring highly illustrated chapters, boxed summaries and links to further resources, ABC of Rheumatology is an accessible reference for all primary care health professional, general practitioners, family physicians, junior doctors, medical students and nurses.

CHAPTER 1
Delivering Musculoskeletal Care Across Boundaries

Samantha L. Hider^1,2, Simon Somerville¹ and Kay Stevenson^1,2

¹ Arthritis Research UK Primary Care Centre, Keele University, Keele, UK

² Haywood Hospital, Burslem, UK

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OVERVIEW

• The burden of musculoskeletal disease is increasing and the importance of a multidisciplinary care pathway in the management of these patients is well established.
• A community‐wide approach encompassing the involvement and education of both patient and primary care physician will lead to earlier diagnosis, speedier and more appropriate secondary care referrals, and quicker treatment and ultimately improved clinical outcomes.
• Innovative models of care have been developed within primary/secondary care interface services for patients with musculoskeletal disease.
• Identifying patients with inflammatory arthritis for rapid secondary care referral remains a key challenge for primary care.

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Introduction

The ever‐increasing demand upon acute hospitals to deliver emergency medicine means that the management of long‐term chronic conditions is being delivered in a number of different settings rather than the traditional acute hospital. This chapter discusses different ways of working to try to ensure that patients with musculoskeletal conditions receive timely, appropriate treatments with the ‘right person, right place and right time’.

One way of transferring rheumatological expertise to the community, without increasing the burden on the primary care team, is to develop the roles of the wider multidisciplinary team such as nurses, physiotherapists and occupational therapists. Such practitioners, working in an extended role, operate at a high level of clinical practice and cross traditional professional boundaries. This is particularly evident within musculoskeletal interface services.

Rheumatology in the community: the impact on primary care

Musculoskeletal problems are common in primary care, representing about 20% of all consultations, although these disorders often are not given the same priority as conditions such as cancer or cardiovascular disease. More years are lived with a musculoskeletal disability than any other condition. These patients often have other co‐morbidities such as depression and cardiovascular disease. Increasing life expectancy and risk factors such as obesity mean that larger numbers of patients with musculoskeletal problems will require help from health and social services in the future. The challenge is to fill gaps and improve co‐ordination of care within existing resources.

Who should be referred to secondary care?

The GP is often viewed as the gatekeeper to secondary care. A more modern and helpful approach is to consider both vertical (with secondary care) and horizontal integration of care, involving primary care‐based agencies such as physiotherapy and social care working together rather than in isolation to deliver individualized care.

Waiting times for new rheumatology appointments vary widely and depend on local resources but also, to some extent, on how clinicians triage referrals from GPs. The majority of patients seen in primary care will have non‐inflammatory problems such as osteoarthritis or back pain and most can be managed in primary care with appropriate advice and education or referral to primary care physiotherapy.

Effective triage depends largely upon the information contained in the referral letter. The GP is well placed to give an overall picture of the patient, particularly including psychosocial as well as biomedical issues. Recognizing and dealing with them is known to improve patient outcomes, reduce costs and increase efficiency. Helpful information to include in a referral letter is given in Box 1.1.

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Box 1.1 Important information to include in a referral letter

• Length of history
• Pattern of joint involvement
• The presence of joint swelling and/or stiffness
• Referrals for and response to previous treatments
• Results of investigations
• Distress or disability – results of screening tools such as STarT Back
• Significant co‐morbidity and risk factors
• Other medical and psychosocial issues

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A number of simple tools, such as the STarTBack tool for low back pain (Hill et al., 2011), are starting to be employed in primary care to quickly screen patients to identify which are at low risk of poor outcome and require minimal intervention and which may benefit from onward referral so that matched packages based on need can be implemented. The STarTBack tool is highlighted in Box 1.2.

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Box 1.2 The STarTBack tool for back pain

Questions 1–8: tick box for agree/disagree	No	Yes
1 My back pain has spread down my leg(s) at some time in the last 2 we...