Design and validation of a referral algorithm for inflammatory arthritis and low back pain: identifying gaps in
Nelly Ziade1,2, Karen Mechleb3,4, Chafika Haouichat5
1Department of Rheumatology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Ville-Dieu Center, Jean-Dominique Ayoub Street, Achrafieh, Beirut, Lebanon. nelly.zoghbi@usj.edu.lb.
Objectives:
Timely referral of patients with inflammatory arthritis (IA) and inflammatory low back pain to rheumatology is crucial. This study designed and validated a referral algorithm for non-rheumatologists in Arab countries and identified gaps in correct referrals and referral parameters.
Methods:
Sixteen rheumatologists adopted referral algorithms, based on validation studies and clinical expertise, and summarized them in educational material (EM), including a PDF and video module. Five illustrative clinical vignettes were electronically sent to non-rheumatologists, to make referral decisions (phase 1). Two weeks later, the EM and the same vignettes were emailed again (phase 2). The primary outcome was the change in correct referral decisions using McNemar's test. Improvement in correct referral parameters was evaluated and factors associated with correct referrals were analysed using logistic binary multivariable analysis.
Results:
Eight hundred participants (general practitioners, family physicians, fellows, surgeons and others) from 13 countries completed phase 1 and 136 phase 2, with no demographic differences between them. Rates of phase 1 correct referral decisions were 72%, 72%, and 86% for referral-requiring cases, and 22% and 19% for others. In phase 2, correct referral decisions improved to 79%, 82%, and 88% for referral-requiring cases and 42% and 25% for others. Rates of most correct parameters improved significantly; factors associated with correct referrals included correct phase 1 referrals, duration of consultation, and fewer years practicing medicine.
Conclusion:
Minor improvements in hypothetical referral decisions were observed after education, while significant improvements were noted for referral parameters. These results will help shape future referral campaigns' design. Key points • Inflammatory arthritis and low back pain referrals to rheumatologists need boosting. • The referral algorithm improved the rate of correct referral decisions. • The referral algorithm improved the rate of correct parameters guiding the decision.
