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Centralized triage of rheumatology referrals and quality improvement initiatives are effective in improving wait times for priority patients as determined by paper referral.

Physical activity (PA) is recommended by osteoarthritis (OA) international organizations as an essential component of first-line management of knee OA. Primary care physicians (PCP) and rheumatologists can play a key role in promoting PA but the extent that PA recommendation is occurring in primary and rheumatology care is unclear. This review provides an overview of current practice of PCP- and rheumatology-delivered PA intervention in the United States, Canada and Europe for the management of knee OA and explores barriers to implementing PA intervention in primary and rheumatology care. A search of MEDLINE from 2000-April 2017 was conducted, 848 abstracts were identified from which 22 relevant articles were selected for this review. Overall, recommendation of PA is suboptimal - the majority of studies reported that < 50% of PCPs and rheumatologists make this recommendation to people with knee OA. Key barriers identified were time constraints, lack of patient motivation, PA-specific resources and financial reimbursement, concerns about inadequate training and knowledge for detailed exercise prescription and beliefs about the efficacy of exercise in the management of OA and their role in providing PA intervention. There is a sparsity of data about rheumatology practice and barriers to PA intervention among this group. In summary, this review suggests that there is a notable gap between what clinical guidelines recommend and what is happening in clinical practice. Addressing this practice gap through addressing key barriers provides an opportunity for improving OA care and ultimately, the health and quality of life of people with OA. This article is protected by copyright. All rights reserved.

aboratory testing is the highest-volume medical procedure, 1 and volumes are increasing annually. 2,3 It has been estimated that 20% of tests are ordered unnecessarily. 4,5 Misuse of laboratory tests is a major challenge affecting the sustainability of health care. 6,7 Improving the appropriateness of rheumatology laboratory testing is a priority of Choosing Wisely campaigns. 8,9 Concerns have been raised about the inappropriate use of antinuclear antibody (ANA) testing. Testing for ANA is indicated only if a patient's clinical history and physical examination show symptoms or signs suggestive of systemic lupus erythematosus, scleroderma, Sjögren syndrome, polymyositis or dermatomyositis. 10,11 The test has high sensitivity, and, thus, a positive test result can contribute to a diagnosis of these conditions. 12 However, it has low specificity, and ANA and can be seen in other conditions and in more than 20% of healthy people, 13 which makes interpretation of test results challenging. 12 Choosing Wisely Canada recommends that "ANA testing should not be used to screen subjects without specific symptoms or without a clinical evaluation that may lead to a diagnosis of systemic lupus or other connective tissue disease." 8 International recommendations strongly advise that "ANA testing is primarily intended for diagnostic purposes, and not for monitoring disease progression" owing to its limited value in monitoring disease activity. 14-17 Thus, it is not appropriate to repeat ANA following a positive test result. 7-9,16,18

Objective Hydroxychloroquine (HCQ) is a commonly used weight-based medication with a risk of retinal toxicity when prescribed at doses above 5 mg/kg/day. The objectives of our study were: (1) To characterize the frequency of inappropriate HCQ dosing and retinopathy screening and (2) to improve guideline-based management by implementing quality improvement (QI) strategies. Methods A retrospective chart review was performed to obtain baseline analysis of HCQ dosing, weight documentation, and retinal toxicity screening to characterize current practices. The primary aim was to increase the percentage of patients appropriately dosed from 30% to 90% over a tenmonth period. The secondary aim was to increase the percentage of documented retinal screening from 59% to 90%. The process measure was the number of patients with a documented weight in the chart. The balancing measure was the physician’s perceived increase in time spent with each patient due to implemented interventions. QI methodology was used to implement sequential change ideas: (1) HCQ weight-based dosing charts to facilitate prescription regimens, (2) addition of scales to patient rooms to facilitate weight documentation, and (3) electronic medical record ‘force function’ involving weight documentation and auto-dosing prescription. Results The percentage of patients being weighed increased from 40% to 92% after ten months. Appropriate HCQ dosing improved from 30% to 89%. Retinal screening documentation improved by 33%. Conclusion Dosing charts in clinic rooms, addition of weight scales, and EMR force function autodosing prescriptions significantly improved appropriate HCQ dosing practices. These interventions are generalizable and can promote safe and guideline-based care.

BackgroundOne-third of primary care providers (PCPs) refer patients with fibromyalgia or chronic pain (FM/CP) to specialist care, typically rheumatology. Yet, comprehensive data on the quality of rheumatology care for patients with FM/CP are currently lacking.MethodsRecords of patients referred for rheumatology consultation for FM/CP and seen at a single academic centre between 2017 and 2018 were extracted by retrospective chart review. Variables were diagnostic accuracy (at referral vs consultation), resource utilisation (investigations, medications, medical and allied health referral), direct costs (physician billing, staff salary, investigation fees) and access (consult wait time). Patient experience and referring PCP experience surveys were administered.Results79 charts were identified. Following consultation, 81% of patients (n=64) maintained the same diagnosis of FM/CP, 19% (n=15) were diagnosed with regional pain and 0% of patients (n=0) were diagnosed with an inflammatory arthritis or connective tissue disease. Investigations were ordered for 37% of patients (n=29), medication prescribed for 10% (n=8) and an allied health referral provided for 54% (n=43). Direct costs totalled $19 745 (average $250/consult; range $157–$968/consult). Consultation wait time averaged 184 days (range 62–228 days). Out of the seven (64%) responses to the patient experience survey, 86% of patients (n=6) were satisfied with provider communication but the consultation ‘definitely’ met the expectations of only 57% (n=4). The PCP survey returned an insufficient response rate.ConclusionsThis study found that no patient referred to rheumatology care for FM/CP was diagnosed with an inflammatory arthritis or connective tissue disease. Furthermore, patients with FM/CP experience lengthy wait times for rheumatology care which delay their management of chronic pain. Interdisciplinary and collaborative healthcare models can potentially provide higher quality care for patients with FM/CP.

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