Quality of rheumatology care for patients with fibromyalgia and chronic pain syndromes

Abstract

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.

UK healthcare services for people with fibromyalgia: results from two web-based national surveys (the PACFiND study)

“…Rheumatologists have traditionally ‘owned’ fibromyalgia [ 61 ]. Yet, some are reluctant to accept patients with fibromyalgia for care [ 17 , 62 ] and the argument for diagnosis and treatment of people with fibromyalgia outwith rheumatology services is growing [ 61 , 63 ]. UK national audits show rheumatology services face challenges meeting quality standards for people with early inflammatory arthritis [ 64 , 65 ] and recent guidance published by the national Getting It Right First Time (GIRFT) programme [ 66 ] recommends that care for people with fibromyalgia should be provided in primary and community settings.…”

Chronic pain and local pain in usually painless conditions including neuroma may be due to compressive proximal neural lesion

“…The diagnostic errors may also be due to incomplete anamnesis caused by miscommunication. It has been found that up to 59% of the patients with chronic pain think they had difficulty in conveying their symptoms ( 224 ), which is not surprising considering the clinical complexity of this condition. Gathering a cPNL-based anamnesis may improve this situation.…”

“…For example, the thoracic outlet syndrome, which produces abundant signs and symptoms in the hand, may not belong to the scope of upper extremity surgeons, but, depending on the clinical institution, may be managed by neurosurgeons, thoracic surgeons, or vascular surgeons. In this regard, the specialized treatment of general chronic pain is even more problematic, because this condition is mostly managed by primary care providers ( 224 , 225 ) who have little experience in peripheral nerve diagnostics and treatment. Obviously, primary care doctors are aware to consult a large spectrum of relevant specialists.…”