Can diagnostic triage by general practitioners or rheumatology nurses improve the positive predictive value of referrals to early arthritis clinics?
OBJECTIVE
To determine whether diagnostic triage by general practitioners (GPs) or rheumatology nurses (RNs) can improve the positive predictive value of referrals to early arthritis clinics (EACs).


METHODS
Four GPs and two RNs were trained in the assessment of early inflammatory arthritis (IA) by four visits to an EAC supervised by hospital rheumatologists. Patients referred to one of three EACs were recruited for study and assessed independently by a GP, an RN and one of six rheumatologists. Each assessor was asked to record their clinical findings and whether they considered the patient to have IA. Each was then asked to judge the appropriateness of the referral according to predetermined guidelines. The rheumatologists had been shown previously to have a satisfactory level of agreement in the assessment of IA.


RESULTS
Ninety-six patients were approached and all consented to take part in the study. In 49 cases (51%), the rheumatologist judged that the patient had IA and that the referral was appropriate. The assessments of GPs and RNs were compared with those of the rheumatologists. Levels of agreement were measured using the kappa value, where 1.0 represents total unanimity. The kappa value was 0.77 for the GPs when compared with the rheumatologists and 0.79 for the RNs. Significant stiffness in the morning or after rest and objective joint swelling were the most important clinical features enabling the GPs and RNs to discriminate between IA and non-IA conditions.


CONCLUSIONS
Diagnostic triage by GPs or RNs improved the positive predictive value of referrals to an EAC with a degree of accuracy approaching that of a group of experienced rheumatologists.
Department of General Practice, Queens University of Belfast, Northern Ireland, UK. gerry@teamgormley.freeserve.co.uk
G J
GJ
Gormley
W K
WK
Steele
A
A
Gilliland
P
P
Leggett
G D
GD
Wright
A L
AL
Bell
C
C
Matthews
G
G
Meenagh
E
E
Wylie
R
R
Mulligan
M
M
Stevenson
D
D
O'Reilly
A J
AJ
Taggart
D001172:Arthritis, Rheumatoid / Q000175:diagnosis*; D002983:Clinical Competence; D003937:Diagnosis, Differential; D005500:Follow-Up Studies; D006300:Health Services Misuse; D006801:Humans; D009660:Northern Ireland; D009722:Nurse Practitioners / Q000592:standards*; D015588:Observer Variation; D016017:Odds Ratio; D010044:Outpatient Clinics, Hospital / Q000706:statistics & numerical data*; D010821:Physicians, Family / Q000592:standards*; D011237:Predictive Value of Tests; D012017:Referral and Consultation / Q000592:standards* / Q000706:statistics & numerical data; D014218:Triage / Q000592:standards*