Implementation of an Early Referral Programme for Patients With Hand Arthralgia

Introduction: Rheumatoid arthritis (RA) is a progressive autoimmune inflammatory disease. According to the European League Against Rheumatism (EULAR), the stages of RA progression include pre-RA, preclinical RA, inflammatory arthralgia, arthralgia with positive antibodies, arthralgia suspected of progressing to RA, undifferentiated arthritis and finally established RA. According to the Community Oriented Program for Control of Rheumatic Diseases (COPCORD), the prevalence of RA in Mexico is 1.6% [2], with approximately 10% of health problems addressed at the primary care level.

Objective: To assess the implementation of an early referral programme for patients with RA and to reduce the time from symptom onset to specialist referral within the Mexican healthcare system.

Materials and methods: This was a prospective, observational cohort study conducted in family medicine units affiliated with the HGZ #17 of the IMSS, Delegación Nuevo León. A pilot early referral programme was implemented as follows. Phase 1: Patients presenting with hand arthralgia during the initial consultation were referred for a pre-consultation, where they were assessed using the EULAR classification criteria for clinically suspicious arthralgia. Phase 2: Patients meeting more than four of these criteria were scheduled for a direct appointment with a rheumatologist within 3-4 weeks. During the same timeframe, these patients were compared to 200 first-time referrals to rheumatology between April and October 2023 who followed the standard referral process. The following time intervals (measured in months) were evaluated: (A) From symptom onset to the first primary care consultation, (B) To the referral consultation, (C) To internal medicine, and (D) To rheumatology consultation.

Results: Patients diagnosed with RA in the early referral group were 14 out of 41 (34.1%) compared to 25 out of 200 (12.5%) in the standard referral group. The total duration from symptom onset to rheumatology consultation was 28.5 months (SD 35.07) in the standard referral group versus 5.4 months (SD 8.9) in the early referral group.

Conclusion: The implementation of this early referral programme significantly reduced the time in months for patients to access rheumatologic care.