CARE referral rule bests REACH for detecting inflammatory arthritis, rheumatic disease
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Compared to the Rotterdam Early Arthritis Cohort referral rule, the Clinical Arthritis Rule had superior specificity and overall diagnostic performance in recognizing inflammatory arthritis and inflammatory rheumatic disease in primary care.
However, researchers noted that a proposed composite rule, combining variables from both the REACH and CARE referral rules, demonstrated “a net benefit” and greater diagnostic performance “compared to the currently available rules.”
“At present there is a challenge for primary care physicians to refer patients suspect for inflammatory arthritis (IA) as quickly as possible,” Elke Theodora Antonia Maria van Delft, MSc, of Maasstad Hospital, in Rotterdam, the Netherlands, and colleagues wrote in Arthritis Care & Research. “Unfortunately, experience on who must be referred or in whom additional investigations are appropriate is lacking. Recently, two separate and distinct referral rules for arthritis have been developed to select patients for referral to the rheumatologist.”
“The aim of both rules was to assist in the decision-making process in patients with musculoskeletal symptoms with suspected IA, in order to promote early identification of IA,” they added. “Both referral rules could promote early identification of IA with the aim of increasing appropriate health care utilization.”
To analyze the performance and clinical use of the REACH and CARE referral rules in recognizing inflammatory arthritis and inflammatory rheumatic disease (IRD), van Delft and colleagues examined control group data from the JOINT referral study. According to the researchers, JOINT was a randomized, controlled trial intended to help general practitioners decide when to refer patients with musculoskeletal symptoms. Enrolled between April 2017 and November 2019, the control group included consecutive new patients who had been referred to the rheumatology outpatient clinic from the Maasstad hospital.
This referral process was conducted as usual based on national guidelines, without any other specific strategy.
For their own prospective, diagnostic study, van Delft and colleagues invited adult participants who were newly suspected of needing a rheumatology referral. In all, 250 patients suspected by their general practitioner of having an IRD were included in the analysis. These participants were seen by a research assistant prior to any consultation with a rheumatologist. During this meeting, patients answered questions in both the REACH and CARE strategies. Demographic data were also collected. The participants then went on to receive their regular rheumatology visit, with the rheumatologist unaware of the referral rule outcome.
The researchers used diagnostic accuracy measures and a net benefit approach to compare both rules to usual care for recognizing inflammatory arthritis and IRD. To determine if “a combination of variables from both rules would lead to a more optimal prediction rule for recognizing IRD,” they also used the least absolute shrinkage and selection operator method, as well as cross-validation, to create a composite “Delft rule” for IRD.
According to the researchers, 22% of the included participants were diagnosed with an IRD, with 17% diagnosed with inflammatory arthritis, 3 months after referral. Regarding inflammatory arthritis, the area under curve (AUC) was 0.72 (95% CI, 0.64-0.8) for REACH and 0.82 (95% CI, 0.75-0.88) for CARE. Regarding IRD, the AUC was 0.66 (95% CI, 0.58-0.74) for REACH and 0.76 (95% CI, 0.69-0.83) for CARE.
The CARE rule demonstrated the highest clinical value when compared to usual care.
Lastly, the composite referral rule for IRD — which included ten parameters such as sex, age, joint features, acute onset of complaints, physical limitations and duration of complaints — had an AUC of 0.82 (95% CI, 0.75-0.88).
“Performance of the REACH and CARE rules are both sufficient for recognizing inflammatory arthritis in daily practice,” van Delft and colleagues wrote. “The CARE even shows sufficient performance in recognizing the entire spectrum of inflammatory rheumatic diseases. The CARE consists of only seven questions that are all easy to use and easy to interpret, hence it will not be necessary to educate primary care physicians about the referral rule before implementation in daily practice. By using this referral rule, the proportion of referred patients with a definite suspicion of IRD can be increased.”
“The high specificity implies that over half of all patients suspected of an IRD by their general practitioner can be withheld from expensive outpatient rheumatology care,” they added. “Therefore, we advise to evaluate the CARE rule on its impact on cost-effectiveness in primary care before implementation. Although the composite Delft referral rule seems more promising, external validation on a larger sample is needed to establish its real potential.”
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