534 SKELETON, MUSCLE SYSTEM, RHEUMATOLOGY LOCOMOTION Zdrav Vestn | November – December 2022 | Volume 91 | https://doi.org/10.6016/ZdravVestn.3287 Copyright (c) 2022 Slovenian Medical Journal. This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. When and how to refer to a rheumatologist Koga, kdaj in kako napotiti k revmatologu Katja Perdan Pirkmajer,1,2 Žiga Rotar,1,2 Matija Tomšič,1,2 Aleš Ambrožič1 Abstract In Slovenia, the number of rheumatologists per capita is 40% lower than the European Union average, which can make the implementation of management guidelines challenging. Despite this problem, rheumatologic patients are managed according to international guidelines and comparable with other developed European countries. Unnecessary referrals put additional strain on the overburdened rheumatology outpatient clinics and may ultimately jeopardize the level of care for patients with rheumatological conditions. Herein, we summarized current rheumatology outpatient clinic directions according to different emergency levels. Izvleček V Sloveniji kljub pomanjkanju revmatologov in s tem daljšimi čakalnimi dobami revmatološkim bolnikom zagotavljamo sodobno obravnavo, ki je primerljiva z delom v najbolj priznanih svetovnih ustanovah. Da visoko raven obravnave tudi vprihodnosti ohranimo, je bistvenega pomena, da so poslane napotnice primerno izpolnjene in opremljene z vsemi podat- ki, ki jih potrebujemo za ustrezno razvrščanje v čakalno knjigo glede na resnost in vrsto bolezni (triažiranje). V prispevku podajamo osnovna navodila glede napotitev v revmatološko ambulanto s strokovno ustreznimi stopnjami nujnosti. 1 Department of Rheumatology, Division of internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia 2 Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia Correspondence / Korespondenca: Aleš Ambrožič, e: ales.ambrozic@mf.uni-lj.si Key words: referral; rheumatology; levels of referral; management Ključne besede: napotna listina; revmatologija; stopnja napotitve; obravnava Received / Prispelo: 21. 6. 2021 | Accepted / Sprejeto: 2. 11. 2021 Cite as / Citirajte kot: Perdan Pirkmajer K, Rotar Ž, Tomšič M, Ambrožič A. When and how to refer to a rheumatologist. Zdrav Vestn. 2022;91(11–12):534–8. DOI: https://doi.org/10.6016/ZdravVestn.3287 eng slo element en article-lang 10.6016/ZdravVestn.3287 doi 21.6.2021 date-received 2.11.2021 date-accepted Skeleton, muscle system, rheumatology locomotion Okostje, mišice, revmatologija, lokomocija discipline Professional article Strokovni članek article-type When and how to refer to a rheumatologist Koga, kdaj in kako napotiti k revmatologu article-title When and how to refer to a rheumatologist Koga, kdaj in kako napotiti k revmatologu alt-title referral, rheumatology, levels of referral, management napotna listina, revmatologija, stopnja napotitve, obravnava kwd-group The authors declare that there are no conflicts of interest present. Avtorji so izjavili, da ne obstajajo nobeni konkurenčni interesi. conflict year volume first month last month first page last page 2022 91 11 12 534 538 name surname aff email Aleš Ambrožič 1 ales.ambrozic@mf.uni-lj.si name surname aff Katja Perdan Pirkmajer 1 Žiga Rotar 1 Matija Tomšič 1 eng slo aff-id Department of Rheumatology, Division of internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia Klinični oddelek za revmatologijo, Interna klinika, Univerzitetni klinični center Ljubljana, Ljubljana, Slovenija 1 Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia Katedra za interno medicino, Medicinska Fakulteta, Univerza v Ljubljani, Ljubljana, Slovenija 2 Slovenian Medical Journallovenian Medical Journal 1 Introduction A large number of rheumatic diseases are chronic autoimmune diseases that, without proper treatment, can lead to irreversible organ or organ system damage, poor quality of life, lower work capability and higher mortality. However, rheumatic diseases are rarely an emergency. While a rheumatologic emergency can lead to death or irreversible organ damage without rapid and appropriate management (1), there are al- so inflammatory rheumatic diseases that do not re- quire an urgent referral to a rheumatologist. Therefore, the referral urgency should be tailored to individual diseases. 535 PROFESSIONAL ARTICLE When and how to refer to a rheumatologist The article discusses currently valid international guidelines on rheumatology referrals and their level of urgency. It is intended to help physicians who face the issue of rheumatology referrals on a daily basis. 2 Referrals A referral is a medical document with which a phy- sician refers a patient to a specialist for consultation or a procedure. It consists of the patient’s basic per- sonal information, the medical service to which they are referred and the level of urgency, which, based on waiting lists, dictates the appointment date. Since 2017, an electronic referral system has been in use in Slove- nia. An e-referral enables the patient to book an ap- pointment with a specialist online instead of physically sending it to a specialist. 3 Level of urgency The referral’s level of urgency depends on the na- ture of the medical problem and expected disease course. In Slovenia, these levels are regular, fast, very fast and urgent, depending on how quickly the patient should be seen by a specialist. The Health Insurance Institute of Slovenia (HIIS) recommends the following maximum waiting times: six months for regular refer- rals, three months for fast referrals, 14 days for very fast referrals and 24 hours for urgent referrals. There are some exceptions to the maximum accept- able waiting time at the fast or regular levels of urgen- cy. Among the exceptions is a first rheumatologist ap- pointment, for which a period of 12 months is allowed at the regular level of urgency. However, the restriction on the maximum acceptable waiting time does not ap- ply if the patient wants a specific provider, regardless of their number of patients in the waiting line. In Slovenia, the waiting times for a first rheuma- tologist appointment exceed the maximum acceptable waiting times as the number of rheumatology referrals exceeds the rheumatologists’ capacities. Therefore, it is crucial that referrals are appropriately completed with all the information required for triage. At the Depart- ment of Rheumatology, University Medical Centre Ljubljana, patients are seen at the emergency rheuma- tology clinic every workday at regular hours, while a very fast referral still enables management of all pa- tients within a 14-day period. Based on the data from April 2021, the waiting time for a first appointment with a fast referral was approximately 12 months, and 18 months with a regular referral. Despite COVID-19 restrictions, we managed to reduce the number of pa- tients in the waiting line by 20%. Despite long waiting times, management of patients with inflammatory rheumatic diseases at the Depart- ment of Rheumatology, University Medical Centre Ljubljana is modern and in accordance with interna- tional guidelines. Patients with newly diagnosed rheumatoid arthritis are mostly seen within 12 weeks of disease onset. The time from referral to clinic visit ranged from one to three days (2). In some respects, we exceed the stan- dards of most developed European countries. For ex- ample, at our department, we manage cases of giant cell arteritis with an extremely short period elapsed between the appearance of first symptoms to diagno- sis and treatment start (one day, including using ul- trasound and/or preliminary temporal artery biopsy histology results, although the latter investigation was practically abandoned in recent years), which is very important in preventing vision loss (our patients ex- perience permanent vision loss in approximately 10%, while the literature describes permanent vision loss in approximately 20% of patients) (3,4). In order to maintain or even improve such a high level of management of rheumatology patients, the co- operation of referring physicians and their consistency in referrals to rheumatology clinics is crucial. The following are recommendations for referrals to a rheumatology clinic. 4 Appropriate referrals When referring a patient to a rheumatology clinic, it is important to correctly, professionally and com- pletely fill out the referral letter. A short description of the patient’s symptoms and significant abnormali- ties found on examination is required. Results of lab- oratory testing that should be performed per general agreement before a first non-urgent rheumatology referral needs to be included in the referral (5): CRP, ESR, complete blood count; other testing can be per- formed at the discretion of the referring physician (6). Taking into account the disease symptoms and signs and basic laboratory testing results, most patients can be placed into one of the proposed levels of urgency. Some patients may have circumstances that are not covered by these recommendations, but significantly affect the time required to see them at a rheumatology clinic. In such cases, it is possible, with a clear referring physician’s written explanation, to triage the patient in- to a different (normally higher) level of urgency than 536 SKELETON, MUSCLE SYSTEM, RHEUMATOLOGY LOCOMOTION Zdrav Vestn | November – December 2022 | Volume 91 | https://doi.org/10.6016/ZdravVestn.3287 recommended. The triage rheumatologist can also de- tect such circumstances and change the level of urgen- cy. We should also be aware that the disease develops over time. A patient may experience a new significant symptom or sign of disease progression while waiting. In such cases, it is necessary to report this so that the triage is repeated and the patient is given a more ap- propriate appointment. In patients with a known inflammatory rheumat- ic disease in whom basic immunosuppressive therapy (methotrexate, leflunomide, sulfasalazine, azathio- prine, mycophenolate mofetil and related drugs) was recently initiated and abnormal laboratory results that could be a consequence of such treatment are found, we recommend a consultation with the patient’s rheu- matologist before referring them to the rheumatology clinic; in case the patient is followed by rheumatolo- gists at the Department of Rheumatology, Universi- ty Medical Centre Ljubljana, the referring physician should consult the consultant rheumatologist at the department (01 522 44 61 every working day from 12.30–13.30 or e-consultation). At the Department of Rheumatology, University Medical Centre Maribor, the rheumatologist is available on the telephone num- ber 02 321 24 87 every workday from 13.00 to 14.00, and e-consultation is also possible. In addition, the number for Murska Sobota General Hospital is 02 512 35 50, and Izola General Hospital is 05 660 61 71; both lines are available from 10.00 to 14.00 on workdays. Similarly, we recommend an initial consultation with a rheumatologist in patients with exacerbation of already known inflammatory rheumatic disease. In patients who have just started taking basic immuno- suppressives, it is important to know that most of these drugs require at least two to three months before im- provement of clinical problems. Therefore, if a patient experiences the same problems as before the newly in- troduced immunosuppressive therapy, re-examination will not contribute to improved management. 5 Emergency rheumatology clinic at the Department of Rheumatology, University Medical Centre Ljubljana The emergency rheumatology clinic is not a typi- cal emergency medicine unit as it does not provide continuous coverage. It is open only in the morning (patient reception takes place between 7 am and 10 am) on workdays. Monitoring the number of exam- ined patients shows that such an arrangement is suf- ficient with respect to the appropriate management of all rheumatological patients needing urgent treatment according to guidelines. We have noticed a distinct proportion of non-urgent referrals, but in recent years, this has significantly improved. In 2016, 2498 patients were referred to the emergency clinic, while in 2020, this number was 1623. Overloading the emergency rheumatology clinic can jeopardize the quality of treat- ment of those patients who truly require urgent or pri- ority management. Only patients with suspected new-onset or acute exacerbation of life-threatening inflammatory rheu- matic disease or a high risk of permanent organ damage should be referred to an emergency rheu- matology clinic. Examples of such diseases or reasonable suspi- cion of them: • Giant cell arteritis (7): referral to emergency rheu- matology clinic only during workdays in the morn- ing with an urgent referral; basic laboratory testing (CRP, ESR, complete blood count) should already be performed. • Acute impending internal organ damage or necro- tizing cutaneous lesions as part of systemic connec- tive tissue disease or vasculitis, acute dysphagia as part of inflammatory myopathy (8): urgent referral to the emergency rheumatology clinic; laboratory testing: as required by the underlying disease. • Septic arthritis: patients are normally referred to an infectious disease specialist or orthopaedist (at the University Medical Centre Ljubljana, this means the emergency clinic at the Department of Infec- tious Diseases; at the University Medical Centre Maribor, this means the clinic at the Department of Orthopaedics; for other regions, it depends on their organization (see the Appropriate referral chapter). • Life-threatening conditions as part of inflammatory rheumatic disease and all urgent conditions when the emergency rheumatology clinic doesn’t accept patients: referral to the Medical Emergency Unit at the University Medical Centre Ljubljana or a re- gional emergency centre (continuous coverage). 6 “Very fast” referrals Patients who need to be seen within four weeks should receive a very fast referral for a rheumatology clinic (referral validity is three days, appointment is within 14 days since receipt of the referral letter). New-onset, exacerbation or reasonable suspi- cion of inflammatory rheumatic disease which can 537 PROFESSIONAL ARTICLE When and how to refer to a rheumatologist permanently damage health, but is not threatening to life or a vital organ. Examples of such diseases or reasonable suspi- cion of them: • New-onset polyarthritis or exacerbation of known chronic arthritis (e.g. rheumatoid arthritis, psori- atic arthritis, spondyloarthritis) when significant improvement doesn’t occur after two to four weeks of treatment with a full dose of a non-steroidal an- ti-inflammatory drug (NSAID) in the absence of contraindications. • Systemic lupus erythematosus (with exacerbation of chronic organ involvement other than the skin). • Systemic vasculitis (with exacerbation of chronic organ involvement other than the skin, unless there are necrotising cutaneous lesions). • Polymyositis / dermatomyositis. • Systemic sclerosis (involvement of an organ other than the skin). • Polymyalgia rheumatica (only in the case of newly developed pain in the shoulder and pelvic girdle if the patient is over the age of 50 years and with in- creased inflammatory parameters). • Uncontrolled gout with involvement of multiple joints. 7 “Fast” referrals This level of referral includes conditions that, ac- cording to guidelines, require examination within three months of the onset of symptoms or signs of in- flammatory rheumatic disease or exacerbation of in- flammatory rheumatic disease. Examples of such diseases or reasonable suspi- cion of them: • Monoarthritis or oligoarthritis that does not re- spond to treatment with a full dose of NSAIDs (two to four weeks if there are no contraindications) and there is no clinical suspicion of septic arthritis. • Recurrent episodes of pseudogout or gout despite adherence to current treatment recommendations. • Inflammatory back pain that does not respond treatment with a full dose of NSAIDs (two to four weeks if there are no contraindications). • Suspicion of systemic connective tissue disease without clear internal organ involvement. • Suspicion of antiphospholipid syndrome (vascular involvement or pregnancy complications). 8 “Regular” referrals This category includes conditions that, according to guidelines, do not require examination within three months, namely the suspicion of inflammatory rheu- matic disease without clear internal organ involve- ment organs or arthritis. Examples of such diseases or reasonable suspi- cion of them: • Dry mouth and eyes – suspicion of Sjögren’s syn- drome. Dryness of the mucous membranes is an ex- tremely unpleasant symptom that can greatly affect a patient’s quality of life. However, even if the diag- nosis is confirmed, since the measures are mostly symptomatic, earlier examination does not change the prognosis. Regular referral is sufficient for these patients, and any preferential management will de- pend on data that may indicate internal organ in- volvement. • Raynaud’s phenomenon without other symptoms or signs of systemic connective tissue disease or dig- ital ulcers. Such patients are predominantly healthy women (9). Patients referred to a rheumatologist are significantly more likely to have an associated connective tissue disease, but they do not need to be seen at the emergency rheumatology clinic. De- pending on associated symptoms, appropriate re- ferral with basic laboratory tests is required. • Inflammatory back pain responding to treatment with a full dose of NSAIDs in patients without increased CRP; as such a patient is already being treated appropriately, the first appointment may therefore be postponed. Which patients do not require referrals to a rheu- matology clinic? Every joint symptom or pain does not warrant a rheumatology referral. Normally, joint pain without oedema or other clear signs of inflammation, e. g. post-traumatic, osteoarthrosis, fibromyalgia, Foresti- er’s disease or condensing osteitis does not require a rheumatologist work-up after imaging had been performed. 9 Conclusion In Slovenia, we are faced with a problem of un- acceptably long waiting times for a rheumatologist appointment. Despite this, the management of our 538 SKELETON, MUSCLE SYSTEM, RHEUMATOLOGY LOCOMOTION Zdrav Vestn | November – December 2022 | Volume 91 | https://doi.org/10.6016/ZdravVestn.3287 References 1. Tomšič M, Praprotnik S. Revmatološki priročnik za družinskega zdravnika, četrta izdaja. Ljubljana: Birografika Bori; 2012. 2. Ješe R, Ambrožič A, Gašperšič N, Hočevar A, Lestan B, Plešivčnik-Novljan M, et al. The performance of a single centre interventional clinic in early rheumatoid arthritis. Ann Rheum Dis. 2016;75:979. DOI: 10.1136/ annrheumdis-2016-eular.1679 3. Hočevar A, Rotar Z, Ješe R, Sodin Šemrl S, Pižem J. Hawlina M e tal. Do early diagnosis and glucocorticoid treatment decrease the riskof permanent visual loss and early relapses in giant cell arteritis. Medicine (Baltimore). 2016;95(14):e3210. DOI: 10.1097/MD.0000000000003210 PMID: 27057850 4. Hočevar A, Ambrožič A, Tomšič M. Correspondence on: ‘What comes after the lockdown? Clustering of ANCA-associated vasculitis:single-centre observation of a spatiotemporal pattern’. Ann Rheum Dis. 2021:annrheumdis-2021-220290. DOI: 10.1136/ annrheumdis-2021-220290 PMID: 33789871 5. Hočevar A, Ambrožič A. 100 navodila za obravnavo bolnika pred prvo nenujno napotitvijo. Brezovica pri Ljubljani: Združenje zdravnikov družinske medicine; 2021 [cited 2021 May 6]. Available from: http:// www.drmed.org/wp-content/uploads/2014/06/100-Priprava-na-prvo- nenujno-napotitev.pdf. 6. Puchner R, Edlinger M, Mur E, Eberl G, Herold M, Kufner P, et al. Interface Management between General Practitioners and Rheumatologists- Results ofa Survey Defining a Concept for Future Joint Recommendations. PLoS One. 2016;11(1):e0146149. DOI: 10.1371/journal.pone.0146149 PMID: 26741702 7. Hočevar A, Ješe R. Revmatična polimialgija in gigantocelični arteritis. In: Košnik M, Štajer D, eds. Interna medicina. 5. izd. Ljubljana: Mediicnska fakultea; 2018. pp. 1419-23. 8. Hočevar A, Ješe R. Vnetje miopatije. In: Košnik M, Štajer D, eds. Interna medicina. 5. izd. Ljubljana: Mediicnska fakultea; 2018. pp. 1396-1401. 9. Wigley FM, Flavahan NA. Raynaud’s Phenomenon. N Engl J Med. 2016;375(6):556-65. DOI: 10.1056/NEJMra1507638 PMID: 27509103 patients is comparable to the world’s leading institu- tions. If we wish to maintain appropriately prompt management of patients who need it most, the emer- gency rheumatology clinic must not be allowed to be- come a tool for solving long waiting times. A patient referred to the emergency rheumatology clinic who does not need an urgent work-up will not benefit from the referral; however, inappropriate management of non-urgent patients endangers patients who do need preferential treatment. Thus, a complete and thorough referral letter is important to enable appropriate triage. Conflict of interest None declared.