AB1187 IMPACT OF IN-CLINIC ULTRASOUND ON AGE AND GENDER OF PATIENTS SCANNED AND DETECTION OF SYNOVITIS – RESULTS FROM A QUALITY IMPROVEMENT PROJECT
Authors: Yacer Asran, Surabhi Wig, Sreekanth Vasireddy
Journal: Annals of the Rheumatic Diseases (2019)

<h3>Background</h3> Inflammatory arthritis is more common in women, and the majority of patients have onset before the 6th decade. Synovitis can be difficult to diagnose clinically in the early stages, and can be especially easy to miss where the index of suspicion is low, such as men and the elderly. Ultrasound (US) can confirm synovitis and other conditions in Rheumatology, particularly where examination features are not very obvious. US has traditionally been offered via Radiology services in our hospital as a separate appointment following referral from the Rheumatology clinic, with variable waiting times causing potential delay in starting treatment such as DMARDs. There is also a cost implication with respect to commissioning of the Radiology scan appointments. In Bolton, an US system was installed in Rheumatology from 2016 to perform in-clinic US, for improving access and reducing referrals to Radiology. <h3>Objectives</h3> We aimed to assess the US usage pattern before and after the new Rheumatology US was installed, with respect to access based on age and gender, the pattern of scanning in-clinic, and rate of synovitis diagnsosis, using a quality improvement framework. <h3>Methods</h3> US referral data from the Radiology department from October 2015 to March 2016 were collated as baseline on a MS Access database. Two Consultant Rheumatologists performed US in-clinic. From May to October 2016 Rheumatology in-clinic data, and also Radiology referral data were collated on the database for comparison. Patient demographics and diagnoses were collated from clinic letters. Descriptive statistics were processed in MS Excel 2010. <h3>Results</h3> Between October 2015 and March 2016, 68 patients (median age 52 yrs; 28% male) had scans in Radiology. Between May and October 2016, 59 patients (median age 60 yrs; 21% male) had scans in Radiology, and 78 patients (median age 59yrs; 35% male) had scans in Rheumatology clinic. There was no significant difference in scanned areas amongst the three cohorts with the most common overall being hand/wrist area (n=57, 54 and 61 respectively; total 84%), followed by foot/ankle (n=6, 4 and 4 respectively; total 7%). Between the two time periods, there was an increased trend in final working diagnoses of inflammatory arthritis (28 [41%] vs 36 [61%] and 39 [50%] in the 3 cohorts respectively); and a decreasing trend in the final working diagnoses of non-inflammatory conditions (OA, FM, other non-inflammatory pain: 36 [53%] vs 22 [37.3%] and 28 [35.9%] in the 3 cohorts respectively). <h3>Conclusion</h3> The availability of Rheumatology US was associated with increased propensity for scanning older patients and a greater proportion of men compared to previously, a qualitative improvement as synovitis diagnosis could be delayed in these groups. The introduction of Rheumatology US was also associated with a trend towards higher proportion of inflammatory diagnoses, suggesting potentially increased appropriate clinical use due to availabiltiy in-clinic. This is supported by the majority being hand/wrist scans, suggesting Rheumatology use is mainly aimed at diagnosing synovitis. Although there was a modest reduction of 13% in Radiology referrals between the two time periods, there was an overall increase of scans performed by 101% following introduction of the Rheumatology US service. We therefore recommend Rheumatology in-clinic US provision, as in addtion to obvious improvement in time to diagnosis, it is likely to increase the range of patients able to access US eg older patients and men, and also likely to increase the pick-up rate of synovitis by improving patient selection. <h3>Disclosure of Interests</h3> None declared