Appendix 1: Summary Table of Recommendations Recommendation Rationale & report reference NHSScotland Quality Strategy Quality Ambition addressed Suggested level for implementation 1. Public awareness of rheumatoid arthritis should be raised in order to limit the delay in patients presenting to their General Practitioner (GP). Early treatment of RA improves outcomes. However, Scottish audit data shows that considerable delays occur in the diagnosis of RA. The greatest delay in diagnosis occurs during the time between symptom onset and the patient’s first presentation to their GP. , Section 4.2.2 & 4.2.3 Quality Ambition: Effective care National 2. Referral guidelines with referral routes should be agreed with GPs, encouraging urgent referral of patients with possible RA to a rheumatology specialist, ideally within 2 weeks of the patient presenting to primary care, in order to facilitate treatment commencing within 12 weeks of onset of symptoms. treatment of RA improves outcomes but audit data shows that considerable delay occurs in the referral of patients from primary care to secondary care for specialist rheumatology assessment. The initial presentation of early RA can be variable, making diagnosis difficult and GP awareness of referral guidelines may be poor. Clear signposting is required. , Section 4.2.4 Quality Ambition: Effective care National / NHS Board 3. Protocols should be developed for physiotherapy triage services and other Concern was expressed during the corporate assessment that the recent development of new Quality Ambition: Safe, Effective care National / NHS Board
new models of care for musculoskeletal (MSK) conditions to facilitate the of patients with potential inflammatory joint disease. Regular auditing of time to specialist assessment should be undertaken to ensure no retrograde steps occur in time to treatment. triage pathways (using telephone based systems) for musculoskeletal presentations may potentially inadvertently lead to delays in the assessment of those with early RA. , Section 4.2.4 4. Rheumatology departments should provide rapid access or urgent appointments for people with possible RA within 4 weeks of referral. intensive management of those with newly diagnosed RA results in superior outcomes and is cost neutral in the short term. , Section 4.2.2 Quality Ambition: Effective care National / NHS Board 5. Patients referred to rheumatology with a possible diagnosis of inflammatory arthritis should be seen by a rheumatology consultant on the specialist register, or a doctor with experience and expertise in the assessment and management of RA but under the overall supervision and responsibility of a consultant rheumatologist. Rheumatoid arthritis is a multi-system disease that requires experience and expertise to diagnose. There are no absolute diagnostic tests for RA - RA is a clinical diagnosis made on the basis of a number of findings. This requires considerable clinical expertise. , Section 4.3 Quality Ambition: Effective care NHS Board 6. Assessment tools should be applied from the outset to enable monitoring of progress and treatment to target. Examples of A number of scoring systems exist to quantify the degree of active RA disease at time of diagnosis. The most commonly used is the DAS-28. It is not Quality Ambition: Effective care NHS Board
appropriate tools are: DAS; DAS28; HAQ; HAD; RA-WIS; and SDAI. The use of such tools should be regularly audited. known how extensively this scoring system is used in at time of diagnosis but there is evidence to show that using such an approach to target treatment improves outcomes. , Section 4.3.3 7. Imaging facilities for ultrasound examination by either a clinician or technician with experience and expertise in musculoskeletal ultrasound scanning of inflammatory arthritis should be available if required, preferably at the initial consultation. The diagnosis of RA can be difficult. Ultrasound scanning (USS) can detect synovitis that cannot be detected clinically and can be useful in the diagnostic process. EULAR has recommended the use of ultrasound in the diagnostic process for those patients where there is diagnostic dubiety. , Section 4.3.5 Quality Ambition: Effective care NHS 8. A concerted effort should be made to facilitate training in ultrasound for trainee rheumatologists and AHPs. Recognised trainers in should be identified and a structured training programme based on the EULAR model or postgraduate certificate developed. There is currently variability of access to ultrasound scanning in . Problems include a lack of skilled operators and a lack of skilled mentors. The use of USS is likely to be incorporated as a required skill for rheumatology trainees as advised by the British Society for Rheumatology (BSR). , Section 4.3.5 Quality Ambition: Effective care NHS Board 9. Smoking cessation should be part of the management plan of all RA patients who smoke. Smoking increases the risk of developing RA. Smoking can also reduce the effectiveness of RA treatments including anti-TNF agents and DMARDs. A recent survey of RA patients in , Quality Ambition: Person-centred, Effective care National / NHS Board