Impact of triage by a rheumatologist on appropriateness of referrals from primary to secondary care: a cluster randomized trial

Abstract

Objective

The quality of referrals is often criticized, and the effectiveness of improvement efforts remains uncertain. We assessed the impact of a rheumatologist triaging patients in primary care on the appropriateness of referrals to secondary care, healthcare utilization, and patient experience and outcomes.

Method

A cluster randomized controlled trial was conducted with patients experiencing musculoskeletal complaints. Intervention practices deployed an experienced rheumatologist triaging patients through in-person review. Usual care was performed in control practices, where practitioners referred patients based on their own judgement. The primary outcome was the proportion of inflammatory rheumatic diseases (IRDs) diagnosed by rheumatologists in referred patients. Healthcare utilization (iMTA Medical Consumption Questionnaire), quality of life (EuroQol 5 Dimensions), and experience of care (Consumer Quality Index) were determined after 3 months of follow-up. Data were analysed according to the intention-to-treat principle.

Results

In total, 544 participants were included [mean age 51.4 (range 18–87) years; 24% were men]. Of all referred patients, 51% had an IRD in the intervention group versus 21% in the control group (p = 0.035). After 3 months of follow-up, patients from the triage intervention showed lower healthcare utilization (p = 0.006) and higher quality of life (p = 0.011), without a decline in experienced quality of care (p = 0.712), compared to controls.

Conclusion

Triage by a rheumatologist in primary care provides appropriate care and adequate experience of care, leading to a higher quality of life. Long-term evidence is needed to assess the value on cost-effectiveness before implementing this strategy nationwide.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethics approval and consent to participate

The JOINT referral study was approved and considered not to be subject to the full extent of the Medical Research Involving Human Subjects Act by the recognized medical ethics committee (TWOR) in October 2016. Informed consent was obtained from all subjects. All methods were carried out in accordance with relevant guidelines and regulations.

Availability of data

The data sets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Authors’ contributions

ED made substantial contributions to the conception and design of the work, and the acquisition, analysis, and interpretation of data, and drafted the work. HH, IT, and AE were involved in the acquisition of data and substantively revised the work. MK made substantial contributions to the analysis and interpretation of data, and substantively revised the work. MH made substantial contributions to the conception of the work and also substantively revised the work. DLB and AW made substantial contributions to the conception and design of the work and interpretation of data, and substantively revised the work. All authors read and approved the final manuscript.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/03009742.2022.2112833

Additional information

Funding

There is no financial support or other benefits from commercial sources to be mentioned for the work reported on in this manuscript. None of the authors has any other financial interests which could create a potential conflict of interest or the appearance of a conflict of interest with regard to the work.