In this cross-sectional study, we observed a significant improvement in the quality of referrals to Rheumatology consultations in the state of Rio Grande do Sul over 10 years. Comparing the results of the 2007/2008 survey with those observed in the present study (2017/2018), we noticed more cases suspected of SIRDs in the latter (52.1%, versus 30.9% in the former). However, we found that the increase in the proportion of SIRDs was more marked in outside counties’ referrals (from 33 to 68%) compared to referrals from the capital (from 29 to 39%) over these 10 years. This change may be explained partly by a general improvement in knowledge of the rheumatic diseases among PHC physicians. However, the more marked increase in the proportion of adequate referrals from outside counties suggest that much of this improvement is related to the application of the triage program and teleconsulting support system [7,8,9].
Previous studies had already demonstrated the benefits of referral screening processes for referrals to specialized care [5, 10]. In a Canadian study similar to ours, the implantation of triage for referrals promoted a reduction in waiting time for patients with suspected inflammatory arthritis (IA) and connective tissue diseases (CTD). In contrast, the waiting time for those with suspected non-IA and non-CTD increased [11]. Teleconsulting support seems to work as a continued medical education process, leading to reduced referrals to specialties and improving the quality of referrals [12]. In our country, Meyama et al. evaluated the impact of teleconsulting in referrals in Santa Catarina (another Southern Brazilian state). They found a decrease of more than 50 % in new solicitations of Rheumatology referrals after starting a mandatory teleconsulting program [12].
Interestingly, we observed a reduction in cases classified as urgent in 2017/2018 compared to the 2007/2008 survey. A difference in the classification methodology can probably explain this finding. In 2007/2008, cases were classified as urgent based on subjective rheumatologist's evaluation without following clear pre-specified criteria. However, in the present survey, we used stricter criteria (pregnancy, risk of vital organ damage, and RA with poor prognosis) to define an urgent case.
We noticed that the waiting time for consultation increased considerably during the time frame encompassed by this study. A possible explanation for this observation is that we collected the data from October 01, 2017, to March 31, 2018, just a year and a half after the changes in the referral system. Given that data from TelessaúdeRS/UFRGS™ shows a decrease in about 30% of referrals after the triage system with protocols was implemented [9], it is likely that the waiting time of our 2017/2018 sample reflects patients already waiting for a long time for a rheumatology consultation before the implementation of the system. To illustrate that, when Telessaúde started the process, there were more than 7000 cases on the waiting list for Rheumatology appointments (unpublished data). Advances in the treatment of rheumatic diseases and the knowledge of the importance of early treatment to obtain better outcomes may also have stimulated a larger number of referrals, increasing the waiting list, and consequently, the waiting time.
There was a significant disparity in the suspicion of fibromyalgia and osteoarthritis among primary care physicians and rheumatologists in the present study. Of the 357 patients referred, only 9.5% (34 patients) had one of these diseases as an initial suspicion by the primary care physician (the screening system accepted these cases, according to the protocol, because they were considered refractory to management in primary care or the diagnosis was doubtful). On the other hand, one of these two diseases was the first hypothesis in 122 patients (34.2%) at the first rheumatology visit. Cases of fibromyalgia and osteoarthritis can usually be managed at the primary care level [6]. The low prevalence of SIRDs and the high frequency of musculoskeletal symptoms in the general population represent a challenge to the general practitioner to identify such patients timely. Equipping him with the necessary knowledge to recognize these patients more safely is crucial for improving the referral process [13]. Measures such as lectures, discussion with the rheumatologist, and educational material are strategies that have already demonstrated benefits on the quality and quantity of referrals [5].
The present study has several strengths. There are no similar studies evaluating referral from primary care to Rheumatology and the impact of applying referral protocols with telemedicine support in our environment. The high number of first consultation visits (the largest in the state of Rio Grande do Sul at that time, compared to other tertiary care centers) in our service allowed us to obtain a significant and representative number of individuals from different origins for the analysis.
Our study also has limitations. The observational design of our research has well-known limitations in comparison to experimental studies. So,we cannot absolutely affirm that the improvement in referral quality is explained only by changes in the referral process. Another limitation is that we did not assess the effects of the different components of the referral process (triage with protocol and teleconsulting) independently. For analytical purposes, we considered as appropriate only referrals suspected of SIRDs. We know that some patients with other diseases (such as gout, osteoarthritis, and fibromyalgia) may sometimes require specialized diagnostic evaluation and treatment, particularly in refractory cases. Even so, the increased proportion of SIRDs among referred patients represents greater adequacy in the referral process, as these patients could hardly be adequately treated at the primary level of care. In such cases, intravenous infusions, immunosuppressants, and specialized tests available only in more advanced levels of care are often required. We based the diagnosis of a SIRD on the first clinical evaluation by the rheumatologist and previous medical exams brought by the patients. Therefore, some initial diagnoses may have changed during medical follow-up. Another potential limitation is that we analyzed only patients referred to the HNSC/GHC Rheumatology Service, not including patients referred to other services. However, considering that the schedule of appointments for different Rheumatology services occurs in a centralized and non-regionalized manner and the large number of patients received by our service, our sample can be considered representative of referrals to Rheumatology in our state.