SAT0563 WHAT CAN WE LEARN FROM NEW MUSCULOSKELETAL EXTENDED SCOPE PRACTITIONER REFERRALS TO RHEUMATOLOGY SECONDARY CARE? A PROSPECTIVE SERVICE EVALUATION

Abstract

Background: Common non-inflammatory musculoskeletal (MSK) problems are increasingly referred in the UK from primary care to extended scope practitioners (ESPs) that are not doctors. A new local ESP service has been established. Primary care is directed to refer inflammatory problems to secondary care, and non-inflammatory cases to the ESP service, with onward referral to rheumatology if required. There is limited data to show how these services perform, and where they can be improved. Objectives: The objective is to understand and learn lessons of the patient journey through ESP services, with a view to supporting service design, evaluation, and training needs analysis for ESP and primary care practitioners. Methods: This is a prospective service evaluation, reviewing patients referred by ESPs to our service seen by a single consultant, over a 42-month period (5/15 –10/18). Patient data was collected prospectively, including age, gender, key clinic-pathologic ESP findings, ESP suspected diagnosis, and the secondary care diagnosis. The ESP suspected diagnosis was recorded in 14 categories, derived from a previous published service evaluation. Our Electronic Patient Record (EPR) was used to check the source data and complete any missing data, and record any secondary care follow up. We excluded any ESP referrals that did not attend, or where missing data could not be found in the EPR. Results: ESP referrals made up 47/1390 (4%) of new patients seen. The average age was 54 (SD 16.9), 38 (81%) were female and 21 (45%) had a history of depression. The main referral concern was ‘small joint inflammatory arthritis’ (20/47, 42%), with 2/20 (10%) confirmed diagnoses requiring follow up (rheumatoid and undifferentiated inflammatory arthritis). The main secondary care diagnosis was osteoarthritis (10/47, 21%), followed by fibromyalgia (9/47, 19%). The majority of ESP referrals ultimately had non-inflammatory problems with only 7/47 (15%) referrals receiving a secondary care diagnosis that was an inflammatory condition. ESPs were most likely to suspect and correctly identify crystal arthritis, correctly suspecting 2/2 cases (100%). They were incorrect for all referrals where they suspected large joint inflammation arthritis (4), polymyalgia rheumatica (1), axial spondyloarthropathy (4) and connective tissue disease (1). We did find unusual non-inflammatory conditions e.g. a glomus tumour (1). This data was used to design a bespoke ESP training session to 20 ESPs, delivered in December 2018. This included raw data, pitfalls in ESP assessments, chronic pain assessment, and investigations, returning universally positive evaluations. Conclusion: This service evaluation provides empirical data to support our understanding of the primary care- ESP- rheumatology interface. We have identified areas for training and service improvements, and implemented new training. Our data support the current inflammatory referral pathways (only 1/47 ESP referrals for new rheumatoid arthritis). This data may help rheumatologists to triage ESP referrals, and data from future research in this area could be used to develop quality metrics for primary care, ESP, and rheumatology practitioners. Disclosure of Interests: None declared