Referral and diagnosis of common rheumatic diseases by primary care physicians

Objective. To describe primary care patterns of referral and diagnoses of p atients with rheumatic diseases referred to rheumatologists. Methods. The medical records of all consecutive patients referred in 1994 b y >300 primary care physicians to two rheumatologists at an academic centre were reviewed. The referring physician diagnosis was compared with the rhe umatologist's diagnosis. Sensitivity, specificity and predictive values of primary care diagnoses were estimated using the rheumatologist diagnosis as the 'gold standard'. Setting. University-based rheumatology out-patient clinic. Results. Over half of the patients referred had a rheumatologist diagnosis of soft-tissue rheumatism or a spinal pain syndrome. Three hundred and fort y-seven patients (49%) had a primary care diagnosis of a defined rheumatic disease. Of these, 142 (41%) of the primary care diagnoses were subsequentl y modified by the rheumatologist. The highest agreement between primary car e physician and rheumatologist was observed for crystal-induced arthritis ( kappa = 0.86), and the lowest agreement for polymyalgia rheumatica (kappa = 0.39) and systemic lupus (kappa = 0.46). Sensitivity was lowest for a prim ary care diagnosis of fibromyalgia (48%) and highest for ankylosing spondyl itis (94%). Positive predictive values were generally low, in particular fo r systemic lupus erythematosus (33%) and polymyalgia rheumatica (30%). Conclusion. Most patients referred to an academic rheumatology centre had s oft-tissue rheumatism or other pain syndromes. In general, diagnostic agree ment between rheumatologists and primary care physicians was low. Increased emphasis on musculoskeletal disorders should be encouraged in medical educ ation to increase the efficiency of rheumatology referrals.