Quality statement 1: Referral

Quality statement

Adults with suspected persistent synovitis affecting more than 1 joint, or the small joints of the hands and feet, are referred to rheumatology services within 3 working days of presenting in primary care. [2013, updated 2020]

Rationale

Rapid referral of adults with suspected persistent synovitis is important to avoid delay in diagnosis and treatment. Rapid referral is particularly important for adults with inflammation of more than 1 joint, or the small joints of the hands and feet because they are likely to have a poor prognosis. Early diagnosis and treatment of rheumatoid arthritis improves long-term outcomes, physical function and quality of life.

Quality measures

Structure

a) Evidence that healthcare professionals in primary care can recognise persistent synovitis.

Data source: Local data collection, for example, training records and evidence of continuous professional development covering inflammatory arthritis.

b) Evidence that systems are in place for adults with suspected persistent synovitis to be referred to rheumatology services within 3 working days of presentation.

Data source: Local data collection, for example, agreed referral pathways.

Process

Proportion of adults presenting in primary care with suspected persistent synovitis affecting more than 1 joint, or the small joints of the hands and feet, who are referred to rheumatology services within 3 working days.

Numerator – the number in the denominator who are referred to rheumatology services within 3 working days of presenting in primary care.

Denominator – the number of adults presenting in primary care with suspected persistent synovitis affecting more than 1 joint, or the small joints of the hands and feet.

Data source: The National Early Inflammatory Arthritis Audit collects data on referral within 3 working days of presentation.

Outcome

Time from presentation in primary care to diagnosis for adults with rheumatoid arthritis.

Data source: Local data collection, for example, audit of patient records.

What the quality statement means for different audiences

Service providers (such as GP practices) ensure that healthcare professionals can recognise the signs and symptoms of inflammatory arthritis. They agree pathways for urgent referral to rheumatology services (within 3 working days of presentation in primary care) of adults with suspected persistent synovitis of more than 1 joint, or the small joints of the hands and feet.

Healthcare professionals (such as GPs, nurses or allied health professionals) recognise the signs and symptoms of inflammatory arthritis and are aware of local referral pathways. They refer adults with suspected persistent synovitis of more than 1 joint, or the small joints of the hands and feet, to rheumatology services within 3 working days of presentation in primary care.

Commissioners (such as clinical commissioning groups) ensure that service specifications include referral criteria and referral pathways for adults presenting with suspected persistent synovitis of more than 1 joint, or the small joints of the hands or feet, to be referred to rheumatology services within 3 working days of presentation in primary care.

Adults with pain, swelling and stiffness of more than 1 joint, or the small joints of the hands or feet, are referred within 3 working days of their GP appointment to a specialist in rheumatology. Early referral means that they can be diagnosed and start treatment sooner if they have rheumatoid arthritis.

Source guidance

Definition of terms used in this quality statement

Persistent synovitis

Signs and symptoms of persistent synovitis include persistent (not resolving within 3 to 4 weeks) pain, swelling, heat, early morning stiffness lasting more than 30 minutes and often recurring after longer periods of rest, and loss of function of the affected joint. Occasionally the joints may also be red, but this is unusual. The person may also have systemic symptoms of inflammation, which may include malaise, fever, sweats, fatigue and weight loss.

[Adapted from NICE's full guideline on rheumatoid arthritis in adults, section 4.1 and from expert opinion]