Supporting primary care to interpret antibody tests and refer patients

Supporting primary care clinicians to refer patients with suspected early inflammatory arthritis or connective tissue disease (CTD) is vital. It ensures prompt diagnosis and treatment.

Situation

Antibody testing can cause confusion for primary care clinicians. This sometimes leads to inappropriate or delayed referral for patients who require specialist input.

The rheumatology team at Lancashire and South Cumbria NHS Foundation Trust (LSCFT), analysed data from the National Early Inflammatory Arthritis Audit.

They identified issues around referrals following antibody tests. Audit data revealed it was taking longer to refer some patients.

Those with negative antibody test results were not referred promptly despite showing symptoms of rheumatoid arthritis (RA).

Aspiration

The Trust wanted to support primary care colleagues when they request antibody tests and interpret results. This would help them decide who to refer to the rheumatology service.

Solution and impact

The rheumatology team at LSCFT worked with the immunology department and primary care colleagues to:

• agree which digital prompt messages to use
• modify the wording of immunology reports

This would ensure primary care clinicians request and interpret antibody tests correctly.

The team incorporated digital prompts into the primary care electronic request system within ICE.

This resulted in clinicians making better use of antibody testing to detect inflammatory arthritis and CTD.

The consistency of the wording for the digital prompts and immunology reports helped to reduce confusion. As a result, patients with negative antibody results are now referred to specialists.

Functionality

When a primary care clinician requests an antibody test, 2 prompts can appear.

The rheumatoid factor request prompt says:

“Patients with suspected inflammatory arthritis, for example, RA should be referred to rheumatology without delay. A negative rheumatoid factor does not exclude RA nor does a positive test equate to a diagnosis of RA.”

The CTD screen request prompt says:

“This test should NOT be requested in the investigation of widespread pain or fatigue alone. Only request a CTD screen if patients present with signs and symptoms of a CTD, for example, lupus. Patients suspected of these conditions should be referred to rheumatology even in the absence of a positive CTD result.”

The clinician can then continue to request the antibody test if appropriate.

These prompts also appear when the primary care clinician gets the test results report.

Capabilities

Using digital prompts supports:

• more appropriate use of antibody testing in primary care
• the education of primary care clinicians to recognise rheumatological conditions

Scope

• Using ICE supports more appropriate investigations by primary care.
• The digital prompts can be aligned to local pathways.
• There is opportunity to implement prompts to a range of tests, like pathology and radiology, to help detect rheumatological conditions.
• Prompts can be used to signpost queries to advice and guidance.

Key learning points

• Work with all key stakeholders to agree what prompt messages are needed.
• Prompts were a simple change to make that have had a significant impact on the quality of referrals.
• Ensure there's consistency with clinical pathways to support primary care clinicians.
• The digital prompts regularly remind clinicians about using antibody tests. This supports the ongoing education of staff.
• Electronic pathology systems, like ICE, can issue prompts to clinicians to use immunology testing to ensure patients are referred in a timely manner. This is in line with the ChoosingWisely UK recommendations (PDF, 505KB. This document may not be accessible to assistive technology.).

Key figures and quotes

• In 2019, before prompts were used, the department received 3,644 antibody tests requests which worked out at 304 a month.
• After the introduction of prompts in 2020, the department received 2,679 antibody tests requests which worked out at 223 a month. This figure also includes the general reduction in requests due to the COVID-19 pandemic.
• In 2021, the department received 3,175 antibody tests requests which worked out at 265 a month.

“We understand that the wide number of antibodies associated with connective tissue diseases can make the investigation of these conditions a diagnostic challenge. We have been dedicated to making the laboratory testing pathway as efficient as possible and to providing guidance to our service users in primary care on how and when to use it.

Following the implementation of electronic prompts in September 2020, we have seen an improvement in appropriate test requests from GPs. Based on data collected in 2019 (pre-pandemic and pre-implementation) compared to 2021 data, we have seen a reduction of 469 tests per year or 39 tests per month.”

Professor Anthony Rowbottom, Clinical Director and Dr Emma Callery, Principal Clinical Scientist, Lancashire and Lakeland Immunology Service

“We have seen a definite improvement in the quality of referrals and a better understanding as to when to request antibodies. Primary care colleagues are also making better use of advice and guidance if they receive a positive antibody result and are unsure whether to refer.”

Elizabeth Macphie, Consultant Rheumatologist and Integrated Musculoskeletal Service Clinical Lead, LSCFT

“This is a fantastic example of collaboration across a system which involved primary care, community and acute trusts and commissioners. This co-produced piece of work has improved the patient pathway for suspected inflammatory arthritis, supported clinicians in primary care in decision making and optimised the use of clinical and laboratory time and resources.”

Lesley Atherton, GP Clinical Lead Elective Care, Central Lancashire Integrated Care Partnership and Lancashire Teaching Hospitals

Key contact

Dr Elizabeth Macphie, Integrated Musculoskeletal Service Clinical Lead, Consultant Rheumatologist and Honorary Senior Lecturer, LSCFT

elizabeth.macphie@lscft.nhs.uk

Dave Johnson, Informatics and Technical services software development manager, Pathology, Lancashire Teaching Hospitals NHS Foundation Trust

dave.johnson@lthtr.nhs.uk