evidence of arthritis …. when there is clinical · 2020-07-09 · when there is clinical evidence...
TRANSCRIPT
June 2019 - In brief June 2019 - In Brief
For links to resources, clinical updates and more, visit news.wapha.org.au
Although it has become common to designate alljoint symptoms as ‘arthritis’, this incorrectterminology can create significant confusion inclinical practice and in communication betweenmedical professionals.
Pain in the joint areas is a well known, frequentlypresenting complaint in general practice and canoriginate from changes to peri articular soft tissuestructures (classified as arthralgia) and/or intra-articular changes such as inflammation of thesynovial joint lining (synovitis, classified as arthritis).
History taking and joint examination are the onlytools needed to make the simple but importantdistinction between arthritis and arthralgia in theevaluation of a patient with joint pain. The clinicaldistinction between arthralgia and arthritis hassignificant practical implications because thepathway for patients with arthralgia differs from thepathway for patients with arthritis.
Arthritis literally means inflammation of a jointand arthritis thus should only be diagnosed,when joint/s are shown to be inflamed. Arthritisis in most cases detectable by clinicalexamination of joints but may sometimes requirehigh resolution imaging (ultrasound or MRI).Finding arthritis/synovitis is a critical step inpatient evaluation, similar to finding lowhaemoglobin levels in a patient with fatigue, andindicates a need to establish the underlyingcause of arthritis.
To establish a cause of the arthritis (e.g. immunemediated such as rheumatoid arthritis or psoriaticarthritis or crystal induced such as gout or pseudogout,infectious), only limited and targeted investigationsneed to be performed to decide on the best course ofmanagement. This process is again, similar to findingthe cause of anaemia in a fatigued person.
Not finding signs of arthritis is an equally importantstep in the evaluation of patients with joint pain as itsuggests pain is arising from peri articular structuresincluding bone, muscles, tendon insertion points(enthesis) and ligaments. These abnormalities canoften be detected on examination (eg Heberden’snodes with osteoarthrosis) or triggered (Achilles tendonor insertional elbow or knee pain). Periarticular causesof pain can be classified as soft tissue pain, can befurther visualised with imaging (ultrasound/MRI), andmanagement is through allied health referral if needed.
It does not require further serological investigation.
9 July 2020
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Arthritis is only arthritiswhen there is clinicalevidence of arthritis ….By Dr Johannes C Nossent, Professor ofRheumatology, University of WesternAustralia, Consultant Rheumatologist SirCharles Gairdiner Hospital
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https://www.ehealth.gov.au/internet/main/publishing.nsf/C
ontent/mbs-review-2018-taskforce-reports-
cp/$File/Pathology-Clinical-Committee-Immunology-
tests.pdf
The Choosing Wisely campaign is a timely reminderof the limited diagnostic utility of most testsperformed in the name of a ‘rheumatology screen’. Itis important to realise that all rheumatic diseases arediagnosed on clinical grounds. The so-called “RheumScreen” at its worst may include tests for ANA,ANCA, RF, ACPA, uric acid and HLA-B27, none ofwhich are sufficiently specific to be diagnosticallyhelpful. Specificity varies between five and 25percent due to the large number of false positives.This is not compatible with judicious use of publicMedicare funding.
In 2014-15, over $10 million dollars was spent onANA testing alone . This already difficult situation isfurther impacted by the lack of standardisationbetween the current pathology providers in WA,where different assays and cut-off values are usedfor these tests.
Therefore, in the absence of a clinical finding ofarthritis/synovitis, no further serological testing isrequired. For patients with arthritis, simpledescriptors are often sufficient to initiate appropriatefirst line management and specialist referral. Forexample, in the patient with acute monoarthritis, oneconsiders gout and /or infection and performs jointaspiration, whereas in the patient with chronic smalljoint polyarthritis one considerers rheumatoidarthritis, and can request anti-CCP antibody testing(more specific and thus preferred over rheumatoidfactor).
In summary, normal joints upon examination excludearthritis and do not require autoimmune bloodtesting. In patients with synovitis, only limited andtargeted blood testing is needed. See also therecently published Arthritis HealthPathway for moreinformation.
References:
1.
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Launch of the VPE initiative delayed
In the 2019-20 Budget, the Australian Governmentannounced a voluntary patient enrolment (VPE)initiative for patients aged 70 years and over. TheGovernment subsequently announced the extension ofthis measure to include Aboriginal and Torres StraitIslander people aged 50 years and over. In light of the COVID-19 pandemic and responseactivities, the Government is currently working withhealth and system experts to review implementationdetails and consider options for refinement. As such,VPE will no longer commence on 1 July 2020. Email [email protected] for furtherinformation or phone 02 6289 7115
New WA Health VAD resources
New Guidelines for TuberculosisControl in WA
The WATB Control Program has published newguidelines for Tuberculosis (TB) in WA.
It includes a complete review of all TB policies in 2019and is available on the WA TB Control Programwebpage under 'Relevant Polices'.
For further information or to provide feedback on theguideline, contact the TB Clinic and ask to speak to aphysician or TB case management nurse by phoning9222 8500 or email [email protected]
The clinic is open Monday to Friday, 8:15am – 4:15pm
A r t h r i t i s i s o n l y a r t h r i t i sw h e n t h e r e i s c l i n i c a le v i d e n c e o f a r t h r i t i s ( c o n t )
Clinical updates
The Department of Health WA’s voluntary assisteddying website has been updated to include newinformation for health services. The aim is to provide aclear overview of the Voluntary Assisted Dying Act2019 and the implementation being undertaken. This includes a Fact sheet for Health and Other ServiceProviders and other resources.
Contact the project team at the Department of HealthWA for further information [email protected]
08 6272 4900 | [email protected] | www.wapha.org.au
Due to significant demand, the waiting list for RoyalPerth Pain Clinic appointments is extremely long.Please advise your patients of this prior to referraland offer them other options if possible, especiallyreferral into community-based pain programs. ThePain Management HealthPathways are a valuableresource, especially the information onInterdisciplinary Persistent Pain Programs.
After an initial one day ‘pain education program’appointment, patients can select appointments withmembers of the RPH multidisciplinary painmanagement team. Following assessment a letterincluding a pain management plan is sent to thepatient’s GP to action.
Please advise every patient you refer to RPH for painmanagement that cannabis products are notprescribed by the RPH Multidisciplinary PainManagement Centre as there is not enough evidenceto support cannabis prescribing for persistent pain(http://fpm.anzca.edu.au/documents/pm10-2018.pdfand NICE guidelines ).
Often patients are attending expecting a cannabisprescription which is not clear from the referral. It isvery frustrating for patients to wait long periods for aPain Clinic appointment only to attend and find thiswill not be recommended or prescribed by ourservice.
Similarly, evidence shows that for most patients withchronic non-cancer pain, opioids do not provideclinically important improvement in pain or functioncompared with placebo and in order to reduceopioid-related harm, the service does not generallyrecommend opioids for chronic non-cancer pain. TheANZCA Faculty of Pain Medicine (FPM) recentlyreviewed their Statement regarding the use of opioidanalgesics in patients with chronic non-cancer pain. Consumer and health professional resources onopioids are available on the TGA prescription opioidsand NPS MedicineWise or Chronic Non-Cancer PainHealthPathway.
Dr Jacquie Garton-SmithHospital Liaison GP, Royal Perth Hospital Email: [email protected] and Thursdays
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GP Hospital Liason Updates
R P H P a i n C l i n i c – D i d y o uk n o w ?
Clinical Updates
NPS MedicineWise has recently launched a new,online information portal to assist health professionalsand consumers navigate evidence-based informationabout medicinal cannabis. The new information covers the regulatory frameworkand process required to access medicinal cannabisand provides summaries on the latest evidence formedicinal cannabis. The content found in the portal supplements clinicalguidance provided by the Therapeutic GoodsAdministration (TGA) for health professionals andprovides additional information for consumer andpharmacist audiences. The portal includes importantresources for prescribers including full evidencesummaries with links to the TGA’s clinical guidanceand a flowchart for prescribers that outlines the stepsto accessing medicinal cannabis. Visit the NPS website find out more.
N P S M e d i c i n e W i s e p o r t a l o nm e d i c i n a l c a n n a b i s
To support the secure delivery of video-basedconsultations, the Australian Government Departmentof Health has worked with PHNs to provide freelicences to healthdirect Video Call for every GP inAustralia until 30 September 2020.
The Department has funded licences for GPs to alignwith current timelines of the Targeted Action Stage ofthe Australian Health Sector Emergency ResponsePlan for COVID-19. The program supports usage ofthe GP MBS Telehealth items for COVID-19. Practicescan sign up for a free licence here.
At the conclusion of the program, eligible practices willbe able to transition to the healthdirect Video CallService Pilot Program available until 30 June 2021.The Department is currently reviewing the Program toensure it is focused on supporting key areas ofprimary care and healthdirect will provide an updatewhen further information is available. Thereis also a 'COVID-19 Telehealth' HealthPathway forWA.
h e a l t h d i r e c t V i d e o C a l l f o rG P s e r v i c e s
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N P S M e d i c i n e W i s e r e s u m i n g C P D p r a c t i c e v i s i t s i n W A
NPS MedicineWise are resuming face to face visitsand delivering the latest free, RACGP accredited CPDtopic, Paediatric asthma: breathing new life intodiagnosis and management.
This topic provides clarity on the latest guidelines forthe diagnosis and treatment of paediatric asthma,including the differences between diagnosing andmanagement in preschool and school-age children,and how treatment of children’s asthma differs fromthat of adults.
For further information, or to book a visit, visit theNPS MedicineWise website
C h a n g e s t o G e n e t i c sS e r v i c e s o f W A i n w a r dr e f e r r a l p r o c e s s
From 1 July 2020, all Genetic Services of WAoutpatient appointment referrals are to be submittedto the Central Referral Service (CRS).
Referrals that are faxed or emailed directly to GeneticServices of WA after 1 July 2020 will not be actioned. To refer to Genetic Services of WA using the CRS,referrers will need to complete one of thestandardised referral forms and send it to the CRSvia: Fax: 1300 365 056Healthlink Secure Messaging: crefservPostal address: PO Box 3462 Midland WA 6056 Genetics Services of WA’s referral criteria remainunchanged. For a full list of referral criteria, pleasevisit their website or phone(08) 6458 2723 between8.30am – 5.00pm, Monday to Friday.
The Child and Adolescent Mental Health Service(CAMHS) Emergency Telehealth Service (ETS)launches on July 13 and provides support for youngpeople, families and carers experiencing a mentalhealth crisis.
For more information see the CAMHS ETS flyer
C A M H S E m e r g e n c yT e l e h e a l t h S e r v i c e
T i p s a n d t r i c k s t o m i n i m i s ea n d i d e n t i f y e r r o r s i nv a c c i n a t i o n r e c o r d i n g
Enhancing data quality of vaccination encountersrecorded in practice software and on AIP - tips andtricks has been developed by the National Centre forImmunisation Research and Surveillance to helpimmunisation providers minimise and identify errorsin vaccination recording. This ensures the informationheld on patient’s records and on the AustralianImmunisation Register is accurate.
V i r t u a l l e a r n i n g o n S T I s i nW A P r i m a r y C a r e
This new online education module from SexualHealth Quarters is intended to provide primary healthcare professionals with comprehensive educationabout discussing STIs with patients, testing andmanagement. It includes public healthresponsibilities and legal issues, and recommendsuseful online resources for ongoing use.
More information is available on the SHQ website
#LGBTIHealthPledge Campaign
COVID-19 does not discriminate; nor
should our health response. This is why
WA Primary Health Alliance has taken
the #LGBTIHealthPledge. The campaign
is for non-LGBTI health and wellbeing
organisations, professional bodies or
workforces, and all services and
programs that may be accessed by
LGBTI people. It is rooted in inclusive
principles to ensure LGBTI people can
receive culturally appropriate and
inclusive care during this challenging
time.
Take the pledge today and help ease theimpact of COVID-19 on LGBTIcommunities.
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W A C H S p r e v e n t a t i v e c h i l dh e a l t h p r o g r a m
The WA Country Health Service (WACHS) islaunching a new primary preventative child healthprogram for vulnerable children aged from birth tofive years and their families.
Where appropriate, contact should be made withfamilies in the antenatal period to establish rapport.
The Enhanced Child Health Schedule (ECHS) aims tosupport families to raise healthy children with optimaldevelopment and wellbeing who are ready tocommence school.
The ECHS focusses attention on common healthissues associated with poor social determinants,including ear, eye, oral, respiratory and skin health,and nutrition, especially iron deficiency anaemia.
WACHS Community Health staff offer up to anadditional ten child health checks in addition to thesix universal (purple book) checks already offeredbetween birth and school entry. The purpose of theextra checks is to provide support and monitoring,early identification of health and development issues,and appropriate, timely referrals.
Staff will encourage parents and carers of Aboriginaland Torres Strait Islander children to attend their GPor Aboriginal Health Centre to have their annualMedicare item 715 completed as appropriate.
Vulnerable families who require this additionalsupport can be referred to the local CommunityHealth team.
For further information, contact Leonie Hellwig,Program Officer Community [email protected] or 6553 0910
J u l y N a t i o n a l I m m u n i s a t i o nP r o g r a m c h a n g e s
From 1 July 2020 some important changes to theNational Immunisation Program (NIP) andrecommendations for pneumococcal, meningococcaland hepatitis A vaccination will take effect.
The National Centre for Immunisation Research andSurveillance (NCIRS) hosted a webinar providing anoverview of the NIP Schedule changes that come intoeffect from 1 July 2020 and the key points thathealthcare professionals need to know.
For further information see Clinical update: NationalImmunisation Program (NIP) schedule changes from1 July 2020 – advice for vaccination providers , or the“Immunisation – Childhood”HealthPathway.
The Safer Baby Bundle is a collection of interventionsdesigned to reduce late pregnancy stillbirth.Resources include eLearning modules for clinicians,and information for pregnant women and theirfamilies, aimed at bridging the gap between bestpractice clinical evidence and maternity serviceprovision across Australia.
Resources have been developed by the NHMRCCentre of Research Excellence in Stillbirth (StillbirthCRE) in collaboration with maternity professionals,state health bodies and bereaved parents.
Visit the website for more information and resourcesor register to attend the official launch by TheMinister for Health, The Hon Greg Hunt on 3November 2020.
T h e S a f e r B a b y B u n d l e
N e w o n l i n e P A N D Ar e s o u r c e s
A group of leading perinatal depression experts,including the team at Perinatal Anxiety andDepression Australia (PANDA), have come togetherto help GPs provide better care for patients withperinatal depression.
The MumMoodBooster and Mum2BMoodBoosterprograms are especially valuable during thepandemic as they provide online support for new andexpecting mums (and dads).
Q u i c k g u i d e t o M B S n o wa v a i l a b l e
Australian Doctor has released the July 2020 MBSQuick Guide. There is also a separate PDF availablelisting the COVID-19 Telehealth items
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N e w R a d a r a r t i c l e o n n e wa n d a m e n d e d P B S o p i o i dl i s t i n g s
A new RADAR article is available regarding recentchanges the listings of many opioids and multipleformulations listed on the PBS General Schedule
Changes include new listings for half pack sizes,increased restrictions, and new and amended clinicalcriteria, prescriber instructions and administrativeadvice. The RADAR article explains these changeswhich have been made to support the appropriateprescribing and use of opioids and reduce harms.
Read Opioids: new and amended PBS listings on theNPS MedicineWise website.
W A S u r v e y o f W e i g h tM a n a g e m e n t C a r e 2 0 2 0
This survey is being coordinated by the EastMetropolitan Health Service (EMHS) in response tothe Sustainable Health Review recommendation tohalt the rise in obesity in WA by July 2024. TheSurvey is sponsored by WA Health Networks as partof the implementation of the WA Healthy WeightAction Plan 2019-2024, and conducted incollaboration with the University of Newcastle andCurtin University.
Responses will help the EMHS understand how WAhealth professionals currently deliver weightmanagement care, and identify the barriers peopleface and opportunities for improvement.
Complete the 20-30 minute survey by 21 July 2020.
C a n c e r r e s e a r c h p r o j e c ts e e k s G P i n p u t
As GPs are key to the delivery of optimal follow-upcare for cancer patients, the Cancer CouncilQueensland in collaboration with the University ofSouthern Queensland invites GPs to participate in animportant research project examining follow-up carepractices for rural cancer survivors.
Complete the anonymous 20 minute survey
Education Events
S a v e t h e D a t e - A g e i n g a n dB e y o n d
This WA Primary Health Alliance; HealthPathwaysWA GP education event is being delivered inpartnership with Joondalup Health Campus, RACGPand North Metropolitan Health Service.
This interactive, online, GP workshop will takeparticipants on a clinical education journey across thespecialties of geriatrics, palliative care and vascularconditions.
It is a requirement that all participants attend amandatory preparation meeting occurring fromMonday 3 August to Wednesday 5 August 2020.
Registrations will open shortly. Registrations areessential as participant numbers will be capped.
Date: Saturday 15 August 2020 Time: 9:00 AM - 3:30PM
Accreditation: This activity is pending approval of 40 CPD AccreditedActivity (formerly Category 1 QI&CPD) points throughRACGP.
More information : Contact the HealthPathways WA team [email protected] or (08) 6272 494