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Improving Access to Specialty Care for Rheumatologic Conditions by Implementation of Algorithmic Testing
and Clinical Pathology Supervision and Consultation
Kerry J. Welsh, Brian N. Chang, Ashok Tholpady, Lei Chen, Robert L. Hunter, and Semyon A. Risin. Sponsor:
Amitava Dasgupta. Department of Pathology and Laboratory Medicine, University of Texas Health Science Center,
Houston.
Objectives: The Harris Health System is a safety net system providing healthcare to the underserved of Harris
County, Texas, the third largest county in the United States. It systematically experiences a shortage of spots for
patient visits, especially for specialist care. For example, there was a six-month waiting period for a rheumatology
consult. Cause analysis determined that a significant number of patients presented to the rheumatology clinic with
incomplete diagnostic work-ups, requiring up to three clinic visits before all diagnostics were obtained; as many as
50% of patients are found to not have a rheumatologic condition at all. The objective of the study was to address this
inefficiency. Methods: An algorithmic approach to testing for systemic lupus erythematosus (SLE) with clinical
pathologist data review, consult, and triaging was implemented. A pilot study of this algorithm was conducted on 80
cases referred to the rheumatology clinic over a three-month period. An additional algorithm for rheumatoid arthritis
(RA) with pathology consult integrating clinical, laboratory, and radiology data was later introduced. These SLE and
RA diagnostic algorithms were implemented system-wide for Harris Health System in July 2014. Results: Of the 80
patients in the SLE pilot study, 31 were approved for referral to rheumatology and 49 were denied. This was in full
agreement with concurrent rheumatologist review. The pilot study resulted in reduction of the wait time for
rheumatology consult from 6 months to 3 months. Data are available from 102 SLE and 324 RA algorithm consults
after system-wide implementation from July through November 2014. A total of 40 patients (39.2%) of the 102 tested
for SLE had positive antinuclear antibodies; however, after the complete algorithmic work-up only 10 cases (9.8%)
were determined to possibly have SLE and were referred to rheumatology. Thirty-two (9.9%) of the 324 patients
tested for RA were suggestive of RA and referred to the rheumatology clinic. Four of the referrals placed by
pathology for SLE and 14 for RA have been evaluated by a rheumatologist, with agreement of the diagnosis in all 4
SLE cases (100%) and 10/14 (71.4%) cases referred for RA. Conclusions: Clinical pathology intervention,
supervision of testing, and triaging can improve diagnostic efficiency and access to care in a busy county healthcare
system.
© American Society for Clinical Pathology
Am J Clin Pathol 2015;143:A003