Impact of Dedicated Ultrasound Clinic on Clinical Rheumatology Practice

Mithu Maheswaranathan, MD

Credit: Duke Health

The use of musculoskeletal or rheumatologic ultrasound (RhUS) in clinical practice has expanded tremendously in the past decade. This imaging modality provides many advantages including low cost, lack of exposure to radiation, and assisting in diagnosing and classifying disease to help inform treatment decisions. Fairchild et al from Stanford University Division of Rheumatology published this recent study with the objective to assess the growth, utilization, and impact of RhUS on physicians and patients.¹ They found that with implementation of RhUS there was a reduction in use of other imaging modalities and often changes in diagnosis and medication management as a result of ultrasound results.

The Stanford RhUS program began in 2017. The authors quantified imaging orders from 2017 to 2022 by rheumatologists at their academic medical center as well as comparator rheumatology community practices. Claims for RhUS were quantified using Current Procedural Terminology (CPT) codes for diagnostic exams and procedures (joint injection/aspiration using ultrasound).Additionally, they reviewed RhUS clinic records over a 9-month period to assess post-RhUS visit medication changes and RhUS-determined diagnoses.Finally, they also obtained surveys of both patients and rheumatologists referring to ultrasound to determine their thoughts on the experience.

Between 2017 and 2022, there were 13 to 16 active clinical rheumatologist at their academic medical center, including 1 to 3 rheumatologists trained in performing RhUS. Comparing 2018 to 2021, they found RhUS diagnostic procedures increased. After adjusting for overall clinic growth, they found XR utilization fell at their center versus community practices, average MRI use was decreased at both and ultrasound use grew by an average of 61%.

The retrospective record review (2021 to 2022) found median time from referral to RhUS clinic visit was 41 days, with 12% seen in less than 10 days. The most common diagnostic indications for referral were “evaluate for inflammatory arthritis” (34%) and joint pain (26%). Around 55% of these ultrasound visits resulted in new diagnostic information, including clarifying differential diagnosis (48%) or resulting in alternative diagnosis compared to referring provider (20%). Of referrals noting “active disease” by their assessment, the RhUS demonstrated no activity in 32% of cases. Of patients with follow-up, medication changes were observed in 22% of the patients with most changes being escalation of therapy.

Robert Fairchild, MD, PhD, assistant professor of medicine at Stanford University School of Medicine and the director of Stanford's Rheumatology Ultrasound Diagnostic and Interventional Clinic, said the frequent discordance in disease activity assessment between referring provider and RhUS results was the most surprising finding of this study.

“There were many instances were referring providers believed disease to be inactive when RhUS found inflammatory disease activity and vice versa,” he said. “While I have encountered this in the care of my own patients, I was surprised by the frequency in which this occurred in our study.”

Survey results of patients also provided some interesting responses.They found overall high patient satisfaction scores with over 80% feeling “extremely satisfied” or “extremely likely to recommend.” Patients reported statistically significant increase in disease understanding after US visit, compared with pre-visit responses. Looking at physicians, they found referrals to an ultrasound clinic to be “very” or “extremely” useful.

This study offers unique examination of the impact of RhUS clinic at an academic medical center. It helps provide evidence that use of RhUS often results in a change in the diagnosis, and for those with known inflammatory arthritis, can often show discordance compared to disease activity assessed by the referring provider. The authors noted a potential limitation of selection bias, given patients referred due to degree of uncertainty regarding diagnosis or time therapeutic changes were being considered. Fairchild also reported challenges of ensuring enough RhUS trained and skilled providers are available to fulfill increasing demand.

Fairchild noted rheumatology ultrasound clinics are poised to play an increasingly central and dynamic role in rheumatology practices.

“I believe their growth is likely to continue as they emerge as a cornerstone in imaging for rheumatic diseases for disease diagnosis, monitoring disease activity and therapeutic response, and point of care interventions,” he said.

These findings demonstrate the impact and practice-changing nature of incorporating RhUS into our clinical practices, likely improving accuracy of diagnostic and therapeutic decisions in management of our patients.

References:

1. ^{Fairchild RM, Deluna MD, Golovko V et al. Evolution and impact of a dedicated ultrasound clinic on clinical rheumatology practice at an academic medical center. Seminars in Arthritis and Rheumatism, October 2023.}