Point: Should ultrasound be routinely used in the rheumatologist's office?
By: M. LARCHÉ, M.D., J. ROTH, M.D., C. PENNEY, M.D., & D. COLLINS, M.D.,
Rheumatology News Digital Network May 01, 2012
Opinion leaders and fellow physicians weigh in regarding key issues that affect rheumatology and your practice.
POINT: All rheumatologists should offer it to their patients.
Like other point-of-care tests used all the time in medicine – spirometry, blood pressure measurement, the finger-stick glucose test – point-of-care ultrasound is invaluable in the diagnosis and management of rheumatologic conditions.
Ultrasound has a number of merits: It is portable and inexpensive; can be used on multiple joints; allows imaging of both bones and soft tissue, and assessment of vascularity; permits contralateral-side comparison; facilitates accurate injections; and serves as an informational and educational tool for patients. Contemporary machines have resolution down to 0.1 mm, much greater than the 1-2 mm for magnetic resonance imaging.
A recent poll of Canadian rheumatologists about musculoskeletal ultrasound yielded some eye-opening findings. For example, 83% reported having to wait more than 2 weeks to obtain this exam if they referred patients to a radiology service, and just 56% reported that their radiology service offered assessment for inflammatory arthritis (Clin. Rheumatol. 2011;30:1277-83).
We know that information provided by ultrasound changes behavior in rheumatology: It leads to a change in diagnosis in 53% of patients and a change in management in 56% (Arthritis Rheum. 2001;44:2932-3). Ultrasound also improves diagnostic confidence in clinical findings (Skeletal Radiol. 2009;38:1049-54). Diagnostic certainty is key, as musculoskeletal symptoms are some of the most imprecise, and although we now have powerful medications for rheumatologic diseases, they don’t come cheap. Yet we are basing treatment decisions on clinical assessment alone. In an era of budget constraints, we owe it to patients and payers to make an accurate diagnosis and assessment: This is really all about providing an adequate standard of diagnosis and care.
In addition to aiding diagnosis, ultrasound helps in other ways, such as determining the risk of erosions (Arthritis Res. Ther. 2003;5:210-3) and predicting response to treatment (Arthritis Care Res. 2011;63:1477-81). It is more sensitive than clinical measures for assessing disease remission (Arthritis Rheum. 2008;58:2958-67). As patients have to live decades with their joints, and their quality of life is on the line, it is our responsibility to confirm clinically apparent remission with ultrasound.
An ultrasound exam can be done in the office in as few as 5 minutes; often, evaluation of just a single joint will suffice. The time spent more than makes up for the time that would be needed to coordinate a referral to radiology and to follow up on that referral. And there are plenty of examples on how to successfully integrate ultrasound into your office workflow.
In summary, ultrasound should be used as an extension of our clinical examination. It allows for immediate imaging correlation, and it assists with decision making in an environment where radiology services have limitations. It is also phenomenally powerful when it comes to patient contact and education. True point-of-care ultrasound is fast, high quality, and cost efficient. If you show this information to patients, their families, taxpayers, and politicians, they will agree: There is no question that point-of-care ultrasound is the way to go.