|Year : 2015 | Volume
| Issue : 3 | Page : 166-171
Assessment of quality of rheumatology care in a rural area of West Bengal, India
Department of Medicine, Midnapore Medical College, Paschim Medinipur, West Bengal, India
|Date of Web Publication||21-Sep-2015|
Dr. Gouranga Santra
Block - P, Flat - 306, Binayak Enclave, 59 Kalicharan Ghosh Road, Kolkata - 700 050, West Bengal
Source of Support: None, Conflict of Interest: None
Introduction: Patients with rheumatic symptoms are frequently misdiagnosed and mismanaged in rural areas. The present study was conducted to assess the level of accuracy in management of musculoskeletal (MSK) symptoms in rural patients. Materials and Methods: The study was conducted over 1-year period involving the patients with rheumatologic symptoms such as MSK pain, swelling and stiffness of joints, and managed outside previously before attending to us for these symptoms. Patients were interviewed regarding their past investigations, diagnosis offered, and management schedules. Level of misdiagnosis and mistreatment was evaluated. Results: One hundred and twenty-five patients (50%) were treated by quacks. Large number of patients also went to homeopathic (12%) and ayurvedic (4%) practitioners. Medical graduates treated 24% cases. Few patients went to postgraduate physicians (4%) or rheumatologists (0.8%). Misdiagnosis and mistreatment were common mainly with quacks and alternative medicine practitioners. Overall only 28.8% cases were diagnosed correctly. Investigations were suggested inappropriately such as antistreptolysin O titer, rheumatoid factor, and uric acid when these were not required. Medicines such as benzathine penicillin, steroid, etc., were prescribed inappropriately. Physiotherapy and rehabilitation were neglected. Conclusion: Gap in quality of rheumatology care is prevalent at rural areas. Awareness program and basic rheumatology training to rural health professionals are of high priority.
Keywords: Antistreptolysin O titer, benzathine penicillin, low back pain, soft tissue rheumatism, steroid
|How to cite this article:|
Santra G. Assessment of quality of rheumatology care in a rural area of West Bengal, India. Indian J Pain 2015;29:166-71
| Introduction|| |
Standard of care is a formal diagnostic and treatment process a doctor will follow for a patient with specific illness to cater for country specific needs. Different organizations of developed countries published guidelines of the standard of care of rheumatologic diseases. ,,,, There is a lack of standard of rheumatology care in developing countries like India.  Information of the quality of rheumatology care at the rural community of India is lacking. Little information is available regarding the appropriateness of diagnosis and management of rheumatology disorders from rural India.
The aims of the study are:
- To describe the improper diagnosis rural patients received previously for their musculoskeletal (MSK) complaints and to compare that diagnosis with the subsequent diagnosis patients received at our clinic.
- To describe the appropriateness of medications and management rural patients had received.
| Materials and Methods|| |
After getting necessary approval from the Institutional Ethics Committee, health camps were organized at 2 weeks interval for 12 months on Sundays in a selected village of Paschim Medinipur District of West Bengal, India. People were informed about the camps and rheumatology patients were motivated to attend the same. Patients with rheumatologic symptoms like MSK pain, swelling, and stiffness of joints who were managed previously by other health care workers for these symptoms were included for the study. Both male and female patients were included. Fresh patients who began treatment from our camps were excluded from the study. Diagnosis of rheumatologic diseases and symptoms was reached by clinical and laboratory evaluation and by following different published criteria. ,,,,,, Soft-tissue rheumatism (STR) was diagnosed by the following characteristics:
- Pain elicited with active but not on passive movements;
- Tenderness away from the joint margin;
- Swelling usually away from the joint; and
- Dramatic relief with local steroid injections in inflammatory conditions. 
Osteoarthritis (OA), cervical and lumber spondylosis, tuberculosis of joints and osteoporosis were diagnosed radiologically. Leukemia cases were diagnosed by blood picture and bone marrow study. Aspiration of synovial fluid was done to diagnose septic arthritis and histoplasmosis. Rheumatic fever was diagnosed by 2002-2003 World Health Organization criteria for the diagnosis of rheumatic fever and rheumatic heart disease (based on the 1992 revised Jones criteria).  Patients were interviewed and past prescriptions and documents were evaluated regarding their past investigations, diagnosis offered previously, and management schedules. Level of misdiagnosis and mistreatment was evaluated.
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki declaration of 1975, as revised in 2008. Informed consent was obtained from all patients for being included in the study.
Simple statistical methods were used for data analysis including percentages, ratio, mean values and standard deviation. GraphPad QuickCalcs software (GraphPad Software Inc., La Jolla, California, USA) was used online for statistical analysis (http://www.graphpad.com/quickcalcs/).
| Results|| |
Two hundred and fifty patients were recruited for the study. Numbers of male and female patients were 140 and 110, respectively. Mean age was 46.92 ± 16.73 years. Majority of patients (92%) was from lower socioeconomic status (e. g., farmer, agricultural laborer) with family income <5000 rupees/month. Education levels of patients were poor and more than 50% patients (129 patients) were either illiterate or studied up to fourth standard. Patients usually had large families (>five family members) [Table 1].
One hundred and twenty-five patients (50%) in our study were treated by quacks [Table 2]. Homeopathic medicines were received by ten cases of STR, nine cases of low back pain (LBP), five cases of knee OA, two cases of rheumatoid arthritis (RA), one case of gout, and one case reactive arthritis. Ayurvedic medicines were received by five cases of STR (one fibromyalgia, two frozen shoulder, and two planter fasciitis), two cases of knee OA, two cases of lumber spondylosis, and one case of cervical spondylosis. One case of RA was treated by acupuncture. Two cases of RA were treated by a rheumatologist.
|Table 2: Distribution of health professionals treating the patients before attending our hospital|
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Among the rheumatologic symptoms, LBP was the most common, followed by STR [Table 3]. Causes of STR were de Quervain's tenosynovitis (five cases), carpal tunnel syndrome (12 cases), tennis elbow (seven cases), Golfer's elbow (two cases), frozen shoulder (13 cases), rotator cuff tendinitis (two cases), trochanteric bursitis (one case), and pes anserine bursitis (one case). Fibromyalgia, a generalized STR, was seen in 10 cases. None of the 10 fibromyalgia cases were diagnosed previously and were misdiagnosed as OA, RA or lumber spondylosis. Two of the fibromyalgia cases were associated with hypothyroidism and thyroid problem of them was also undiagnosed previously. Planter fasciitis was seen in 12 cases and none of them was diagnosed previously. One case had hypermobility syndrome predisposing to STR, but the case was undiagnosed.
|Table 3: Extent of misdiagnosis, inappropriate investigations and mistreatment of rheumatology patients|
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Low back pain was the most common rheumatologic symptom in our study and was present seventy-three cases (29.2%). Among them lumber spondylosis and mechanical low back pain (MLBP) were common. MLBP was frequently over-diagnosed as lumber spondylosis (15 cases). Lumber spondylosis cases were occasionally misdiagnosed as gout and rheumatic fever.
Cervical spondylosis was seen in 22 cases (8.8%) and among them five patients were young (age 25-34 years) who used to carry weight (agricultural products) on head. Twelve cases of cervical spondylosis were undiagnosed. One case of cervical spondylosis was diagnosed as gout and another case was diagnosed as rheumatic fever erroneously.
Systemic lupus erythematosus (SLE) cases were misdiagnosed as RA and rheumatic fever. Two cases of Sjögren's syndrome were undiagnosed and one of them was secondary to RA. RA patients were frequently misdiagnosed as rheumatic fever, OA or gout. Leprosy (right ankle) and tuberculosis (hip-1, spine-3) cases were misdiagnosed as OA or lumber spondylosis.
Mismanagement of rheumatologic disorders was common. Assessment of antistreptolysin O (ASO) titer, rheumatoid factor, and uric acid was done in diseases where the diagnosis of rheumatic fever, RA, and gout were remote possibilities. Erroneous use of steroids, penicillin injections, diacerein, and glucosamine, was seen in 48 (19.2%), 24 (9.6%), 14 (%), and 16 (6.4%) cases, respectively. Out of five septic arthritis patients three were undiagnosed, one was misdiagnosed as RA and another case was misdiagnosed as OA. None of them got antibiotics previously. One patient received steroid and another patient received glucosamine and chondroitin sulfate erroneously. RA patients were erroneously treated with penicillin in two cases, and allopurinol in one case. Four RA patients were diagnosed properly, but three of them received inadequate treatment with DMARDs.
Fifteen patients (6%) believed in religious cure and went to different temples. Physiotherapy and rehabilitation were neglected in 210 (84%) patients. Patients engaged in inappropriate exercises were also seen. Five patients with knee OA were engaged in prolonged walking believing cure of OA.
| Discussion|| |
Wide prevalence of rheumatologic disorders is seen in rural and urban areas throughout India. , Gap in quality of rheumatology care is prevalent worldwide; however, no study regarding it is available from rural India. Our study revealed that rheumatology care is at rudimentary level in rural India.
Most cases in our study were treated by untrained and unrecognized quacks and alternative medicine practitioners (AMPs) like homeopathic and ayurvedic doctors. Without any formal training quacks and AMPs had to diagnose and treat patients with MSK diseases leading to mismanagement. Quacks managed 50% of all MSK complaints, but they diagnosed correctly only in 12% of their cases. AMPs especially homeopathic doctors were well known to our rural patients. Patients went to homeopathic (12% cases) and ayurvedic doctors (4% cases) believing cure of their diseases without side effects of allopathic drugs. AMPs diagnosed correctly only in 27.5% cases. Though misdiagnosis was highly prevalent with AMPs in our study, in another Indian study quality of life of patients attending rheumatology clinic was significantly improved with use of complementary alternative medicine including ayurveda, massage, yoga asana, and homoeopathy.  Despite this improvement, lack of formal training in AMPs may lead to suboptimal patient care as seen in our study.
Accuracy of diagnosis and treatment was also poor with medical graduates. A lack of well-developed curricula for teaching rheumatology in India has resulted in inadequate teaching in medical graduates. Overall only 28.8% rheumatic disorder cases were diagnosed correctly before their presentation to our clinic. Postgraduate physicians and rheumatologists were found to provide proper management in MSK patients. However, rheumatologists may also be reluctant to thoroughly examine rheumatic patients.  Hence, sensitive and caring physicians are of great importance to improve the quality of rheumatology care.
In our study, STR and LBP patients were misdiagnosed frequently. MLBP patients were frequently over-diagnosed as lumber spondylosis. Despite the high prevalence, knee OA, lumber, and cervical spondylosis cases were frequently misdiagnosed. RA patients were also misdiagnosed. Gout patients were frequently misdiagnosed as OA. None of the cases of SLE, scleroderma, Sjogren's syndrome, polymyositis, reactive arthritis, psoriatic arthritis, and osteoporosis were diagnosed correctly. Septic arthritis and leukemia remained undetected. Despite the high awareness of rheumatic fever, inappropriate diagnosis was common.
In a study from developed country fibromyalgia was over-diagnosed, but in our study fibromyalgia cases were not detected previously.  Awareness of fibromyalgia is low in our country among primary care health professionals.
Leprosy and osteoarticular tuberculosis, either affecting the spine or peripheral joints, were misdiagnosed in our study, but they continue to be a major diagnostic challenge and without proper and early diagnosis can cause joint destruction or paraplegia. In our study, the single case of histoplasmosis of the knee in a HIV positive patient was previously misdiagnosed as OA. MSK disorders caused by fungi are uncommon and difficult to diagnose, particularly in the early stages. Hence, high level of suspicion is needed to diagnose fungal involvement of joints. Septic arthritis should also be diagnosed early to prevent joint destruction. Reactive arthritis is not uncommon but remains undiagnosed because of unawareness as in our study.
Inappropriate investigations including ASO titer, uric acid and rheumatoid factor were done frequently when the diagnosis of corresponding disorders was of remote possibility. Erroneous use of steroids, penicillin, diacerein, and glucosamine was frequent. Despite the decreased prevalence of rheumatic fever nowadays, a large number of MSK cases was investigated with ASO titer and treated with penicillin inappropriately.
Rheumatology research and daily practice are now directed toward using the tools of modern molecular biology in developed countries.  Biologic agents revolutionize the treatment of RA and other inflammatory rheumatic diseases. However, their use is restricted in resource poor countries.  No one of our patients received biologics and rural health workers had little awareness and experience of their use.
Our study is unique as no other study regarding the quality of rheumatology care in rural India is found in the literature. Studies on quality of care of specific rheumatologic disorders are available from different countries. Disease-specific studies have highlighted the finer aspects of disease management, and they are hardly comparable with our study as rheumatology care of our rural patients is at the very basic stage.
Our study has limitations. It was done from a specific location of rural India. Every household in the area was not approached and all rheumatology patients from the area did not report to us. The study population does not represent the rural areas of whole India, which has diversities in culture and socioeconomic status. A large multicenter study may highlight the standard of rheumatology care in rural India as a whole. Our study was done in health camps, but not in health center. It included all health professionals in a rural area including allopathic, homeopathic, and quacks. Quacks and homeopaths have different perspectives of diagnosing and treating the diseases. However, they were included in our study to highlight the total health scenario of the rural area. Comparing the MSK pain management of primary health center and their follow-up at higher center where modern allopathic medicine is practiced can highlight the loopholes of our public health care system.
Rheumatology management fits with the term "clinical inertia" (inadequate management of chronic diseases). Translation research is the current need to translate the acquired knowledge of rheumatology into readily useable interventions for routine practice in rural areas. National program is needed for developing strategies for detecting barriers and delivering the optimum quality of rheumatology care. 
| Conclusion|| |
Gross inadequacy in the quality of rheumatology care is prevalent in the rural area. Patients are frequently misdiagnosed and mismanaged. Poor awareness of rheumatologic diseases is common in rural health professionals. Quack practitioners and AMPs take a major part in rural health care. Basic rheumatological training should be provided to all rural health professionals.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]