Mini Review - International Journal of Clinical Rheumatology (2023) Volume 18, Issue 2

Examination of Tunisian referral letters for rheumatology consultations

Asma Bachali*

Department of Clinical Laboratory, Mohamed Tahar Maamouri Hospital, Nabeul, Tunisia

*Corresponding Author:
Asma Bachali
Department of Clinical Laboratory, Mohamed Tahar Maamouri Hospital, Nabeul, Tunisia

Received: 01-Feb-2023, Manuscript No. fmijcr-23-90002; Editor assigned: 03- Feb-2023, Pre-QC No. fmijcr-23-90002 (PQ); Reviewed: 16-Feb-2023, QC No. fmijcr-23-90002; Revised: 20-Feb-2023, Manuscript No. fmijcr-23-90002 (R); Published: 27-Feb-2023, DOI: 10.37532/1758- 4272.2023.18 (2).24-26


Aim of the work : ur ideal was to dissect the content and quality of referral letters to rheumatology discussion. Cases and styles: This is across-sectional study conducted on the rheumatology consultations in a tertiary sanitarium over six months (April- October 2014). Cases were canvassed and their rheumatology discussion referral letters anatomized. The applicability of referent reasons, suggested opinion and fresh tests requested previous to reclamation were studied Results: We studied 302 referral letters for rheumatology discussion. The average age of cases was55.34 ± 15 times (13 – 85). The coitus rate M/ F was0.3. All cases consulted for painful symptoms affecting substantially the lumbar chine (20) and knees (20). The current clinical problem was meetly presented in 43 of the referral letters. Only 6 letters (2) were unreadable, 28 letters didn't contain the discussion date (9). General interpreters represented 59 of pertaining croakers. The age and patient history were more detailed in the letters written by croaker specialists (p = 0.002 and p<0.001 independently). The reciprocal examinations were more requested by private sector croakers (p = 0.04) and croaker specialists (p = 0.011). Of the 76 croakers who had proposed an opinion, 42(55) had proposed a correct bone. The applicability of judgments showed no significant difference between GPs and specialists Conclusion: Referral letters earn further attention in order to ameliorate communication between croakers and rheumatologists. Analysis of the quality of referral letters can be part of original and continuing medical education. The referral letters have several failings. A model referral letter has been proposed in this study


Rheumatology • Signs and symptoms • Referral letter• Opinion • General interpreters


The referral letter is a device of communication between the pertaining croaker and the rheumatologist. The pertaining croaker must insure that the referral letter has some criteria similar as delicacy, clarity and applicability, since it'll come a part of the medical record. Else, the referral letter would waste time and can raise threat of crimes. Many studies have concentrated on the analysis of referral letters in rheumatologic discussion. This cross-sectional study was conducted with the objects to dissect the different parameters of the referral letter in rheumatologic discussion and to study the acceptability of consultations patterns described on the referral letter, issued judgments and examinations requested in advance by the pertaining croaker [1, 2].

Materials and Method

Thiscross-sectional study was conducted in the rheumatology clinic of Tunis El Manar University sanitarium over a 6- month period (April- October 2014). Cases that refused to share in this study were barred. All cases had a careful medical history and physical examination, and fresh tests if necessary. A complete analysis of referral letter of each case was carried out readability, citation of the age, coitus and the case's medical history, the presence of the croaker’s stamp, the citation of reference pattern or opinion issued by the croaker. The tradition of fresh examinations was noted. The study conforms to the 1995 Helsinki protestation, was approved by the institutional ethical commission and all cases gave their informed concurrence previous to their addition [3, 4].

Statistical analysis

The data were collected, tabulated and anatomized by SPSS package interpretation 15 (SPSS pot, USA). The data were presented as number and frequence and mean ± SD (range). Mann – Whitney tests was used for relative analysis of 2 quantitative data [5].


Five hundred new cases were transferred for a rheumatology discussion during the period of this study. Of these, 302 cases (60) were addressed with a referral letter. All the letters were handwritten. Only 6 referral letters were unreadable (2).

The date was specified in 274 referral letters (91). Case age wasn't specified in 48 referral letters (16). The average age of the cases was55.34 ± 15 times (13 – 85) and the coitus rate M/ F = 0.3. Case history were specified in 140 referral letters (47) and were further noted in the letters from sidekicks working in university sanitarium (UHA) (p = 0.016). A stamp was fixed to 288 referral letters (95). Twenty- eight pertaining croakers (9.3) were from private sector and the rest were from the public sector.


This study showed that the referral letters have several inefficiencies which depend substantially on the pertaining croaker’s profile. The request of fresh tests was more specified by a specialist or a private sector croaker .The date is generally specified in referral letters (88 – 100). Date of discussion allows rheumatologist to assess the time of case's operation and can indeed guide the individual and remedial approach. Case’s age is major information that can save time and makes trust between the case and rheumatologist. Utmost pertaining croakers in our study didn't miss to specify the age of case in their referral letters (84). Also, the average age of cases was similar to the published series. The case's medical history was infrequently specified 47 in our series and 31 in another study in the oncology department. It's recommended to include the medical history details especially those of applicability to rheumatologic conditions. The typical illustration is cardiovascular complaint with rheumatoid arthritis with systemic lupus erythematous or metabolic pattern comorbidity with other rheumatic conditions [6, 7].

In our study, there was little collaboration between the private sector and the public sector. Indeed, in developing countries, cases who consult in the private sector prefer to stay there. The reasons given by the private sector followers were bettered access, more flexible hours, a shorter delay and lesser sequestration. In addition, the private sector croakers are transferring to public hospitals two groups of cases those who don't have the fiscal means and those whose pathology cannot be duly supported in private sector.

Despite the presence of health establishment in the first line, the cases from university hospitals represented 40 of advisers during the period of our study. Fifty- nine percent of advisers were addressed by GPs. This could be explained by the fact that the GPs is« typically the point of first medical contact within the health care system» and« makes effective use of health care coffers through coordinating care, by managing the interface with other fortes» according to the description of general practice outlined by WONCA Europe and validated by the European office of the World Health Organization. This part was corroborated by the “gatekeeping” term, applied in several countries, that describes the process by which a case is obligatory to consult a primary care professional (generally a GP) before seeing a specialist. This model both wide and controversial didn't impact the results of our study in public sanitarium [8, 9].

Many letters contains a individual thesis. This is considered a low rate compared to the results of other studies (between 64 and 95). All cases consulted for painful symptoms especially downward back pain and knee pain. It was the same for other studies attesting that the pain of lumbar chine, knee and the cervical chine are the most common musculoskeletal problems. Other reasons of consultations were symptoms related to connective towel complaint, arthritis, osteoporosis and neurological diseases. Several studies have shown that 80 of Americans have suffered of reverse pain at some moment in their lives, and that this pain is the fifth reason for discussion among all specialties.

In conclusion, we can note that the referral letters earn further attention in order to ameliorate communication between croakers and rheumatologists. Analysis of the quality of referral letters can be part of original and continuing medical education. We propose a model type for referral letters for rheumatology discussion [10].

Conflict of Interest

None declared.


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