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 Table of Contents  
Year : 2015  |  Volume : 29  |  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 Publication21-Sep-2015

Correspondence Address:
Dr. Gouranga Santra
Block - P, Flat - 306, Binayak Enclave, 59 Kalicharan Ghosh Road, Kolkata - 700 050, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-5333.159784

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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

How to cite this URL:
Santra G. Assessment of quality of rheumatology care in a rural area of West Bengal, India. Indian J Pain [serial online] 2015 [cited 2023 Feb 1];29:166-71. Available from: https://www.indianjpain.org/text.asp?2015/29/3/166/159784

  Introduction Top

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. [1],[2],[3],[4],[5] There is a lack of standard of rheumatology care in developing countries like India. [6] 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:

  1. 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.
  2. To describe the appropriateness of medications and management rural patients had received.

  Materials and Methods Top

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. [7],[8],[9],[10],[11],[12],[13] Soft-tissue rheumatism (STR) was diagnosed by the following characteristics:

  1. Pain elicited with active but not on passive movements;
  2. Tenderness away from the joint margin;
  3. Swelling usually away from the joint; and
  4. Dramatic relief with local steroid injections in inflammatory conditions. [7]

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). [14] 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.

Statistical method

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 Top

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].
Table 1: Demographic profile of study population

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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 Top

Wide prevalence of rheumatologic disorders is seen in rural and urban areas throughout India. [15],[16] 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. [17] 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. [18] 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. [19] 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. [20] Biologic agents revolutionize the treatment of RA and other inflammatory rheumatic diseases. However, their use is restricted in resource poor countries. [21] 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. [22]

  Conclusion Top

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.

  References Top

Saag KG, Yazdany J, Alexander C, Caplan L, Coblyn J, Desai SP, et al. Defining quality of care in rheumatology: The American College of Rheumatology white paper on quality measurement. Arthritis Care Res (Hoboken) 2011;63:2-9.  Back to cited text no. 1
Kennedy T, McCabe C, Struthers G, Sinclair H, Chakravaty K, Bax D, et al. BSR guidelines on standards of care for persons with rheumatoid arthritis. Rheumatology (Oxford) 2005;44:553-6.  Back to cited text no. 2
Adhikesavan LG, Newman ED, Diehl MP, Wood GC, Bili A. American College of Rheumatology quality indicators for rheumatoid arthritis: Benchmarking, variability, and opportunities to improve quality of care using the electronic health record. Arthritis Rheum 2008;59:1705-12.  Back to cited text no. 3
MacLean CH, Louie R, Leake B, McCaffrey DF, Paulus HE, Brook RH, et al. Quality of care for patients with rheumatoid arthritis. JAMA 2000;284:984-92.  Back to cited text no. 4
Khanna D, Arnold EL, Pencharz JN, Grossman JM, Traina SB, Lal A, et al. Measuring process of arthritis care: The arthritis foundation′s quality indicator set for rheumatoid arthritis. Semin Arthritis Rheum 2006;35:211-37.  Back to cited text no. 5
Yousefi H, Chopra A, Farrokhseresht R, Sarmukaddam S. Clinical assessment and health status in standard care in Indian and Iranian patients suffering from rheumatoid arthritis (RA). Indian J Rheumatol 2014;9:57-61.  Back to cited text no. 6
Malaviya AN. Clinical approach to patients with joint disease: Importance of distinguishing inflammatory from non-inflammatory conditions. Int J Rheum Dis 2006;9:11-7.  Back to cited text no. 7
Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO 3 rd , et al. 2010 Rheumatoid arthritis classification criteria: An American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum 2010;62:2569-81.  Back to cited text no. 8
Shiboski SC, Shiboski CH, Criswell L, Baer A, Challacombe S, Lanfranchi H, et al. American College of Rheumatology classification criteria for Sjögren′s syndrome: A data-driven, expert consensus approach in the Sjögren′s international collaborative clinical alliance cohort. Arthritis Care Res (Hoboken) 2012;64:475-87.  Back to cited text no. 9
Rudwaleit M, van der Heijde D, Landewé R, Listing J, Akkoc N, Brandt J, et al. The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): Validation and final selection. Ann Rheum Dis 2009;68:777-83.  Back to cited text no. 10
Petri M, Orbai AM, Alarcón GS, Gordon C, Merrill JT, Fortin PR, et al. Derivation and validation of the Systemic Lupus International Collaborating Clinics classification criteria for systemic lupus erythematosus. Arthritis Rheum 2012;64:2677-86.  Back to cited text no. 11
Taylor W, Gladman D, Helliwell P, Marchesoni A, Mease P, Mielants H, et al. Classification criteria for psoriatic arthritis: Development of new criteria from a large international study. Arthritis Rheum 2006;54:2665-73.  Back to cited text no. 12
Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken) 2010;62:600-10.  Back to cited text no. 13
Rheumatic fever and rheumatic heart disease. World Health Organ Tech Rep Ser 2004;923:1-122.  Back to cited text no. 14
Mathew AJ, Chopra A, Thekkemuriyil DV, George E, Goyal V, Nair JB, et al. Impact of musculoskeletal pain on physical function and health-related quality of life in a rural community in south India: A WHO-ILAR-COPCORD-BJD India study. Clin Rheumatol 2011;30:1491-7.  Back to cited text no. 15
Joshi VL, Chopra A. Is there an urban-rural divide? Population surveys of rheumatic musculoskeletal disorders in the Pune region of India using the COPCORD Bhigwan model. J Rheumatol 2009;36:614-22.  Back to cited text no. 16
Jadhav MP, Jadhav PM, Shelke P, Sharma Y, Nadkar M. Assessment of use of complementary alternative medicine and its impact on quality of life in the patients attending rheumatology clinic, in a tertiary care centre in India. Indian J Med Sci 2011;65:50-7.  Back to cited text no. 17
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Pincus T, Segurado OG. Most visits of most patients with rheumatoid arthritis to most rheumatologists do not include a formal quantitative joint count. Ann Rheum Dis 2006;65:820-2.  Back to cited text no. 18
Fitzcharles MA, Boulos P. Inaccuracy in the diagnosis of fibromyalgia syndrome: Analysis of referrals. Rheumatology (Oxford) 2003;42:263-7.  Back to cited text no. 19
Adebajo A, McGill P, Tikly M. Tropical rheumatology - A global issue. Rheumatology (Oxford) 2009;48:599-601.  Back to cited text no. 20
Adebajo A, Fursts DE. Biologic agents and their use in resource-poor countries. J Rheumatol 2005;32:1182-3.  Back to cited text no. 21
Mathew AJ, Rahim A, Bina T, Paul BJ, Chopra A. A call to integrate musculoskeletal disorders into the national programme for non-communicable diseases (NCD). Indian J Med Res 2012;136:499-501.  Back to cited text no. 22
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