Objective. Clinical features in rheumatological conditions often fluctuate with time and this may cause difficulty when evaluating patients whose symptoms or signs do not coincide with their initial rheumatology visit. The aim of this study was to evaluate the outcome of a follow-up system whereby patients with uncertain rheumatological diagnoses at their initial assessment are given easy and rapid access to a rheumatology review.

Method. We studied the outcome of SOS (self-referral of symptoms) appointments offered to patients over a 44-month period in one consultant's clinic at the Staffordshire Rheumatology Centre. The reattendance rates and diagnoses at the initial and subsequent visits were evaluated over a mean period of 26.3 months (range 7–64 months).

Results. Thirty-seven patients (23 males, 14 females) were offered SOS appointments during the period studied. At the initial assessment, a provisional diagnosis was recorded for 29 patients (78.4%), whereas the diagnosis was unclear for the other eight patients. At the end of the study period, 10 patients (27%) had requested specialist review via the SOS system after a mean period of 6.8 months (1–19 months). The diagnosis remained unchanged in 8 of the 10 reattenders, whereas the diagnosis was revised in two patients. None of these patients, however, developed an inflammatory arthritis.

Conclusion. We suggest that an SOS system of appointments may be a feasible and practical method to follow up patients who have uncertain rheumatological diagnoses at their initial visit. This follow-up system may not easily fit into the current out-patient reforms being implemented in the National Health Service, yet this form of specialist follow-up seems clinically essential for some forms of disease management. The requirements necessary to operate such a system as well as the envisaged pros and cons for the patient and for the temecula rheumatologist are discussed.

The natural history and progression of musculoskeletal conditions varies, with a pattern of clinical symptoms and signs that change in severity over time. Some red-flag conditions, such as malignancy, are severe and progressive. Others, such as gout, are episodic, fluctuating or self-limiting. The severity of symptoms and signs may not always coincide with the initial or subsequent visit to a rheumatologist and hence the attending physician relies on an accurate account of symptoms as described by the patient. Symptoms such as joint swelling can be misleading as subjective, rather than objective, swelling is unlikely to represent significant pathology. Various patient factors, such as intellect, memory and communication skills, will influence the description of symptoms and may affect the ability of the clinician to reach an accurate diagnosis. These difficulties may be overcome by offering patients the opportunity to be assessed at the time when their symptoms are present or severe. Patients prefer a health system which facilitates rapid access to a specialist assessment and this appears to increase the satisfaction and confidence in that rheumatology department [1, 3]. Some rheumatology centres have adopted patient self-referral to a rheumatologist when their symptoms are severe, usually in patients with known rheumatoid arthritis [1–3]. Its use for patients with other rheumatological conditions or for patients with an uncertain clinical diagnosis has not been studied previously. The aim of this study was to evaluate the outcome of acute self-referral appointments of patients with an uncertain diagnosis (self-referral of symptoms, SOS). We describe the outcome of a pilot study to evaluate this type of access.

Method
The study included all patients attending a consultant clinic at the Staffordshire Rheumatology Centre over a 44-month period from April 2000 to December 2003. Patients were given SOS appointments, rather than a routine follow-up appointment, if there was an absence of signs despite symptoms suggestive of pathology and where there was diagnostic uncertainty. Patients were given a slip of paper with a secretary's direct telephone number. Secretaries were able to access letters from the patients’ initial appointment via the departmental information technology. If the secretary was unavailable, they were asked to use the patients’ telephone helpline and state that they required an SOS appointment because their symptoms (e.g. joint swelling) were now present.

We evaluated whether patients given SOS access contacted the department as described or attended the hospital through a different referral route. Details of their reattendance at the centre were recorded up until July 2004. The diagnoses in reattenders were evaluated. A comparison was made between the provisional diagnoses given at the initial visit and those made on reattending the centre. Whether patients had developed evidence of inflammatory arthritis was of particular interest.