Use of musculoskeletal ultrasound in Japan: a survey of practicing rheumatologists

We aimed to describe how often Japanese rheumatologists currently use musculoskeletal ultrasound (MSUS), and how they are currently being trained in the use of this imaging technique. Questionnaires were sent to 200 Japanese rheumatologists: 100 to participants attending the first Scientific Meeting of the Japanese Society of Imaging in Rheumatic Diseases in 2006, and 100 to other randomly selected rheumatologists certified by the Japan College of Rheumatology. A total of 139 questionnaires (74 from meeting participants, 65 from randomly selected rheumatologists) were completed and analyzed. Twenty-four of the 74 respondents (32.4%) in the meeting participants group used MSUS imaging for patient management, while only 7 of the 65 respondents (10.8%) in the certified rheumatologists group used MSUS imaging for patient management. Sixty-five of the 74 respondents (87.8%) in the meeting participants group and 54 of the 65 respondents (83.1%) in the certified rheumatologists group considered MSUS to be a useful tool. Only a minority of respondents used MSUS in the management of their patients. Lack of training in MSUS was the principal reason for not performing MSUS. Japanese rheumatologists would prefer future training in the form of intensive courses and training sessions.     

The 12th International Rheumatology Symposium in Tokyo

Abstract

We aimed to describe how often Japanese rheumatologists currently use musculoskeletal ultrasound (MSUS), and how they are currently being trained in the use of this imaging technique. Questionnaires were sent to 200 Japanese rheumatologists: 100 to participants attending the first Scientific Meeting of the Japanese Society of Imaging in Rheumatic Diseases in 2006, and 100 to other randomly selected rheumatologists certified by the Japan College of Rheumatology. A total of 139 questionnaires (74 from meeting participants, 65 from randomly selected rheumatologists) were completed and analyzed. Twenty-four of the 74 respondents (32.4%) in the meeting participants group used MSUS imaging for patient management, while only 7 of the 65 respondents (10.8%) in the certified rheumatologists group used MSUS imaging for patient management. Sixty-five of the 74 respondents (87.8%) in the meeting participants group and 54 of the 65 respondents (83.1%) in the certified rheumatologists group considered MSUS to be a useful tool. Only a minority of respondents used MSUS in the management of their patients. Lack of training in MSUS was the principal reason for not performing MSUS. Japanese rheumatologists would prefer future training in the form of intensive courses and training sessions.     

Challenges to expanding the clinical application of musculoskeletal ultrasonography (MSUS) among rheumatologists: from a second survey in Japan

Abstract

Our previous survey in 2008 revealed that only 22% of Japanese rheumatologists used musculoskeletal ultrasonography (MSUS) for patient management, because of insufficient educational opportunities. To clarify the current state of MSUS usage and to identify further challenges, we conducted a second survey between October 2010 through January 2011 by sending questionnaires to 200 randomly selected Japanese rheumatologists, consisting of 100 participants in a meeting in 2009 on imaging in rheumatic diseases and 100 board-certified rheumatologists. Among the respondents, a majority (85 and 67%, respectively) used magnetic resonance imaging (MRI). MSUS users had increased from 32 to 60% of meeting participants and from 11 to 27% of other rheumatologists. The majority of MSUS users had begun using MSUS within the previous 3 years. Whereas most respondents in the previous survey had been self-taught, in the current survey many had attended training courses or had received informal training from skilled users. Despite an increase in skills and equipment ownership, obstacles to implementing MSUS remained, most prominently a lack of time. In conclusion, training courses and informal training have contributed to the popularization of MSUS in Japan. To further increase MSUS usage, additional training opportunities and education about the advantages of MSUS will be needed.     

Challenges to expanding the clinical application of musculoskeletal ultrasonography (MSUS) among rheumatologists: from a second survey in Japan

Our previous survey in 2008 revealed that only 22% of Japanese rheumatologists used musculoskeletal ultrasonography (MSUS) for patient management, because of insufficient educational opportunities. To clarify the current state of MSUS usage and to identify further challenges, we conducted a second survey between October 2010 through January 2011 by sending questionnaires to 200 randomly selected Japanese rheumatologists, consisting of 100 participants in a meeting in 2009 on imaging in rheumatic diseases and 100 board-certified rheumatologists. Among the respondents, a majority (85 and 67%, respectively) used magnetic resonance imaging (MRI). MSUS users had increased from 32 to 60% of meeting participants and from 11 to 27% of other rheumatologists. The majority of MSUS users had begun using MSUS within the previous 3 years. Whereas most respondents in the previous survey had been self-taught, in the current survey many had attended training courses or had received informal training from skilled users. Despite an increase in skills and equipment ownership, obstacles to implementing MSUS remained, most prominently a lack of time. In conclusion, training courses and informal training have contributed to the popularization of MSUS in Japan. To further increase MSUS usage, additional training opportunities and education about the advantages of MSUS will be needed.     

Comparison of musculoskeletal ultrasound practices of a rheumatologist and a radiologist

OBJECTIVE: There is considerable debate regarding the role of the rheumatologist ultrasonographer and how this development will impact on musculoskeletal ultrasound (MSUS) performed by radiologists. We compared the MSUS practices of a rheumatologist and a radiologist working within the same National Health Service Trust. METHODS: A retrospective review of MSUS reports of consecutive scans performed by a consultant rheumatologist with a special interest in MSUS and a consultant musculoskeletal radiologist. Reports were analysed for referring specialties, indications for MSUS, joint regions scanned, MSUS findings, frequency with which patients were referred for injection and how often injection was performed. RESULTS: A total of 170 patients were referred to the rheumatologist for MSUS of 282 joint regions (91% referred by rheumatologists). Of those, 84 (49%) patients had MSUS examination of more than one joint region, with up to five regions scanned per sitting. One hundred patients were referred to the radiologist for MSUS of 111 joint regions (49% referred by orthopaedic surgeons). The most frequently requested primary indication for MSUS performed by the rheumatologist was detection of synovitis [74 (44%) patients] while MSUS performed by the radiologist was most frequently for assessment for major structural changes [44 (44%) patients]. The rheumatologist performed MSUS-guided injection in 59 of 170 (35%) patients scanned and the radiologist in 13 of 100 (13%). CONCLUSION: MSUS performed by the rheumatologist was predominantly requested by rheumatologists to aid diagnosis of synovial and tendon inflammation and to guide injections, while MSUS performed by the radiologist was predominantly requested by orthopaedic surgeons to aid diagnosis of structural pathology. Curriculums in MSUS designed for rheumatologists may need to place appropriate emphasis on the identification of synovial and tendon inflammation, and injection guidance.     

Musculoskeletal ultrasound training in rheumatology: the Belfast experience

OBJECTIVES: Despite the increasing use of musculoskeletal ultrasound (MSUS) as a clinical tool in rheumatology, there is no consensus yet regarding the standards required to achieve a basic level of competence in the use of this imaging technique. A number of sonographers worldwide are developing curricula and standardizing teaching methods in order to improve training in MSUS for rheumatologists. In the meantime, clinicians are devising informal means of training in order to acquire these new skills. Here we describe the informal team approach to MSUS training adopted by a group of rheumatologists from the Regional Rheumatology Centre in Belfast, UK. METHODS: Over a 5-yr period, eight rheumatologists from Musgrave Park Hospital in Belfast used a variety of means to learn the basic skills of MSUS. RESULTS: Seven of the team underwent a formal assessment of their competency in a practical examination devised by an experienced sonographer. All were judged to have attained a basic competency in MSU. CONCLUSIONS: This Belfast experience shows what can be achieved despite the absence of formal MSUS training. Nevertheless, the development of recognized training programmes and international standards of competency are important goals on the way to achieving more widespread acceptance of MSUS as a useful tool in everyday clinical practice.     

Musculoskeletal ultrasound--a state of the art review in rheumatology. Part 2: Clinical indications for musculoskeletal ultrasound in rheumatology

Rheumatologists remain divided on whether they should introduce musculoskeletal ultrasound (MSUS) into their clinical practice. A central issue in the application of MSUS in clinical rheumatology is the need for proof of clinical relevance and improved patient care. There is now accumulating evidence that MSUS improves clinical diagnosis and intervention skills. High-resolution ultrasound is superior to clinical examination in the diagnosis and localization of joint and bursal effusion and synovitis. MSUS is the imaging modality of choice for the diagnosis of tendon pathology. MSUS is seven times more sensitive than plain radiography in the detection of rheumatoid erosions, allowing earlier diagnosis of progressive rheumatoid arthritis. Ligament, muscle, peripheral nerve and cartilage pathology can also be readily demonstrated by MSUS. There is exciting evidence that MSUS may potentially be used by rheumatologists to non-invasively diagnose and monitor not just joint and muscle disease but also nerve compression syndromes, scleroderma, vasculitis and Sj?gren's syndrome. Joint aspiration and injection accuracy can be improved by MSUS, with initial evidence confirming improved efficacy. As the number of rheumatologists performing MSUS increases and the technical capabilities of MSUS improve, there is likely to be a growing number of proven clinical indications for the application of MSUS in rheumatology practice. This paper reviews the evidence for the application of MSUS in rheumatology.     

Musculoskeletal ultrasonography in Europe: results of a rheumatologist-based survey at a EULAR meeting

OBJECTIVE: To document the practice of musculoskeletal ultrasound (US) by a sample of European rheumatologists attending an annual general meeting of the European League Against Rheumatism (EULAR). METHODS: English-language questionnaires were distributed to 180 randomly selected participants attending imaging-related sessions at the XIV EULAR meeting in Glasgow, UK, in 1999. The questionnaire was divided into four sections: Demographics, Education and Training, Current Practice, and Equipment. RESULTS: Ninety-two rheumatologists responded, representing 74 centres from 19 European countries. Seventy-eight (85%) of the respondents either already used US in their clinical practice or would like to use it in the future. Thirty-seven (40%) respondents performed US within their own department. Few had received training at undergraduate level and most had learned informally or by attending courses. Scans were considered most useful for large joints and ligaments/tendons. Only 28 (30%) respondents valued US for guided injections. CONCLUSIONS: This study, although containing an element of selection bias, confirms a great interest in musculoskeletal US by rheumatologists across Europe and a demand which is likely to increase. The reported variation in training and practice between countries suggests a need for standardized training guidelines.     

The role of ultrasound in the diagnosis and management of psoriatic arthritis

Psoriatic arthritis (PsA) presents many diagnostic, management and research challenges for rheumatologists who wish to obtain early diagnosis, differentiate synovitis and enthesitis, monitor disease activity accurately and objectively, prevent the development of structural damage, deliver local therapy accurately, and obtain PsA tissue for research purposes. Musculoskeletal ultrasound (MSUS) is widely used by European rheumatologists in their clinical practice to meet these challenges and has the potential to become the rheumatologist’s stethoscope in Europe and North America. This paper examines the evidence that MSUS can improve clinical evaluation of patients with PsA for synovitis and enthesitis, that MSUS is more sensitive than plain radiography in detecting structural damage in joints, that MSUS can improve the success of joint aspiration and guide biopsy of PsA tissues. Recent exciting developments in the management of PsA are detailed including the role of power Doppler in the diagnosis of enthesitis in PsA, the role of MSUS in objective monitoring of disease activity, the evaluation of MSUS in the diagnosis of sacroiliitis, and the use of MSUS to guide therapeutic injection of the sacroiliac joints.     

Musculoskeletal ultrasound--a state of the art review in rheumatology. Part 1: Current controversies and issues in the development of musculoskeletal ultrasound in rheumatology

As we begin the 21st century, musculoskeletal ultrasound (MSUS) is routinely used by an increasing number of rheumatologists throughout Europe and there is a growing interest in the application of MSUS in rheumatological practice in the UK. MSUS allows high-resolution, real-time imaging of articular and periarticular structures and has the advantages of being non-radioactive, inexpensive, portable, highly acceptable to patients and repeatable. There are a number of critical issues that need to be addressed in order to develop the role of MSUS within rheumatology. These include issues of equipment costs, training and certification and the relationship of rheumatologists and radiologists in advancing the field of MSUS. Rheumatologists must demonstrate the relevance of MSUS in their clinical practice through high-quality research. Emerging technologies such as power Doppler and 3D imaging will further improve imaging capabilities and the range of clinical applications of MSUS systems. This paper reviews how MSUS in rheumatology has evolved and the controversies and issues that rheumatologists must now address in developing MSUS as an indispensable, everyday clinical tool.     

Clinical implementation of musculoskeletal ultrasound in rheumatology in Austria

The aim of the study is to assess the clinical implementation of musculoskeletal ultrasound (MSUS) in rheumatology in Austria. A survey was conducted among Austrian rheumatologists and physicians of other specialties with a focus on rheumatology. The questionnaire was designed by the members of the Austrian Radiology–Rheumatology Initiative for Musculoskeletal UltraSound including the following items: demographics, access to MSUS and MSUS training, application of MSUS to support diagnosis, monitoring and treatment decisions, and obstacles for the routine performance of MSUS. Eighty-eight (21.9 %) out of the 402 surveyed physicians responded. No access to MSUS and/or inadequate training in the technique was more commonly reported by senior (>50 years; 64.3 and 67.7 %, respectively) than by younger physicians (16.7 %, p = 0.01 and 18.5 %, p < 0.001, respectively). The lowest availability of sonography was found among senior rheumatologists (25.0 %, p = 0.001 compared to the total group). MSUS is routinely used for diagnosis and/or monitoring purposes by 12.5 % of physicians and 20.5 % perform sonography in clinically unclear cases. A limited number of physicians apply the method to support treatment decisions and/or to evaluate treatment success. The most important obstacles for routine application of MSUS in rheumatology are limited access to ultrasound machines, lack of training/education in the technique, and time constraints in daily routine. Low access to high-end ultrasound devices, lack of training, and time constraints may explain the low appreciation of MSUS among Austrian physicians evaluating patients with rheumatic diseases.     

Most visits of most patients with rheumatoid arthritis to most rheumatologists do not include a formal quantitative joint count

OBJECTIVE: To ask rheumatologists about the likelihood of performing a formal joint count at each visit of a patient with rheumatoid arthritis (RA) in standard clinical care. METHOD: Direct query of rheumatologists at an international meeting of about 600 rheumatologists from 17 European countries. RESULTS: Overall, 14% of rheumatologists reported performing a formal joint count at each visit of each patient, and 44% of rheumatologists reported performing a formal joint count at more than 50% of visits of patients with RA. Therefore, 56% of rheumatologists reported performing a joint count at fewer than 50% of visits, including 45% at fewer than 25% of visits. One in eight rheumatologists (13%) reported never performing a formal joint count. CONCLUSION: Although the joint count remains the most specific measure for RA, most visits of most patients with RA to most rheumatologists do not include a formal quantitative joint count.     

Surgical management of the rheumatoid hand: consensus and controversy among rheumatologists and hand surgeons

OBJECTIVE: Rheumatoid arthritis (RA) is a common cause of debilitating hand deformities, but management of these deformities is controversial, characterized by large variations in the surgical rates of common RA hand procedures. We conducted a national survey evaluating potential differences in physicians' management of RA hand deformities. METHODS: We mailed a survey instrument to a random national sample of 500 rheumatologists and 500 hand surgeons in the US. We evaluated physicians' attitudes toward the other specialties' management of common RA hand deformities and toward the indications for performing rheumatoid hand surgery. RESULTS: We found 70% of rheumatologists consider hand surgeons deficient in understanding the medical options available for RA, while 73.6% of surgeons believe rheumatologists have insufficient knowledge of the surgical options for RA hand diseases. However, 66.9% of surgeons and 79.5% of rheumatologists had no exposure to the other specialty during training. The 2 physician groups disagree significantly on the indications for commonly performed RA hand procedures such as metacarpophalangeal joint arthroplasty (p < 0.001), small joint synovectomy (p < 0.001), and distal ulna resection (p = 0.001). When physicians do not agree with others' management of RA hand deformities, only 62.4% of surgeons and 61.9% of rheumatologists relay their concern to the other specialty. CONCLUSION: Rheumatologists and hand surgeons have minimal interdisciplinary training, communicate with each other infrequently, and significantly disagree on the indications for RA hand surgery. Research must focus on the surgical outcomes of RA hand procedures and on improving communication between rheumatologists and hand surgeons.     

Usage of intra-articular corticosteroid injections for the treatment of juvenile idiopathic arthritis: a survey of pediatric rheumatologists in the United States and Canada

OBJECTIVE:To characterize the current usage of intra-articular corticosteroid injections (IACI) by pediatric rheumatologists and the perceived disadvantages of and obstacles to IACI therapy.METHODS:We mailed a 32-item questionnaire to pediatric rheumatologists in the United States and Canada (n=201) to assess treatment strategies for the initial treatment of monoarthritis of the knee in juvenile idiopathic arthritis (JIA). Information regarding the usage of IACI for all patients with JIA and physicians' perceptions of IACI therapy was obtained. Respondents were dichotomized into those who performed frequent pediatric IACI (greater than 50 IACI in the last 12 months) and those who did not.RESULTS:One hundred and twenty-nine (64%) completed questionnaires were returned. IACI were recommended as one therapy for JIA by 99% of respondents, and 90% personally perform IACI. Frequent IACI were performed by 22%, and 15% had performed greater than 10 IACI in a single pediatric patient at one time. Those who did not perform frequent IACI were more likely to report concern about the pain of the procedure, the availability of nursing support, and their own comfort with performing the procedure; they were less likely to have performed greater than 20 pediatric IACI during fellowship training and evaluated fewer clinic patients per week.CONCLUSION:IACI are essentially universally recommended in the treatment regimen for JIA. However, there are differences in the usage of IACI among pediatric rheumatologists. The frequency of IACI use is associated with different perceptions of and training received in IACI therapy.     

Self‐directed learning of basic musculoskeletal ultrasound among rheumatologists in the United States

Objective

Because musculoskeletal ultrasound (MSUS) is highly user dependent, we aimed to establish whether non‐mentored learning of MSUS is sufficient to achieve the same level of diagnostic accuracy and scanning reliability as has been achieved by rheumatologists recognized as international experts in MSUS.

Methods

A group of 8 rheumatologists with more experience in MSUS and 8 rheumatologists with less experience in MSUS participated in an MSUS exercise to assess patients with musculoskeletal abnormalities commonly seen in a rheumatology practice. Patients' established diagnoses were obtained from chart review (gout, osteoarthritis, rotator cuff syndrome, rheumatoid arthritis, and seronegative arthritis). Two examining groups were formed, each composed of 4 less experienced and 4 more experienced examiners. Each group scanned 1 predefined body region (hand, wrist, elbow, shoulder, knee, or ankle) in each of 8 patients, blinded to medical history and physical examination. Structural abnormalities were noted with dichotomous answers, and an open‐ended answer was used for the final diagnosis.

Results

Less experienced and more experienced examiners achieved the same diagnostic accuracy (US‐established diagnosis versus chart review diagnosis). The interrater reliability for tissue pathology was slightly higher for more experienced versus less experienced examiners (κ = 0.43 versus κ = 0.34; P = 0.001).

Conclusion

Non‐mentored training in MSUS can lead to the achievement of diagnostic accuracy in MSUS comparable to that achieved by highly experienced international experts. Reliability may increase slightly with additional experience. Further study is needed to determine the minimal training requirement to achieve proficiency in MSUS.     

Does practice mirror the evidence base in the treatment of rheumatoid arthritis?

A large base of evidence exists regarding treatments for rheumatoid arthritis (RA) and how they may be used to preserve long-term function and improve patient outcomes. However, little is known about whether real-life rheumatology practice reflects the evidence base. This survey aimed to capture differing perceptions among rheumatologists in the identification and treatment of patients and to understand how their management of and treatment decisions for patients with RA may be influenced by the current published literature. Rheumatologists from five European countries and Canada participated in a survey between April and May 2006 to establish how rheumatologists identify and treat particular patient types in everyday practice. In total, 458 rheumatologists responded to the online and telephone survey. Rapidly progressing disease was overwhelmingly recognized (97%) as a distinct subtype among patients with RA, and the majority (88%) of respondents make treatment decisions based on this distinction. Most rheumatologists use measures including C-reactive protein, erythrocyte sedimentation rate, tender/swollen joint counts, and X-ray progression to diagnose and monitor this particular group of patients; a minority (30%) used magnetic resonance imaging to identify and monitor patients with rapidly progressing disease. Although treatment goals for these patients were similar among rheumatologists, the treatment approach varied considerably across countries. Overall, rheumatologists agree on the management goals for patients with rapidly progressing RA; however, their treatment patterns have some dissimilarities.     

Variation in the initial treatment of knee monoarthritis in juvenile idiopathic arthritis: a survey of pediatric rheumatologists in the United States and Canada

OBJECTIVE: To characterize variations in initial treatment for knee monoarthritis in the oligoarthritis subtype of juvenile idiopathic arthritis (OJIA) by pediatric rheumatologists and to identify patient, physician, and practice-specific characteristics that are associated with treatment decisions. METHODS: We mailed a 32-item questionnaire to pediatric rheumatologists in the United States and Canada (n = 201). This questionnaire contained clinical vignettes describing recent-onset chronic monoarthritis of the knee and assessed physicians' treatment preferences, perceptions of the effectiveness and disadvantages of nonsteroidal antiinflammatory drugs (NSAID) and intraarticular corticosteroid injections (IACI), proficiency with IACI, and demographic and office characteristics. RESULTS: One hundred twenty-nine (64%) questionnaires were completed and returned. Eighty-three percent of respondents were board certified pediatric rheumatologists. Respondents' treatment strategies for uncomplicated knee monoarthritis were broadly categorized: initial IACI at presentation (27%), initial NSAID with contingent IACI (63%), and initial NSAID with contingent methotrexate or sulfasalazine (without IACI) (10%). Significant independent predictors for initial IACI were believing that IACI is more effective than NSAID, having performed > 10 IACI in a single patient at one time, and initiating methotrexate via the subcutaneous route for OJIA. Predictors for not recommending initial or contingent IACI were believing that the infection risk of IACI is significant and lacking comfort with performing IACI. CONCLUSION: There is considerable variation in pediatric rheumatologists' initial treatment strategies for knee monoarthritis in OJIA. This variation is primarily associated with perceptions of medication effectiveness and proficiency with IACI. Further studies are warranted to clarify the optimal treatment of OJIA.     

Survey of arthroscopy performed by rheumatologists

OBJECTIVE: To determine the international distribution and practice of arthroscopy performed by rheumatologists and to evaluate proposed guidelines on minimum standards for training in arthroscopy in the context of current clinical practice. METHODS: A questionnaire was sent to all rheumatology centres identified as practising arthroscopy, by (i) searching Medline from 1966 to 1999, (ii) searching the abstract books of the annual general meetings of ACR, BSR and EULAR from 1980 to 1999, and (iii) correspondence with all the centres identified. RESULTS: Thirty-six rheumatology centres were confirmed as performing arthroscopy (24 in Europe, 10 in USA and two in Australia) and 33 (92%) centres completed the questionnaire. Twenty-five (76%) of the 33 centres performing arthroscopy had started to perform it since 1990 and 72 rheumatologists are now trained in arthroscopy. A total of 16532 arthroscopies had been performed (median=220 arthroscopies/centre, range 20-5000); 50.5% of the arthroscopies had a primary clinical indication and 49.5% had a primary research indication. Most centres fulfilled the minimum standards for arthroscopic facilities and the proposed minimum standards in training were acceptable to 76% of respondents. Complication rates were calculated for 15682 arthroscopies where routine follow-up data were available [joint infection, 16 (0.1%); wound infection, 17 (0.1%); haemarthrosis, 141 (0.9%); deep venous thrombosis, 31 (0.2%); neurological damage, 3 (0.02%), thrombophlebitis, 12 (0.08%), other, 8 (0.06%)]. Irrigation volume correlated with wound infection rate (r=0.41, P=0.03) and centres performing cartilage biopsy had a higher rate of haemarthrosis (P=0.007). CONCLUSION: The last decade has seen rapid growth in arthroscopy performed by rheumatologists in an out-patient setting under local and regional anaesthesia. Proposed minimum standards for training in rheumatological arthroscopy reflect current practice accurately and are acceptable to the majority of arthroscopists. Complication rates of rheumatological arthroscopy are similar to those reported in the orthopaedic literature.     

Musculoskeletal ultrasound imaging training,use, and knowledge among rheumatologists in China

Clinical Rheumatology - Musculoskeletal ultrasound (MSUS) has been extensively studied by rheumatologists in Europe and the Americas, but less is known about MSUS use in Asia. Our hypothesis is...     

Comparing the self-reported referral and management preferences of pediatricians and family physicians for children with juvenile rheumatoid arthritis

OBJECTIVE: The symptoms of juvenile rheumatoid arthritis (JRA) are often first recognized by primary care physicians. Little is known about the determinants of the initial management and referral patterns of these physicians for children with JRA. We compared the self-reported preferences and practices of pediatricians (PD) and family physicians (FP) in the diagnosis and management of children with JRA. METHODS: Surveys were mailed to a national random sample of 700 PD and 867 FP. Questions included prior experience with JRA, usual patterns in the diagnosis and management of JRA, perception of the need for guidelines for referral and management of this condition, and physician demographic information. Data analysis included univariate and bivariate analysis. RESULTS: Response rates were 69% for PD and 49% for FP. Most respondents had seen very few JRA cases in the previous 5 years. Only 1% of respondents reported that they provided all diagnosis and management for patients with JRA. Forty-two percent of PD and 32% of FP refer all JRA diagnosis and management to subspecialists, while 46% of PD and 61% of FP refer only to confirm the diagnosis and guide initial therapy (p = 0.011). More PD than FP (PD 92% vs FP 76%; p = 0.001) referred patients with JRA to pediatric rheumatologists, while more FP than PD referred to general rheumatologists (PD 17% vs FP 37%; p = 0.001). The majority of FP reported feeling more comfortable managing rheumatologic disease in adults than children (82%). Few respondents felt that they were up to date on the latest advances in JRA treatment (PD 10% vs FP 4%; p = 0.024). CONCLUSION: Multiple factors may contribute to physicians' referral practice, including a patient's clinical status and the physician's beliefs of inadequacy of training and inability to stay up to date. The pattern of care that children with JRA receive likely will be influenced by initial presentation to a PD or to a FP.