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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 45-52

The practice of referring patients with rheumatic diseases and respiratory involvement to respirology clinics: A survey study

Department of Internal Medicine, Division of Pulmonology, Faculty of Medicine, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah, Saudi Arabia

Date of Submission24-Jul-2022
Date of Decision09-Sep-2022
Date of Acceptance17-Sep-2022
Date of Web Publication25-Jan-2023

Correspondence Address:
Dr. Rahmah Abdulhadi Alsilmi
King Abdulaziz University, P.O. Box: 80200, Zip Code: 21589, Jeddah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ara.ara_13_22

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Background: There is a significant association between rheumatic diseases and pulmonary complications, mandating careful assessment for patients. Aim: We aimed to assess the current practice of rheumatologists in referring patients with rheumatic diseases and respiratory involvement to respirology clinics in Saudi Arabia. Materials and Methods: This study is a cross-sectional online survey conducted among rheumatologists and distributed from September 15th, 2021, to December 30, 2021. The first part of the questionnaire aimed to determine the participants' demographic data. The second part assessed the current practice of referring patients with respiratory symptoms to respirology clinics. The third part assessed the participants' awareness of evaluating respiratory diseases in patients with rheumatic conditions. Results: The survey was distributed to 250 rheumatologists using social media and E-mail. We received 61 responses. The majority, 56 (91.8%), did not have a preset respiratory questionnaire and 55 (90.2%) reported ordering pulmonary function tests and high-resolution computerized tomography of the chest before referring patients to a pulmonologist. Forty respondents (65.6%) screen their high-risk patients for respiratory involvement at baseline, and annually, 53 (86.9%) collaborate with a pulmonologist to manage patients who have lung involvement on a long-term basis. The majority of the respondents, 60 (98.4%), did not have an established combined rheumatology-respirology clinic; however, 43 (70.5%) believed that it was feasible to establish such a clinic in their workplace. There is consistency in agreement among the respondents regarding the importance of screening high-risk patients for pulmonary complications. Conclusion: Among the respondents, there was an appreciation of the importance of pulmonary complication screening and collaboration with a pulmonologist to comanage their patients. The concept of the combined rheumatology-respirology clinic is not widely adopted, considering its potential effect on prompt patient evaluation.

Keywords: Connective tissue diseases, pulmonary complication, respirology, rheumatic disease clinic referral

How to cite this article:
Alsilmi RA. The practice of referring patients with rheumatic diseases and respiratory involvement to respirology clinics: A survey study. Ann Rheumatol Autoimmun 2022;2:45-52

How to cite this URL:
Alsilmi RA. The practice of referring patients with rheumatic diseases and respiratory involvement to respirology clinics: A survey study. Ann Rheumatol Autoimmun [serial online] 2022 [cited 2023 Feb 4];2:45-52. Available from: http://www.ara.ssr.com/text.asp?2022/2/2/45/367435

  Introduction Top

Rheumatic diseases can have a pathological association with the respiratory system where the respiratory tract can be involved as a part of the systemic autoimmune disease process, as a sequela of drug-induced lung injury, or as an infectious process due to the immunosuppressed status secondary to the immunomodulatory therapies the patients usually receive.[1] Rheumatoid Arthritis (RA), Systemic Sclerosis (SSc), Systemic Lupus Erythematosus (SLE), Sjogren's Syndrome (SS), Idiopathic Inflammatory Myopathies (IIM), Mixed Connective Tissue Disease (MCTD), Overlap Syndrome, Undifferentiated Connective Tissue Disease (UCTD), and Antineutrophil Cytoplasmic Antibodies (ANCA)-Associated Vasculitis (AAV) are examples of the autoimmune conditions that are linked with respiratory complications in variable prevalence and clinical presentations.[2] The occurrence of respiratory involvement in the setting of rheumatic diseases can be subclinical, i.e. has no clinical presentation or presenting frankly with symptoms and signs that vary in degree and complexity. In addition, the prevalence of pulmonary complications can substantially vary depending on the type of underlying rheumatic conditions; for instance, SS and IIM are mostly linked with the development of interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH) and thus require frequent clinical and imaging monitoring to detect those complications early on the disease course.[3],[4] In addition, the timeline at which respiratory involvement manifests can be early on, concomitantly, or after the rheumatic disease manifestations first appear, making it of utmost importance to screen for symptoms and signs of pulmonary complications, not only at the initial patients' encounter but also during follow-up periods.[2] A robust and collaborative approach should be initiated between rheumatologists and pulmonologists in assessing and managing those patients with prompt referral between these two clinical services to help appropriately manage the complications and prevent long-term sequelae. We did an online survey to assess the current practice of rheumatologists in referring patients with rheumatic diseases and respiratory involvement to respirology clinics in Saudi Arabia.

  Materials and Methods Top

Study design

This study is a cross-sectional online-based survey conducted among rheumatologists practicing across Saudi Arabia. The study aimed to assess the current practice of rheumatologists in referring patients with rheumatic diseases and respiratory involvement to respirology clinics. We also assessed their awareness of the importance of evaluating respiratory diseases in their patients.

Data collection

The questionnaire consists of three domains with 21 questions. The first part of the questionnaire was to determine the participant's demographic data, the second part was to assess the current practice of referring patients with respiratory symptoms to respirology clinics, and the third part was to assess the participant's awareness of the importance of evaluating respiratory complications among their patients. The survey took around 5 min to be completed by the participants.

Validation process

After constructing the questionnaire based on the study design and objectives, we did a validation process using a pretest respondent-driven method where four rheumatologists assessed the preliminary questionnaire. Their feedback on the questionnaire items regarding relevance, difficulty, appropriateness, clarity, objective meeting, and length of the questionnaire was collected and acted on modifying the questionnaire accordingly. Reliability of the survey by measuring the internal consistency of the questionnaire scale was tested on eight samples using Cronbach's alpha which yielded a result of 0.818, signifying a high level of internal consistency among the scale items.

Sampling method and size

The survey was distributed among the targeted population through E-mail and social media. The participants provided their consent in participation upon accepting and conducting the survey. Ethical approval was obtained from King Abdulaziz University Faculty of Medicine's Unit of Biomedical Ethics; research committee (registration No. 424-21). The sample size is estimated at 152 using an estimated size of 250 practicing rheumatologists with a 5% margin of error and a 95% confidence interval. We used the "Raosoft.com" website to calculate the sample size.


We used descriptive analysis utilizing frequency and percentage for the respondents' demographics and answers. We used Pearson's correlation coefficient to evaluate the relation between the participants' years of experience and the number of patients seen in their clinic with their answers. P < 0.05 was considered statistically significant.

  Results Top

Demographic data

We received 61 responses across the collection period from September 15, 2021, to December 30, 2021. The age of the respondents, the professional level of practice, the region of practice in Saudi Arabia, duration of practicing as a rheumatologist, number of patients seen in the clinic per week, and the type of health-care facility are shown in [Table 1]. There were no differences in the respondent' answers based on their year of experience or the number of patients they see in the clinic (P > 0.05).
Table 1: Demographic data of the respondents

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Current practice assessment

The respondents' different aspects of clinical practice were assessed in our survey, and their responses were collected and shown in [Table 2]. Frequency of the respondents enquiring about their patients' respiratory symptoms, referring them to pulmonologists, screening of high-risk patients for pulmonary complications such as ILD and PAH using pulmonary function test (PFT), high-resolution computerized tomography (HRCT) of the chest, and echocardiogram and the time of reply from the pulmonologist to the referring rheumatologist were assessed in the questionnaire and demonstrated in [Figure 1].
Figure 1: Responses of clinical practice assessment questions illustrated in pie charts. Data in the charts are shown in number and %. *Screening high-risk patients include those with newly diagnosed systemic sclerosis, scleroderma spectrum disorders, and idiopathic inflammatory myopathies for pulmonary complications such as interstitial lung disease and pulmonary arterial hypertension using pulmonary function test, high-resolution CT chest, and echocardiogram. CT: Computed tomography

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Table 2: Assessing the current practice

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Assessing the awareness of the importance of evaluating respiratory involvement in patients with rheumatic diseases

We evaluated the awareness of the respondents using the Likert scale of agreement (strongly agree, agree, neutral, disagree, and strongly disagree) regarding the importance of screening for respiratory involvement in their patients and whether the recommendation for screening of ILD and PAH in high-risk patients has clearly been stated in the international clinical practice guidelines. We collected the respondents' opinions regarding whether the combined rheumatology-respirology clinic service (combined rheumatology-respirology clinic means both rheumatologist and pulmonologist attend the same clinic to coassess and comanage the patients) can promptly provide optimal care for patients and whether it should be the standard of care for patients with rheumatic conditions and pulmonary complications [Figure 2].
Figure 2: Data on the top of the bars represent the number of responses. RD: rheumatic diseases. ILD: Interstitial lung disease. PAH: Pulmonary arterial hypertension. CPG: clinical practice guidelines

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  Discussion Top

Our study demonstrated the approach of the respondents in collaborating with pulmonologists in comanaging patients with rheumatic diseases and concomitant lung involvement where a high proportion of the respondents reported having to refer a rheumatological case to a pulmonologist at least once a month, and 87% of the respondents cooperate with pulmonologists to provide continuous care to the patients. In addition, as rheumatic diseases contribute to a considerable part of ILD diagnoses; a small but significant proportion of patients with rheumatic conditions present initially to the pulmonologists who might diagnose a rheumatic disease and make the referral to a rheumatologist for assessment; thus, the referral pathway is back and forth between these two specialties.[5] In a busy rheumatology clinic (77% of the respondents see >20 cases per week), substantial numbers of patients might have respiratory complaints that need further diagnostic tests to assess for potential pulmonary involvement. The majority of the respondents order PFT and chest images before referring their patients to a pulmonologist helping to expedite the referral and assessment pathway.

Our study highlighted the high degree of awareness among the respondents regarding screening their patients for lung involvement (100% agreed–strongly agreed). Screening for ILD and PAH in rheumatic diseases in a particularly high-risk group such as SSc has been highlighted in clinical and research fields. In patients with SSc, the association between pulmonary complications, in particular ILD and PAH, and poor patients outcomes has been demonstrated in multiple studies[6],[7] that would further support the importance of increasing the awareness of these two lung complications among rheumatologists in the clinical practice and expanding the research field in establishing clear and robust data for the screening pathway and the management strategy. Furthermore, the rheumatic disease outcome might be greatly altered by an early identifying subset of patients who developed ILD or PAH or who are at risk of developing these complications, and by initiating or intensifying medical management the patient already receives. The majority of the respondents would screen the high-risk group for lung involvement at baseline and upon follow-up using PFT, chest HRCT, and echocardiogram, which is a crucial clinical approach to timely diagnose and properly treat any pulmonary complication that might occur in the context of rheumatic diseases. The respondents of our study had variability in answering the questions about the existence of clinical practice guidelines addressing the screening of ILD and PAH in their patients. Although there is no released clinical practice guideline clearly stating the proper approach in screening for ILD in rheumatic diseases, including the appropriate time of screening initiation and frequency of follow-up screening studies utilizing evidence-based data; expert consensus statements have been published recommending the screening of ILD in SSc by symptoms, PFT, and HRCT.[8],[9] On the other hand, PAH screening has been suggested in recommendation following the 6th World Symposium on Pulmonary Hypertension in 2018 by annually screening patients with scleroderma and scleroderma spectrum disorder incorporating echocardiogram with other measures utilizing clinical tools such as DETECT algorithm.[10],[11] Identifying PAH in the asymptomatic high-risk group of SSc patients and thus considering initiating PAH-directed therapy might significantly impact the long-term outcome, as shown in prior studies.[12],[13] The expert consensus statement is applied clinically to help guide treating physicians regarding screening, management, and following their patients. However, the clinical practice guidelines composing would require more robust data and powerful evidence to develop protocols for screening and management, which is still lacking in the literature regarding pulmonary involvement in this subset of patients.

A significant proportion of the respondents reported practicing by inquiring about respiratory symptoms during the patient follow-up period and not only at the first clinic assessment, which is considered an integral aspect of assessing such highly associated conditions in this group of patients. Pulmonary complications in rheumatic diseases have been reported to develop after a considerable lag period from the first rheumatic disease diagnosis.[2] On the other hand, some rheumatic conditions are highly associated with early onset of respiratory involvement that can coincide with the development of rheumatic features or even precede its full clinical picture.[14] This observation highlights the importance of continuous inquiry about respiratory symptoms at baseline and upon follow-up for these patients. One of the ways to emphasize the screening of respiratory symptoms is to create a self-administered screening questionnaire in the clinic for the patients to answer. An example of such a screening tool is in Appendix S1, which is under validation processes. Not surprisingly, most of the respondents did not have such a screening tool. The lack of well-established and validated questionnaires might contribute to this lag in practice. Incorporating a respiratory questionnaire with physical examination, physiological lung function measurement, chest radiological images, and echocardiogram can increase the accuracy of detecting clinical pulmonary complications. This approach is considered rational in conditions highly associated with lung involvement, such as SSc and scleroderma spectrum disorders. However, in conditions with less known risk factors for respiratory involvement, such as SLE, it would be more necessary to capture those patients who developed pulmonary complications by simply applying a standard respiratory symptoms questionnaire. This might also give an opportunity to establish research tools that will help in understanding more about the risk factors, clinical behavior, and progression patterns of these patients. Implementing such a respiratory questionnaire to identify symptomatic patients might enhance the loop of referring patients to pulmonologists for further evaluation and management.

The collaboration between rheumatologists and pulmonologists supports the concept of the multidisciplinary team in providing the best care for the patients.[15] Although the concept of the combined rheumatology-respirology clinic is not widely implemented, as around 98% of the respondents reported that they do not routinely have this kind of practice, two-thirds of them conveyed that it is applicable to initiate it in their care facility. Our results demonstrated that most of the respondents agree that combined rheumatology-respirology clinic should be the standard of care for the shared cases between these two specialties and that this type of practice delivers care promptly. The concept of combined rheumatology-respirology clinic, if implemented, can indeed help in expediting the patients' care by allowing experts to give their input on the patients' conditions at the same time, raising otherwise hidden concerns and addressing them, increasing the patients' trust in health-care providers and improve patients care and outcome.[16],[17] The mean time of patients being evaluated in the rheumatology clinic can be prolonged;[18],[19] in a similar line, almost a third of the respondents reported that they get a reply from the pulmonologists they referred their patients to in more than 4 weeks period from the referral time. The delay in referral time points starting from the first patient complaints to the first rheumatology assessment, followed by identification of respiratory complication and involving pulmonologists, can be modified by implementing a fast track for referral of a patient with rheumatic diseases and suspected pulmonary complication supported by the integrated clinic care and evaluation of the patients concomitantly by both specialists.

Our research studied the current practice of rheumatologists collaborating with pulmonologists in taking care of shared cases, and the concept of integrated clinical care between these two specialties, and addressed the common practical points in the referral pathway. The limitation of our study includes that, due to the relatively small sample size, the result may not represent the actual practice and current concepts among a larger rheumatologist group.

  Conclusion Top

This study highlighted the rheumatologists' awareness of the pulmonary involvement in patients with rheumatic diseases, the importance of pulmonary complications screening, and collaboration with pulmonologists. The practice for the combined rheumatology-respirology clinic is still not widely executed. The concept of this kind of integrated care can positively affect multiple levels of health care ranging from the patients to the treating physicians delivering and promoting optimal care. The effect of such practice on the health-related economy requires a cost-effectiveness study to evaluate its usefulness from that perspective.


The author would like to thank all the participants for their participation in answering the survey questions.

Data availability

All data obtained from the study are available in the published manuscript.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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