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Evaluation of a Knee and Shoulder Arthrocentesis Training Program for Primary Care Providers

To the Editor:

Referrals to rheumatologists for rather routine knee and shoulder arthrocenteses are common. Such referrals might be decreased if primary care providers (PCP) were more comfortable doing these procedures. Residents in internal medicine and family practice do have opportunities for procedures during their training but the few reports evaluating the effect of any such training suggest that physicians do not feel confident after residency^1,2.

A few evaluations on the influence of arthrocentesis training for residents and hospital staff have suggested that at least in the short term increased confidence was achieved^3-5. We describe the effects of a series of 5 training programs to PCP on arthrocentesis techniques.

We evaluated effects of a series of free programs conducted at Pri-Med meetings in 5 different cities. Half-hour sessions were provided for 4 trainees at each session by 1 of 5 experienced rheumatologists for each session. In addition to the physician authors, trainers at the 5 sites are listed in the acknowledgment below.

Sessions covered indications for arthrocentesis, contraindications, supplies needed to be prepared, materials to inject, and importance of synovial fluid analysis. We reviewed the anatomy and the joint aspiration procedures in detail, providing hands-on experience with knee and shoulder models (Sawbones®, Pacific Research Laboratories, Vashon, WA, USA). Participants also palpated shoulder landmarks on each other. Instructions included both glenohumeral and subacromial bursal procedures with demonstration and practice on both anterior and posterior approaches to the glenohumeral joints. Knee practice included both medial and superolateral retropatellar approaches.

Simple satisfaction questionnaires were completed by all attendees at the conclusion of their half-hour session. A more detailed questionnaire was mailed to all attendees 3 months after their training.

A total of 1969 individuals attended the 5 programs. Family and general practitioners were 38%, internists 24%, nurse practitioners 22%, physician assistants 7%, and others 9%. Seventy-one percent of all people attending had never done joint aspirations or had done none since training.

On the initial satisfaction questionnaire virtually all (99%) reported that they found the training useful. Seven percent, or a total of 131, responded to the more detailed followup questionnaire at 3 months. Of these responders, 96% reported that they felt more comfortable aspirating joints and administering injections.

Respondents at 3 months were much more likely to have done aspirations than the 29% of the whole group. Table 1 shows numbers of reported knee aspirations or injections per 3-month period before and after the training. Table 2 shows similar figures for shoulder procedures. Twenty responders at 3 months, who had done no procedures before, now did knee procedures and 15 did shoulder aspirations or injections.

Table 1. Average number of knee aspirations or injections per 3-month period.

Table 2. Average number of shoulder aspirations or injections per 3-month period.

These results provide the first, although still limited, evidence on the reported effect of training of PCP about joint aspiration and injection. A project with similar models for residents and faculty reported by Jolly, et al described only greater comfort with procedures⁴. Vogelgesang, et al³ trained residents with a lecture and practice on a model. Those so trained did better on a quiz and reported more confidence than a control group given only a normal clinic rotation.

In addition to procedures done we asked for comments. A few felt that they still needed a mentor to do the first few actual patients. Most were using the training to give injections rather than for diagnosis. Many wanted instruction about other sites for injections. Others felt that the hectic practice pace left no time for procedures.

There are some limitations made evident by our study. We had only a 7% response rate at 3 months. Information from initial nonresponders to the 3-month survey would be helpful. Comparison with programs with actual use in patients or different models would be important. Despite instruction and handouts on synovial fluid analysis, we did not receive any responses about this helping with diagnosis. We have no information on the true effect of this brief training on patient care⁶. How should we evaluate quality and effect on patient care of these procedures by PCP?

H. RALPH SCHUMACHER, MD; LAN X. CHEN, MD, PhD, University of Pennsylvania and Veterans Administration Medical Center, Philadelphia, Pennsylvania; LESLEY GLICK, MD, Phase Five Communications, New York, New York, USA. Address reprint requests to Dr. H.R. Schumacher, VA Medical Center, 151K University & Woodland Aves., Philadelphia, PA 19104.

Supported in part by an investigator initiated grant from TAP Pharmaceuticals.

ACKNOWLEDGMENT

We thank additional trainers: Alan Marks, Robert Zurier, Sharon Katz, and Christine Kovacs at Boston; Filemon Tan, Sean Xiang Tao, Francis Williams, and George Duna at Houston; David Alboukrek, Jeffrey Kaine, Robert Levin, David Makover, Ira Pardo, and Adam Rosen at Fort Lauderdale; Darcy Majka, Prya Damaraju, Eric Gall, Lori Siegel, and Calvin Brown Jr at Rosemont; and Gail Kerr, Raymond Flores, Sean Whelton, Mark Gourley, Kenneth Austin, Charles Via, and Violet Rus at Baltimore.

REFERENCES

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