Fall 2022 (Volume 32, Number 3)

Infographics to Facilitate the Diagnosis and Management of Giant Cell Arteritis and Gout by Emergency Physicians

By Monish Ahluwalia, MSc; Sabrina Campbell, HBSc; Sangeeta Bajaj, MD, FRCPC; Raman Joshi, MD, FRCPC; Tripti Papneja, MD, FRCPC; and
Vandana Ahluwalia, MD, FRCPC

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Patients with rheumatologic complaints account for up to 8% of all emergency department visits.¹ Two diagnostic challenges of interest are giant cell arteritis (GCA) and gout. GCA is a medium-large vessel vasculitis with low prevalence, high morbidity, and variable presentation, making it a difficult diagnosis and one where patients often first present to the emergency department.^2,3 Models suggest that referrals for GCA could be better triaged to avoid unnecessary imaging, specialist referrals, and temporal artery biopsies.^4,5 Gout is a urate crystal arthropathy with increasing prevalence and increasing associated healthcare costs, yet still characterized by suboptimal treatment and patient outcomes.^6,7 Retrospective cohort analyses demonstrate that more than 30% of patients with a diagnosis of an acute gout flare may not receive anti-inflammatory medications and that medication errors in gout treatment are common.^8-11 Despite the importance of these diagnoses in clinical practice, much of the literature is not directed toward emergency physicians and additional educational resources are required.²

Unfortunately, continuing medical education for physicians is challenging due to overwhelming volumes of literature, time constraints, and imperfect information retention.¹² The awareness-to-adherence model describes that physicians who are regularly trying to implement knowledge into practice first require awareness, agreement, and intention.¹³ To mitigate these barriers, infographics have been used to improve both exposure and knowledge.¹²

Infographics (or information graphics) are data visualizations that can convey large amounts of complex information succinctly and comprehensibly.^12,14 Infographics have been shown to be superior to text alone in terms of information retention due to a phenomenon known as the picture superiority effect – the idea that pictures are more likely to be remembered than words.^14,15 Compared to text-based resources, infographics are associated with higher reader preference, decreased cognitive load, and increased accessibility online and on mobile devices, which are preferred by emergency physicians.^12,16

Thus, we created two infographics that illustrate the emergency diagnosis and management of GCA and gout. Our goal was to provide easily accessible and consumable educational resources for emergency physicians (Figures 1 and 2). These serve as clinical diagnostic and management tools that providers can use on-the-job, while also being available as posters and educational tools for practicing physicians, medical trainees, and other healthcare professionals. If a rheumatologist receives a referral for one of these conditions, they may consider attaching the infographic in their letter back to the referring provider or posting the infographic on their clinic website to promote continuing education.

The GCA infographic was created using the 1990 and 2016 American College of Rheumatology (ACR) diagnostic criteria and 2021 ACR and 2018 European League Against Rheumatism (EULAR) management recommendations.^17-20 The gout infographic was created using the 2020 ACR guidelines for gout management.²¹ Each infographic was created in collaboration with four community rheumatologists to ensure accuracy and appropriateness, and reviewed with multiple community emergency physicians to ensure relevance. In addition, the GCA infographic is paired with a video synopsis by Dr. Joanne Jiang, a vasculitis fellow in Toronto, which can be found hyperlinked at youtube.com/watch?v=7bcJQTRztX8.

The infographics available in this article are to be used as a guideline only and may be re-distributed in their unmodified form in a non-commercial manner. Specifically, the algorithm proposed in the GCA infographic has not been empirically validated; however, future research will analyze its performance in classifying referrals from the emergency department.

Disclosure: The creation of these infographics was supported by
F. Hoffmann-La Roche AG through an unrestricted educational grant.

Monish Ahluwalia, MSc
MD Candidate (Class of 2023)
University of Toronto
Toronto, Ontario

Sabrina Campbell, HBSc
MD/MSc Candidate
University of Toronto
Toronto, Ontario

Sangeeta Bajaj, MD, FRCPC
Corporate Chief Division of Rheumatology
William Osler Health System
Brampton, Ontario

Raman Joshi, MD, FRCPC
Rheumatologist,
Brampton, Ontario

Tripti Papneja, MD, FRCPC
Clinician-Teacher,
University of Toronto
William Osler Hospital
Brampton, Ontario

Vandana Ahluwalia, MD, FRCPC
Former Corporate Chief of Rheumatology,
William Osler Health System
Brampton, Ontario

References:

1. Schlosser G, Doell D, Osterland C. An analysis of rheumatology cases presenting to the emergency room of a teaching hospital. J Rheumatol. 1988; 15(2):356-358.

2. Lacy A, Nelson R, Koyfman A, Long B. High risk and low prevalence diseases: Giant cell arteritis. Am J Emerg Med. 2022; 58:135-40.

3. Lazarewicz K, Watson P. Giant cell arteritis. BMJ. 2019 May 30; 365:l1964.

4. Weis E, Waite C, Roelofs KA. A predictive model for temporal artery biopsy in the setting of suspected giant cell arteritis: a validation study. Ophthal Plast Reconstr Surg. 2021; 37(3S):S23-S26.

5. Melville AR, Donaldson K, Dale J, et al. Validation of the Southend giant cell arteritis probability score in a Scottish single-centre fast-track pathway. Rheumatol Adv Pract. 2022; 6(1):rkab102.

6. Jinno S, Hasegawa K, Neogi T, et al. Trends in emergency department visits and charges for gout in the United States between 2006 and 2012. J Rheumatol. 2016; 43(8):1589-1592.

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9. Brunetti L, Vekaria J, Lipsky PE, et al. Treatment of Acute Gout Flares in the Emergency Department: Prescribing Patterns and Revisit Rates. Ann Pharmacother. 2022; 56(4):422-429. doi:10.1177/10600280211032295.

10. Towiwat P, Phungoen P, Tantrawiwat K, et al. Quality of gout care in the emergency departments: a multicentre study. BMC Emerg Med. 2020; 20(1):27. doi:10.1186/s12873-020-00319-w.

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12. Martin LJ, Turnquist A, Groot B, et al. Exploring the role of infographics for summarizing medical literature. Health Prof Educ. 2019; 5(1):48-57. doi:10.1016/j.hpe.2018.03.005.

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14. Scott H, Fawkner S, Oliver C, et al. Why healthcare professionals should know a little about infographics. Br J Sports Med. 2016; 50:1104-1105. doi:10.1136/bjsports-2016-096133.

15. Paivio A, Csapo K. Picture superiority in free recall: Imagery or dual coding? Cognit Psychol. 1973; 5(2):176-206.

16. Kalnow A, Beck-Esmay J, Riddell J, et al. Continuing medical education delivery preferences among physicians and advanced practice providers in emergency medicine. Cureus. 2021;13(12).

17. Hunder GG, Bloch DA, Michel BA, et al. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum. 1990; 33(8):1122-1128.

18. Maz M, Chung SA, Abril A, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and Takayasu arteritis. Arthritis Care Res. 2021; 73(8):1071-1087.

19. Hellmich B, Agueda A, Monti S, et al. 2018 Update of the EULAR recommendations for the management of large vessel vasculitis. Ann Rheum Dis. 2020; 79(1):19. doi:10.1136/annrheumdis-2019-215672.

20. Salehi-Abari I. 2016 ACR revised criteria for early diagnosis of giant cell (temporal) arteritis. Autoimmune Ther Approaches Open Access. 2016; 3:1-4.

21. FitzGerald JD, Dalbeth N, Mikuls T, et al. 2020 American College of Rheumatology guideline for the management of gout. Arthritis Care Res. 2020; 72(6):744-760.