Rheumatology is the part of medicine that studies, diagnoses and treats medical diseases of the musculoskeletal system and connective tissue.1

The rapid transformation undergone by rheumatology from the syndromes described a century ago (arthritis, arthrosis, gout) to our days has affected not only the pathologies that we can identify, but also the diagnostic techniques that have been developed and the treatments that are used. Rheumatology has clearly evolved more quickly than the resources and criteria which are allocated to our work.

One of the missions of the Sociedad Española de Reumatología (SER) is to supply all of the agents involved in treating rheumatological patients with the instruments that are necessary to improve their quality of life, ensuring they receive the best treatment. To this end it is necessary to create a list of the services that are available in excellent rheumatological care in the 21st century, while also determining their degree of complexity. This list will make it possible to offer the whole range of diagnostic-therapeutic procedures used in rheumatology, together with the standardised degree of complexity of each intervention. It will also be a fundamental instrument for minimising geographical variability in the offer of medical procedures, ensuring that excellent rheumatological care is available throughout Spanish territory.

A list of updated medical interventions agreed by rheumatology professionals and ranked according to their level of complexity would function as a reference to reduce variability in resource availability and improve the quality of care for patients with rheumatic pathology. Although several working criteria currently exist for this purpose, they are obsolete and none of them meets the needs of doctors. The nomenclature of the Organización Médica Colegial does not cover a large part of the work in the speciality of rheumatology2 (Appendix B). On the other hand, the terms applied by insurance companies are very short and incomplete, and they vary widely from province to province.

There is therefore a need to update, broaden and standardise these criteria. In 2006 Olivé et al. prepared a nomenclature for the speciality of Rheumatology with the aim of validating acronyms.3 Although this work covered medical interventions, it did not take their complexity into account. This study has the aim of preparing a nomenclature of medical interventions that is based on a complexity index (CI) which includes the difficulty of the said interventions as well as how long they take to implement. The duration that is desirable in carrying out each medical intervention was stipulated in the work by Alonso et al.4 using the criterion of care quality. This was set in their work using a similar method to ours, that of agreement by a panel of experts using the two-round Delphi process.

The CI was suggested as an approximate measurement of the difficulty of care, with all of the limitations that this involves, as there is no precedent at all in the literature in this field that could be used as a standardised template. Other complex elements such as doctors’ experience or training, the possibility of access to technology or the cost of materials were not included, to prevent increasing variability and arbitrariness.

A total of 54 interventions were identified and evaluated. 93.3% (28/30) of the panellists took part in the Delphi method.

This work made is possible to prepare an updated ranked nomenclature of the 54 medical procedures undertaken by Spanish rheumatologists in their habitual clinical practice.

The reference criterion for the whole state is the one approved by the Organización Médica Colegial,2 with data from the year 2003. This only includes 20 procedures, of which 4 are hospital visits on different days after admission. This criterion contains no more than half of the interventions which are intrinsic to rheumatology. Individually, each hospital and each insurance company applies a different list of care interventions, and these lists vary widely.

Caring for patients with systemic or inflammatory pathology requires the quantification of outcome assessments to establish treatment strategies, in the search for a therapeutic objective. For decades, patient perception of their own health and how disease affects different areas of their life has been taken into account in evaluating quality of life. It is also used as a disease activity parameter. These assessments are obtained in part from questionnaires completed by patients, which are routinely applied in medical departments (Patient Reported Outcomes). Their use and application are considered to be indispensible for the standardised quantification of working in many pathologies.5–7 This is also the case for therapeutic decision-making and measuring the results of clinical trials, so that they have to be included as tasks which are intrinsic to the speciality. Depending on whether they consist of evaluations of quality of life, psychopathological factors, functional impact or pain, their complexity index is said to stand at from 58.5 to 69.3.

In recent decades rheumatology has seen exponential progress in new treatments. The administration of intravenous therapies such as bisphosphonates in metabolic bone diseases, biological therapies in systemic or inflammatory diseases and intravenous immunoglobulin or cyclophosphamide all form part of the usual routine in contemporary rheumatology. Due to the need to administer these drugs, rheumatology departments began to include day hospital care departments, and this is now habitual. They also include the administration of diagnostic or therapeutic techniques, as well as support for clinical trials. 77.7% of rheumatologists have a day hospital (unpublished SER data). In the VALORA study, 91% of Day Hospital Units use integrated visits that cover clinical evaluation, analysis and procedures. The average number of treatments carried out in these units by rheumatology amounted to 748.3, while it totalled 1126.73 in complex hospitals.8 It was found that work in these units should be updated and included within our nomenclature, and it was evaluated with a resulting complexity index of from 159 to 114, depending on whether it was the first or a post-treatment visit.

Rheumatology has progressed thanks to the inclusion of new treatments, and another major revolution has occurred in the use of new diagnostic and therapeutic tools and techniques such as capillaroscopy, which are intrinsic to the speciality and in widespread use. In fact, 72.1% of rheumatologists have direct access to this technique (unpublished SER data) together with, and more recently, ultrasound scan imaging.

Ultrasound imaging really has become a highly useful complementary form of examination for rheumatologists. It permits the harmless, static and dynamic evaluation of joint, muscle, tendon and ligament pathologies, as well as compression and vascular neuropathies. Given its usefulness, the SER founded an ultrasound imaging school in 1996. This has a teaching staff of 28 experts, and they have taught 420 courses to date, training more than 1000 rheumatologists. 71.7% of rheumatologists had their own ultrasound scan device in 2014 (unpublished SER data). Ultrasound imaging has attained a position of honour in the current nomenclature of the speciality. It is an effective diagnostic tool as it offers a good approximate view of lesion anatomy and inflammatory activity by using a scale of greys9 and the Doppler signal,10,11 respectively. It is a technique that supports other imaging tests for ultrasound-guided intra-articular contrast injection. For treatment, the spread of ultrasound imaging has led rheumatologists to adopt new interventionist techniques that can be undertaken with greater precision. These include blockages, arthrocentesis or infiltrations and ultrasound-guided treatments. These processes were graded with a complexity index of up to 387, in the case of paediatric joint puncture with sedation.

Although some techniques such as synovial, nerve, saliva gland, temporal artery or bone biopsy are not exclusive to rheumatologists, it should not be forgotten that they are habitually performed in some rheumatology units. Nor should it be forgotten that in other rheumatology units, rheumatologists themselves control pain by using more specific interventionist techniques such as epidural infiltrations.12 The interventionist techniques defined as the most complex were biopsies, particularly bone biopsy.

Densitometry has been validated as a bone density quantification technique13 and its result may form part of the international indexes used to calculate the risk of fracture.14 Rheumatologists perform this test or evaluate its results regularly in their work for the diagnosis and treatment of osteoporosis. In fact, 20% of rheumatology departments have their own densitometer (unpublished SER data) so that we agree that they should be present in all lists of medical procedures concerning our speciality, with a complexity rating somewhat higher than that of a successive visit (111 vs 100).

Rheumatic diseases are one of the main causes of disability and disease burden worldwide. Data on the impact of musculoskeletal diseases on health indicate that almost 1 in 4 Spanish people have a rheumatic disease; neck pain and lumbago were the chief causes of disability in Spain in 2016.15,16 This justifies the frequency with which rheumatologists are asked for reports in their clinical practice that officially justify some type of disability or handicap. Moreover, rheumatologists may intervene as experts or prepare special expert reports as a part of their work outside care. Such reports were evaluated as having a complexity index of 322 and 370.

This work supplies the first ranked and agreed nomenclature of a medical speciality undertaken by a state scientific society. A tool has been constructed to improve patient care and minimise geographical variations in all areas of care.

This work was financed by the Sociedad Española de Reumatología from the assignment for Services to Members and Private Practice.

The authors have no conflict of interests to declare.