The Development and Implementation of a Rheumatology Referral‐Based, General Internal Medicine‐Led Fibromyalgia Clinic and Preliminary Patient Outcomes

Fibromyalgia is a debilitating pain syndrome affecting 2%–10% of Americans (Gota 2021). Patients with fibromyalgia frequently seek care from their primary care physician (PCP) or rheumatologist; however, patients encounter several barriers to finding high-quality care. Challenges include inadequate fibromyalgia knowledge among PCPs, difficulty accessing rheumatology speciality care and negative provider perceptions towards patients with fibromyalgia (Battafarano et al. 2018; Byrne et al. 2023; Pang et al. 2021; Van Wilgen et al. 2024). We created a rheumatology referral-based general internal medicine-led fibromyalgia clinic. The goals of the clinic were multifactorial. The clinic aimed to provide patients with fibromyalgia compassionate, evidence-based care and to shift the care of patients with fibromyalgia from rheumatology to general internal medicine. We conducted a quality improvement study to assess the short-term and long-term impacts of our fibromyalgia clinic on patients' symptom control. The fibromyalgia clinic was created via an institutional collaboration between the division of rheumatology and the division of general internal medicine and was supported by the department of medicine. The division of rheumatology was struggling with two issues that prompted the creation of the fibromyalgia clinic: (1) local rheumatology practices were receiving many referrals to aid in the diagnosis and management of fibromyalgia and (2) the burden of increased referrals led to long wait times for new patient appointments. By creating a specific fibromyalgia clinic, we aimed to provide timely, high-quality care and increased access to the rheumatology department for patients with autoimmune/inflammatory conditions. Patients had an initial evaluation with a rheumatologist to ensure no concomitant autoimmune/inflammatory condition was present and then were referred to the fibromyalgia clinic for fibromyalgia specific care and ongoing management needs. The initial rheumatology evaluation was conducted in various ways based on patient needs and degree of suspicion for autoimmune/inflammatory disease. Some patients were referred after a brief telemedicine appointment, whereas others were referred after a longer evaluation necessitating several in-person appointments. Although fibromyalgia and autoimmune/inflammatory conditions frequently co-occur, the fibromyalgia clinic targeted patients with only fibromyalgia. The division of rheumatology continued to manage patients with fibromyalgia and concurrent autoimmune/inflammatory conditions, but the fibromyalgia clinic was available to these patients if the fibromyalgia care team could offer additional services (e.g., medical marijuana certification) that were not readily available through rheumatology. The care team at the fibromyalgia clinic consisted of two pharmacists, two physicians, one behavioural health therapist and nurses. The initial visit included a 30-min pharmacist visit and a 1-h physician visit. The pharmacist performed a medication reconciliation, reviewed prior pharmacological therapies and discussed additional pharmacological options. The pharmacist also made a recommendation to the physician regarding pharmacologic options and was available to help with medication changes or cross tapers (e.g., changing gabapentin to pregabalin or selective serotonin reuptake inhibitors [SSRIs] to selective norepinephrine reuptake inhibitors [SNRIs]). The goals of the initial physician visit were to confirm the diagnosis of fibromyalgia; identify other pain generators (e.g., osteoarthritis) or concurrent chronic pain conditions (e.g., migraines and irritable bowel syndrome), provide empathetic listening, validation and education about fibromyalgia; review prior treatment modalities and create a new treatment plan involving pharmacologic, non-pharmacologic and behavioural health interventions. Pharmacologic management options offered included SNRIs (e.g., duloxetine and milnacipran), tricyclic antidepressants (TCAs) (e.g., nortriptyline and amitriptyline), gabapentinoids (e.g., gabapentin and pregabalin), muscle relaxers (e.g., cyclobenzaprine), low-dose naltrexone, and medical marijuana (Bair and Krebs 2020; Macfarlane et al. 2017; Ram et al. 2023; Strand et al. 2023; Thorpe et al. 2018; Yang et al. 2023). Non-pharmacologic intervention options included physical therapy, aqua therapy, chronic pain occupational therapy and cognitive rehabilitation (Braz Ade et al. 2011; Poole and Siegel 2017; Rodriguez-Huguet et al. 2024). Acupuncture and chiropractor services were also discussed depending on patient interest and insurance coverage (Deare et al. 2013; Han et al. 2023; Schneider et al. 2009). Non-pharmacologic services were not co-located at the fibromyalgia clinic and patients had to make separate appointments for these services. The behavioural health therapist did not routinely evaluate all patients but was available to work with patients if they desired cognitive behavioural therapy, counselling, emotional support, stress reduction techniques and/or for patients with comorbid mood disorders (Cojocaru et al. 2024). Nurses assisted with inter-visit care by answering patient questions or concerns, processing medication refills and coordinating referrals. The nonpharmacologic management options and the selection of team members were based on guidelines, studies and expert recommendations in the literature and influenced by the availability of local resources (Bair and Krebs 2020; Häuser et al. 2009; Giusti, Castelnuovo, and Molinari 2017; Gota 2021; Macfarlane et al. 2017). Patients were offered 20-min follow-up physician visits every 6 weeks for three follow-up visits to review the response to treatment modalities and modify the treatment plan as needed. At the end of the four visits, care was returned to the patients' PCP with anticipatory guidance. This structure allowed us to continually accept new patients on a weekly basis and provide enough follow-up appointments for patients enrolled in the program. Physicians had 4 h of fibromyalgia clinic time per week (two new patient appointments and six follow-up appointments). Rheumatology was available for re-consultation if new concerns emerged for an autoimmune/inflammatory disease. We assessed patient outcomes using the Fibromyalgia Impact Questionnaire-Revised (FIQR), a validated questionnaire that quantifies fibromyalgia symptoms, overall impact and functional impact with scores increasing in severity from 0 to 100 (Bennett 2005; Bennett et al. 2009; Burckhardt, Clark, and Bennett 1991; Williams and Arnold 2011). The FIQR was administered at the intake appointment (initial FIQR), within 6 months of the final appointment (final FIQR) and 6 months or more after the final appointment (post-final FIQR). FIQRs were completed in a variety of ways including paper surveys, electronic surveys through electronic medical records and over the phone. To be included in the study, patients had to satisfy the American College of Rheumatology (ACR) 2016 diagnostic criteria for fibromyalgia, complete an initial FIQR, attend a minimum of 2 appointments and complete either a final FIQR or a post-final FIQR or both. The primary outcome was change in FIQR score with a score reduction of 8 points considered clinically significant (Williams and Arnold 2011). Patients were organised into three groups based on FIQR completion status (Figure 1). Patient characteristics of the three groups were compared using Fisher's Exact test for sex and race, and Kruskal–Wallis test for age, FIQR scores, number of formal non-pharmacologic services utilised per patient and number of prescribed fibromyalgia-specific medications per patient. Non-pharmacologic services included formal programmes such as aqua therapy, occupational therapy and physical therapy within our health system. Fibromyalgia-specific medications included SNRIs, TCAs, gabapentinoids, muscle relaxers, low dose naltrexone and medical marijuana. A mixed model with repeated measures analysis was performed to determine if observed reductions in FIQR scores were statistically significant between timepoints. This study was approved by the institutional quality improvement committee. As this was a service evaluation, ethical approval was not required. Study design flow chart. †American College of Rheumatology, ‡Fibromyalgia Impact Questionnaire-Revised. We also collected and reviewed informal verbal and written feedback about aspects of the fibromyalgia clinic. Patients were asked what aspects they found beneficial and what aspects they would change about the fibromyalgia clinic. Patient feedback was collected after the final follow-up visit. Feedback questionnaires were administered through the electronic medical record or verbally if the final- or post-final FIQR was administered over the phone and the patient had not previously completed the electronic questionnaire. Between February 2021 and June 2022, 146 patients were evaluated; 56 patients were included in the study (Figure 1). Most patients were white (50/56, 89%) and women (51/56, 91%); patients' mean age was 45 years. FIQR scores by group are reported in Figure 2. Group 1, as compared to group 2 and group 3, had lower mean FIQR scores (p = 0.01 and p = 0.04 respectively). There was not a significant difference in mean FIQR scores between group 2 and group 3. All three groups had similar patient characteristics with regard to age, sex, race, number of formal non-pharmacologic services utilised per patient and number of prescribed fibromyalgia-specific medications per patient (Table 1). Groups 1 and 2 demonstrated a statistically and clinically significant reduction from initial FIQR to final FIQR scores. Group 1 maintained a clinically significant, but not statistically significant, FIQR score reduction at the post-final timepoint. Group 3 did not demonstrate a significant change between initial FIQR and post-final FIQR scores. Fibromyalgia Impact Questionnaire-Revised scores over time by patient groups. *p < 0.001, †Fibromyalgia Impact Questionnaire-Revised. Informal verbal and written patient feedback was positive, with patients noting a benefit from empathetic listening, symptom validation and education. Multiple patients requested long-term follow-up options. The fibromyalgia clinic significantly improved symptom control for patients within 6 months of programme completion, but we observed regression in fibromyalgia control 6 months or more after programme completion. The fibromyalgia clinic has some differences as compared to other programmes or clinics previously described. The fibromyalgia clinic provides individualised care, whereas other programmes are primarily group-based (Häuser et al. 2009; Giusti, Castelnuovo, and Molinari 2017). Most other programmes, as compared to the fibromyalgia clinic, are shorter (less than 12 weeks) but more intense, ranging from 8 to 150 h (Giusti, Castelnuovo, and Molinari 2017). Despite the unique features of the fibromyalgia clinic, our findings are consistent with other studies of fibromyalgia programmes, which demonstrated short-term (3–4 months) symptom improvement but not long-term (6–12 months) symptom improvement (Häuser et al. 2009). Several factors may have contributed to the regression of fibromyalgia control, including returning care to providers without fibromyalgia expertise, the short-term nature of some non-pharmacologic treatments such as a set number of occupational therapy visits, lapse in prescription medications and the waxing and waning nature of fibromyalgia. As a result of the regression of fibromyalgia control and patient requests for long-term follow-up, the clinic has implemented booster sessions. Booster sessions are 30-min follow-up appointments reserved for patients who have completed the acute management phase of the programme and wish to follow-up at longer intervals (e.g., 6–12 months for check-ins or ongoing medication management) or for patients who previously graduated from the programme and wish to be re-evaluated. To implement booster sessions, one new patient slot per month per physician was converted to two booster sessions. Although this decreased new patient access slightly, we felt this was the best balance between serving new patients and continuing to serve our established patient population. Limitations of this study include small sample size, lack of a control group and single institution design. Unfortunately, we are unable to comment as to whether the fibromyalgia clinic led to decreased wait times for rheumatology as several interventions to improve patient access were implemented concurrently. The uptake of formal non-pharmacological services appears low; however, we were only able to quantify patients' participation in formal programmes within our health system. Many patients also participated in non-formal pharmacological therapies at home (e.g., yoga and light exercise) or programmes outside of our health system (e.g., private practice acupuncture). Strengths of the study include assessing both short-term and long-term patient outcomes of a novel, individualised fibromyalgia programme. Next steps, specifically for our clinic, include continuing to evaluate and develop the clinic in an iterative fashion to ensure we are meeting patient needs. We plan to study short-term and long-term patient outcomes including symptom severity and patient satisfaction after the implementation of booster sessions. Other important areas of study to advance the delivery of care to patients with fibromyalgia include continuing to define the most effective elements of a multicomponent fibromyalgia programme and providing ongoing medical education to other providers to enhance the care patients with fibromyalgia receive in all settings. We described the development and implementation of a novel rheumatology referral-based general internal medicine-led fibromyalgia clinic. Preliminary findings from a quality improvement study demonstrated improved fibromyalgia control after completion of the programme; however, patients experienced a regression in symptom control 6 months after completion. Based on these findings and informal patient feedback, the fibromyalgia clinic implemented booster sessions that provide a 6- to 12-month follow-up option for patients who prefer to continue to follow with the clinic or patients who have completed the programme and experience regression in symptom control. Catherine Pressimone and Katherine Lane were primarily responsible for the acquisition of data and organisation of data. Rachel Vanderberg, Jillian Kyle, Carly Gabriel, and Trisha Miller were responsible for conception, design, and critical review of the study. Kristine Ruppert was responsible for analysing the data. All authors have made substantial contributions, were involved in drafting/revising the manuscript, given final approval for the manuscript and are accountable for the integrity of the work. The authors would like to acknowledge Ethan Lennox for his editorial support. This study was approved by the UPMC Quality Improvement Committee. As this was a service evaluation, ethical approval was not required. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.