Objectives (1) To investigate the demographic and clinical characteristics contributing to the delay from symptom onset to the first visit to a rheumatologist; (2) to compare clinical, radiographic and patient-reported outcome measures of those who saw a rheumatologist early in their disease course with those who were diagnosed later. Methods All psoriatic arthritis (PsA) patients, fulfilling CASPAR criteria, with an average disease duration of >10 years were invited for detailed clinical evaluation. The total lag time from symptom onset to their first rheumatological encounter was studied. The data were extracted from the referral letters and medical records. Patients were classified as early consulters or late consulters depending on whether they were seen by a rheumatologist within or beyond 6 months of symptom onset. Results 283 PsA patients were studied. Median lag time from the disease onset to the first rheumatological assessment of the cohort was 1.00 years (IQR 0.5–2). 30% (n=86), 53% (n=149) and 71% (n=202) of the cohort were seen by a rheumatologist within 6 months, 1 and 2 years of symptom onset, respectively. PsA patients with low education status (OR 2.09, p=0.02) and Body Mass Index (OR 0.92, p=0.01) were significantly more likely to have a diagnostic delay of >2 years. On multiple stepwise regression analysis, the model predicted significant association of late consulters with the development of peripheral joint erosions (OR 4.25, p=0.001) and worse Health Assessment Questionnaire scores (OR 2.2, p=0.004). Conclusions Even a 6-month delay from symptom onset to the first visit with a rheumatologist contributes to the development of peripheral joint erosions and worse long-term physical function.

https://ard.bmj.com/content/annrheumdis/74/6/1045.full.pdf

Diagnostic delay of more than 6 months contributes to poor radiographic and functional outcome in psoriatic arthritis

Objective
During the last decade, rheumatologists have learned to initiate disease-modifying antirheumatic drugs (DMARDs) early to improve the outcome of rheumatoid arthritis (RA). However, the effect of delay in assessment by a rheumatologist on the outcome of RA has scarcely been explored. The purpose of this study was to examine the association between delay in assessment by a rheumatologist, rates of joint destruction, and probability of achieving DMARD-free remission in patients with RA. Patient characteristics associated with components of delay (by the patient, by the general practitioner [GP], and overall) were assessed.

Methods
A total of 1,674 early arthritis patients from the Leiden Early Arthritis Clinic cohort were evaluated for patient delay, GP delay, and total delay in assessment by a rheumatologist. Among 598 RA patients, associations between total delay, achievement of sustained DMARD-free remission, and the rate of joint destruction over 6 years followup were determined.

Results
The median patient, GP, and total delays in seeing a rheumatologist among patients with early arthritis were 2.4 weeks, 8.0 weeks, and 13.7 weeks, respectively. Among all diagnoses, those diagnosed as having RA or spondylarthritis had the longest total delay (18 weeks). Among the RA patients, 69% were assessed in ≥12 weeks; this was associated with a hazard ratio of 1.87 for not achieving DMARD-free remission and a 1.3 times higher rate of joint destruction over 6 years, as compared with assessment in <12 weeks. Older age, female sex, gradual symptom onset, involvement of the small joints, lower levels of C-reactive protein, and the presence of autoantibodies were associated with longer total delay.

Conclusion
Only 31% of the RA patients were assessed in <12 weeks of symptom onset. Assessment in <12 weeks is associated with less joint destruction and a higher chance of achieving DMARD-free remission as compared with a longer delay in assessment. These results imply that attempts to diminish the delay in seeing a rheumatologist will improve disease outcome in patients with RA.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/art.27692

Long-Term Impact of Delay in Assessment of Patients With Early Arthritis

Objective: The first 3 months after symptom onset represent an important therapeutic window for rheumatoid arthritis (RA). This study investigates the extent and causes of delay in assessment of pa ...

https://ard.bmj.com/content/annrheumdis/70/10/1822.full.pdf

Delays in assessment of patients with rheumatoid arthritis: variations across Europe

Objective To evaluate whether treating patients with very early inflammatory polyarthritis (IP) with a 3-week course of intramuscular (IM) methylprednisolone acetate may postpone the need for disease-modifying antirheumatic drugs (DMARDs) and prevent IP from evolving into rheumatoid arthritis (RA). Methods Patients with very early IP (4–10 weeks’ duration) were randomised to receive three injections of either 80 mg IM methylprednisolone acetate or placebo, given at weekly intervals. Assessments were monthly until 6 months after the first injection, and then concluded at 12 months. The primary outcome was the need to start DMARDs by the 6-month assessment. Secondary outcomes included disease activity and final clinical diagnosis by the rheumatologist at 12 months. Results Patients in the placebo group (76%) were more likely to need DMARDs during the first 6 months of the trial than patients in the glucocorticoid group (61%) (adjusted OR = 2.11, 95% CI 1.16 to 3.85, p = 0.015). Disease activity did not differ between the two groups at 12 months, probably because many patients in the placebo group started DMARDs early in the study. After 12 months, the arthritis had resolved without the need for DMARDs in 9.9% (11/111) of the patients in the placebo group and in 19.8% (22/111) in the glucocorticoid-treated group (adjusted OR = 0.42, 95% CI 0.18 to 0.99, p = 0.048). Conclusion Treatment of patients with very early IP with IM methylprednisolone acetate appears to postpone the prescription of DMARDs and prevent one in 10 patients from progressing into RA.

https://ard.bmj.com/content/annrheumdis/69/3/503.full.pdf

Beneficial effects of a 3-week course of intramuscular glucocorticoid injections in patients with very early inflammatory polyarthritis: results of the STIVEA trial

Background Despite the importance of timely
management of patients with infl ammatory arthritis (IA),
delays exist in its diagnosis and treatment.
Objective To perform a systematic literature review
to identify strategies addressing these delays to inform
an American College of Rheumatology (ACR)/European
League Against Rheumatism (EULAR) taskforce.
Methods The authors searched literature published
between January 1985 and November 2010, and ACR
and EULAR abstracts between 2007–2010. Additional
information was obtained through a grey literature search,
a survey conducted through ACR and EULAR, and a hand
search of the literature.
Results (1) From symptom onset to primary care,
community case-fi nding strategies, including the use
of a questionnaire and autoantibody testing, have been
designed to identify patients with early IA. Several
websites provided information on IA but were of varying
quality and insuffi cient to aid early referral. (2) At a
primary care level, education programmes and patient
self-administered questionnaires identifi ed patients with
potential IA for referral to rheumatology. Many guidelines
emphasised the need for early referral with one providing
specifi c referral criteria. (3) Once referred, early arthritis
clinics provided a point of early access for rheumatology
assessment. Triage systems, including triage clinics,
helped prioritise clinic appointments for patients with
IA. Use of referral forms standardised information
required, further optimising the triage process. Wait
times for patients with acute IA were also reduced with
development of rapid access systems.
Conclusions This review identifi ed three main areas of
delay to care for patients with IA and potential solutions
for each. A co-ordinated effort will be required by the
rheumatology and primary care community to address
these effectively.

https://ard.bmj.com/content/annrheumdis/early/2012/04/23/annrheumdis-2011-201063.full.pdf

A systematic literature review of strategies promoting early referral and reducing delays in the diagnosis and management of inflammatory arthritis

Objectives. To study the delay from the time of symptom onset to assessment by a Rheumatologist in patients with rheumatoid arthritis (RA) and to determine the contributions of patient and physician dependent factors to this delay. Methods. Data were collected from 169 consecutive patients with RA at the time of assessment by Rheumatologists working in hospitals serving an inner city population in Birmingham, UK. Dates were recorded for: (i) onset of inflammatory joint symptoms; (ii) initial assessment in primary care; and (iii) referral from primary to secondary care. (iv) initial assessment by a rheumatologist in secondary care. Results. The median delay from the onset of symptoms to a patient being assessed in secondary care was 23 weeks (IQR 12–54 weeks). The median delay before the patient was assessed in primary care was 12 weeks (IQR 4–28 weeks). For 96 patients (57%) more than half of the overall delay in assessment in secondary care was accounted for by a delay in assessment in primary care. Conclusions. Patient dependent factors, leading to a delay in consulting primary care physicians, are the principal reasons for the delay in patients with RA being seen by Rheumatologists in our population. A considerable body of evidence demonstrates that the earlier that therapy is introduced the better the clinical outcome. Consequently it is important to understand why some patients with RA delay in seeking medical advice, in order to allow effective interventions to reduce this delay.

/pdf/delay-in-presentation-to-primary-care-physicians-is-the-main-3wj5r0sxc2.pdf

E Daley

Papers

Delay in presentation to primary care physicians is the main reason why patients with rheumatoid arthritis are seen late by rheumatologists