Objective The aim of this study was to evaluate referral and treatment delays by ethnicity/race in patients with rheumatoid arthritis (RA) treated at an academic rheumatology center. Methods We reviewed the medical records of all RA patients evaluated at an outpatient clinic between 2011 and 2016 to identify newly diagnosed and naive-to-treatment patients. We determined the durations between symptom onset and first rheumatology visit and time to initiate treatment. Data extraction included referral source, demographics, treatment, and laboratory tests. Routine use of a multidimensional health assessment questionnaire allowed us to calculate baseline RAPID3 (routine assessment of patient index data 3) scores. Comparisons between self-reported ethnicity/race groups were performed. We used logistic regression models to analyze associations between baseline variables and early referral. Results Data from 152 disease-modifying antirheumatic drug-naive RA patients were included in the study; 35% were white, 37% black, 20% Hispanic, and 8% other. The range in median time to first rheumatology visit was 6 to 8 months for all patient groups, except Hispanic. This group had a median time of 22.7 months (p = 0.01). The referral pattern was considerably variable between-groups; 40% of Hispanic patients were self-referred (p = 0.01). There were no statistically significant between-group differences for time to treatment initiation according to ethnicity/race. RAPID3 scores (p = 0.04) and erythrocyte sedimentation rates (p = 0.01) were significantly higher in the black and Hispanic groups. A high C-reactive protein value at baseline was associated with earlier referral. Conclusions There is significant delay in initial presentation to a rheumatologist that was associated with a higher disease severity at presentation, especially for Hispanic patients.
BackgroundDespite introduction of powerful biologic medications over the last 2 decades, rates of remission and low disease activity rates in RA remain less than 50%. One possible basis is that measures and indices such as disease activity score 28 (DAS28) and clinical disease activity index (CDAI), while sensitive primarily to disease activity in clinical trial patients selected for high inflammatory activity, may also reflect clinically important joint damage and patient distress in unselected patients in routine care. Similar considerations may pertain to systemic lupus erythematosus disease activity index (SLEDAI), Bath ankylosing spondylitis disease activity index (BASDAI), and other measures and indices initially designed to assess disease activity. Levels of organ damage and patient distress, as well as inflammation, may be quantitated according to 3 physician (0-10) visual analog scales (VAS), in addition to physician global assessment VAS (DOCGL), scored in fewer than 10 seconds in routine care.ObjectivesTo test a hypothesis that damage and distress may be prominent in patients with inflammatory conditions, according to mean VAS for inflammation or reversible findings (DOCINF), damage or irreversible findings (DOCDAM), and distress (DOCSTR), e.g., fibromyalgia.MethodsAll patients at one site complete a multidimensional health assessment questionnaire (MDHAQ), which includes patient global VAS (PATGL), at each visit in routine care. Physicians complete four 0–10 (none-highest) VAS for DOCGL, DOCINF, DOCDAM, and DOCSTR, and a query to estimate the proportion of clinical decisions (total=100%) attributed to each of the 3 findings. Patients were classified into various diagnostic groups, in which scores were analyzed according to mean and standard deviation.ResultsAnalyses included 563 patients (Table). Mean levels of DOCGL ranged from 3.2 to 5.2, and PATGL from 3.6 to 6.5, which might be interpreted to indicate high disease activity. Highest mean DOCINF scores were seen in patients with RA, SLE, vasculitis, polymyalgia rheumatica (PMR), spondyloarthropathy (SpA), and gout (2.2-2.8), while highest mean DOCDAM was seen in OA (4.9) and DOCSTR in FM (6.2) (Table). However, in RA, mean DOCDAM was 3.7 vs 2.4 for DOCINF. DOCDAM also was almost as high or higher than DOCINF in SLE, SpA, vasculitis, and gout. Mean estimates of distress were also ≥1.5 in patients with all inflammatory diagnoses. Diagnosis (per ICD code) N (%) Global Estimates (0-10) Physician subscales (0-10) PATGL DOCGL DOCINF DOCDAM DOCSTR RA644.9 (2.9)4.5 (2.4)2.4 (2.2)3.7 (2.8)1.9 (2.7)SLE474.1 (3.1)3.7 (2.8)2.2 (2.4)1.5 (1.7)1.8 (2.5)SpA and psoriatic arthritis344.1 (2.9)3.9 (2.4)2.4 (2.5)2.7 (2.3)1.9 (2.8)Vasculitis and PMR233.6 (2.6)3.4 (3.0)2.6 (1.8)2.3 (2.2)1.7 (2.6)Gout214.4 (2.9)4.2 (2.7)2.8 (2.5)3.2 (2.8)1.5 (1.9)Osteoarthritis1355.8 (2.9)4.9 (2.2)1.2 (1.9)4.9 (2.5)2.2 (2.7)Fibromyalgia846.5 (2.6)5.2 (2.2)0.9 (1.2)1.7 (2.0) 6.2 (2.6)Other diagnosis1554.0 (3.0)3.2 (2.2)1.6 (2.0)2.4 (2.3)1.6 (2.1)TOTAL5634.8 (3.0)3.9 (2.4)1.6 (2.0)2....
BackgroundSeveral outcomes and clinical response measures have been used in patients with polymyalgia rheumatica (PMR), but there is no consensus about the optimal endpoint for evaluating response to treatment. A PMR activity score has been proposed which includes three patient reported outcomes (PROs)1. RAPID3 is an index found on a multidimensional health assessment questionnaire (MDHAQ) only including PROs, which is effective to document improvement not only in RA but also in other rheumatic diseases2ObjectivesTo prospectively evaluate the performance of RAPID3 and other PROs included on the MDHAQ to document improvement in clinical status over time in patients with PMR.MethodsThis study was conducted at an academic rheumatology center at which all patients complete a MDHAQ, which includes 0–10 scores for physical function (FN), pain (PN), and patient global estimate (PATGL), compiled into a 0–30 RAPID3. The MDHAQ also scores fatigue, morning stiffness, self-reported joint counts and demographic data. Data collection included MDHAQ, acute-phase reactants, and prednisone dose. PMR patients with complete data seen between 2010 and 2014 were included. A baseline visit and the most recent visit were compared using paired t-test and McNemar's test. Spearman correlation analysis for non-normally distributed variables was performed between RAPID3 and ESR and CRP.Results34 PMR patients seen in routine care were included: 59% were females, 71% Caucasian, and mean age was 71.6 years. The mean duration from a baseline visit to most recent visit was 15.5 months. At initial presentation, RAPID3 was 12.2, FN 2.2, pain 5.3, and PATGL 4.7, fatigue 3.9, and morning stiffness 63.1 minutes; 64.7% of the patients had painful hips, 79.4% had painful shoulders, 73.5% had abnormal ESR, and 70.6% had abnormal CRP. Significant improvement was seen between baseline and last visit in mean level of RAPID3 and all other MDHAQ measures, except fatigue (p<0.05), as well as ESR and CRP (Table). The mean dose of prednisone was decreased from 12.2 mg at first visit to 4.3 mg at most recent visit. The RAPID3 was significantly correlated with ESR (rho=0.52), and with CRP (rho=0.50).Table 1PMR patients (n=34)Mean change% ImprovementBaselineMost recent visitP valueMDHAQ: patient self-reported measures RAPID3, mean (SD)12.2 (7.0)8.5 (7.2)0.023.730.7% MDHAQ – Function, mean (SD)2.2 (2.1)1.5 (1.7)0.030.627.2% MDHAQ – Pain, mean (SD)5.3 (2.9)3.4 (3.4)0.0021.935.8% MDHAQ – PATGL, mean (SD)4.7 (2.9)3.1 (3.1)0.011.634.0% RADAI – painful hip, n (%)22 (64.7%)12 (35.3%)0.0229.445.4% RADAI – painful shoulder, n (%)27 (79.4%)17 (50%)0.0051037.0% MDHAQ – Fatigue, mean (SD)3.9 (3.6)3.5 (3.3)0.540.410.5% Morning stiffness duration, minutes, mean (SD)63.1 (97.7)19.1 (34.1)0.0543.969.5%Laboratory measures Abnormal ESR, n (%)25 (73.5%)14 (41.1%)0.0023243.5% Abnormal CRP, n (%)24 (70.6%)13 (38.2%)0.013245.3%Medication Prednisone dosage, mg, mean (SD)12.2 (6.8)4.3 (3.5)<0.0017.964.7%ConclusionsIn patients with PMR, improvement was seen according to PROs included on a ...
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