Long‐term impact of delay in assessment of patients with early arthritis

Abstract

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.

Has the Severity of Rheumatoid Arthritis at Presentation Diminished Over Time?

“…It is now widely accepted that patients should start DMARD as soon as possible and preferably within the first 12 weeks of the disease 11,12 . There has therefore been a decline in the time between a patient's first visit to a rheumatology clinic and the initiation of DMARD treatment 13,14 .…”

Disease‐specific knowledge and clinical skills required by community‐based physiotherapists to co‐manage patients with rheumatoid arthritis

“…These 2 knowledge themes, being alert to a presentation that may suggest RA and the importance of early referral to a rheumatologist, reflect the current medical management of RA, where a narrow window of opportunity exists in the early disease phase to slow or halt joint damage (41). Consequently, it is vital that a community-based physiotherapist is cognizant about the clinical features of early RA, in order to facilitate timely referral to a rheumatologist.…”

Who’s Holding Up the Queue? Delay in Treatment of Rheumatoid Arthritis

“…Several studies have identified patient characteristics such as female sex and older age as delaying presentation to the rheumatologist based on both patient and PCP delay 10,16 , although that was not a factor in this analysis or in other cohorts 15 . Jamal, et al actually report a trend toward significance of increased age and higher education in predicting earlier treatment.…”

“…Some authors have found patient delay to be significant 15 , others less so 10 . Several studies have identified patient characteristics such as female sex and older age as delaying presentation to the rheumatologist based on both patient and PCP delay 10,16 , although that was not a factor in this analysis or in other cohorts 15 .…”