Rheumatoid arthritis

Six months to specialist review: dissecting treatment delay in RA

Patient delay in presenting to the GP with symptoms of rheumatoid arthritis is one of the more significant factors in overall treatment delays in patients with new disease.

A retrospective review of 88 patients with RA seen at the Princess Alexandra Hospital’s Early Arthritis Clinic in Brisbane, found a median patient delay of 8.7 weeks in seeking care from a GP compared to just 4.0 weeks in subsequent investigations and referral from a GP to rheumatology.

Lower disease activity (DAS28) and fatigue scores reflecting the ‘more insidious onset of disease’ as well as lower socioeconomic status predicted greater patient delay.

Similarly, the study found lower disease activity, higher ESR and higher total joint count were associated with longer GP delay.

“Again this suggests that a more insidious disease onset process and non-specific markers of inflammation and musculoskeletal pain may lead to the consideration of alternative diagnoses ahead of RA and subsequently delayed rheumatology referral,” the study said.

They added the higher total joint count may have been dismissed as more generalised musculoskeletal pain.

The study also found longer overall delay from symptom onset to specialist review was related to clinical remission at six months.

About 80% of patients seen in less than 16 weeks enjoyed clinical remission compared to 63% of patients seen at 16-24 weeks, and just 38% of patients seen later than 24 weeks.

Rheumatologist Dr Helen Benham, from the Early Arthritis Clinic, told the limbic better patient education about the specific signs of inflammatory joint disease would be helpful.

“For example, morning stiffness, swelling and pain in the joints that is slightly outside of general pain or injury-related pain. So if we got more patients presenting with those symptoms of concern then the outcome would be better.”

Patients waited a median of 8.4 weeks from GP referral to rheumatology review. Overall time from symptom onset to specialist review was 26.4 weeks.

“12 weeks is considered to be this golden window of opportunity to capture the disease so that you can have a better outcome overall,” Dr Benham said.

“Most big centres will have a triaging process to ensure that inflammatory arthritis is seen within a window or an Early Arthritis Clinic. And most private rheumatologists will triage inflammatory arthritis from their referrals as well because everybody is aware of this window of opportunity.”

One of the other critical factors noted in the study was failure of some patients to attend their first scheduled appointment.

“This may be more likely at a weekly specialist clinic than in a setting with a range of appointment options, and in patients of lower socio-economic status who face a range of logistic challenges to attend or reschedule,” the study said.

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