Positive outcomes in rheumatoid arthritis are closely associated with early diagnosis and treatment with disease-modifying antirheumatic drugs, Dr. Vivian Bykerk stressed at the annual European Congress of Rheumatology. "Several important studies have shown that early intervention can lead to optimal outcomes for patients with early inflammatory arthritis. And the window of opportunity has been pushed back to 3 months, if not sooner."
That remark referred in particular to the recent study out of Leiden (the Netherlands) University Medical Center looking at 1,674 early arthritis patients from the Leiden Early Arthritis Clinic cohort, including 598 patients with rheumatoid arthritis (RA) (Arthritis Rheum. 2010;62:3537-46).
"The Leiden researchers looked at the association between delay to care and how many patients met sustained drug-free remission, and what happened to their rate of joint destruction over time. The first thing they saw, no matter how many years back they looked in their clinic, was that patients who were seen before 12 weeks of persistent symptoms had a much higher probability of reaching drug-free or DMARD-free sustained remission compared with those seen after 12 weeks," said Dr. Bykerk of Brigham and Women’s Hospital in Boston. Further, patients seen before 12 weeks had much less radiographic damage than did patients seen after 12 weeks of symptoms.
Although recent years have seen improvements in facilitating earlier access to rheumatologic care in patients with inflammatory arthritis, "persistent barriers to access still prolong time to diagnosis and treatment in many patients," said Dr. Bykerk, who addresses the nature of these treatment delays and strategies to overcome them in this month’s column.
Question: What is the typical path that patients with RA have to follow to get to rheumatologic care?
Dr. Bykerk: Most people who develop some kind of symptom of synovitis, swollen joint pain in their hands or feet, go to their primary care provider, who has to identify that the patient has inflammatory arthritis and make the decision to refer to an arthritis specialist. The specialist, depending on their wait list, will probably have some kind of triage system to determine how soon the patient should be seen. At some point, the patient will see the rheumatologist, who can diagnose RA quickly using the new ACR/EULAR diagnostic criteria (Arthritis Rheum. 2010;62:2569-81). Then the patient has to accept the fact that he or she has the disease, which isn’t always done quickly, and initiation of DMARDS has to occur.
Q: Where are the bottlenecks in the process that contribute to treatment delays?
Dr. Bykerk: In a new study, Dr. Shahin Jamal of the University of British Columbia and colleagues conducted a telephone survey and chart review to determine where treatment delays occurred in 204 patients and to identify contributing factors. Fewer than 25% of the patients were treated within 3 months of symptom onset. The median time from symptom onset to DMARD treatment was more than 6 months. The median time from symptom onset to rheumatology referral was 3 months, and from PCP [primary care provider] referral to rheumatology appointment to DMARD initiation was more than 2 months. There was no delay between RA diagnosis and DMARD treatment (J. Rheumatol. 2011;38:1282-8).
Q: What are the obstacles that contribute to the delays in getting rheumatologic care?
Dr. Bykerk: Many rheumatologists in many centers have very long waiting lists, and some have even closed their practices or will see only inflammatory disease. In many countries, patients require a referral to see a rheumatologist, so the primary care provider becomes the gatekeeper. As you can imagine, the squeaky wheel here gets the grease. The patients who present with polyarticular disease or very swollen joints are much more likely to get into the rheumatologist earlier, while patients with very subtle, early presentations, where you cannot detect any swelling in metacarpophalangeal [MTP] joints or where there are only a couple of MTP or proximal interphalangeal joints that are swollen, will probably have more of a delay. Also, the delays vary by geography and health care system. In some systems, there are financial disincentives for primary care physicians to refer patients out of their practices. In rural and suburban areas, there tend to be longer waiting lists. There may be primary care factors as well, such as a lack of awareness of the impact of early diagnosis and referral, and uncertainty as to whom to refer patients to.
Q: How can these barriers be overcome?
Dr. Bykerk: Several strategies have been implemented to address these delays. Some of them are well developed and validated, others are less developed, and some are very new in their design.