Background The National Institute for Health & Clinical Excellence (NICE) issued guidelines for the management of rheumatoid arthritis (RA). It proposes urgent referral for specialist treatment if more than three months delay since symptom onset; offer combination disease modifying anti-rheumatic drugs (DMARDs) as first line treatment and if not appropriate to initiate monotherapy with fast escalation1. The British Society of Rheumatology (BSR) conducted a national audit to determine the speed of referral and onset of DMARD therapy2in RA patients. There were delays from onset of symptoms to referral, review by specialists and diagnosis to DMARD therapy. There is a perception there may be differences between ethnic groups in time of onset of symptoms to referral to a specialist centre and further institution of DMARDs.
Objectives We aimed to audit the above features in centres that are geographically located within areas containing a high BME population.
Methods Four centres were identified and a prospective proforma was devised and piloted. Consecutive BME RA patients on DMARDS that attended outpatient clinics were audited over an 8 week period and analysed. A brief comparison with a cohort of 23 Caucasian patients collected contemporaneously from Leicester was made in addition to the BSR National DMARD audit.
Results In total 101 patients were audited. 81% female with average age 50-59 years and disease duration of 6-10 years. 46% were Asian, 23% Afro-Caribbean and 23% Caucasian. 38% (BME group) compared with 7% (Caucasians) had more than six-months time delay from symptom onset to specialist referral. Time from referral to specialist treatment greater than three months was 24% BME group vs. 14% Caucasian group vs. 7% BSR group. 21% BME group vs. 3% Caucasian group vs. 18.7% BSR group had a delay of more than three months from diagnosis to initiation of DMARD therapy. 19% of the BME group had monotherapy in comparison to 16% of the Caucasian group. 22% of the BME group had biologic therapy with an average of 2-5 years post diagnosis, whilst no Caucasians had biologic therapy.
Conclusions Our results highlight differences in time from presentation and initiation of treatment for RA patients of BME origin. There may be a range of ethnically specific culturally centred reasons for such delays3,4. Culturally different migrant and non-migrant internal or national minorities can inadvertently become the objects of discrimination and exclusion. It is paramount that we gain further understanding of these reasons and cultural differences in order to educate and facilitate appropriate healthcare and support within this population. By empowering individual patients and their communities through culturally appropriate health education we can hopefully encourage patients to seek medical attention early and engage in the benefits of potentially toxic DMARDs and Biologics.
NICE Clinical Guideline 79, February 2009
Kumar et al. Delay in presentation to primary care physicians is the main reason why patients with rheumatoid arthritis are seen late by rheumatologists. Rheumatology 2007 46(9): 1438-1440
Kumar et al. The influence of ethnicity on the extent of, and reasons underlying, delay in general practitioner consultation in patients with RA. Rheumatology 2010 49(5): 1005-1012
Disclosure of Interest None Declared