Background Rheumatologists are increasingly performing ultrasound (US) imaging in the clinic as an additional tool to aid patient diagnosis and management decisions. The National Institute for Clinical Excellence (NICE) has recognised the importance of early detection of persistent synovitis and initiation of disease-modifying anti-rheumatic drugs (DMARDs), which have beneficial effects on long-term patient outcomes. The recent NICE appraisal on RA management highlights the need to determine the role of imaging in assisting with early diagnosis and whether the added cost is justified by better outcomes1.
Objectives To describe the impact of US use by rheumatologists on the diagnosis and management of RA patients in routine UK clinical practice when compared to those not using US.
Methods A prospective, non-interventional, multi-centre study was conducted within 4 secondary care rheumatology clinics. Eligible centres were those that had one consultant using US to aid diagnosis and management and one consultant who did not. Patients aged > 18, newly referred to the rheumatology clinic with suspected inflammatory arthritis were included. Data were collected on demographics, investigations (such as US, MRI, blood tests), diagnosis, subsequent management, and for patients diagnosed with RA, outcomes at 1 year.
Results 258 patients were included across 4 centres. Of these, 134 were diagnosed and managed by clinicians routinely using US and 124 by clinicians not routinely using US. Mean age was 51.28 (SD 15.75) years in the US group and 53.12 (SD 17.34) in the non-US group. The percentage of males in the US and non-US groups was 31% and 35%, respectively. 42% (56/134) of the US and 47% (58/124) of the non-US group had a diagnosis of RA.
A significantly greater proportion of patients in the US group received a formal diagnosis at their 1st clinic visit (36% v 19%, respectively, Fisher’s exact test p=0.002). A similar difference was observed for patients with a diagnosis of RA (46% v 19%, respectively, Fisher’s exact test p=0.003).
Where patients had a diagnosis of RA, there was a significant difference in the time to diagnosis (1.27 v 1.94 months in US and non-US group, T test, p=0.043). For those initiated on a DMARD, there was a significant difference in time to initiation (1.45 v 2.38 months in US (n=54) and non-US group (n=55), T test p=0.02).
Conclusions This study shows that routine use of US in newly referred patients is associated with an earlier diagnosis and earlier DMARD initiation in patients with RA. Whilst earlier diagnosis and treatment is known to lead to better outcomes2, a large prospective study is required to explore the long-term clinical impact and cost-effectiveness of wider routine use of US by rheumatologists in the UK NHS.
NICE CG79: Rheumatoid arthritis: The management of rheumatoid arthritis in adults.
M. van der Linden et al. Long-term Impact of Delay in Assessment of Early Arthritis Patients. Arthritis & Rheumatism; Online: August 18, 2010
Acknowledgements This study was sponsored by AbbVie. pH associates, a company specialising in real world evaluation, supported Abbott and the authors to develop the protocol, conduct the study and analyse the results.
Disclosure of Interest None Declared