Background Giant cell arteritis (GCA) requires prompt diagnosis and treatment to prevent irreversible neuro-ophthalmic complications. Conversely, misdiagnosis leads to unnecessary treatment with high dose glucocorticosteroids (GC) and their associated complications. The British Society of Rheumatologists (BSR) Guideline emphasises early recognition of symptoms and prompt treatment when index of clinical suspicion is high.
At East Surrey Hospital (ESH), we noted that some patients were not managed in accordance with BSR guidelines. Additionally, there is no existing care pathway for patients with suspected GCA to be referred to Rheumatology and for Temporal Artery Biopsy (TAB), often resulting in delayed care provision, or unnecessary use of healthcare resources.
Objectives This study aims to audit the management of patients with suspected GCA against BSR guidelines. It also aims to evaluate patients' journey, to identify inefficiencies within the management pathway, in order to initiate improvements in service.
Methods Case notes of patients seen in ESH with suspected GCA between March 2015 and December 2016 were reviewed retrospectively. Cases were identified through keyword search on hospital discharge letters and Rheumatology clinic letters.
Results Case notes of 67 patients (21M, 46F) were analysed. Of those presenting with suspected GCA, 31% fulfilled ACR classification criteria. 28% had documented visual symptoms at presentation.
Concordance with BSR guidelines: 79% of patients were started on GC at presentation. Of these 15% had a TAB within 7 days of starting GC. 34% were seen by a Rheumatologist within a week of presentation. Of those referred for a TAB 47% were performed within a week of referral.
Care Pathway: The majority of patients (78%) first presented to GPs. Despite this, only 64% of referrals to rheumatology were by GPs. Other referral sources included the Acute Medical Unit (27%) and ophthalmology (5%). 49% were seen by a Rheumatologist within 7 days from referral. 25% had a final diagnosis of GCA.
Conclusions The small proportion of patients with a final diagnosis of GCA highlighted that early Rheumatology assessment is important to minimise unnecessary TAB and high dose GC. Additionally, the lack of a structured care pathway and a standardised referral system for GCA meant that a large proportion of patients had delay in the diagnosis, inappropriate treatment with GC, and unnecessary TAB. These added to the burden of other already stretched medical specialities.
In light of this; a GCA pathway was implemented to enable rapid access to Rheumatology in patients with suspected GCA. The on-call team was advised to redirect any GP or A&E referrals with suspected GCA to the rheumatology on-call bleep. Patients will be assessed and managed by the rheumatology on-call Registrar or Consultant within 24 hours. The impact of these new implementations will be reaudited in 2017.
Bhaskar Dasgupta, Frances A. Borg, Nada Hassan, Leslie Alexander, Kevin Barraclough, Brian Bourke, Joan Fulcher, Jane Hollywood, Andrew Hutchings, Pat James, Valerie Kyle, Jennifer Nott, Michael Power, Ash Samanta; BSR and BHPR guidelines for the management of giant cell arteritis. Rheumatology 2010;49(8):1594–1597.
Disclosure of Interest None declared