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Abstract
Background Early diagnosis is one of the mainstay of rheumatoid arthritis (RA) management. Early diagnosis reflects on early treatment, better response with reduction of long-term detrimental disease outcomes. Early arthritis clinics (EAC) are the healthcare services devoted to facilitate early diagnosis and optimize treatment of early onset inflammatory arthritis. Despite the a priori beneficial potential of EAC, no strong experimental data support EAC efficacy. Interrupted time series analysis is one of the “next best” approaches for dealing with interventions when randomisation is not possible or clinical trial data are not available.
Objectives To evaluate the impact of the implementation of an EAC in terms of probability of starting second-line biologic DMARDs, using a quasi-experimental approach.
Methods RA patients fulfilling 1987 ACR criteria who attended the outpatient rheumatology clinic (RC) between 2002 and 2008 and the Early Arthritis Clinic between 2009 and 2014 were retrospectively analyzed. The EAC was developed as a healthcare service integrating primary care with tertiary rheumatology care to provide early referral of suspected inflammatory arthritis and tight monitoring and standardized therapeutic approach according to “treat to target” (T2T) strategy and EULAR guidelines to early RA. The two sub-cohorts were compared in terms of: 1) lag time from symptoms onset to RA treatment with DMARDs; and 2) risk of treatment with bDMARDs at 24 months. Interrupted time analysis was performed to compare lag time from onset to treatment and log-transformed 24-month risk of biologics periods before the implementation of the EAC with subsequent periods.
Results A total of 353 RA patients were included: 208 (mean±SD age 58.7±12.6 years, 164 F, baseline DAS28 4.76±1–23) followed in RC and 145 (mean±SD age 58.8±14.9 years, 106 F, DAS28 5.09±1.31) in EAC. Lag time from symptoms onset to treatment resulted significantly lower (median [IQR] months 4 [2–7] vs 12 [5–24]; p<0.0001) in patients managed in EAC compared with RC. Within 24 months a biologic therapy was started in 62/208 (29.8%) of patients followed in RC, and 21/145 (14.5%) in EAC group (p=0.001), along with an increased remission rate at 24 months (43% vs 62%, p<0.001). Analyzing the time series “interrupted” by the implementation of the EAC, comparing before and after intervention periods, a significant change in slope was observed for both lag time (coefficient -8.85 [95% CI -17.25, -0.44], p=0.04) and risk of treatment with biologics (coefficient -1.17 [95% CI -2.09, -0.24], p=0.01). As expected in more recent years - according to a T2T approach - a monotonous positive trend in percentage of patients treated with biologics is also observed in EAC (coefficient 0.31 [95% CI 0.05, 0.58]).
Conclusions The implementation of an EAC that integrates care and applies tight control and standard of care, leads to early diagnosis and treatment and may lower the need – overtime - of second-line biologic drugs, with a significant impact both on individuals and health care systems.
Disclosure of Interest None declared