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AB0212 Diagnostic delay for rheumatoid arthritis: a systematic review
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  1. C.A. Hay1,
  2. J.A. Prior1,
  3. I. Scott1,
  4. K. Raza2,
  5. S. Hider1,
  6. C.D. Mallen1
  1. 1Research Institute for Primary Care and Health Sciences, Keele University, Keele
  2. 2Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK

Abstract

Background Rheumatoid arthritis (RA) is a common inflammatory condition, affecting 1% of the population and causing pain, stiffness and swelling, leading to significant disability and loss of function[.1 Delays in the diagnosis and treatment of RA can lead to worsened joint damage and disability, in addition to a reduced rate of disease-modifying antirheumatic drugs(DMARD)-free remission. Current (2016) EULAR guidelines specify that combination DMARD treatment be initiated within 3 months of the onset of persistent RA symptoms[.2 Unfortunately, this target is not always achieved due to delays between symptom onset to treatment initiation.

Objectives The aim of this systematic review, was to determine the extent of delay that occurs at different points in the patient’s journey from RA symptom onset to treatment initiation, providing benchmarks of delay.

Methods Embase and Medline were searched for articles examining diagnostic and treatment delay of RA. To be included, articles had to report a time-period of delay in an adult RA population. Papers were screened by three authors (CAH, JAP, IS). The primary outcome was the reported time-period of delay at any point from RA symptom onset to treatment. Due to skewed delay data, medians (with Interquartile range (IQR)) were selected and reported using narrative synthesis. Different time-periods of delay were categorised to facilitate comparison.

Results Of 4925 returned articles, 1501 duplicates were removed. The remaining articles were then screened by title, abstract and full text, leaving 26 from which we extracted data. Delay periods were categorised as 1) symptom onset to initiation of DMARDs (n=9), 2) symptom onset to diagnosis (n=14), 3) symptom onset to 1st healthcare professional (HCP) appointment (n=15), 4) 1 ST HCP appointment to rheumatology referral (n=4) and 5) 1 ST HCP appointment to diagnosis (n=4). Time-periods of delay were typically skewed to the right. The total delay from symptom onset to receiving DMARDs has dropped since the 1980’s (429 weeks before 1987) and by 2014 data indicates an average delay of 23 (IQR 14, 43) weeks. Within this total delay period, delay from symptom onset to diagnosis is at a minimum 16(7,55 weeks and delay from symptom onset to first contact with a HCP predominantly ranges from 2 (1,8) to 10(4,24 weeks in data from 2010 onwards. Delay between 1st HCP appointment and Rheumatology referral can be as quick as 2 (1,5) weeks and is within 12(2,48 weeks across all data points. Delay acquired between 1st HCP appointment and receiving a diagnosis has decreased overtime, most recently, delay was reported as 21 weeks.

Conclusions Time from RA symptom onset to receiving treatment has reduced considerably in recent decades. However, despite current guidelines and research indicating an optimal treatment window for RA of twelve weeks from symptom onset, this remains unmet, with this delay approximately twice the recommended period. Continued effort is required in reducing delay across all areas of the RA patients’ journey to the early treatment needed to improve outcome.

References [1] Scott DGI. What is RA? https://www.nras.org.uk/: National Rheumatoid Arthritis Society; 2014. Available from https://www.nras.org.uk/what-is-ra-article

[2] Combe B, et al. 2016 update of the EULAR recommendations for the management of early arthritis. Annals of the rheumatic diseases 2017.

Disclosure of Interest None declared

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