August 01, 2011

By: Diana Mahoney

Positive outcomes in rheumatoid arthritis are closely associated with early diagnosis and treatment with disease-modifying antirheumatic drugs, Dr. Vivian Bykerk stressed at the annual European Congress of Rheumatology. “Several important studies have shown that early intervention can lead to optimal outcomes for patients with early inflammatory arthritis. And the window of opportunity has been pushed back to 3 months, if not sooner.”

That remark referred in particular to the recent study out of Leiden (the Netherlands) University Medical Center looking at 1,674 early arthritis patients from the Leiden Early Arthritis Clinic cohort, including 598 patients with rheumatoid arthritis (RA) (Arthritis Rheum. 2010;62:3537-46).

“The Leiden researchers looked at the association between delay to care and how many patients met sustained drug-free remission, and what happened to their rate of joint destruction over time. The first thing they saw, no matter how many years back they looked in their clinic, was that patients who were seen before 12 weeks of persistent symptoms had a much higher probability of reaching drug-free or DMARD-free sustained remission compared with those seen after 12 weeks,” said Dr. Bykerk of Brigham and Women's Hospital in Boston. Further, patients seen before 12 weeks had much less radiographic damage than did patients seen after 12 weeks of symptoms.

Although recent years have seen improvements in facilitating earlier access to rheumatologic care in patients with inflammatory arthritis, “persistent barriers to access still prolong time to diagnosis and treatment in many patients,” said Dr. Bykerk, who addresses the nature of these treatment delays and strategies to overcome them in this month's column.

Dr. Bykerk: Most people who develop some kind of symptom of synovitis, swollen joint pain in their hands or feet, go to their primary care provider, who has to identify that the patient has inflammatory arthritis and make the decision to refer to an arthritis specialist. The specialist, depending on their wait list, will probably have some kind of triage system to determine how soon the patient should be seen. At some point, the patient will see the rheumatologist, who can diagnose RA quickly using the new ACR/EULAR diagnostic criteria (Arthritis Rheum. 2010;62:2569-81). Then the patient has to accept the fact that he or she has the disease, which is not always done quickly, and initiation of DMARDs has to occur.

RN: Where are the bottlenecks in the process that contribute to treatment delays?

Dr. Bykerk: In a new study, Dr. Shahin Jamal of the University of British Columbia and colleagues conducted a telephone survey and chart review to determine where treatment delays occurred in 204 patients and to identify contributing factors. Fewer than 25% of the patients were treated within 3 months of symptom onset. The median time from symptom onset to DMARD treatment was more than 6 months. The median time from symptom onset to rheumatology referral was 3 months, and from PCP [primary care provider] referral to rheumatology appointment to DMARD initiation was more than 2 months. There was no delay between RA diagnosis and DMARD treatment (J. Rheumatol. 2011;38:1282-8).

RN: What are the obstacles that contribute to the delays in getting rheumatologic care?

Dr. Bykerk: Many rheumatologists in many centers have very long waiting lists, and some have even closed their practices or will see only inflammatory disease. In many countries, patients require a referral to see a rheumatologist, so the primary care provider becomes the gatekeeper. As you can imagine, the squeaky wheel here gets the grease. The patients who present with polyarticular disease or very swollen joints are much more likely to get into the rheumatologist earlier, while patients with very subtle, early presentations, where you cannot detect any swelling in metacarpophalangeal [MCP] joints or where there are only a couple of MCP or proximal interphalangeal joints that are swollen, will probably have more of a delay. Also, the delays vary by geography and health care system. In some systems, there are financial disincentives for primary care physicians to refer patients out of their practices. In rural and suburban areas, there tend to be longer waiting lists. There may be primary care factors as well, such as a lack of awareness of the impact of early diagnosis and referral, and uncertainty as to whom to refer patients to.

RN: How can these barriers be overcome?

Dr. Bykerk: Several strategies have been implemented to address these delays. Some of them are well developed and validated, others are less developed, and some are very new in their design.

Dr. Kevin Deane of the University of Colorado in Aurora and his colleagues have conducted community health fairs to detect undiagnosed inflammatory arthritis. In one, 601 individuals were screened with a connective tissue–screening questionnaire and were tested for rheumatoid factor and anti–cyclic citrullinated protein [anti-CCP] antibodies. Of these, nine people had inflammatory arthritis; screening found they met four or more of the seven ACR criteria for RA but had no prior diagnosis. Another 15 had inflammatory arthritis and were rheumatoid factor and/or anti-CCP positive, suggesting early RA (Arthritis Rheum. 2009;61:1624-9). Most of us are not going to go out and organize health fairs, but this is potentially a way to identify patients very early.

Also out of the University of Colorado, investigators are screening relatives of probands with RA to identify those with symptoms of early disease (Arthritis Rheum. 2009;61:1735-42).

Other strategies being investigated include the use of self-administered questionnaires, including a recent one comprising 11 questions deemed to be predictive of early disease (BMC Musculoskelet. Disord. 2010 March 17 [doi:10.1186/1471-2474-11-50]); Internet-based case identification (J. Clin. Rheumatol. 2009;15:218-22); and primary care education, including continuing medical education programs that teach the benefits of screening and early diagnosis of patients. In addition, wide dissemination of and frequent reminders about early referral guidelines have been being investigated. One such set was authored by Dr. Paul Emery, professor of rheumatology and head of the academic unit of musculoskeletal medicine at the University of Leeds in England and his colleagues. These guidelines advise rapid referral to a rheumatologist for patients with three or more swollen joints, metatarsophalangeal/MCP involvement, and morning stiffness lasting 30 minutes or more (Ann. Rheum. Dis. 2002;61:290-7).

RN: How can triage systems be implemented to streamline time to treatment?

Dr. Bykerk: Triage refers to prescreening patients before referral. It depends in large part on the information that's provided to the rheumatologist from the patient and the primary care provider. Many rheumatologists have tried to use referral forms, which can be effective, but primary care providers in general don't like them because they get them from all directions – cardiology, endocrinology, pulmonology – and completing them all can be time consuming. As a result, triage efforts can be hampered by the lack of basic history, examination, and lab markers that would be needed to appropriately triage urgent cases.

Rapid triage, which I like to fondly call “speed dating,” seems to be promising. In this model, patients with early disease attend a triage clinic where they come in for a few minutes and are seen by a rheumatologist or allied health professional; they may get a questionnaire to fill out, and are rapidly identified as having early inflammatory arthritis or not. This approach has been shown to reduce wait times dramatically in early studies. The limitation is that patients must be aware that they can get to these clinics.

Similarly, early arthritis clinics, which have popped up all over the world, have reduced patient wait times, as we've seen in the Canadian Arthritis Cohort (CATCH) multicenter research project (www.earlyarthritis.com

RN: Where should rheumatologists focus their energies in order to identify and treat inflammatory arthritis patients as early as possible?

Dr. Bykerk: Overcoming delays for patients requires interventions at many levels: the symptomatic level, potentially through community initiatives; the primary care level, including referral guidelines and other methods to comanage patient care with primary care colleagues; and the rheumatology level, where we need to make a concerted effort to triage appropriately and, with the new criteria, diagnose and start treatment earlier. At all of these levels, we need to promote our evidence-based solutions, and they have to be health care specific. We should also consider promoting the idea of value-based incentives for referring patients with early arthritis to specialty care and removing disincentives for doing so.

DR. BYKERK is a staff physician in the division of rheumatology, allergy, and immunology at Brigham and Women's Hospital, Harvard Medical School, Boston. She disclosed financial relationships with Abbott, Amgen, BMS, Hoffmann-La Roche, Pfizer, Sanofi-Aventis, Schering-Plough, UCB, and Wyeth.

A video interview with Dr. Bykerk can be viewed by scanning the QR code with a smart phone application.

VIVIAN BYKERK, M.D.