Outcomes of the fast-track pathway in Giant cell arteritis: A sight saver

Background/Purpose:   Giant cell arteritis (GCA) is a medical emergency, with permanent visual loss occurring in about 20-30% of patients. We have identified that delayed recognition, multiplicity of referral routes and absence of a standard pathway of care increases the complications rate in GCA. We report our experience of developing and implementation of a fast-track referral pathway (FTP) to reduce the incidence of sight loss in GCA.

Methods: All patients with suspected GCA seen between Jan 2012 to Dec 2012 were enrolled into a FTP. Patients were started immediately on high dose glucocorticosteroids (GC) by the referring doctor and seen by a rheumatologist within one working day. We compared data from the FTP with that of a longitudinal cohort of suspected GCA patients seen through standard referral routes between January 2009 and December 2012. A logistic regression method was used to investigate the effect of several variables on sight loss.

Results:  GCA was diagnosed in 46 (56.8%) patients in the standard pathway and in 33 (58.9%) in the FTP. As shown in table 1, complete sight loss was more commonly observed in standard compared to FTP [n=17 (37.0%) versus 3 (9.1%), p=0.005 in univariate and p=0.007 in multivariate analysis adjusting for clinical risk factors of sight loss]. There was no difference in the staring dose of GC or the number of patients receiving intravenous GC in both groups.

In the standard pathway, a higher proportion of GCA patients were referred to other specialties before rheumatology [n=11 (23.9%) vs. n=5 (15.2%), p=0.34].  The majority of patients in FTP were seen within a day of presenting to general practitioner compared to a median time of 3.0 (1.0-71.0 days) in the standard pathway (p=0.068). Interestingly, a significantly lower number of patients who subsequently lost sight presented with headache [n=13 (65.0%)] compared to those who did not lose sight [57 (98.3), p<0.001].

Table 1. Types of sight loss in conventional and fast track pathways

^¥ n (percentage)

Conclusion: Implementation of a GCA fast track pathway led to a reduction of permanent sight loss in newly referred GCA patients. The effect is explained by a reduction of the delay in treatment of GCA as well as by other, difficult to measure factors including increased awareness of GCA by public and general practitioners and reduction in the multiplicity of referral routes to rheumatology clinic. We recommend adoption of the FTP as a standard of care for GCA.