Background/Purpose: Diagnostic delay in Psoriatic Arthritis (PsA) is not uncommon with a recent study of psoriasis patients attending a dermatology clinic showing that 29% of patients had undiagnosed PsA. Delay in diagnosis in turn delays introduction of appropriate disease-modifying treatment and may contribute to poor patient outcome. The objectives of this study were: 1) to investigate the demographic and clinical characteristics contributing to the delay from symptom onset to the first visit with a rheumatologist; 2) to compare clinical and radiographic features and patient-reported outcome measures in those who saw a rheumatologist early in their disease course compared to those who were diagnosed later, in a long-term follow-up cohort of PsA patients.

Methods: All PsA patients, fulfilling CASPAR criteria, with an average disease duration of >10 years were invited for detailed clinical evaluation. The total lag time from symptom onset to their first rheumatologic encounter was studied. All patients were interviewed in order to determine the date of symptom onset, defined as onset of stiffness, pain, or joint swelling, and the subsequent first visit to a rheumatologist,  dates which were further confirmed by data extracted from referral letters and medical records. Patients were classified as early consulters or late consulters depending on whether they were seen by a rheumatologist within or beyond 6 months of symptom onset. Following informed consent, patients underwent a detailed skin and rheumatologic assessment including disease activity measures.

Results: A total of 283 PsA patients [mean age 54.6±12 years; 52% female; mean PsA duration of 19±9 years] were studied. Median lag time from the disease onset to the first rheumatologic assessment of the cohort was 1.00 years (IQR 0.5-2). Thirty percent (n=86) of the cohort was seen by a rheumatologist within 6 months of the disease onset. Similarly, 53% (n=149) and 71% (n=202) of the cohort was reviewed within one and 2 years of the symptoms onset, respectively.  On univariate analysis,  late consulters (>6 months delay at first encounter), had significantly more erosions (OR 4.58, p=<0.001), osteolysis (OR 3.6, p=0.01), sacroiliitis (OR 2.28, p=0.01), arthritis mutilans (OR 10.6, p=0.02), deformed joints (OR 2.28, p=0.002), number of deformed joints (OR 1.06, p=0.006), more DMARDs/TNFi failures (OR 1.47, p=0.007), less patients achieving drug free remission (OR 0.42, p=0.01), and worse functional disability as reflected by the HAQ scores (OR 2.17, p=0.003). On multiple step-wise regression analysis, the model predicted significant association of late consulters with the development of peripheral joint erosions (OR 4.25, p=0.001), radiographic sacroiliitis (OR 1.47, p=0.09) and worse HAQ scores (OR 2.2, p=0.004). 

Conclusion: Even a 6 month delay from symptom onset to the first visit with a rheumatologist contributes to the development of peripheral joint erosions, sacroiliitis and worse long-term physical function.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/diagnostic-delay-of-even-more-than-6-months-contributes-to-poor-radiographic-and-functional-outcome-in-psoriatic-arthritis/