Background/Purpose: National guidelines mandate urgent referral of rheumatoid arthritis (RA) for specialist treatment if more than three months from symptom onset; initial combination therapy with disease modifying anti-rheumatic drugs (DMARDs) and only if not appropriate, monotherapy with rapid escalation¹.  A national audit of patients with RA conducted by The British Society for Rheumatology (BSR) showed that there were considerable delays from symptom onset to referral, from referral to specialist review, and initiation of DMARD therapy². There were also wide variations regionally and a perception that there may be a differential between black and minority ethnic (BME) groups in terms of time of onset of symptoms to referral to a specialist centre and starting DMARDs. This study aimed to investigate the above features in centres that are geographically located within areas containing a high BME population and to compare this with the white Caucasian population.

Methods: Four centres were identified based on a high local BME population.  Data were collected prospectively for potential time delays in the following areas: symptom onset to GP (general practice) consultation; GP to specialist referral; referral to specialist review; diagnosis to DMARD treatment, combination therapy, and biologic therapy. All consecutive BME and Caucasian RA patients on DMARDS attending outpatient clinics were included over an 8 week period. 

Results: In total 189 patients were analysed.  111 (59%) were Caucasian vs. 78 (41%) BME ( 60 (77%) Asian, 2 (3%) Afro-Caribbean). 146 (77%) were female with an average age between 50-59 years, and average disease duration of 6-10 years. 30 (38%) of the BME group compared with 40 (36%) of the Caucasian group had more than six-months time delay from symptom onset to specialist referral. Time from referral to specialist review greater than three months was 10 (13%) BME group vs. 21 (19%) Caucasian group. 16 (21%) BME group vs. 18 (16%) Caucasian group had a delay of more than three months from diagnosis to initiation of DMARD therapy. Interestingly, 58 (74%) of the BME group had monotherapy in comparison to 79 (71%) of the Caucasian group. 17 (22%) of the BME group had biologic therapy with an average of 2-5 years post diagnosis, whilst 20 (18%) of Caucasians had biologic therapy.

Conclusion: Our results importantly highlight a significant delay in time from presentation and initiation of treatment for RA patients of BME origin.  There may be a range of ethnically specific culturally centred reasons for such delay³. Culturally different migrant and non-migrant internal or national minorities may inadvertently be subjected to indirect discrimination and exclusion. It is paramount to gain a deeper understanding of potential underlying cultural differences in order to educate and facilitate appropriate healthcare and support within minority populations. The empowerment of patients of minority communities through culturally appropriate health education initiatives can encourage such persons to seek early medical advice and treatment thereby promoting equity amongst diverse populations.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/a-british-survey-of-time-to-presentation-and-treatment-of-rheumatoid-arthritis-in-subjects-of-black-and-minority-ethnic-origin/