Background/Purpose:

Despite
a proliferation of early arthritis (EA) clinics intended to expedite the
diagnosis of rheumatoid arthritis (RA), patients continue to experience
substantial and multifactorial delays between symptom onset and treatment initiation.
In this study we determined whether time to treatment following symptom onset
differs between rheumatoid arthritis (RA) patients according to autoantibody
status.

Methods:

A
single-centre retrospective analysis of a UK early RA inception cohort was
undertaken to identify those components of the “patient journey” that differed by
serological sub-type. Where available, the components studied included (i)
symptom onset to assessment in primary care, (ii) primary care assessment to
secondary care rheumatology referral, (iii) rheumatology referral to
rheumatology assessment, and (iv) rheumatology assessment to disease modifying
anti-rheumatic drug (DMARD) initiation. Non-parametric ANOVA were used to
compare groups, and time-to-event data were analysed using Kaplan-Meier
survival plots.

Results:

173
RA patients were diagnosed over a 31 month period, of whom 80 (46%) were anti-citrullinated
peptide antibody / rheumatoid factor “double-seropositive” (ACPA+/RF+), 53 (31%)
ACPA-/RF-, 17 (10%) ACPA+/RF- and 23 (13%) RF+/ACPA-. Overall, ACPA+/RF+ patients
experienced significantly longer symptom duration before disease modifying
anti-rheumatic drug (DMARD) initiation (p=0.006). This was accounted for by delays
in their presentation to primary care following symptom onset (Figure 1A). By
contrast, ACPA-/RF- patients were significantly more likely to experience
delays in DMARD initiation after presenting to secondary care (Figure 1B).

Conclusion:

Causes
of treatment delays in early RA differ according to patients’ autoantibody
status. More insidious symptom onset and/or distinct health-seeking behaviours amongst
ACPA+/RF+ patients may contribute to late presentations in primary care,
whereas ACPA-/RF- patients experience delayed diagnosis and treatment in
secondary care. These observations could inform future design of service
delivery for early arthritis patients.

Figure
1. “Survival” from (A) symptom onset to 1^st primary care visit and
(B) 1^st EA clinic consultation to DMARD initiation, stratified by
autoantibody status as indicated.