Background/Purpose: Psoriatic arthritis (PsA) remains widely underdiagnosed and misdiagnosed worldwide, leading to delays in appropriate management and increased disease burden. While diagnostic delay has been extensively studied in axial spondyloarthritis (axSpA), there remains a significant research gap in understanding delays specific to PsA. This study aims to examine the extent and consequences of diagnostic and referral delays in PsA and their impact on radiographic outcomes.

Methods: We systematically searched PubMed, Web of Science, and Scopus from inception until March 16, 2025, following PRISMA guidelines (Fig.1) to identify observational studies reporting diagnostic delay in PsA. Studies were included if they diagnosed PsA patients based on the CASPAR classification criteria, confirmed diagnosis by a rheumatologist or self-reported physician diagnosis. Diagnostic and referral delays were extracted if reported as mean (SD) or median (IQR). Meta-analysis was conducted using Review Manager software 5.4 (RevMan), employing random- and fixed-effects models using the inverse variance method. Heterogeneity was assessed using I² statistics following Cochrane guidelines.

Results: A total of 20 observational studies were included encompassing 23,894 participants, with 15 contributing to the meta-analysis encompassing 22,749 participants. The pooled mean diagnostic delay was 31.24 months (95% CI: 22.48, 40.00) using a random-effects model, with considerable heterogeneity (I² = 100%) (Fig. 2). The mean referral delay was analyzed using both fixed- and random-effects models, with the random-effects model yielding a pooled mean referral delay of 21.69 months (95% CI: 15.02, 28.35) and the fixed-effects model yielding 15.32 months (95% CI: 13.98, 16.67), with considerable heterogeneity (I² = 92%) (Fig. 2). Patients with prolonged diagnostic delay had significantly increased odds of radiographic damage. The fixed-effects model yielded a pooled OR of 2.80 (95% CI: 2.31, 3.39), while the random-effects model showed an OR of 2.54 (95% CI: 1.58, 4.09). Heterogeneity for both was moderate (I² = 49%) (Fig. 2). Studies indicated substantial geographic variation in diagnostic delay, with reports ranging from 6.55 months in India to over 62.4 months in Italy (Fig. 3).

Conclusion: This is the first systematic review and meta-analysis that explores diagnostic and referral delays in PsA, and their relationship to radiographic joint damage. This meta-analysis confirmed that both diagnostic and referral delays in psoriatic arthritis are statistically and clinically significant, with longer delays linked to an increased risk of radiographic joint damage. These delays reflect gaps in disease recognition and care coordination. Improving early detection, particularly in primary care and dermatology settings, and streamlining referral pathways to rheumatology are essential in reducing structural damage and improving patient outcomes.

Fig (1) PRISMA Flow Chart Illustrating Search Strategy and Selection of Included Studies

Fig 2. (A) Forest Plot of PsA Diagnosis Delay (Months): Forest plot of PsA diagnosis delay (months). Studies included: Bedaiwi 2021, Iacovantuno 2024, NAS 2017, Wang 2023, Xiang 2021, Chandrashekara 2024, Sørensen 2015, Astete 2021, Zundell 2024, Henkemans 2024, Kilic 2024. The plot shows the mean diagnosis delay for each study and the overall pooled mean delay of 31.24 months (95% CI: 22.48 to 40.00), with considerable heterogeneity (I²=100%).

(B) Forest plot of PsA first visit delay (months) (Random and Fixed effects model). Studies included: Chandrashekara 2024, Haroon 2015, Karmacharya 2021, Lubrano 2021. The plot shows the mean first visit delay for each study and the overall pooled mean delay of 15.32 months (95% CI: 13.98 to 16.67), with considerable heterogeneity (I²=92%). (C) Forest Plot of Odds Ratio Comparing Late Diagnosis to Early Diagnosis in PsA Patients (Random and Fixed effects model). Forest plot of odds ratio comparing late diagnosis to early diagnosis in PsA patients. Studies included: Gladman 2011, Karmacharya 2021. The overall pooled odds ratio was 2.80 (95% CI: 2.21 to 3.55), indicating a significant association (P < 0.00001), with moderate heterogeneity (I²=49%). CI, confidence interval; df, degrees of freedom; IV, inverse variance; SD, standard deviation.

Fig 3. Map of Mean Diagnostic Delay in Years for PsA by Country. Countries included: United States, Netherlands, Turkey, Italy, India, China, Singapore, Spain, Saudi Arabia, Denmark. The accompanying table provides classification criteria, sample size, mean delay, and 95% CI for each country. Map powered by Bing.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/diagnostic-delay-in-psoriatic-arthritis-and-its-impact-on-radiological-outcomes-a-systematic-review-and-meta-analysis-of-23894-patients/