Background/Purpose: Timely diagnosis is the cornerstone of effective rheumatoid arthritis (RA) management, with early treatment shown to significantly improve outcomes through a treat-to-target strategy. While diagnostic delay has been well-characterized in axial spondyloarthritis (axSpA), there remains a significant research gap in understanding diagnostic delays specific to RA, causing many patients to miss the critical “window of opportunity” to prevent irreversible joint damage. This study aims to evaluate the extent of diagnostic delay in RA across multiple countries and examine its impact on radiographic joint damage, with emphasis on erosive outcomes.

Methods: We systematically searched PubMed, Web of Science, and Scopus from inception until April 5th, 2025 following PRISMA guidelines (Fig.1) for observational studies reporting diagnostic delay and radiographic outcomes in RA. Studies were included if RA diagnosis was confirmed by a rheumatologist according to a classification criteria. Diagnostic delays were extracted if reported as mean (SD) or median (IQR). Meta-analyses were conducted for the pooled mean diagnostic delay and prevalence of radiographic damage in delayed diagnosis patients. Heterogeneity was assessed using I² statistics following Cochrane guidelines.

Results: A total of 48 studies were identified encompassing 100,066 participants of which 28 were included in the meta-analysis encompassing 15,226 participants. The pooled mean diagnostic delay was 31.92 months (95% CI: 27.48, 36.37) with considerable heterogeneity (I² = 100%, τ² = 122.29) (Fig. 2). Radiographic outcomes, primarily bone erosions, were reported in a subset of studies. The pooled proportion of patients with radiographic joint damage was 51.4% (95% CI: 43.3%, 59.5%), with considerable heterogeneity (I² = 96.16%) (Fig. 2). There was marked geographic variation in diagnostic delay, with reported mean delays ranging from 5.47 months in Singapore to 120.5 months in Brazil (Fig. 3).

Conclusion: This is the first systematic review and meta-analysis to evaluate diagnostic delay in RA. It revealed a significant mean diagnostic delay, with over half of the patients exhibiting radiographic erosions. These findings highlight critical gaps in early disease recognition, which hinder the implementation of the treat-to-target approach and contribute to irreversible structural damage. The development of clear diagnostic criteria and expansion in the use of diagnostic technologies such as ultrasonography are vital to facilitate earlier detection.

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

Figure (2) Forest Plots of Diagnostic Delay and Radiographic Damage Prevalence in Rheumatoid Arthritis (RA). (A) Mean Diagnostic Delay (Months): Studies included: Albuquerque 2023, Badsha 2008, Barnabe 2014, Chan 1994, Cho 2019, da Rocha Castelar-Pinheiro 2018, de Albuquerque 2023, Fazaa 2022, Hussain 2016, Iacovantuono 2024, Ibn Yacoub 2012, Jain 2023, Khan 2025, Kim 2017, Naeem 2021, Ndongo 2009, Rodríguez-Polanco 2011, Rosa 2020, Sakr 2023, Sørensen 2015, Teh 2008, Tillmann 2013, Turkcapar 2006, Xiang 2021, Zafar 2012. Overall: Pooled mean diagnostic delay = 31.92 months (95% CI: 27.48–36.37), with considerable heterogeneity (I2 =100% I2 =100%, Tau2=122.2). Test for overall effect: Z= 14.09 (P < 0.00001) Z=14.09(P < 0.00001). (C) and (B) Prevalence of Radiographic Damage (Random- and Fixed-Effects Models):

Random-effects model: Pooled prevalence = 0.51 (95% CI: 0.43–0.59), with considerable heterogeneity (I2 = 96.16%) I2 =96.16%, Tau2= 0.132). Fixed-effects model: Pooled prevalence = 0.55 (95% CI: 0.54–0.56). Studies included: Badsha 2008, Chitins 2013, Cho 2019, Da Rocha Castelar-Pinheiro 2018, Fazaa 2022, Gomes 2018, Kim 2017, Ndongo 2009, Riad 2020,Rosa 2020, Sakr 2023.

CI, confidence interval; RA, rheumatoid arthritis; Tau2 , between-study variance; I2 , heterogeneity index.

Figure (3) Map of Mean Diagnostic Delay in Months for RA by Country

Countries included: United Arab Emirates (UAE), Canada, United States, South Korea, Italy, Morocco, India, Pakistan, Venezuela, Argentina, Denmark, Malaysia, Brazil, Turkey, Tunisia, Saudi Arabia, Senegal, Egypt, UK , and Singapore. The accompanying table provides 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-rheumatoid-arthritis-and-its-impact-on-radiographic-outcomes-a-systematic-review-and-meta-analysis-of-100066-patients/