Date: Monday, November 11, 2019
Session Title: Measures Of Healthcare Quality Poster II: Improving Care
Session Type: Poster Session (Monday)
Session Time: 9:00AM-11:00AM
Background/Purpose: Giant Cell Arteritis (GCA) is an autoimmune vasculitis, most common in older adults with a peak incidence in the seventh decade. The diagnosis is often considered in any patient over age 50 years with new-onset headache, acute visual disturbances, jaw claudication, or elevated inflammatory markers. Because the manifestations of GCA can vary considerably, accurate diagnosis can be challenging. Even in the setting of a negative temporal artery (TA) biopsy, many patients are treated empirically based on the perceived probability of disease. This approach can lead to significant morbidity from prolonged medication exposure and unnecessary procedures. The aim for this project was to look at the impact of a collaborative effort amongst three specialties, rheumatology, neurology, and ophthalmology, a consultation based “GCA team”; the goal of which was to improve how GCA is diagnosed and subsequently managed.
Methods: We conducted a retrospective study of all patients suspected to have GCA at our institution over the last 2.5 years either been seen by the GCA team or not. The GCA team met either in person or had a conference call to discuss each case to make a joint decision regarding the diagnosis and treatment. Data extracted included patient demographics, symptoms on presentation, labs, biopsy results and accumulative prednisone dose.
Results: A total of 36 patients (23 female, 13 male) were evaluated; 26 were seen by the GCA team and 10 were not. The mean ages of patients between the GCA team and No GCA team were similar [71.2 (SD 11.0) vs 70.4 (SD 13.0)], as well as the mean ESR (52.0 vs 54.4), and presenting clinical symptoms: visual complaints (76.9% vs 80.0%) and headache/ jaw claudication/ TA tenderness (46.2% vs 40.0%).
All patients not seen by the GCA team underwent bilateral TA biopsy; however, none were positive on histology. Regardless, all were continued on high dose prednisone with a 6-month cumulative mean dose of 5,350 mg.
Of the 26 patients seen by the GCA team, 10 were determined to be low probability (LP) for GCA and thus were spared TA biopsy. These patients were recommended a rapid steroid taper and the cumulative mean dose of prednisone was only 491 mg. Over 6 months of follow-up, none of these patients had a subsequent diagnosis of GCA.
Compared to patients deemed high probability (HP) by the GCA team, LP patients were younger in age (71.0 vs 74.0), more often female (80% vs 55%), had lower ESR (44.6 vs 72.8), and presented with more visual complaints (70% vs 54.5%).
In the 13 HP GCA patients, 12 underwent TA biopsy (one refused) with 6 biopsies read as positive for GCA. Over 6 months of follow up, none of these patients had flares after they were started on treatment.
Conclusion: While the accuracy of a GCA diagnosis cannot be determined in our cohort of patients not seen by the GCA team, it is likely that evaluation by a multispecialty team would have found several to be low probability for GCA, especially as none of the patients had a positive TA biopsy. By adopting a collaborative approach to diagnosing GCA, unnecessary biopsies and unnecessary corticosteroid exposure can be avoided. More prospective data are needed to provide an accurate assessment of this team approach for GCA which can serve as a model for other healthcare facilities.
To cite this abstract in AMA style:Hassantoufighi A, Lu-Do R, Sherchan M, Collins C, Dhillon J, Constantinescu F. Utilization of a Multispecialty Team for the Diagnosis of Giant Cell Arteritis Reduces Patient Morbidity [abstract]. Arthritis Rheumatol. 2019; 71 (suppl 10). https://acrabstracts.org/abstract/utilization-of-a-multispecialty-team-for-the-diagnosis-of-giant-cell-arteritis-reduces-patient-morbidity/. Accessed March 21, 2023.
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ACR Meeting Abstracts - https://acrabstracts.org/abstract/utilization-of-a-multispecialty-team-for-the-diagnosis-of-giant-cell-arteritis-reduces-patient-morbidity/