Rheumatology Advance Access originally published online on March 7, 2008
Rheumatology 2008 47(4):559-560; doi:10.1093/rheumatology/ken031
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Comment on: Delay in presentation to primary care physicians is the main reason why patients with rheumatoid arthritis are seen late by rheumatologists
1Primary Care Musculoskeletal Research Centre, Keele University, Staffordshire, UK, 2Department of Psychology, University of Otago, New Zealand, 3Department of Rheumatology, Dudley Group of Hospitals NHS Trust, Dudley, 4Department of Rheumatology, Selly Oak Hospital, Birmingham, 5Department of Rheumatology, Worcestershire Royal Hospital, Worcester, 6Department of Audit, Dudley Group of Hospitals NHS Trust, Dudley, 7Research Institute in Healthcare Science, University of Wolverhampton, West Midlands and 8arc Epidemiology Unit, University of Manchester, Manchester, UK
Correspondence to: I. F. Rowe, Highfield Unit, Worcester Centre for Rheumatic Diseases, Worcestershire Royal Hospital, Charles Hastings Way, Worcester WR5 1DD, UK. E-mail: Ian.Rowe{at}worcsacute.nhs.uk
SIR, We read with interest the report by Kumar et al. [1] and felt that it may be of value to highlight some of the results of our contemporaneous regional survey, which support and extend their findings. Our study explored the accessibility and quality of secondary care rheumatology services for people with inflammatory arthritis (IA) in the West Midlands [2]. A total of 1877 patients were surveyed in 11 rheumatology centres in February 2005. These centres did not include the Sandwell and West Birmingham NHS Trust, where the data in the study by Kumar et al. [1] were collected. We focused on patients diagnosed with IA in the previous 2 yrs (n = 236) to provide a picture of recent practice and minimize recall bias with better access to accurate information in the medical notes. Mean age was 57 yrs (S.D. 15); 156 (66.1%) were females; 163 (69.1%) were diagnosed with RA. Information on the timeframe from symptom onset to seeing their general practitioner (GP), subsequent referral to a rheumatologist, being seen in clinic, receiving a diagnosis and commencement of DMARD therapy was recorded by the clinician with the aid of the medical notes and the patient.
Our study also revealed significant delays from symptom onset to patients consulting their GP. Of the 236 patients, 61.7% had waited longer than 6 weeks and 37.9% had waited over 3 months before seeing their GP. A third of patients (33.2%) waited longer than 3 months after their first GP consultation before their GP referred them to a rheumatologist. The majority (84.5%) of patients was seen by a rheumatologist within 12 weeks of the GP referral, meeting the standard set by the Arthritis and Musculoskeletal Alliance (ARMA) [3]. We recognize that our data measured the timeframe for all patients with IA. However, none of the above times differed by diagnosis with RA, across departments and by age or sex.
We conducted multivariate analyses making use of logistic regressions and found that patients who waited <6 weeks to see their GP after symptom onset were more likely to wait for <12 weeks to be referred to rheumatology by their GP after the first consultation (83.1%) than those who waited for >6 weeks to see their GP [59.2%; odds ratio (OR) 3.40, 95% CI 1.69, 6.83; P < 0.001]. Furthermore, patients who waited <6 weeks to see their GP after symptom onset were more likely to wait for <12 weeks for a rheumatology appointment (91.9%) than those who waited for >6 weeks to see their GP (78.4%; OR 3.11, 95% CI 1.21, 8.01; P < 0.05).
Patients who waited for <6 weeks for a rheumatology appointment were more likely to wait for <6 weeks to be diagnosed (91.0%) than those who waited for >6 weeks for a rheumatology appointment (71.6%; OR 4.01, 95% CI 1.76, 9.17; P < 0.001). Among the 170 patients who had commenced a DMARD by the time of the study, those who waited for <6 weeks to be diagnosed were more likely to wait for <6 weeks from diagnosis to DMARD initiation (78.6%) than those who waited for >6 weeks to be diagnosed (52.2%; OR 3.37, 95% CI 1.33, 8.55; P < 0.05).
In summary, our data support and extend the findings by Kumar et al. [1] that patients with IA, including those with RA, delay seeing their GP following the onset of symptoms. In addition to this, analysis of predictors of the timeframe of the patient's journey from symptom onset to DMARD commencement demonstrate how this delay was predictive of the subsequent delay in time taken to be referred by the GP, and be seen by the rheumatologist. Furthermore, a prompt rheumatology appointment after referral was predictive of diagnosis at first appointment. A prompt diagnosis (and the presence of RA) was predictive of early DMARD therapy in those who had commenced such treatment.
The sum of the predictive relationships in our study suggests a core of ‘fast track’ IA patients who report swiftly to their GP, are seen quickly in rheumatology and then have a clear diagnosis and best practice treatment. Kumar et al. [1] describe having a rapid access early arthritis clinic, which is actively promoted to local GPs. This strategy may explain the reason why their study showed patients being promptly referred by their GP and subsequently seen quickly by a rheumatologist. We agree that further research to identify the reasons why patients delay in seeking initial medical advice is warranted. It would be important to determine the potential differences in patient demographics and explore the nature of onset of IA and outcomes between these ‘fast track’ patients and those presenting and being treated later.
Disclosure statement: The authors have declared no conflicts of interest.
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- Kumar K, Daley E, Carruthers DM, et al. Delay in presentation to primary care physicians is the main reason why patients with rheumatoid arthritis are seen late by rheumatologists. Rheumatology (2007) 46:1438–40.
[Abstract/Free Full Text] - Sandhu RS, Treharne GJ, Justice EA, et al. Accessibility and quality of secondary care rheumatology services for people with inflammatory arthritis: a regional survey. Clin Med (2007) 7:579–84.[Web of Science][Medline]
- Arthritis and Musculoskeletal Alliance. Standards of care for people with inflammatory arthritis. (2006) (16 October 2007, date last accessed). London: Arthritis and Musculoskeletal Alliance. http://www.arma.uk.net/pdfs/ia06.pdf.
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