Diagnostic and therapeutic delay in Rheumatoid Arthritis patients: Impact on disease outcome

Faiza Naeem; Saira Elaine Anwer Khan; Muhammad Ahmed Saeed; Sumaira Farman

doi:10.12669/pjms.37.4.3471

Diagnostic and therapeutic delay in Rheumatoid Arthritis patients: Impact on disease outcome

Pak J Med Sci. 2021 Jul-Aug;37(4):1001-1007. doi: 10.12669/pjms.37.4.3471.

Authors

Faiza Naeem¹, Saira Elaine Anwer Khan², Muhammad Ahmed Saeed³, Sumaira Farman⁴

Affiliations

¹ Faiza Naeem, FCPS Internal Medicine, Rheumatology Fellow, Division of Rheumatology, Fatima Memorial Hospital College of Medicine & Dentistry (FMH), Lahore, Pakistan.
² Saira E.A Khan, MRCP (UK), SCE Rheumatology (UK) Assistant Professor, Division of Rheumatology, Fatima Memorial Hospital College of Medicine & Dentistry (FMH), Lahore, Pakistan.
³ Muhammad Ahmed Saeed, FCPS Rheumatology, FACR, FCPS Internal Medicine Associate Professor, Al-Aleem Medical College, Head Department of Rheumatology, Gulab Devi Teaching Hospital, Lahore, Pakistan. Consultant Rheumatologist, National Hospital and Medical Center, Lahore.
⁴ Sumaira Farman, FRCP, FACP, FACR, SCE Rheumatology (UK) Graduate Certificate Paediatric Rheumatology (Australia) Professor, Division of Rheumatology, FMH, Consultant Rheumatologist, National Hospital and Medical Center, Lahore, Pakistan.

Abstract

Objective: To identify factors causing diagnostic and therapeutic delay in patients with rheumatoid arthritis, and to evaluate relationship of diagnostic and therapeutic delay with disease outcome.

Methods: This cross-sectional study was conducted in Rheumatology Department, Fatima Memorial Hospital, Lahore, Pakistan, from May 2018 to July 2018. In this study 102 patients fulfilling ACR/EULAR criteria 2010 were enrolled. Lag times were calculated in months: lag-1 (delay in initial medical consultation); lag-2 (delay in consulting rheumatologists); lag-3 (diagnostic delay); lag-4 (therapeutic delay). Disease activity and functional outcome were measured by DAS28, HAQ-DI respectively. Association of lag-3 and lag-4 with HAQ-DI and DAS28 was calculated by Pearson correlation.

Results: Median (IQR) disease duration of study group was 6(2-10) years. Initial consultations were with; orthopedic surgeon 40(39.2%), general practitioner 27(26.5%), rheumatologist 13(12.7%), medical specialists 14(13.7%). Median (IQR) lag times in months: lag-1 (delayed initial consultation): 2(0-5), lag-2 (delay in consulting rheumatologist): 30(7.7-72), lag-3 (diagnostic delay): 12(3-48), lag-4 (therapeutic delay):18(5.7-72). Factors attributed to lag-3 (diagnostic delay) and lag-4 (therapeutic delay) (p<0.05): older Age (r= 0.2), education level(r= - 0.2), initial consultation (non-rheumatologist) (r=0.2), lag-2(r=0.8), >three doctors visited before diagnosis(r=0.6). Positive anti-CCP antibodies(r=0.2) and lag-1 (delayed initial consultation) (r=1) were associated with lag-3 (diagnostic delay) only; no association was found with positive RA factor. Significant correlation (p=<0.05) of lag-3 (diagnostic delay) was found with both DAS28(r=0.2) & HAQ-DI(r=0.2). Similarly lag-4 (therapeutic delay) also correlated with both & DAS28(r=0.2) & HAQ-DI(r=0.3) (p=<0.05).

Conclusion: Diagnostic and therapeutic delay were associated with older age, lower education and delayed consultation with rheumatologist but not with positive RA factor. Positive anti-CCP antibodies were associated with diagnostic delay only. Diagnostic and therapeutic delay led to high disease activity and poor functional outcome in RA patients.

Keywords: DAS28; Diagnostic delay; HAQ-DI; Rheumatoid arthritis; Therapeutic delay.