Early intervention with disease-modifying therapy for rheumatoid arthritis: where do the delays occur?

Sir, The recent paper by Quinn et al. has added to the growing consensus that suggests that disease‐modifying anti‐rheumatic drugs (DMARDs) should be initiated within 3 months of onset of rheumatoid arthritis (RA) [1, 2]. However, the few reports that have been published which have measured the speed of DMARD prescription for RA patients have emphasized the wide gap that exists between such an ideal and reality in the UK [3–5]. Irvine et al. [3] found that less than half of the RA patients attending a UK centre were prescribed a DMARD within 6 months of symptom onset, never mind 3 months. We wanted to measure the delay between symptom onset and initiation of DMARD therapy and attribute the delay to the patient [delay in presentation to general practitioner (GP)], the GP (delay in onward referral) or the hospital specialist (delay in first out‐patient appointment and/or initiation of DMARD). A two‐centre audit was undertaken at the rheumatology departments at Birmingham Heartlands and Solihull NHS Trust (BHT) and Mid‐Staffordshire General Hospitals NHS Trust (MSGH), the former an academic unit serving a mainly urban population and the latter a non‐academic unit serving a mixed urban and rural area. The audit focused on the patients of one consultant at each unit (MP, DM) who had RA diagnosed between 1 January 1998 and 31 December 2000 and who attended for follow‐up between May and September 2001. Information collected was based on patient recall of events prior to GP referral, a review of the likely diagnosis based on the GP referral letter and case notes review of events following referral. The Birmingham Heartlands and Solihull NHS Trust Teaching Ethics Committee and the Cannock Chase Hospital Ethics Committee approved the audit. During the audit, 77 patients were identified, including 42 from BHT. The median (range) age was 59 (22–79) yr and 71% were female. Table 1 summarizes the delays experienced by the patients during various stages of the care pathway. The range of delay between symptom onset and first visit to GP was between 1 day and 15 yr; 38% waited more than 3 months before seeing their GP. Similarly, the delay from the initial visit to the GP to specialist referral was 1 day to 10 yr; for 44% of patients the delay before referral was more than 3 months, although two of these patients were initiated on DMARDs by their GP. The referral letter was an important determinant of the delay experienced: of 13 patients seen by the specialist within 1 month of referral, all referral letters suggested a diagnosis of RA; this compares with the 18 patients who waited more than 3 months to be seen, for whom only eight of the letters suggested RA. Six patients were already taking a DMARD prior to their first specialist appointment. Only five patients received DMARD therapy within 3 months of symptom onset. This audit has revealed the wide gap between the ideal of DMARD prescription to RA patients within 3 months of disease onset and practice. The long delays in initiating such therapy occur at all stages of the patient care pathway, substantial proportions of patients waiting more than 3 months before they present to their GP, attending their GP for more than 3 months before referral or waiting more than 3 months for a specialist appointment and even waiting for DMARD therapy after their specialist appointment. Considerable resources may be required to enable primary and secondary care services to deliver DMARDs within the currently recommended time‐scale. Even with a well‐resourced service, such as exists within the USA, delays can still occur, emphasizing the importance of educating patients and their clinicians [4, 6]. If our local experience is representative, much needs to be done at the coalface of rheumatology care in the UK to deliver better care to patients. Correspondence to: M. Pugh, Department of Rheumatology, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, West Midlands B9 5SS, UK. Duration of delay between symptom onset and prescription of DMARD therapy for 77 patients with RA Data are number (%) of patients. OP, out‐patient. aNot applicable to eight patients, six of whom were prescribed a DMARD before their first hospital visit and two where DMARD therapy was felt to be unnecessary. Duration of delay between symptom onset and prescription of DMARD therapy for 77 patients with RA Data are number (%) of patients. OP, out‐patient. aNot applicable to eight patients, six of whom were prescribed a DMARD before their first hospital visit and two where DMARD therapy was felt to be unnecessary. Sir, Pugh and colleagues have identified a very real problem in the management of patients with early inflammatory arthritis. Almost 40% of patients had a wait of 3 months before seeing their general practitioner (GP). This delay can only be improved by greater patient awareness and by publication of the reversibility of the early symptoms of rheumatoid arthritis. More worryingly, perhaps, is the 44% who were delayed more than 3 months before referral on from general practice. In an attempt to improve this, we have constantly emphasized to GPs that a good response to a non‐steroidal anti‐inflammatory drug (NSAID) (which blocks prostaglandin production by inhibiting cyclo‐oxygenase II) is a reason to consider that there is a major inflammatory process occurring. All such patients responding well should have their NSAIDs stopped and the inflammatory response should be assessed. Whilst these delays can undoubtedly be improved, there is an inherent problem in the management of rheumatoid arthritis, in that the most characteristic feature of this disease is its insidious onset. Furthermore, the important facts that it affects the small joints and initially responds well to symptomatic therapy complicate the matter even further. As emphasized above, education on the new data regarding the importance of early disease combined with a range of new treatments that are now available may allow this unfortunate delay to be diminished. Correspondence to: P. Emery, University of Leeds, Old Nurses Home, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK.