Rheumatoid arthritis

We are grateful to Harnden and colleagues (easily missed, April 1st) for highlighting the importance of early detection and referral of inflammatory joint problems such as Rheumatoid Arthritis (RA). Significant delays in referrals from primary care to rheumatology services were identified within the 2016 annual report for the national audit of RA and early inflammatory arthritis [1], highlighting the importance of education regarding this condition.

In 2014 the National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis (EIA) was launched to assess performance against the NICE Quality Standards for RA, QS33 [2], encompassing timelines to referral, specialist assessment and treatment, including multidisciplinary care, and impact of disease on patients.

Data from 6,354 people were collected in the first 12 months of the audit. In England and Wales 97% of trusts participated; patients were predominantly women (66%) and 70% were of working age (aged 16-65 years).

Quality Standard (QS) 1 recommends that patients presenting to primary care with new persistent (>3-4 weeks) synovitis, should be referred to rheumatology within 3 working days. Only seventeen percent of patients were referred within 3 days of presentation with persistent symptoms. There was wide variation in achievement rates for this QS across NHS regions (11% in the Midlands and East of England, 40% in Wales) and between trusts. The median delay between presentation and referral was 34 days. One quarter of patients waited more than 3 months for referral.

As recognised by NICE timely specialist management of RA is critical. In addition to the delays in referral detailed above the audit identified delays in attaining a specialist opinion once referral was initiated. Higher consultant numbers per head of population and the presence of EIA clinics were significantly associated with shorter specialist assessment waiting times (odds ratio (95% CI) 1.3 (1.1–1.4) and 1.6 (1.4–1.7) respectively.

A key message from this audit for all clinicians, and highlighted by Harnden and colleagues, is that once a clinical suspicion of inflammatory arthritis arises, prompt referral to rheumatology services is warranted. Whilst most patients will present to their GPs some could be identified and referred via secondary care. RA is an autoimmune disorder and associates with other autoimmune diseases. Inflammatory arthritis also associates with inflammatory bowel and lung disease, other lung disease including bronchiectasis, psoriasis and with several ophthalmology conditions (sicca syndrome, iritis, scleritis, episcleritis). There needs to be a high index of suspicion when patients with these conditions develop joint symptoms and clinicians need to bear in mind that investigations will not always show the expected abnormalities. Elevated inflammatory markers and positive autoantibodies can support, but do not confirm, a diagnosis. Equally, and importantly, negative results do not exclude RA; inflammatory markers may be normal, and autoantibodies are negative in up to a third of cases.

A systems enquiry should always include questions about musculoskeletal symptoms but does not usually do so. Enquiring about joint pain, joint swelling and early morning stiffness would improve awareness and assessment of musculoskeletal problems and help detect inflammatory arthritis patients for early specialist referral.

1. http://rheumatology.org.uk/resources/audits/national_ra_audit/annual_rep...

2. National Institute for Health and Care Excellence. Rheumatoid Arthritis: NICE Quality Standard [QS33]. https://www.nice.org.uk/guidance/qs33 2013