Original Article

Use of Rheumatologic Testing in Patients Who Eventually Receive a Diagnosis of Rheumatoid Arthritis

Authors: Dilpreet K. Singh, MD, Jasdeep Badwal, MD, Ritika Vankina, MD, Santhi Gokaraju, MD, Jennifer Friderici, MS, Scott Halista, MD, Tara Lagu, MD, MPH

Abstract

Objectives: Anti-cyclic citrullinated peptide antibody (ACPA) has excellent specificity and prognostic value in patients with early rheumatoid arthritis (RA). The American College of Rheumatology included ACPA in their 2010 classification criteria for RA, but we hypothesize that primary care physicians (PCPs) underuse ACPA, even when clinical suspicion for RA is high. We aimed to describe their use of diagnostic testing in patients who were referred to a rheumatologist and eventually diagnosed as having RA.

Methods: In this retrospective cohort study, a systematic abstraction tool was used to review the medical records of patients seen between January 1, 2010 and June 15, 2014 in two rheumatology clinics: one private practice and one community health center associated with an academic medical center. For purposes of hypothesis generation, we compared the characteristics of patients with and without testing using unpaired t tests or Fisher exact tests.

Results: We identified 173 patients with RA referred from 141 different PCPs: 82.7% were women with a mean ± standard deviation age of 55.5 ± 18.6 years. ACPA and rheumatoid factor were ordered in 28.9% (95% confidence interval 22.6–36.2) and 41.0% (95% confidence interval 33.9–48.6) of patients, respectively. Imaging was underused. Almost half (45.7%, or 37/81) of the patients with documented symptom duration had a delay of at least 1 year before referral; however, ACPA utilization was not associated with the delay to treatment initiation.

Conclusions: Most PCPs failed to order diagnostic tests for RA before referring a patient with polyarthritis who eventually received a diagnosis of RA. We also observed delays in diagnosis, with half of the patients waiting >1 year from symptom onset to diagnosis. These findings suggest educational efforts for PCPs should focus on emphasizing earlier diagnostic workups, especially ACPA, in patients suspected to have RA.
Posted in: Rheumatology and Orthopedics24 Rheumatoid Arthritis2

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Scott DL, Wolfe F, Huizinga TWJ. Rheumatoid arthritis. Lancet 2010;376:1094-1108.
2. An J, Nyarko E, Hamad MA. Prevalence of comorbidities and their associations with health-related quality of life and healthcare expenditures in patients with rheumatoid arthritis. Clin Rheumatol 2019;doi: 10.1007/s10067-019-04613-2.
3. Lundkvist J, Kastäng F, Kobelt G. The burden of rheumatoid arthritis and access to treatment: health burden and costs. Eur J Health Econ 2008;8(suppl 2):S49-S60.
4. Eriksson JK, Johansson K, Askling J, et al. Costs for hospital care, drugs and lost work days in incident and prevalent rheumatoid arthritis: how large, and how are they distributed? Ann Rheum Dis 2015;74:648-654.
5. Jansen ALMA, van der Horst-Bruinsma I, van Schaardenburg D, et al. Rheumatoid factor and antibodies to cyclic citrullinated peptide differentiate rheumatoid arthritis from undifferentiated polyarthritis in patients with early arthritis. J Rheumatol 2002;29:2074-2076.
6. Rantapää-Dahlqvist S, de Jong BAW, Berglin E, et al. Antibodies against cyclic citrullinated peptide and IgA rheumatoid factor predict the development of rheumatoid arthritis. Arthritis Rheum 2003;48:2741-2749.
7. Nielen MM, van Schaardenburg D, Reesink HW, et al. Specific autoantibodies precede the symptoms of rheumatoid arthritis: a study of serial measurements in blood donors. Arthritis Rheum 2004;50:380-386.
8. Goldbach-Mansky R, Lee J, McCoy A, et al. Rheumatoid arthritis associated aut
9. Schellekens GA, Visser H, de Jong BA, et al. The diagnostic properties of rheumatoid arthritis antibodies recognizing a cyclic citrullinated peptide. Arthritis Rheum 2000;43:155-163.
10. Catrina AI, Deane KD, Scher JU. Gene, environment, microbiome and mucosal immune tolerance in rheumatoid arthritis. Rheumatology (Oxford) 2016;55:391-402.
11. Catrina AI, Svensson CI, Malmströ V, et al. Mechanisms leading from systemic autoimmunity to joint-specific disease in rheumatoid arthritis. Nat Rev Rheumatol 2017;13:79-86.
12. Hunt L, Emery P. Defining populations at risk of rheumatoid arthritis: the first steps to prevention. Nat Rev Rheumatol 2014;10:521-530.
13. Wigerblad G, Bas DB, Fernades-Cerqueira C, et al. Autoantibodies to citrullinated proteins induce joint pain independent of inflammation via a chemokine-dependent mechanism. Ann Rheum Dis 2016;75:730-738.
14. Emery P. Evidence supporting the benefit of early intervention in rheumatoid arthritis. J Rheumatol Suppl 2002;66:3-8.
15. Combe B. Progression in early rheumatoid arthritis. Best Pract Res Clin Rheumatol 2009;23:59-69.
16. Cush JJ. Early rheumatoid arthritis-is there a window of opportunity? J Rheumatol Suppl 2007;80:1-7.
17. Finckh A, Bansback N, Marra CA, et al. Treatment of very early rheumatoid arthritis with symptomatic therapy, disease-modifying antirheumatic drugs, or biologic agents: a cost-effectiveness analysis. Ann Intern Med 2009;151:612-621.
18. Lee W, Weisman MH. The predictive power of anti-cyclic citrullinated peptide antibodies: window into understanding gene/environment/immunity interactions. J Rheumatol 2006;33:1216-1218.
19. Nishimura K, Sugiyama D, Kogata Y, et al. Meta-analysis: diagnostic accuracy of anti-cyclic citrullinated peptide antibody and rheumatoid factor for rheumatoid arthritis. Ann Intern Med 2007;146:797-808.
20. van Dongen H, van Aken J, Lard LR, et al. Efficacy of methotrexate treatment in patients with probable rheumatoid arthritis: a double-blind, randomized, placebo-controlled trial. Arthritis Rheum 2007;56:1424-1432.
21. Aletaha D, Neogi T, Silman AJ, et al. 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum 2010;62:2569-2581.
22. Sørensen J, Hetland ML, all departments of rheumatology in Denmark. Diagnostic delay in patients with rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis: results from the Danish nationwide DANBIO registry. Ann Rheum Dis 2015;74:e12.
23. Jamal S, Alibhai SMH, Badley EM, et al. Time to treatment for new patients with rheumatoid arthritis in a major metropolitan city. J Rheumatol 2011;38:1282-1288.
24. Hernández-García C, Vargas E, Abásolo L, et al. Lag time between onset of symptoms and access to rheumatology care and DMARD therapy in a cohort of patients with rheumatoid arthritis. J Rheumatol 2000;27:2323-2328.
25. Palm Ø, Purinszky E. Women with early rheumatoid arthritis are referred later than men. Ann Rheum Dis 2005;64:1227-1228.
26. Raza K, Stack R, Kumar K, et al. Delays in assessment of patients with rheumatoid arthritis: variations across Europe. Ann Rheum Dis 2011;70:1822-1825.
27. van der Linden MP, le Cessie S, Raza K, et al. Long-term impact of delay in assessment of patients with early arthritis. Arthritis Rheum 2010;62:3537-3546.
28. Massardo L, Pons-Estel BA, Wojdyla D, et al. Early rheumatoid arthritis in Latin America: low socioeconomic status related to high disease activity at baseline. Arthritis Care Res (Hoboken) 2012;64:1135-1143.