Do it fast! Early access to specialized care improved long-term outcomes in rheumatoid arthritis: data from the REAL multicenter observational study

Albuquerque, Cleandro Pires; Reis, Ana Paula Monteiro Gomides; Santos, Ana Beatriz Vargas; Bértolo, Manoel Barros; Louzada Júnior, Paulo; Giorgi, Rina Dalva Neubarth; Radominski, Sebastião Cezar; Guimarães, Maria Fernanda B. Resende; Bonfiglioli, Karina Rossi; Sauma, Maria de Fátima L Cunha; Pereira, Ivânio Alves; Brenol, Claiton Viegas; Mota, Licia Maria Henrique; Santos Neto, Leopoldo; Pinheiro, Geraldo Rocha Castelar

doi:10.1186/s42358-023-00301-7

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Sumário

Research • Adv. rheumatol. 63 • 2023 • https://doi.org/10.1186/s42358-023-00301-7 copy

Do it fast! Early access to specialized care improved long-term outcomes in rheumatoid arthritis: data from the REAL multicenter observational study

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background

Early rheumatoid arthritis (RA) offers an opportunity for better treatment outcomes. In real-life settings, grasping this opportunity might depend on access to specialized care. We evaluated the effects of early versus late assessment by the rheumatologist on the diagnosis, treatment initiation and long-term outcomes of RA under real-life conditions.

Methods

Adults meeting the ACR/EULAR (2010) or ARA (1987) criteria for RA were included. Structured interviews were conducted. The specialized assessment was deemed “early” when the rheumatologist was the first or second physician consulted after symptoms onset, and “late” when performed afterwards. Delays in RA diagnosis and treatment were inquired. Disease activity (DAS28-CRP) and physical function (HAQ-DI) were evaluated. Student's t, Mann-Whitney U, chi-squared and correlation tests, and multiple linear regression were performed. For sensitivity analysis, a propensity score-matched subsample of early- vs. late-assessed participants was derived based on logistic regression. The study received ethical approval; all participants signed informed consent.

Results

We included 1057 participants (89.4% female, 56.5% white); mean (SD) age: 56.9 (11.5) years; disease duration: 173.1 (114.5) months. Median (IQR) delays from symptoms onset to both RA diagnosis and initial treatment coincided: 12 (6–36) months, with no significant delay between diagnosis and treatment. Most participants (64.6%) first sought a general practitioner. Notwithstanding, 80.7% had the diagnosis established only by the rheumatologist. Only a minority (28.7%) attained early RA treatment (≤ 6 months of symptoms). Diagnostic and treatment delays were strongly correlated (rho 0.816; p < 0.001). The chances of missing early treatment more than doubled when the assessment by the rheumatologist was belated (OR 2.77; 95% CI: 1.93, 3.97). After long disease duration, late-assessed participants still presented lower chances of remission/low disease activity (OR 0.74; 95% CI: 0.55, 0.99), while the early-assessed ones showed better DAS28-CRP and HAQ-DI scores (difference in means [95% CI]: −0.25 [−0.46, −0.04] and − 0.196 [−0.306, −0.087] respectively). The results in the propensity-score matched subsample confirmed those observed in the original (whole) sample.

Conclusions

Early diagnosis and treatment initiation in patients with RA was critically dependent on early access to the rheumatologist; late specialized assessment was associated with worse long-term clinical outcomes.

Keywords
Rheumatoid arthritis; Delivery of healthcare; Health care outcome and process assessment; Accessibility of health services; Rheumatology

Population characteristics	Results	N^* * Number of patients with available information on each characteristic.
Female sex	89.4% (n = 945)	1057
Race, White	56.5% (n = 597)	1057
Positive rheumatoid factor	78.2% (n = 813)	1039
Corticosteroid use	47.3% (n = 500)	1057
Biological DMARD use	35.5% (n = 375)	1057
Disease activity levels^ Based on DAS28-CRP scores.		886
Remission	38.4% (n = 340)
Low	15.3% (n = 136)
Moderate	34.7% (n = 307)
High	11.6% (n = 103)
Age in years, mean (SD)	56.9 (11.5)	1057
Years of schooling, mean (SD)	8.1 (4.3)	1021
Disease duration, mean (SD)^* ***** Values in months.	173.1 (114.5)	1056
Delay to diagnosis, median [IQR]^* ***** Values in months.	12 [6-36]	1024
Delay to first DMARD, median [IQR]^* ***** Values in months.	12 [6-36]	944
HAQ-DI score, median [IQR]	0.875 [0.250-1.500]	1053
DAS28-CRP score, mean (SD)	3.27 (1.37)	886

Medical Specialty	First consulted the patient Number of cases (%)	First established RA diagnosis Number ofcases(%)
Rheumatologist	202 (19.3)	838 (80.7)
General practitioner	674 (64.6)	156 (15.0)
Orthopedist	131 (12.5)	29 (2.8)
Other	37 (3.5)	15 (1.4)
Total^* * Numbers of cases with data available for the analyses.	1044 (100)	1038 (100)

Considered window for early RA treatment (thresholds)	Position of the rheumatologist in the sequence of attending physicians ^* * The values in the cells represent the relative and absolute frequencies of patients who missed the opportunity for early RA treatment within the considered windows (thresholds).		Chances of missing the window of opportunity with belated assessment OR [95% CI] ^ Odds ratios for missing the opportunity of early RA treatment when the consultation by the rheumatologist was belated (position 3rd or later) compared to early consultation (positions 1st or 2nd); all differences were significant at p < 0.001, on Pearson's chi-squared test.
Considered window for early RA treatment (thresholds)	1st or 2nd (N = 665)	3rd or later (N = 279)
12 months	42.7% (n = 284)	60.6% (n = 169)	2.06 [1.55, 2.74]
6 months	65.9% (n = 438)	84.2% (n = 235)	2.77 [1.93, 3.97]
3 months	84.2% (n = 560)	93.2% (n = 260)	2.57 [1.54, 4.27]

Characteristics	Position of the rheumatologist in the sequence of attending physicians^* * The values in cells are the observed means (standard deviations) for each feature.		Difference in means^ Differences between groups of patients consulted by the rheumatologist early (as the 1st or 2nd physician) or late (as the 3rd physician or later on); all differences were significant at p < 0.05, on bivariate (unadjusted) students' t tests. [95% CI]
Characteristics	1st or 2nd (N = 753)	3rd or later (N = 304)
Years of schooling	8.40 (4.38)	7.19 (3.92)	1.22 [0.67, 1.77]
Total disease duration^(a)	167.04 (112.56)	188.03 (118.20)	−20.99 [−36.58, −5.41]
Delay to diagnosis^(a)	26.90 (46.67)	44.55 (60.07)	−17.65 [−25.28, −10.02]
Delay to first DMARD^(a)	32.48 (58.53)	50.58 (69.98)	−18.10 [−27.46, −8.73]
HAQ-DI score	0.877 (0.715)	1.074 (0.857)	−0.196 [−0.306, −0.087]
DAS28-CRP score	3.20 (1.32)	3.45 (1.48)	−0.25 [−0.46, −0.04]

Sociedade Brasileira de Reumatologia Av. Brigadeiro Luís Antônio, 2466, Jardim Paulista, 01402-000 - São Paulo, SP, Tel.: +551132897165 - São Paulo - SP - Brazil
E-mail: rbreumatol@terra.com.br

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[1] *Correspondence: Cleandro Pires Albuquerque, cleandro.albuquerque@gmail.com