Decreasing delays in the diagnosis and treatment of rheumatoid arthritis in Brazil: a nationwide multicenter observational study

Albuquerque, Cleandro Pires de; 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. da Cunha; Pereira, Ivânio Alves; Brenol, Claiton Viegas; Mota, Licia Maria Henrique da; Santos Neto, Leopoldo; Pinheiro, Geraldo R. Castelar

doi:10.1186/s42358-022-00265-0

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Sumário

Research • Adv. rheumatol. 63 • 2023 • https://doi.org/10.1186/s42358-022-00265-0 copy

Decreasing delays in the diagnosis and treatment of rheumatoid arthritis in Brazil: a nationwide multicenter observational study

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background

Management delays imply worse outcomes in rheumatoid arthritis (RA) and, therefore, should be minimized. We evaluated changes in diagnostic and treatment delays regarding RA in the last decades in Brazil.

Methods

Adults fulfilling the ACR/EULAR (2010) criteria for RA were assessed. Delays in diagnosis and treatment, and the frequencies of early management initiation within thresholds (windows of opportunity) of 3, 6, and 12 months from symptoms onset were evaluated. The Mann–Kendall trend test, chi-squared tests with Cramer’s V effect sizes and analysis of variance were conducted.

Results

We included 1116 patients: 89.4% female, 56.8% white, mean (SD) age 57.1 (11.5) years. A downward trend was found in diagnostic (tau = - 0.677, p < 0.001) and treatment (tau = - 0.695, p < 0.001) delays from 1990 to 2015. The frequency of early management increased throughout the period, with ascending effect sizes across the 3-, 6-, and 12-month windows (V = 0.120, 0.200 and 0.261, respectively). Despite all improvements, even in recent years (2011–2015) the diagnostic and treatment delays still remained unacceptably high [median (IQR): 8 (4–12) and 11 (5–17) months, respectively], with only 17.2% of the patients treated within the shortest, 3-month window.

Conclusion

The delays in diagnosis and treatment of RA decreased during the last decades in Brazil. Improvements (effect sizes) were greater at eliminating extreme delays (≥ 12 months) than in attaining really short management windows (≤ 3 months). Very early treatment was still an unrealistic goal for most patients with RA.

Keywords
Rheumatoid arthritis; Therapeutics; Epidemiology; Outcome and process assessment; Health care

Disease onset (year)	Delay from symptoms onset to RA diagnosis^[a] [a] The table shows the frequencies (%) of early diagnoses considering different delay thresholds (windows of opportunity) , ^[b] [b] A significant association between the year (period) of disease onset and the frequency of early RA diagnoses was observed within all considered windows, i.e., for the 3-month (p = 0.002), 6-month (p < 0.001) and 12-month (p < 0.001) delay thresholds; the Mantel–Haenszel linear-by-linear chi-squared test			N^* * Numbers of participants with data available for the analyses
Disease onset (year)	≤ 3 months	≤ 6 months	≤ 12 months
≤ 1990	12.4%	23.6%	41.6%	161
1991–1995	10.7%	24.3%	44.7%	103
1996–2000	10.5%	25.3%	48.1%	162
2001–2005	13.9%	29.1%	57.4%	237
2006–2010	19.9%	39.1%	65.6%	256
2011–2015	20.6%	43.8%	76.9%	160

Disease onset (year)	Delay from symptoms onset to the first DMARD^[a] [a] The table shows the frequencies (%) of early RA treatment (early initiation of the first DMARD) considering different delay thresholds (windows of opportunity) ,^[b] [b] A significant association (p < 0,001) was found between the year of disease onset and the frequency of early RA treatment within all considered windows (delay thresholds); the Mantel–Haenszel linear-by-linear chi-squared test			N^* * Numbers of participants with data available for the analyses
Disease onset (year)	≤ 3 months	≤ 6 months	≤ 12 months
≤ 1990	8.5%	14.9%	33.3%	141
1991–1995	5.3%	15.8%	34.7%	95
1996–2000	12.3%	24.7%	44.5%	146
2001–2005	11.5%	26.3%	49.8%	217
2006–2010	17.2%	38.9%	61.1%	239
2011–2015	17.2%	36.3%	72.0%	157

Disease onset (year)	Diagnostic delay (months)		N^* * Numbers of participants with data available for the assessments	Treatment delay (months)		N^* * Numbers of participants with data available for the assessments
Disease onset (year)	Mean (SD)	Median [IQR]		Mean (SD)	Median [IQR]
≤ 1990	71.2 (92.6)	24 [8–120]	161	101.7 (118.5)	60 [12–163]	141
1991–1995	47.8 (56.2)	24 [8–72]	103	52.5 (1.3)	36 [12–82]	95
1996–2000	35.3 (44.3)	21 [6–48]	162	40.0 (53.3)	24 [6.75–49]	146
2001–2005	28.2 (38.3)	12 [6–36]	237	32.5 (41.5)	13 [6–37.5]	217
2006–2010	17.8 (19.8)	12 [5–24]	256	17.8 (19.0)	12 [5–24]	239
2011–2015	11.1 (9.4)	8 [4–12]	160	12.2 (9.8)	11 [5–17]	157

Reference period	Comparison period	Mean difference [95% CI] (months)
Reference period	Comparison period	For diagnostic delay	For treatment delay
2011–2015	≤ 1990	- 60,2 [- 81.3, - 39.0]	- 89,6 [- 118.5, - 60.6]
	1991–1995	- 36,7 [- 52.9, - 20.5]	- 40,4 [- 55.9, - 24.8]
	1996–2000	- 24,2 [- 34.5, - 13.9]	- 27,8 [- 40.7, - 14.9]
	2001–2005	- 17,1 [- 24.6, - 9.7]	- 20,3 [- 28.7, - 11.9]
	2006–2010	- 6,7 [- 10.8, - 2.6]^* * p = 0.002; all other differences shown in the table were significant at p < 0.001 on Games-Howell post-hoc tests following one-way ANOVA	- 5,7 [- 9.8, - 1.5]

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 de Albuquerque cleandro.albuquerque@gmail.com