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Early Arthritis Clinics
Mieke HazesProf. of RheumatologyErasmus Medical CenterRotterdam, The Netherlands
BJD Global Alliance for musculoskeletal Health World Summit 2014
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The burden of Inflammatory arthritis
Prevalence: 3-5%
Rheumatoid arthritis (RA): 1%
Gout
Psoriatic arthritis
Spondylarthropathies
Undifferentiated arthritis
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Rheumatoid Arthritis is a destructive disease
Impact:• QOL: pain• disabillity• impaired participation
40% work disabled after 5yup to 70% disabled after 15y
• Premature death
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Early arthritis clinics: early RA diagnosis
Adapted from: Hazes, J. M. W. & Luime, J. J. Nat. Rev. Rheumatol. 7, 381–390 (2011); published online 14 June 2011
1987 ACR2010 ACR/EULAR
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Early arthritis clinics: window of opportunity
Early diagnosis and intensive treatment lead to better outcomes
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Early arthritis clinics: challenges
Awareness
• Rheumatologists
• GP’s
• Population
Need
• Campaign
• Referral criteria
External factors
• Money (GNP)
• Organisation of health care
• Access to care
• Number of professionals
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Round table discussion
How to set up an early arthritis clinic
What would you like to achieve locally
What is necessary to reach goal
Referral criteria
Educational program
GP campaign
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Early referral of inflammatory arthritis
The Leiden Early Arthritis Clinic (EAC) experience 1993-1997The Rotterdam Early Arthritis CoHort (REACH) experience >2003
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Campaign for GPs
Explain advantages of early referralFacilitate early referral by simple instructions:
PainSwellingLimited joint mobility 2 out of 3 present
Call number………., Appointment <2 weeks
Early arthritis recognition clinicEARC
Suspicion of inflammatory arhtritis (synovitis)
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Rotterdam Early Arthritis CoHort (REACH) 2004-
Inclusion criteria:< 1 year symptomsPresence of arthritisorInflammatory joint complaints ≥ 2 following criteria:
MS ≥ 1 hourComplaints of hands and feetNon fitting rings or shoesBilateral compression pain of forefeetRA in familySymmetryParaesthesia fingersRecent unexplained fatique <1 year
Not mechanical or traumatic
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REACH criteria: 51% of RA seen <12 weeks
EARC: 53% of RA seen < 12 weeks
Early arthritis clinics: window of opportunity
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REACH – GP Delay, median (range)
Direct Indirect
Arthritis, RA/ other
GP delay , days 27 (2-358)* 56 (0-357)
Inflam. complaints
GP delay , days 36 (2-364)* 62 (1-323
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Patient’s lag time
Patients who were referred to EAC by routine (not directly) also waited approximately 2 months longer to first contact their GP’s because of their symptoms⇒ patient lag time 2 months
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Results EAC: Early RA
GP-EAC/REACH Routine
Leiden LeidenRF, % 59% 50 %Erosive 25% 28 %
Median symp. Duration,days
31 164*
-
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Results EAC Leiden and REACH Rotterdam
GP-EAC/REACH Routine
Leiden LeidenFemale, % 48 % 59 %Median age 47 53
Median symp. Duration,days
31 122*
Acute onset,%
73 % 54 %*
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Health-Related Quality of Life (SF-36) in REACH
Kk
0102030405060708090
100
Physicalfunctioning
Physicalrole
Bodily pain
Generalhealth
Vitality Socialfunctioning
Emotional role
Mental health
Sco
re o
n su
bsca
les
of th
e S
F-36
(0-1
00)
Dutch populat ion (P icavet et al., 2004)Rheumatoid arthrit is(Non-RA) arthrit isInflammatory joint complaint s without synovit is
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Conclusions
Early referral of recent onset arthritis is possibleGPs still do not recognise RA earlyRA tends to have an insidious onset and relative long patient delayPatients’ discomfort appears to be similar in all patients with inflammatory complaints irrespective of clinically recognizable arthritis
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