Early referral, diagnosis, and treatment of rheumatoid arthritis: evidence for changing medical practice

Objectives-To study the delay in starting disease modifying anti-rheumatic drugs (DMARDs) in patients with rheumatoid arthritis (RA), and any changes in medical practice between 1980 and 1997. Methods-198 consecutive RA patients attending the rheumatology clinics at a teaching hospital, for routine review, had their case sheet reviewed. The dates of symptom onset, general practitioner (GP) referral, first clinic appointment and first use of DMARD were recorded. Data were collected on the erythrocyte sedimentation rate, C reactive protein, rheumatoid factor, and the presence/absence of erosions at the first clinic assessment. Patients were split into four groups according to the date of their first clinic assessment-before 1986, 1987-9, 1990-3, and 1994-7. Results-There was a sharp drop in the delay between symptom onset and GP referral (before 1986, 21 months; 1987-89, 23 months; 1990-3, 7 months; 1994-7, 4 months, p<0.03), and in the delay between first assessment at the rheumatology clinic and the start of DMARD treatment (before 1986, 32 months; 1987-89, 21 months; 1990-1993, 8 months; 1994-7, 1 month, p<0.001). The number of patients given DMARD treatment within six months of symptom onset increased from 5% (before 1994) to 44% (1994-7). Seventy three per cent of patients waiting more than a year from symptom onset to first clinic appointment already had erosive change, compared with 34% of patients seen within a year. Conclusions-Patients are being referred earlier in their disease, and DMARDs are prescribed sooner in the disease course. There has been a substantial increase in the proportion of patients treated with a DMARD within six months of symptom onset.