Improving outcomes for rheumatoid arthritis

Rheumatoid arthritis (RA) is a disease of unknown cause that leads to widespread inflammation, predominantly manifesting itself in the joints, with pain, swelling and stiffness. Uncontrolled, it is a progressive disease that damages joints and can lead to joint deformity and difficulties with daily functioning. It is common, affecting approximately 580,000 people in England.1 Recent advances in research have led to improvement in the use of existing treatment as well as in the development of new drugs, so that disabling joint deformities are becoming less common. Rheumatologists are now able to concentrate on aspects of quality of life for patients that were previously elusive, such as keeping people in work, maintaining their independence, as well as their contributions to families and society. The key to success is early recognition of RA and commencement of prompt and effective treatment. Numerous studies have shown that the best predictor of a poor outcome is the duration of symptoms when the patient first goes onto drugs that can slow the progress of the disease (so called “disease modifying anti-rheumatic drugs” or DMARDs). In other words, the longer the delay from first symptoms to appropriate medication, the less the chances of preventing long-term disability. Rapid suppression of disease activity results in less joint damage. This, in turn, leads to reduced disability and increases the chances of continuing in work and other social roles, and may lead to a reduction in need for new expensive biological treatments. Good communication and shared care, between primary and secondary care, is essential to prompt intervention. NICE recommends that for early RA the optimal time from symptom onset to receiving specialist treatment is within three months.2 At three months changes in the pathology of RA seem to lead to a tendency to perpetuation of the disease, where as before this time, intervention seems to have a far greater chance of effecting remission.3 Time is therefore of the essence.

Barriers to early treatment

Current barriers to early treatment, as highlighted in the National Audit Office report,1 include: patients with symptoms delaying seeing their GP; GPs delaying referral due to diagnostic uncertainty; and geographic variability in secondary care service availability, particularly with regard to the MDT. Of all of these, the greatest delay is in patients delaying seeing their GP with symptoms in the first place. On the one hand, we do not want to encourage all patients with musculoskeletal aches and pains to instantly visit their GP, which would overwhelm colleagues in primary care. On the other hand, we need a public health campaign to highlight the urgency for medical attention of certain signs and symptoms, particularly pain, swelling and stiffness of the small joints of the hands and feet. The Rheumatology Futures Group and Arthritis Research UK have sponsored a poster campaign for GP surgeries called the “S factor” – Swelling, Stiffness and pain on Squeezing the joints (see Fig. 1) – to highlight the importance of this area. It is important for GPs to receive ongoing reminders of the importance of early referral, relying more on signs and symptoms than test results, which may all be normal in the early stages of RA, and lead to delays in referral while waiting for the results. It is important that GPs have rapid access to a rheumatologist-led multidisciplinary specialist team who can see patients quickly and start appropriate medication. The Choose and Book system can be fine for convenient, routine appointments, but often gets in the way of efficient urgent inflammatory arthritis referrals. If necessary it needs to be circumvented with direct contact with the multidisciplinary specialist team. Recent health policies have had a tendency to drive a wedge between primary and specialist care, to the detriment of the optimal management of the patient. GPs have, on occasions, been under pressure to not refer patients to specialist care to save money. There are times when this may lead to more appropriate use of limited resources, but not in the area of early inflammatory arthritis, where all patients merit a specialist opinion, and many of them urgently. “Payment by Results” may have resulted in less shared care between primary and specialist care, so that when patients have had their disease stabilised, much of their ongoing care can be conducted in general practice. This also helps to increase capacity in specialist care so that early patients can be seen quickly. What is needed are care pathways that bridge primary and secondary care so that there are no disincentives to prompt referral, rapid disease control, then shared care once this has been achieved. The Department of Health has produced an inflammatory arthritis care pathway to act as a template for commissioners to assist this process.4 Diagnosis of early arthritis requires the identification of painful joints that may be swollen. If the squeeze test (where the metacarpophalangeal or metatarsophalangeal joints are squeezed) is positive, and particularly if several areas are affected, this in itself should merit concern and referral to the specialist team. Most specialists would rather see patients quickly with no tests having been requested in general practice, rather than a thoroughly worked up patient with detailed investigations, but several weeks or months of symptoms. Early diagnosis can be tricky, even for specialists. An evolving area is the use of musculoskeletal ultrasound and magnetic resonance imaging to aid diagnosis of early and clinically undetectable arthritis. This is not yet universally available, but increasing access is occurring in specialist departments because of the objective assistance these imaging modalities provide in diagnosing early inflammatory arthritis.