Abstract
Objective:To identify factors causing diagnostic and therapeutic delay in patients with rheumatoid arthritis, and to evaluate relationship of diagnostic and therapeutic delay with disease outcome.Methods:This cross-sectional study was conducted in Rheumatology Department, Fatima Memorial Hospital, Lahore, Pakistan, from May 2018 to July 2018. In this study 102 patients fulfilling ACR/EULAR criteria 2010 were enrolled. Lag times were calculated in months: lag-1 (delay in initial medical consultation); lag-2 (delay in consulting rheumatologists); lag-3 (diagnostic delay); lag-4 (therapeutic delay). Disease activity and functional outcome were measured by DAS28, HAQ-DI respectively. Association of lag-3 and lag-4 with HAQ-DI and DAS28 was calculated by Pearson correlation.Results:Median (IQR) disease duration of study group was 6(2-10) years. Initial consultations were with; orthopedic surgeon 40(39.2%), general practitioner 27(26.5%), rheumatologist 13(12.7%), medical specialists 14(13.7%). Median (IQR) lag times in months: lag-1 (delayed initial consultation): 2(0-5), lag-2 (delay in consulting rheumatologist): 30(7.7-72), lag-3 (diagnostic delay): 12(3-48), lag-4 (therapeutic delay):18(5.7-72). Factors attributed to lag-3 (diagnostic delay) and lag-4 (therapeutic delay) (p<0.05): older Age (r= 0.2), education level(r= - 0.2), initial consultation (non-rheumatologist) (r=0.2), lag-2(r=0.8), >three doctors visited before diagnosis(r=0.6). Positive anti-CCP antibodies(r=0.2) and lag-1 (delayed initial consultation) (r=1) were associated with lag-3 (diagnostic delay) only; no association was found with positive RA factor. Significant correlation (p=<0.05) of lag-3 (diagnostic delay) was found with both DAS28(r=0.2) & HAQ-DI(r=0.2). Similarly lag-4 (therapeutic delay) also correlated with both & DAS28(r=0.2) & HAQ-DI(r=0.3) (p=<0.05).Conclusion:Diagnostic and therapeutic delay were associated with older age, lower education and delayed consultation with rheumatologist but not with positive RA factor. Positive anti-CCP antibodies were associated with diagnostic delay only. Diagnostic and therapeutic delay led to high disease activity and poor functional outcome in RA patients.
Highlights
Rheumatoid arthritis (RA) is an autoimmune, systemic, chronic inflammatory disorder with articular and extra-articular manifestations.[1]
Long term studies reported that 50% RA patients have had to stop working after 10 years of disease which is 10-times the average rate caused by other medical conditions.[1]
Threshold of disease activity with DAS28 was interpreted as follow: Remission 2.6-5.1.14 HAQ-DI index was interpreted in three categories: 0-1: mild to moderate disability, 1-2: moderate to severe disability, 2-3: severe to very severe disability.[15]
Summary
Rheumatoid arthritis (RA) is an autoimmune, systemic, chronic inflammatory disorder with articular and extra-articular manifestations.[1] Worldwide RA affects 0.24 to 1% adult population[2] with female to male ratio 3:1. Peek age of onset in females is late childbearing years while in males is in sixth to seventh decade.[1] Point prevalence. Pak J Med Sci July - August 2021 Vol 37 No 4 www.pjms.org.pk 1001 of RA reported from Karachi has increased from 12.9% in 2011 to 26.9% in 2015.3 Musculoskeletal disorders contribute to 6.7% of “total overall global burden” of disease.[4]. Hypertension, smoking and self-use NSAIDS/ Hakeem medication lead to impaired renal function in RA patients.[8]
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