POS0260 ULTRASOUND ASSESSMENT OF HANDS AND FEET FOR SYNOVITIS PRIOR TO FIRST CLINICAL VISIT MARKEDLY REDUCES TIME TO DIAGNOSIS - EXPERIENCE FROM ROUTINE CARE

Abstract

Background:All patients referred to our Rheumatology department suspected of having arthritis are scheduled for a visit in the out-patient fast track clinic (FTC) for arthritis. Routine blood samples including C-reactive protein (CRP), anti-CCP, IgM RF, and x-ray of hands and feet are available at the first clinical visit where the medical history and clinical examination is obtained by rheumatologists or rheumatologists-in-training under supervision. The role of ultrasound (US) in routine care for diagnosing arthritis is not fully elucidated but US is more sensitive than clinical joint examination for detecting synovitis. Therefore, US may facilitate diagnosis of arthritis.Objectives:To assess whether US examinations of hands and feet in relation to the first clinical visit impact the time to diagnosis and number of clinical visits needed.Methods:From Oct. 2017 to June 2018, US examination of hands and feet (wrist, metacarpophalangeal and proximal interphalangeal joints, ankle, and metatarsophalangeal joints) were performed prior to the first clinical visit by ultrasound-experienced rheumatologists. Using the OMERACT scoring system for grey-scale (GS) and Doppler, synovitis was defined as GS score >1 with or without Doppler score ≥1. Examination time was 20 minutes.Time from the first clinical visit to the final clinical diagnosis and the number of clinical visits needed in the FTC was assessed and compared to a similar patient cohort the previous year (Nov. 2016 to June 2017) where ultrasound was performed ad hoc. Number of revised diagnoses and the number of patients re-referred after 12 months was noted. Local ethics committee ruled that approval was not needed.Results:From 2017- 2018, 163 referred patients had US prior to first clinical visit. 76(47%) were diagnosed with inflammatory arthritis (IA), 12(7%) with crystal-related arthritis, 39(24%) with other Rheumatic Diseases (RMDs) and 36(22%) with no RMD diagnosis. The comparative cohort comprised of 109 patients of whom 29(27%) were diagnosed with IA, 16 (15%) with crystal-related arthritis, 31(28%) with other RMDs and 33 (30%) with no RMD diagnosis. Adding US to the first clinical visit reduced the time to diagnosis from mean 31 (standard deviation(SD) ±32.2) days to mean 12 (±17.3) days. The number of clinical visits needed was reduced from mean 2.8(±1.1) to 2.1 (±1.3) corresponding to a reduction of 114 visits in the period from 2017–2018. The mean number of all US examinations in the FTC was 1.1 (±0.3) in the US cohort versus 0.8(±0.7) in the comparative cohort. In the US cohort vs. comparative cohort 8 (4.9%) vs. 17 (15.7%) patients had a revised diagnosis at 1 year-follow-up, and 7 (4%) vs. 12 (11%) were re-referred, respectively. For demographics, clinical, US, and laboratory characteristics see Table 1 where median values and inter-quartile range (IQR) for all parameters.Conclusion:Adding routine US examination to the first clinical visit reduces time to diagnosis markedly, lowers the number of clinical visits needed thereby reducing the time patients spent away from work, and freeing time for visits in the FTC to be used for other patientsTable 1.Comparative cohortUS cohortP(n=109)(n=163)AgeMedian [IQR]55.5[42;69]53[40;67]0.44Mean ±SD54.7±16.153.2±17.2Time to diagnosis daysMedian [IQR]12.4[10;42]0[0;25]<0.01Mean ±SD30.6±32.212.4±17.3Visits in FTCMedian [IQR]3[2;3]2[1;2]<0.01Mean ± SD2.8±1.12.1±1.3US assessments in the FTCMedian [IQR]1[0;1]1[1;1]<0.01Mean ±SD0.8±0.71.1±0.27Swollen joint count (0-28)Median [IQR]0[0;1]0[0;2]0.19Mean ±SD1.1±2.11.8±3.1Tender joint count (0-28)Median [IQR]1[0;5]1[0;5]0.06Mean ±SD3.1±3.73.1±5.2Grey-scale US sum score (0-72)*Median [IQR]1[0;3]4[1;8]<0.01.Mean ± SD2.8±5.96.3±7.9Colour Doppler US sum score (0-36)*Median [IQR]0[0;0]0[0;2]<0.01Mean ±SD1.2±4.02.8±5.9CRP (mg/l)Median [IQR]4[1;16.5]3[1.75;12]0.42Mean ± SD13.4±23.19.6±14.6P, p-value for Mann-Whitney U test for comparing independent data.* US sum score for both hands and feet.Disclosure of Interests:Mads Ammitzbøll_Danielsen: None declared, Uffe Møller Døhn Speakers bureau: Roche, Lilly, Novartis, Viktoria Fana: None declared, Torsten Møller: None declared, Sin Ngai Ng: None declared, Anne Emilie Secher: None declared, Jens Jørgen Lykkegaard: None declared, Lene Terslev Speakers bureau: Novartis, Pfizer, Roche,