Early arthritis service is cost effective, improves outcomes and reduces biologic use
Rheumatology, Luton and Dunstable University Hospital, Luton, UK
Background: There is good evidence that dedicated early arthritis clinics (EACs) improve referral lag time and reduce delay in establishing disease-modifying therapy. However it remains arguable whether such clinics improve relevant disease outcomes. Nationally, only 57% of units have dedicated EACs.
Objectives: We established Early Arthritis Service (EAS), centred on NICE RA quality standards, to reduce the time to diagnosis and the start of definitive therapy with an aim to accomplish good outcomes by the introduction of dedicated Early Arthritis Clinics (EACs).
Methods: The department set up an early arthritis service with introduction of six clinics (EACs) every week. An agreed treatment protocol incorporating ultrasound was developed to ensure standardised approach to early initiation of treatment, drug education and timely review. This is a retrospective study of all patients presenting to the service in the first year.
Results: Our catchment area covers a population of 3 50 000 with 40% ethnic minorities. Of 1884 patients referred, 482 (25.5%) were triaged into EACs based on set criteria. All were reviewed within 3 weeks. 247 (51%) were confirmed to have early arthritis. Mean age was 52.4 years (17–86y). 157 (63.5%) were women. 177 (71.6%) were White, 58 (23.5%) of Asian and twelve of other background. 159 (64.3%) had RA, 57 (23%) with PsA and 31 had other inflammatory arthritides. 25 (10%) had erosions at presentation. There was median 26 weeks delay (0.4–1043 weeks) from symptom onset to GP presentation. Median time for GP referral to the department was 4.0 days (0–84 days). Mean DAS28 at first visit was 4.65 (0.6–8.0, n=166).
95% commenced their DMARDs within 3 week of initial review. Other 5% who missed the target was owing to patient factors. Treating to target achieved DAS28 remission for 84 (53.5%) and low disease activity for a further 44 (34%). Median time to achieve remission or LDA was 20 weeks (0–52 weeks, n=128). Similarly, 40/57 (70%) of PsA patients achieved good PsARC response in median 24 weeks. Of 247, only 21 (8.5%) patients required escalation to biologic therapy.
Conclusions: Dedicated EACs help achieve good clinical outcomes in majority of patients. Nearly 87% of our cohort attained remission or low disease activity in less than six months. This was despite a significant delay in patients presenting to their GPs and moderately-high disease activity. 100% of our patients were treated to target facilitated by protocol driven escalation of therapy in these clinics. This is in contrast to the national audit findings whereby only 68% of patients were treated with disease modifying drugs within 6 weeks of referral and 89% had treatment to target. Patient experience also improved (94% would now recommend the service compared to 76% prior to the initiative).
The project was a financial success with total savings for the year, accounting for most generous cost estimates, were £1 36 973. In addition, there was a 42% reduction in biologic use in this group compared to 2015. These savings are on top of wider economic and societal benefits achieved by inducing low disease activity or remission.
Disclosure of Interest: None declared
Citation: Ann Rheum Dis, volume 77, supplement Suppl, year 2018, page A1724
Session: Public health, health services research and health economics