Background: Patients with rheumatic and musculoskeletal diseases (RMD) can present in many ways, often requiring substantial expertise for diagnosis. Depending on symptom severity and healthcare access, a substantial proportion of patients with RMD initially present to the emergency department (ED). Very little is known about the disease spectrum of these not yet diagnosed RMD patients. In addition, RMD patients utilize a significant amount of health care recourses. They are not only prone to disease flares but also other conditions such as infections, malignancies and cardiovascular diseases, all of which can lead to presentation to the ED. Differentiating between these conditions can be challenging.

Objectives: We wanted to assess the spectrum of rheumatological patients that present to the ED, both those with known RMD and those without. We specifically wanted to analyze this with regard to need for rheumatological expertise in the ED and healthcare resource utilization.

Methods: The University Medical Center Hamburg-Eppendorf (UKE) is an academic tertiary care hospital, with departments for all medical specialties. The emergency department (ED) sees over 70,000 patients a year. Patients with suspected internal medicine problems are treated by the ED internal medicine team. If specialist rheumatological expertise is needed, a rheumatological consultation (RC) is requested. We retrospectively identified all ED patients between 01/2019 and 06/2022 that had an RC. Next, we extracted detailed clinical information from the EHR including pre-ED aspects (e.g. known RMD), ED aspects (e.g mode of presentation) and post-ED aspects (e.g. final diagnosis). A total of 332 (RC) in the ED over a period of 42 months were analysed.

Results: A total of 332 (RC) in the ED over a period of 42 months were analysed. In (37%) a RC for a suspected flare of a known RMD was the overarching question. Specific findings leading to RC included a variety of symptoms and laboratory findings, with arthritis (32%) and general malaise/B-symptoms (28%) being the most common. 39% had complex medical issues with multiple affected organ systems. Rheumatoid arthritis (RA, 27%) followed by giant cell arteritis (GCA, 9.3%), systemic lupus erythematosus (SLE, 8.5%), small vessel vasculitis (SVV, 7.8%) and psoriatic arthritis (PsA, 5.4%) were the most common RMDs but we had substantial numbers even for rarer conditions (e.g. myositis 3.1% and adult onset still’s disease 2.3%). Despite the general goal of glucocorticoid (GC) free remission in most RMD, 32% of patients were treated with maintenance GC prior to admission. Methotrexate was the most common DMARD (6.7%) but all types of b-, cs-, and ts-DMARDs were seen. Even though all of these patients had a prior RMD diagnosis and presented with symptoms warranting an RC for suspected flare, only 11% were sent by their rheumatologist. The majority (60%) presented to the ED on their own accord and another 16% were sent by their family doctor. Furthermore, 73% of patients presented to the ED as walk-in patients and 52% had symptoms present for more than a week. 49% of patients were admitted to the hospital, with (55%) of these under rheumatology care. Patients admitted to rheumatology had significantly higher inflammatory markers (mean CRP 82 mg/l) compared to those discharged from the ED (mean CRP 47 mg/l). Finally, 73% of patients with RC for suspected disease flare had this as their discharge diagnosis. Next we analysed the 187 (56%) of patients without known RMD where suspected RMD was the overarching RC question. A large proportion of patients presented to the ED on their own accord (46%) and another 37% were sent by their family doctor. Symptoms had been present for more than a week in 67% of patients. 78% presented to the ED as walk-in patients. The most common reasons for RC were arthritis (39%), abnormal blood tests (31%), B-symptoms (21%) and non-arthritic pain (19%). Skin rash (11%) and peripheral oedema (6%) were the most common non-arthritis symptoms that lead to RC. 53% of patients were admitted to the hospital, the majority of these under care of rheumatology (61%). Upon discharge from hospital 62% of patients with RC for suspected RMD had a diagnosis of RMD. This number rose significantly when RMD was also suspected by the consulting rheumatologist (91%). RA (11%), Polymyalgia rheumatica (9%) and gout (6%) were the most common rheumatological diagnoses. A substantial number of rare RMD were also diagnosed, accounting in aggregate for 19% of diagnosis. In 26% of patients an RMD was ruled out as final diagnosis, with infections accounting for 42% diagnoses for this group.

Conclusion: Our data provide a detailed picture of the broad spectrum of rheumatological conditions presenting to the ED and the need for rheumatological expertise. Our data suggests that, given the right recourses in the outpatient sector, a substantial proportion of ED visits from RMD patients could probably be avoided.

REFERENCES: NIL.

Acknowledgements: NIL.

Disclosure of Interests: Pavels Klimicevs: None declared, Frederic Christian Feindt: None declared, Phillip Kremer: None declared, Marie-Therese Holzer Abbvie, Rheumaakademie e.V., Abbvie, Boehringer-Ingelheim, Isabell Haase: None declared, Martin Krusche UCB, Novartis, Sobi, Medac,, UCB, Novartis, Sobi, Medac, Ina Kötter Abbvie, Janssen, Lilly, Medac, Novartis, Sobi, GSK, Eusapharm und Boehringer,, Simon Melderis: None declared.

© The Authors 2025. This abstract is an open access article published in Annals of Rheumatic Diseases under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ). Neither EULAR nor the publisher make any representation as to the accuracy of the content. The authors are solely responsible for the content in their abstract including accuracy of the facts, statements, results, conclusion, citing resources etc.