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How Early Should Rheumatoid Arthritis Be Diagnosed And Why Is That Important?

Mar 12, 2008
Rheumatoid arthritis (RA) is a common inflammatory, chronic, systemic, autoimmune disease for which there is no known cure. It affects approximately 2.1 million Americans.

RA is one of the leading causes of disability.

And, because it is a systemic disease it can cause significant damage to other organ systems besides the joints including the eyes, heart, lungs, and blood.

The prognosis for this condition has improved dramatically in recent years because of the advent of new drug therapies that make it possible to put RA into complete remission. Unfortunately, aggressive therapy depends most on making a correct diagnosis early on so that appropriate medications can be instituted as soon as possible.

A significant barrier to this problem occurs at the primary care level. Patients with rheumatoid arthritis are often not diagnosed early enough, not sent to rheumatologists quickly enough, and a new study finds that sometimes the diagnosis appended to the patient by the primary care physician may be erroneous.

In this recent article, researchers looked at the way rheumatoid arthritis is diagnosed by analyzing the administrative databases used by physicians in Quebec.

The authors of the paper, published in Arthritis & Rheumatism (Feldman DE, et al Arthritis Rheum. 2007; 57: 1419-25), reported that general practitioners diagnosed 79% of the 10,001 rheumatoid arthritis cases but only 27% of patients then saw a rheumatologist. Roughly, half of these patients were seen in the first three months following the initial diagnosis and then of these remaining patients, only 17% actually were confirmed with the diagnosis of rheumatoid arthritis.

Senior author, Annelies Boonen commented that, "The low referral rates of cases with suspected rheumatoid arthritis to rheumatologists is worrisome, especially when considering the discrepancy in diagnoses between the initial diagnosis by the non-rheumatologists and the following diagnosis by the rheumatologists."

The authors recommended further research to confirm the findings and explore the wider implications of the study. They went on to say, "If we really feel the window of opportunity for treatment of rheumatoid arthritis exists, rheumatologists should increase their efforts to raise diagnostic capabilities of first-line physicians towards early diagnosis and referral of suspected patients with rheumatoid arthritis".

The study points out several significant problems when it comes to the early diagnosis of rheumatoid arthritis. First, rheumatology training for primary care physicians is not adequate. In the United States, many primary care residency programs spend little time on educating their residents on rheumatic disorders. Therefore, the diagnostic capabilities of primary care physicians when it comes to rheumatic disease is less than it should be. This is not the fault of the primary care physician; rather, it is a flaw in the educational process. And this flaw extends to care extender programs such as those for nurse practitioners as well as those for physicians' assistants.

Second, the magnitude of the problem- early RA- has not been impressed enough on primary care providers. Early RA is essentially a medical emergency in that there is a small window of opportunity that exists in which permanent damage can either be slowed or avoided by institution of aggressive therapy. RA can be put into remission but timing is critical.
Third, there are other rheumatic diseases that can look like RA and the treatment is very different. Proper diagnosis is key to correct treatment. Just as important as making the diagnosis of RA and instituting proper aggressive therapy is not applying anti-RA treatment to patients who do not have RA.

Fourth, the early diagnosis of RA is often a difficult one to make and patients with suspected RA should be referred as soon as possible to a rheumatologist.
About the Author
Nathan Wei, MD FACP FACR is a rheumatologist and Director of the Arthritis and Osteoporosis Center of Maryland. He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine. For more info: Arthritis Treatment
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