Inflammatory arthritis: case review and primary care perspectives

Abstract

Inflammatory arthritis (IA) has significant physical, psychosocial and economic consequences. Delays in diagnosis and initiation of treatment significantly impact on prognosis. The infrequent, variable, non-specific and, sometimes, indolent presentation make recognition of IA by primary care physicians (PCPs) challenging. To undertake an in-depth case review assessing the diagnostic trajectory of patients diagnosed with IA to inform development of practical recommendations to facilitate timely recognition and referral of suspected IA to specialist services, a case review was undertaken in one UK general practice using a proforma to collect information on patient demographics, diagnostic activities (presentation to PCP, specialist referral and final diagnosis) and documentation of disease-specific features for all patients diagnosed with IA between January 2000 and February 2011. Cases were excluded if consultation notes, a definitive diagnosis or evidence of specialist assessment were absent. Twenty-four cases were included in the final analysis. Duration from first primary care presentation to specialist rheumatological referral ranged from 4 to 2,165 days. Undertaking radiographs significantly lengthened delays from presentation to referral. Patients with IA attended between 2 and 41 primary care appointments before being referred. None of the cases identified had a comprehensive record of symptoms documented in the medical record. Once patients present to primary care, specialist referral is not always in accordance with the urgency necessitated in current guidelines. Improving PCPs’ knowledge and awareness of IA, development of screening tools and improvement in record keeping are proposed to facilitate early recognition and referral of IA and subsequently reduce the disease burden of IA.