S. Hider

AB0212 Diagnostic delay for rheumatoid arthritis: a systematic review

Background Rheumatoid arthritis (RA) is a common inflammatory condition, affecting 1% of the population and causing pain, stiffness and swelling, leading to significant disability and loss of function[.1 Delays in the diagnosis and treatment of RA can lead to worsened joint damage and disability, in addition to a reduced rate of disease-modifying antirheumatic drugs(DMARD)-free remission. Current (2016) EULAR guidelines specify that combination DMARD treatment be initiated within 3 months of the onset of persistent RA symptoms[.2 Unfortunately, this target is not always achieved due to delays between symptom onset to treatment initiation. Objectives The aim of this systematic review, was to determine the extent of delay that occurs at different points in the patient’s journey from RA symptom onset to treatment initiation, providing benchmarks of delay. Methods Embase and Medline were searched for articles examining diagnostic and treatment delay of RA. To be included, articles had to report a time-period of delay in an adult RA population. Papers were screened by three authors (CAH, JAP, IS). The primary outcome was the reported time-period of delay at any point from RA symptom onset to treatment. Due to skewed delay data, medians (with Interquartile range (IQR)) were selected and reported using narrative synthesis. Different time-periods of delay were categorised to facilitate comparison. Results Of 4925 returned articles, 1501 duplicates were removed. The remaining articles were then screened by title, abstract and full text, leaving 26 from which we extracted data. Delay periods were categorised as 1) symptom onset to initiation of DMARDs (n=9), 2) symptom onset to diagnosis (n=14), 3) symptom onset to 1st healthcare professional (HCP) appointment (n=15), 4) 1 ST HCP appointment to rheumatology referral (n=4) and 5) 1 ST HCP appointment to diagnosis (n=4). Time-periods of delay were typically skewed to the right. The total delay from symptom onset to receiving DMARDs has dropped since the 1980’s (429 weeks before 1987) and by 2014 data indicates an average delay of 23 (IQR 14, 43) weeks. Within this total delay period, delay from symptom onset to diagnosis is at a minimum 16(7,55 weeks and delay from symptom onset to first contact with a HCP predominantly ranges from 2 (1,8) to 10(4,24 weeks in data from 2010 onwards. Delay between 1st HCP appointment and Rheumatology referral can be as quick as 2 (1,5) weeks and is within 12(2,48 weeks across all data points. Delay acquired between 1st HCP appointment and receiving a diagnosis has decreased overtime, most recently, delay was reported as 21 weeks. Conclusions Time from RA symptom onset to receiving treatment has reduced considerably in recent decades. However, despite current guidelines and research indicating an optimal treatment window for RA of twelve weeks from symptom onset, this remains unmet, with this delay approximately twice the recommended period. Continued effort is required in reducing delay across all areas of the RA patients’ journey to the early treatment needed to improve outcome. References [1] Scott DGI. What is RA? https://www.nras.org.uk/: National Rheumatoid Arthritis Society; 2014. Available from https://www.nras.org.uk/what-is-ra-article [2] Combe B, et al. 2016 update of the EULAR recommendations for the management of early arthritis. Annals of the rheumatic diseases 2017. Disclosure of Interest None declared

OP0293 Patient Priorities for PMR Research: A Primary Care Survey

Background Polymyalgia rheumatica (PMR) is a common inflammatory disorder of older (>50 years) adults, frequently managed in primary care. PMR remains under-researched despite the significant impact this condition has on patients quality of life. Existing research is typically focused in secondary care settings and as such may not be generalizable to the wider PMR patient population. The importance of involving patients in research is increasing recognised as best practice, yet to date patient priorities for PMR research have not been examined. Objectives To identify patient priorities for PMR research. Methods All adults aged ≥50years registered with 150 English general practices who had a first Read code for PMR in their medical records in the preceding 3 years were mailed a self-completion questionnaire (n=704). Survey items included questions on patient demographics and PMR symptoms. Questions regarding patient priorities for PMR research were developed in collaboration with patient members of the leading UK patient group (PMRGCAuk). Patients were asked to indicate what their priorities for research were from a predefined list of 8 items and an additional free-text option. Results 550 patients responded (78%). The mean (SD) age was 74.2 (8.4) years and 365 (66%) were female. Non-responders did not differ significantly from responders in terms of age (mean age 75 (9.2) vs 74.2 (SD 8.4), p=0.21) or gender (73% vs 66% females, p=0.14).Priorities areas for research were focused on how to manage pain, stiffness and fatigue (440, 80%), improving the diagnosis of PMR (391, 71%), steroid management (341, 62%) and improving self-management (330, 55%). The development of giant cell arteritis (74, 13%), a key concern for clinicians, was the item rated as least important by participants for future research. Conclusions Meaningful involvement of patients in the research process is essential if we are to generate evidence that improves outcomes for those suffering with this painful and disabling condition. This survey of PMR patients in primary care suggests that symptom management and managing medication are key areas for patients for future research. Researchers and funding organisations should be aware of these priorities if we to generate research findings that are relevant to the widest range of stakeholders. Acknowledgement This abstract presents independent research funded by the National Institute for Health Research (NIHR). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Disclosure of Interest None declared

AB0600 How do General Practitioners Identify GIANT Cell Arteritis (GCA)

Background Giant Cell Arteritis (GCA) is the commonest large vessel vasculitis yet a full time UK general practitioner (GP) can expect to see just 1 case every 1-2 years [Barraclough]. GCA may be difficult to identify, particularly in atypical cases. For example headache has been shown to be absent in just under a quarter of GCA patients which may falsely reassure clinicians resulting in delayed diagnosis and potential visual loss [Ezeonyeji]. Objectives The aim of this study was to investigate how GPs identify GCA. Methods A postal questionnaire survey of 5000 randomly selected UK general practitioners was undertaken. Questions included experience of managing patients with GCA, presenting symptoms used to identify GCA and the referral pathways used. Results 1249 questionnaires were returned. The mean age of responder was 43 years and they had been qualified as a GP for a mean of 14 years (SD 9.03). Respondents were more likely to be from larger practices. 879 responders (70.4%) indicated that they had diagnosed and managed a patient with GCA. Figure 1 illustrates the combinations of the main symptoms that GPs use to identify GCA with headache being the predominant feature (n=1071 (86%)). Other commonly reported features were visual disturbances (n=671 (53.9%)), jaw symptoms (n=420 (33.7%)) and temporal artery/scalp tenderness (n=468 (37.6%)). 21.86% (n=273) indicated that they only use headache as a symptom for identifying GCA. Figure 1. Venn diagram of symptoms used to identify GCA. Conclusions General practitioners in the UK rely overly on headache when diagnosing GCA. Educating clinicians about other presenting symptoms and atypical presentations is essential to optimise diagnosis and reduce the potential for visual loss for this patient group and to reduce potentially serious long term complications. References Barraclough K et al. Br J Gen Pract. 2012 Jun;62(599):329-3 Ezeonyeji A et al. Clin Rheumatol. 2011;30(2):259-262 Acknowledgements Administration and support staff at Keele University Department of Primary Care and Health Sciences. IT Staff Zoe Mason and Ashley Ford. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4634

OP0298-PC How General Practitioners Diagnose Polymyalgia Rheumatica

Background The initial diagnosis of polymyalgia rheumatica (PMR) is often made in primary care. Given the non-specific nature of PMR symptoms, diagnosis can be challenging especially as many disorders can mimic the symptoms of PMR. Although guidelines are available1, studies suggest guidelines are rarely followed2 and that diagnostic accuracy is poor3. However, previous studies have relied upon data from retrospective case review or data from referral letters. Objectives The aim of this study was to describe how general practitioners (GPs) in the UK, report that they diagnose PMR based on symptoms, investigations and exclusion of other disorders. Methods 5000 randomly selected GPs in the UK were mailed a questionnaire on PMR. As part of the survey GPs were asked, in their routine practice, which clinical features were most important in diagnosing PMR and, what investigations they performed. They were also asked, what they would do if the inflammatory markers were normal and which disorders they would routinely try to exclude before making a formal diagnosis of PMR. Results 1249 (25.1%) GPs responded. Responders were generally from practices with larger list sizes and more GP principals than non-responders. GPs rated bilateral shoulder pain, raised inflammatory markers and response to corticosteroids as the most important clinical features for diagnosing PMR. Most respondents performed full blood count and ESR or CRP. Other recommended blood tests were performed less frequently (figure 1 ). 25% (n=315) of GPs reported that they would exclude PMR in patients with normal inflammatory markers, whilst 31% (n=392) would refer their patients to secondary care for specialist review. 80% (n=1001) of GPs sought to exclude giant cell arteritis (GCA). 61% (n=759) routinely excluded other rheumatological disorders, but just 55% (n=682) considered excluding relevant malignancies. Image/graph Conclusions This large GP survey suggests that despite using recommended clinical features to diagnose PMR and seeking to exclude GCA, many GPs do not routinely exclude other diagnoses as a cause of symptoms. This has significant implications for diagnostic accuracy which could result in prolonged, inappropriate treatment with corticosteroids or a missed opportunity for timely more appropriate intervention in disorders such as malignancy or rheumatoid arthritis. Further work is needed to investigate the accuracy of the diagnosis of PMR in primary care. References Rheumatology, 49(1), pp. 186-90. Family Practice, 25(5), pp. 328-333. Clinical rheumatology, 19(4), pp. 278-280. Disclosure of Interest None Declared