'Build-up' of arthritis, axial symptom diagnoses often precede PsA diagnosis
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Diagnoses of arthritis, axial symptoms and tendonitis or enthesitis often increase over time before a patient is finally diagnosed with psoriatic arthritis, according to data published in Arthritis Research & Therapy.
The researchers added that, in the 6 years prior to diagnosis, patients with PsA tend to have an increased history of codes for osteoarthritis, rheumatoid arthritis and psoriasis — “suggestive of PsA symptom build-up” — compared with those without PsA.
“A timely diagnosis of PsA is critical because a delay in diagnosis negatively impacts patient outcomes,” Alexis Ogdie, MD, MSCE, of the Perelman School of Medicine at the University of Pennsylvania, in Philadelphia, and colleagues wrote. “Unfortunately, diagnostic delay is common in PsA.”
“In a cross-sectional study of 203 participants with self-reported PsA in the USA, approximately one-third received their diagnosis within 6 months to 4 years, while another one-third had to wait for > 5 years,” they added. “These participants also consulted with numerous health care providers prior to receiving their diagnosis. A 6-month delay from PsA symptom onset to initial rheumatology consult may lead to joint erosion and damage. An increased awareness of the heterogeneity of PsA symptoms and diagnostic barriers may lead to a timely diagnosis.”
To analyze patient experience prior to a diagnosis of PsA and assess whether preceding health events may predict said diagnosis, Ogdie and colleagues conducted a retrospective cohort study of administrative claims data from Truven MarketScan. According to the researchers, MarketScan research databases include information on more than 263 million patients with commercial, Medicare supplemental and Medicaid coverage.
For their study, Ogdie and colleagues focused on the period from January 2006 to April 2019. They included a total of 13,661 adults with at least two PsA diagnoses — ICD-9-CM/ICD-10-CM — spaced at least 30 days apart, with at least 6 years of continuous enrollment prior to PsA diagnosis. These patients were matched 2:1 to a group of control individuals without PsA. The researchers examined diagnoses recorded prior to the PsA diagnosis, as well as the provider types that issued the diagnoses, all additionally stratified by the presence of psoriasis.
According to the researchers, patients with PsA demonstrated an increased history of coding for arthritis and dermatologic events, compared with those without PsA. These events included osteoarthritis — 48% in those with PsA versus 22% among controls — rheumatoid arthritis — 18% versus 2% — and psoriasis — 61% versus 2%. In addition, diagnoses of arthritis, axial symptoms, and tendonitis/enthesitis increased over time preceding an ultimate diagnosis of PsA. The researchers also noted a sharp rise in psoriasis diagnoses 6 months prior to a PsA diagnosis.
Consultations with a rheumatologist were more common immediately preceding a PsA diagnosis. Dermatologists were, in general, unlikely to code for arthritis and musculoskeletal issues, while rheumatologists were unlikely to code for psoriasis. General practitioners, meanwhile, tended to focus on axial and musculoskeletal symptoms. Among the examined PsA diagnoses, 40% were made by rheumatologists, 22% were made by general practitioners and 7% were made by dermatologists.
“An overall prevalence of skin and nonspecific musculoskeletal manifestations, in addition to consultations with various types of health care providers, may collectively serve as predictors of PsA,” Ogdie and colleagues wrote. “Greater awareness of patterns or trends of health events as seen in our study may alert general practitioners and other health care providers in primary care settings to suspect a diagnosis of PsA among their patients.”
“As PsA is associated with considerable health care costs, the number of non-PsA diagnoses, potentially suggestive of misdiagnoses, and health care visits across different types of providers suggest the increased utilization of health care resources,” they added. “The clinical and economic burden associated with PsA will most likely impact disease management and medical and pharmacy policy formulation. Increased awareness and understanding of diagnostic barriers may lead to timelier diagnosis, cost savings, and appropriate intervention to improve outcomes.”
Perspective
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This study supports many rheumatologists’ feelings that more timely diagnosis and treatment impacts disease outcomes. Recognizing specific trends in the patient journey to diagnosis may lead to more prompt referral to specialists who are more equipped to make the diagnosis without overburdening the rheumatologist office with nonspecific musculoskeletal complaints, especially in view of the projected 30% decrease in rheumatologists by the year 2030.
This study also suggests that innovative software to calculate targets based on both patient- and physician-reported outcomes to determine disease activity could be implemented. Screening tools, patient education and referral guidelines for primary care may enhance an earlier diagnosis and treatment. The concept of creating algorithms using EMR or insurance databases may help identify patients with PsA in a more timely manner.
I personally believe that education of the practitioners that PsA patients contact along their journey to diagnosis – including primary care, orthopedists, physiatrists, podiatrists, ophthalmologists and gastroenterologists – is key to earlier referral to dermatologists and rheumatologists, and thus earlier diagnosis and treatment for this patient population. Accessibility of education for our patients is key to their understanding of their disease and will guide their journey as well.
In addition, utilizing specific patterns and trends, such as skin and musculoskeletal complaints, as predictors and incorporating algorithms in EMR to capture targets may reduce the clinical and economic burden associated with PsA.
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