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Are early arthritis clinics necessary?

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Landmark studies published in the 1980s were the first to reveal the long-term consequences of rheumatoid arthritis (RA). Instead of the benign outcomes previously reported from early population studies, disability, deformity and excess mortality were evident. At this time, the conventional pyramid approach was the standard for therapeutic intervention. Patients were initially treated with non-steroidal anti-inflammatory drug with rest and splinting a approach. Disease-modifying anti-rheumatic drugs and corticosteroids were reserved for patients with joint damage and disability, who had ‘earned their treatment’ and the perceived risk of toxicity. Thus irreversible damage and disability occurred prior to effective therapy being instituted, with the consequences of poor outcomes.

The late 1980s saw the introduction of the concept of early intervention in RA and, shortly after, the introduction of specialist clinics for early assessment of patients with inflammatory arthritis (IA), so-called ‘early arthritis clinics’ (EACs). Such clinics, initially in large research units, targeted patients with early RA or IA with the potential to evolve to RA, with the aim of early case definition and treatment. After all, the common sense approach to treatment of a chronic inflammatory, destructive condition would be to treat it effectively from its onset, prior to the development of irreversible damage. The detailed documentation undertaken in these clinics subsequently provided much information regarding persistence and prognosis in early IA.

Since their initial introduction, EACs have become commonplace, not only in academic units, but also kas part of clinical service provision in many institutions. This review details what an EAC is, who should be referred and when, and the benefits and potential future benefits of their introduction.

Section snippets

What is an early arthritis clinic?

The first early rheumatoid arthritis (RA) clinical cohort was established in Bath, UK in 19571 with further cohorts established in Middlesex, UK2 and Memphis, Tennessee, USA3 in the 1960s. However, the concept of early arthritis clinics (EACs) only emerged in the late 1980s4 with growing evidence for the destructive and debilitating natural history of RA.5., 6. Conceptually, there were obvious clinical and academic benefits from this approach.

From the clinical perspective, if effective therapy

Who should be referred?

There are inherent difficulties in defining the patient population that is most appropriate for EAC assessment (Table 1). Of principal importance is the relationship with primary care and the awareness of the service provision offered. A letter detailing the aims and objectives of the service with the emphasis on improving patient outcomes is often useful and should be distributed to primary care colleagues. Reminding them of what services are available, developments in the field, and which

When should patients be referred?

In order for the maximum potential to be achieved from EACs, all patients with the potential to develop RA should be referred as soon as the condition is suspected in primary care. However, two critical areas of delay can be identified. The first is the time it takes the patient to recognize the symptoms of IA and seek appropriate medical advice. The second is the time it takes the primary care physician to make the diagnosis, as the earliest features of RA may be non-specific and inconclusive.

Disease assessment

As already mentioned, the EAC should offer rapid access for all patients with suspected RA (Table 3). Patient assessments should be comprehensive and provide a full diagnostic and prognostic evaluation. The more complete the initial review, the more likely it is that intervention or reassurance can be provided reliably. To allow objectivity, clinical assessments may be quantified, with the use of joint counts or composite scores such as the disease activity score (DAS).22., 23. Additional

What data should be collected?

The information collected from the EAC will vary between clinically-orientated and research-orientated services. It has, however, been proposed that a common core set of data should be collected in order for comparisons between series to be made.35 The proposed ‘standard protocol to evaluate rheumatoid arthritis’ comprises five pages of data collection that may be completed in 15–30 minutes.36 The data collected include clinical features such as the American College of Rheumatology (ACR)

Gains for the patient

The principal objective of the early arthritis movement was to improve patient assessment and outcome. A review of primary trial data from 14 randomized controlled trials of DMARD therapies in RA indicated disease duration as a significant determinant of response to therapy, with patients with short disease duration responding more favourably.39 Patients presenting with a disease duration of less than 1 year showed response in 53% of cases, whereas patients presenting with a disease duration of

Summary

The clinician is now better informed than ever regarding the assessment of early IA. Factors predicting persistence in early IA, in addition to new therapeutic options in previously unresearched areas, have been proposed. As well as assessing persistence where a diagnosis of RA is made, predicting severity is important for therapeutic decision making. Research tools, e.g. US and MRI, are being introduced into the clinic that may allow more specific case definition and severity assessment.Box 1

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