Autoimmune inflammatory arthritis (IA) encompasses an overlapping group of conditions that includes rheumatoid arthritis (RA), psoriatic arthritis (PsA), axial spondyloarthritis (axSpA), and undifferentiated IA. Early diagnosis of IA and prompt treatment with disease-modifying anti-rheumatic drugs (DMARDs; e.g. methotrexate) improves outcomes for patients and increases the likelihood of remission.
In England and Wales, the quality of care for people with IA is benchmarked in the National Early Inflammatory Arthritis Audit (NEIAA). Metrics benchmarked include the time from primary care referral to initial rheumatology assessment, and the time to initiation of a DMARD. However, during the COVID-19 pandemic, mandatory data collection in NEIAA was paused, thereby preventing comparisons of care.
The aim of this report is to use the OpenSAFELY platform to replicate key metrics from NEIAA, and assess the impact of COVID-19 on care for people with new diagnoses of IA in England. The results shown below are from a study population consisting of all patients aged 18 years or above who are registered with a general practice in England that uses TPP health software.
This graph shows the monthly incidence of new IA diagnoses in England, corresponding to the appearance of new IA diagnosis codes (RA, PsA, axSpA, undifferentiated IA) in patients' primary care records between 1 April 2019 and 31 December 2022. The denominator for calculating diagnostic incidence was all adults registered with a TPP general practice as of 1 April 2019 (17.7 million). The vertical hashed line in the graph corresponds to the start of the first COVID-19 lockdown in England (March 2020).
The table below summarises the number of new IA diagnoses and corresponding diagnostic incidence (per 10,000 adult population), by year of diagnosis.
The table below summarises the median time, in days, from primary care referral to first assessment by a rheumatology specialist for people with new IA diagnoses, separated by date of diagnosis and by disease subtype.
Data are shown for all patients with new IA diagnoses who had their first rheumatology outpatient appointment captured and who had a minimum of 6 months of available follow-up (from 1 April 2019 to 30 June 2022). Rheumatology outpatient clinics were defined by the presence of a '410' treatment function code. A proxy of primary care referral date was used, defined as the last primary care appointment before the first rheumatology appointment.
The graph below shows the proportion of patients who received their first rheumatology assessment within 3 weeks of primary care referral. The 3-week target is recommended in national guidelines (NICE). Trends during each full-year period from April are shown.
Summarised below is the regional variation in rheumatology assessment times for new IA patients. Results are compared by time period: Year 1 (1 April 2019 to 31 March 2020); Year 2 (1 April 2020 to 31 March 2021); Year 3 (1 April 2021 to 31 March 2022); and Year 4 (1 April 2022 to 30 June 2022).
The graph below shows the proportion of patients who were prescribed conventional synthetic DMARDs (csDMARDs: methotrexate, leflunomide, sulfasalazine or hydroxychloroquine) in primary care within 6 months of their first rheumatology appointment. Trends during each full-year period from April are shown. Decreases were observed in March 2020 and April 2020, corresponding to the start of the first COVID-19 lockdown in England.
Data are shown for all patients with new diagnoses of RA, PsA or undifferentiated IA who had their first rheumatology appointment captured and a minimum of 6 months of available follow-up (from 1 April 2019 to 30 June 2022). Data for patients with axSpA are not included, due to small numbers of these patients receiving csDMARDs. Only primary care-issued prescriptions for DMARDs are captured, representing shared-care prescribing between primary care and secondary care clinicians; secondary care-issued prescriptions are not currently captured.
Summarised below is the regional variation in time to first csDMARD prescription in primary care. Results are compared by time period: Year 1 (1 April 2019 to 31 March 2020); Year 2 (1 April 2020 to 31 March 2021); Year 3 (1 April 2021 to 31 March 2022); and Year 4 (1 April 2022 to 30 June 2022).
The table below shows the choice of first DMARD for IA patients who were prescribed at least one csDMARD in primary care within 6 months of diagnosis.
Data are shown for patients with new diagnoses of RA, PsA or undifferentiated IA who had their first rheumatology appointment captured and a minimum of 6 months of available follow-up (from 1 April 2019 to 30 June 2022). Data for patients with axSpA are not included, due to small numbers of these patients receiving csDMARDs. Similarly, prescriptions for leflunomide are not shown, as these represent <2% of DMARD prescriptions. Only primary care-issued prescriptions for DMARDs are captured, representing shared-care prescribing between primary and secondary care clinicians; secondary care-issued prescriptions are not currently captured.