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Identification of people with very early RA for optimal care: a public health challenge

Nature Clinical Practice Rheumatology volume 4, pages 114–115 (2008)Cite this article

Emerging data suggest that if rheumatoid arthritis (RA) is detected and treated in the early stages of disease, long-term treatment might not be necessary.1,2 The aim of this article is to address how we might identify persons with symptoms of early RA in the general population. Early RA is defined as disease duration <6 weeks, since 6 weeks is the earliest that the current American College of Rheumatology (ACR) criteria can be achieved;3 however, our discussion applies to any length of disease duration.

Identification of persons with early-onset RA—an endeavor for which there is no precedent in any public health system—will be a major challenge. It is well documented that persons with new symptoms do not usually seek medical attention. Studies during the past 60 years have shown that, in an average month, 800 out of every 1,000 persons in the US experience symptoms of some sort, and of those, approximately 217 visit a physician.4 Little is known about the health-care-seeking behavior of people with early RA. A study in 1994 showed that the median duration between onset of joint symptoms and first clinical visit was 4 weeks (range 1–52 weeks), and the duration between first clinical visit to a definite diagnosis of RA ranged from 1 week to >10 years, with a median of 18 weeks.5 We suspect that with 46.6 million people uninsured for health care in the US, delayed diagnosis of RA will only increase the numbers of people who do not get into the medical system and increase the time till treatment. The diagnosis of early synovitis is also a challenge. The ACR criteria for RA, which are not expressly for clinical diagnosis, show poor performance in early disease.6,7 Using an RA incidence of 0.045% per annum8 and the best estimates of sensitivity and specificity of the ACR criteria in early synovitis, which are approximately 62% and 50%, respectively,7 the positive predictive value of the ACR criteria is only 0.056%.

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Acknowledgements

The work presented is supported in part by NIH grant number AR47782. A Hwang was the recipient of the Ginzi Memorial Summer Fellowship from the Lupus Foundation.

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  1. A Hwang is a medical student at Brown University, S Gupta is an Instructor of Medicine at Harvard Medical School and MH Liang is Professor of Medicine at Harvard Medical School and Professor of Health Policy and Management at the Harvard School of Public Health, Boston, MA, USA.,

    Andrew Hwang, Samardeep Gupta & Matthew H Liang

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Correspondence to Matthew H Liang.

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Hwang, A., Gupta, S. & Liang, M. Identification of people with very early RA for optimal care: a public health challenge. Nat Rev Rheumatol 4, 114–115 (2008). https://doi.org/10.1038/ncprheum0724

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