Significant Number of Patients with RA Went Undiagnosed During the COVID-19 Pandemic

Diagnoses of inflammatory arthritis, including rheumatoid arthritis (RA), significantly decreased during the early phase of the pandemic, according to a study published in The Lancet.¹ However, the impact on assessment times and disease-modifying antirheumatic drug (DMARD) prescription in primary care facilities were less marked than original predictions. Investigators believe that results of the study emphasize the feasibility of utilizing routinely captured data in secure platforms, such as OpenSAFELY, to standardize care quality without manually collected data.

“The COVID-19 pandemic placed enormous strain on health-care services and their ability to deliver optimal care for patients with chronic conditions,” investigators explained. “OpenSAFELY is a secure data analytics platform for electronic health records (EHRs), built with the approval of National Health Service (NHS) England to deliver urgent research and health service evaluation on the direct and indirect impacts of the pandemic.”

Primary care and hospital data, which included 17,683,500 adults, were collected in this population-level cohort study based in England between April 2019 and March 2022. Investigators utilized the OpenSAFELY platform to replicate key metrics from the National Early Inflammatory Arthritis Audit (NEIAA) and determine the impact the COVID-19 pandemic had on care delivery for people with inflammatory arthritis. Sociodemographic characteristics and comorbidities were obtained for both the inflammatory arthritis cohort and the reference population, including age, sex, ethnicity, deprivation, smoking status, obesity, history of stroke, cancer, chronic kidney disease, chronic cardiac disease, chronic respiratory disease, diabetes, and hypertension. Other data assessed included the incidence of inflammatory arthritis diagnoses reported in primary care, such as RA, psoriatic arthritis (PsA), axial spondyloarthritis (axSpA), and undifferentiated inflammatory arthritis, the time to first rheumatology assessment, the time to first prescription of a DMARD, and the choice of the first DMARD.

Of the 17.7 million adults, 31,280 inflammatory arthritis diagnoses were identified. The mean age of patients was 55.4 years, 59.5% (n = 18,615) were female, and 88.3% (n = 22,925) were White.

New diagnoses of inflammatory arthritis decreased by 20.3% in the year beginning April 2020 when compared with the preceding year (5.1 vs 6.4 diagnoses per 10,000 adults). The median time to first assessment was shorter during the pandemic when compared with before the pandemic (18 days vs 21 days, respectively). While the proportion of patients prescribed DMARDs was similar before and after April 2020, fewer patients were prescribed methotrexate (63.5% vs 56.7%, respectively) or leflunomide (1.3% vs 1.0%, respectively) and more were prescribed sulfasalazine (14.6% vs 19.8%, respectively) or hydroxychloroquine (20.6% vs 22.4%, respectively).

The study was strengthened by being able to benchmark care metrics in a large population using routinely captured data in OpenSAFELY which limits the likelihood of reporting bias and increases case ascertainment. Limitations, which are common in studies using coded EHR data, included misclassification of diagnoses and overestimation of arthritis incidence is a possibility. Further, using the last primary care appointment before assessment as a proxy for referral date may have underestimated assessment delays.

“No rebound increase in incidence above pre-pandemic levels was observed in later months, suggesting there remains a burden of undiagnosed inflammatory arthritis as a consequence of the pandemic,” investigators concluded. “Perhaps the most important message of this study, however, is that it is feasible to use routinely captured clinical data on a national scale to benchmark care quality for a long-term condition.”

Reference:

Russell, M. D., Galloway, J. B., Andrews, C. D., MacKenna, B., Goldacre, B., Mehrkar, A., Curtis, H. J., Butler-Cole, B., O’Dwyer, T., Qureshi, S., Ledingham, J. M., Mahto, A., Rutherford, A. I., Adas, M. A., Alveyn, E., Norton, S., Cope, A. P., & Bechman, K. (2022). Incidence and management of inflammatory arthritis in England before and during the COVID-19 pandemic: a population-level cohort study using OpenSAFELY. The Lancet Rheumatology, 0(0). https://doi.org/10.1016/s2665-9913(22)00305-8