ABSTRACT
BackgroundInflammatory rheumatic and musculoskeletal diseases (iRMDs), including rheumatoid arthritis (RA) and juveneille inflammatory arthritsi (JIA), are common and cause a high disease burden globally. Early diagnosis of iRMDs and subsequent timely access to disease modifying therapies is associated with improved health and socio-economic outcomes. However, the COVID-19 pandemic meant that the way healthcare was delivered changed abruptly as all consultations were ‘remote by default' was widely implemented, replacing traditional ‘face-to-face' healthcare.ObjectivesTo describe the impact of the COVID-19 pandemic upon referral patterns and incident diagnosis of iRMDs.MethodsData from the Clinical Practice Research Datalink Aurum were analysed from 01/04/17 to 01/10/2021 to describe episodes of care for patients with musculoskeletal (MSK) conditions, in a primary care setting, for pre-COVID-19 (01/04/2017–31/03/2020), early-COVID-19 (01/04/2020–31/07/2021), and late-COVID-19 pandemic (01/08/2020–31/10/2021) periods. Prevalent and incident MSK consultations were determined. Referrals were matched to these consultations. Trends in referrals to MSK services and further incident diagnoses of iRMDs were described using Joinpoint regression and comparisons made between time-periods. Negative binomial regression was used to compare incident rates between time-periods: first MSK consultation to RA/JIA/iRMD diagnosis;first MSK consultation to first referral;first referral to RA/JIA/iRMD diagnosis. The number of consultations between first MSK consultation and referral/diagnosis were described. Results were adjusted for age and sex and further stratified by geographical region and deprivation.ResultsThe incidence of RA and JIA reduced by -13.3% (from 32.0 to 17.2 per 100,000) and -17.4% (from 1.8 to 0.97 per 1,000,000) per month respectively between January 2020 and April 2020, and then increased by 1.9% (from 17.2 to 25.2 per 100,000) and 3.7% (from 0.97 to 1.3 per 1,000,000) per month respectively between April 2020 and October 2021. The incidence of all diagnosed iRMDs was stable until October 2021. Referral incidence decreased between February 2020 and May 2020 by -16.8% (from 4.8 to 2.4 per 100) per month in patients presenting with a MSK condition. After May 2020, referrals increased significantly (16.8% per month from 2.4 to 4.5 per 100) to July 2020. Time from first MSK consultation to RA diagnosis, and referral to RA diagnosis increased in the early-pandemic period (rate ratio (RR) 1.11, 95% confidence interval (CI) 1.07-1.15;RR 1.23, 95%CI 1.17-1.30) and remained consistently higher in the late-pandemic (RR 1.13, 95%CI 1.11-1.16;RR 1.27, 95%CI 1.23-1.32) periods respectively, compared to the pre-COVID-19 period.ConclusionPatients with underlying RA/JIA that developed during the pandemic may be yet to present, or in the process of being referred and/or diagnosed. Primary care clinicians should remain alert to this possibility and consider the use of fast-track referral pathways where indicated. It is apparent that patients developing incident episodes of inflammatory arthropathies may display a prodrome of other MSK symptoms and conditions, which alone may not warrant referral but in combination require further investigation. Commissioners should be alert to these findings to allow for the appropriate planning and commissioning of services.References[1]Jordan KP, Kadam UT, Hayward R, et al. Annual consultation prevalence of regional musculoskeletal problems in primary care: an observational study. BMC Musculoskeletal Disorders 2010;11:144.[2]NHS England and NHS Improvement. Important and urgent - Next steps on NHS response to COVID-19 2020. Available at: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0098-total-triage-blueprint-september-2020-v3.pdf Accessed Oct 2, 2021.AcknowledgementsWe wish to acknowledge: members of our PPIE group who helped to formulate the research question and provide insight into the implications of our results;and to Prof Edward Roddy, Prof Sa antha Hider and Dr Lorna Clarson for their insights as consultant rheumatologists and commissioners of healthcare services.Disclosure of InterestsNone Declared.
ABSTRACT
Background/Aims The COVID-19 pandemic abruptly changed healthcare delivery. This study describes the impact the pandemic had on time to referral and diagnosis of inflammatory arthropathies (IA), including rheumatoid arthritis (RA) and juvenile inflammatory arthritis (JIA), in patients presenting in primary care with musculoskeletal problems. Methods Data from the Clinical Practice Research Datalink (CPRD) Aurum were analysed from 01/04/17 to 01/10/2021 to describe episodes of care for patients with musculoskeletal conditions for pre-COVID-19 (01/04/ 2017-31/03/2020), peri-COVID-19 (01/04/2020-31/07/2021), and post- COVID-19 lockdown (01/08/2020-31/10/2021) periods. Prevalent and incident musculoskeletal consultations were determined. Referrals were matched to these consultations. Trends in referrals to musculoskeletal services and further incident diagnoses of IA were described using Joinpoint Regression and comparisons made between timeperiods. Negative binomial regression was used to compare incident rates between time-periods of: RA/JIA/IA diagnosis and referral from first musculoskeletal consultation;and RA/JIA/IA diagnosis from first referral. The number of consultations between first musculoskeletal consultation and referral/diagnosis were described. Results were adjusted for age and sex and further stratified by geographical region and deprivation. Results The incidence rate of RA and JIA reduced by average -13.32% (from 31.98 per 1,000,000 to 17.15 per 1,000,000) and -17.43% (from 1.77 per 1,000,000 to 0.97 per 1,000,000) per month respectively between January 2020 and April 2020, then increased by 1.9% (from 17.15 per 1,000,000 to 25.22 per 1,000,000) and 3.7% (from 0.97 per 1,000,000 to 1.28 per 1,000,000) per month respectively between April 2020 and October 2021. Referral incidence decreased between February 2020 and May 2020 by -16.8% per month in patients presenting with a musculoskeletal condition. After May 2020, referrals increased significantly (16.8% per month) July 2020. Time from first musculoskeletal consultation to RA diagnosis, and referral to RA diagnosis increased in the peri-COVID-19 period (IRR 1.11, 95%CI 1.07-1.15;IRR 1.23, 95%CI 1.17-1.30) and remained consistent in the post- COVID-19 (IRR 1.13, 95%CI 1.11-1.16;IRR 1.27, 95%CI 1.23-1.32) periods respectively, compared to the pre-COVID-19 period. Similarly, number of consultations between first musculoskeletal consultation and referral/RA diagnosis reduced significantly in the peri-COVID-19 (IRR 0.92, 95%CI 0.88-0.96) and post-COVID-19 (IRR 0.92, 95%CI 0.90-0.95) periods. No change was observed between first musculoskeletal consultation and first referral. Similar results were observed for IA but not for JIA. Conclusion Patients with RA/JIA onset during the pandemic may be yet to present or are currently transitioning through referral and diagnosis. Primary care clinicians should remain alert to possible IA diagnosis and consider fast-track referral pathways where indicated. Patients developing incident episodes of IA may display a prodrome of other musculoskeletal symptoms and conditions, which alone may not warrant referral but in combination require further investigation. Commissioners should be alert to these findings to allow for the appropriate planning and commissioning of services.