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Published on: December 3, 2017
Pre-referral laboratory completeness and diagnostic yield in an early arthritis clinic: a retrospective single-centre
Luisa Schneider1, Jörg Christoph Henes1, Sebastian Jonas Saur2
1Centre for Interdisciplinary Clinical Immunology, Rheumatology and Autoinflammatory Diseases and Department of Internal Medicine II (Oncology, Haematology, Immunology and Rheumatology), University Hospital Tuebingen, Otfried-Mueller-Strasse 10, Tuebingen, Germany.
Abstract:
To characterise patients presenting to a specialised early arthritis clinic (EAC) at a German university rheumatology centre, and to analyse referral patterns, waiting times, pre-referral laboratory completeness, working diagnoses, serological markers, and independent associates of arthritis confirmation and DMARD initiation. Single-centre retrospective analysis of 290 consecutive patients. At each EAC appointment, a structured assessment comprising medical history, review of available laboratory results, focused physical examination, and arthrosonography was performed. Variables included demographics, serology (RF, anti-CCP), CRP, ESR, imaging, referral source, waiting time, and treatment decisions. Chi-squared, Mann-Whitney U, Kruskal-Wallis tests, and binary logistic regression were performed; p < 0.05 was considered significant. The cohort comprised 212 women (73.1%) and 78 men (26.9%), mean age 49.4 ± 15.9 years. Median waiting time was 23 days (Q1-Q3, 14-40). Although a complete baseline panel (RF, anti-CCP, CRP, ESR) was requested from referring physicians, it was available in only 110 patients (37.9%). Anti-CCP was missing in 34.5%, with missingness significantly associated with referral source (p = 0.013). Inflammatory arthritis was confirmed in 145 patients (50.0%) and DMARD initiation recommended in 130 (44.8%). In multivariable logistic regression (n = 163 with full serology), anti-CCP positivity was independently associated with arthritis confirmation (OR 4.25; 95% CI 1.68-10.74) and DMARD initiation (OR 4.49; 95% CI 1.80-11.22). Orthopaedist referral was independently associated with higher arthritis confirmation (OR 2.97; 95% CI 1.20-7.36). RF was not significantly associated with either outcome. EACs demonstrate high diagnostic yield for inflammatory joint disease. Anti-CCP positivity showed the strongest independent association with both outcomes. Pre-referral laboratory submission was achieved in fewer than 40% of patients despite being a stated referral requirement, with missingness associated with referral source. Targeted educational interventions for referring physicians are warranted.