Incidence and management of inflammatory arthritis in England before and during the COVID-19 pandemic: a population-level cohort study using OpenSAFELY - The Lancet
Get link
Facebook
Twitter
Pinterest
Email
Other Apps
Introduction
Autoimmune inflammatory arthritis encompasses an overlapping group of conditions that include rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis, and undifferentiated inflammatory arthritis. Early diagnosis of inflammatory arthritis, and prompt treatment with disease-modifying antirheumatic drugs (DMARDs), improves outcomes for patients and increases the likelihood of remission.
1
Coates LC
Conaghan PG
D'Agostino MA
et al.
Remission in psoriatic arthritis—where are we now?.
,
2
Treating rheumatoid arthritis early: a window of opportunity?.
,
3
Seo MR
Baek HL
Yoon HH
et al.
Delayed diagnosis is linked to worse outcomes and unfavourable treatment responses in patients with axial spondyloarthritis.
The COVID-19 pandemic placed enormous strain on health-care services and their ability to deliver optimal care for patients with chronic conditions.
4
Williams R
Jenkins DA
Ashcroft DM
et al.
Diagnosis of physical and mental health conditions in primary care during the COVID-19 pandemic: a retrospective cohort study.
In the UK, primary care referrals decreased by over 50% during the pandemic; hospital outpatient services transitioned to virtual consultations; and individuals delayed seeking care due to fear of infection or burdening services.
5
Thornton J
Covid-19: A&E visits in England fall by 25% in week after lockdown.
,
6
Mafham MM
Spata E
Goldacre R
et al.
COVID-19 pandemic and admission rates for and management of acute coronary syndromes in England.
,
7
The Health Foundation Use of primary care during the COVID-19 pandemic.
,
8
British Medical Association The hidden impact of COVID-19 on patient care in the NHS in England.
In the USA, reductions in rheumatology visits were observed, with increased use of telemedicine.
9
Li J
Ringold S
Curtis JR
et al.
Effects of the SARS-CoV-2 global pandemic on U.S. rheumatology outpatient care delivery and use of telemedicine: an analysis of data from the RISE registry.
,
10
George MD
Danila MI
Watrous D
et al.
Disruptions in rheumatology care and the rise of telehealth in response to the COVID-19 pandemic in a community practice-based network.
In Sweden, a 7% decrease in the incidence of inflammatory joint diseases was seen in 2020, relative to 2015–19, continuing an overall downward trend in incidence; additionally, modest reductions in rheumatology visits (–16%) and conventional synthetic DMARD dispensations (–8·5%) were reported during the pandemic, while biologic and targeted synthetic DMARD dispensations increased by 6·5%.
11
Bower H
Frisell T
di Giuseppe D
et al.
Effects of the COVID-19 pandemic on patients with inflammatory joint diseases in Sweden: from infection severity to impact on care provision.
Research in context
Evidence before this study
We performed a literature search for population-level, observational cohort studies that compared the incidence or management of inflammatory arthritis diagnoses (rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis, or undifferentiated inflammatory arthritis) during and before the COVID-19 pandemic. We searched PubMed for articles published from the date of database inception to Sept 8, 2022, with no language restrictions, using the terms "incidence", "assessment", "management", "treatment", "arthritis", "spondyloarthritis", and "COVID". A study in Sweden reported a 7% decrease in the incidence of inflammatory joint diseases during the pandemic, in addition to a 16% reduction in rheumatology visits, 8·5% decrease in conventional synthetic disease-modifying antirheumatic drug (DMARD) dispensations, and 6·5% increase in biological and targeted synthetic DMARD dispensations. Two US-based studies used electronic health record data from participating rheumatology practices to demonstrate reduced rheumatology visits during the pandemic and increased telemedicine use.
Added value of this study
Our study used the OpenSAFELY data platform of 17·7 million adults (representing 40% of the English population) to compare incident diagnoses and care delivery for patients with inflammatory arthritis between April 1, 2019, and March 31, 2022. We found that the monthly incidence of inflammatory arthritis diagnoses decreased by 40% early in the pandemic. Further decreases coincided with rising COVID-19 numbers, before returning to prepandemic levels by the end of the study period. Overall, in the year commencing April, 2020, there was a 20% decrease in inflammatory arthritis diagnoses relative to the preceding year. For people who sought medical care for new inflammatory arthritis, we showed that the time to first rheumatology assessment was shorter during the pandemic than before. The proportion of patients prescribed conventional synthetic DMARDs in primary care was similar, although fewer patients were prescribed methotrexate or leflunomide during the pandemic, and more were prescribed sulfasalazine or hydroxychloroquine.
Implications of all the available evidence
There were marked decreases in new inflammatory arthritis diagnoses during the pandemic, which coincided with rising COVID-19 case numbers in England. No rebound increase in incidence above prepandemic levels was observed in later months, indicating that there is likely to be a substantial burden of undiagnosed inflammatory arthritis as a consequence of the pandemic. For people who sought medical care, the impact of the pandemic on rheumatology assessment times and DMARD prescribing in primary care was less marked than might have been expected. Our study demonstrates the feasibility of using routinely captured data in the secure OpenSAFELY platform to benchmark care quality on a national scale and without the need for manual data collection.
In England and Wales, the Healthcare Quality Improvement Partnership (HQIP) commissions national audit programmes, with the aim of monitoring health-care services and improving outcomes.
12
Healthcare Quality Improvement Partnership Measuring and improving our healthcare services.
The National Early Inflammatory Arthritis Audit (NEIAA) is the largest audit of its kind globally, reporting annually on care delivered across all National Health Service (NHS) rheumatology services in England and Wales.
13
British Society for Rheumatology National Early Inflammatory Arthritis Audit (NEIAA) second annual report.
In NEIAA, hospitals are benchmarked against National Institute for Health and Care Excellence (NICE) guidance and other indicators of care quality.
13
British Society for Rheumatology National Early Inflammatory Arthritis Audit (NEIAA) second annual report.
,
14
NICE Rheumatoid arthritis in over 16s.
Metrics include time from primary care referral to initial rheumatology assessment, and time to initiation of a DMARD.
15
Ledingham JM
Yates M
Galloway JB
NEIAA: driving EIA service quality in a shifting clinical landscape.
Data for NEIAA are entered manually by participating hospitals; however, data capture is often incomplete, especially in underperforming units where poor engagement in a national audit programme correlates with the quality of care provided.
16
Yates M
Bechman K
Dennison EM
et al.
Data quality predicts care quality: findings from a national clinical audit.
Mandatory data collection in NEIAA was paused during the pandemic, preventing comparisons of care.
OpenSAFELY is a secure data analytics platform for electronic health records (EHRs), built with the approval of NHS England to deliver urgent research and health service evaluation on the direct and indirect impacts of the pandemic.
17
OpenSAFELY About OpenSAFELY.
It was created as a collaboration between the University of Oxford DataLab, the London School of Hygiene & Tropical Medicine, TPP (a software provider for general practitioners), and NHS England. OpenSAFELY provides a secure software interface, enabling analyses of pseudonymised health records in near real-time within the EHR vendor's highly secure data centre, avoiding the need for data transfer off-site. Pseudonymised data, such as coded diagnoses and medications, are included in OpenSAFELY, but free-text data are not included. Analyses can run across individuals' full, raw, pseudonymised EHRs at 99% of English general practices, including patient-level linkage to secondary care data.
Our objective was to use OpenSAFELY to replicate key metrics from NEIAA and to assess the impact of COVID-19 on care delivery for people with inflammatory arthritis in England.
Methods
Study design and participants
We did a cohort study using EHR data. We compared the incidence of inflammatory arthritis diagnoses in primary care, and timing of assessment and treatment for people with incident inflammatory arthritis, before and after the onset of the COVID-19 pandemic in England.
Due to data availability, we piloted our approach in OpenSAFELY-TPP, which contains data for 24 million people registered with general practices using TPP SystmOne software (approximately 40% of the English population). OpenSAFELY-TPP is representative of the English population in terms of age, sex, index of multiple deprivation (IMD), ethnicity, and causes of death.
18
Andrews C
Schultze A
Curtis H
et al.
OpenSAFELY: Representativeness of electronic health record platform OpenSAFELY-TPP data compared to the population of England.
Primary care records were linked to NHS Secondary Uses Service data through OpenSAFELY.
The reference population consisted of all adults, aged 18–110 years, registered with practices using TPP software in England for at least 12 months as of April 1, 2019. From this population, we defined the inflammatory arthritis cohort as people with index diagnostic codes for rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis, or undifferentiated inflammatory arthritis between April 1, 2019, and March 31, 2022 (see appendix p 11 for codelists).
We defined the index diagnosis date as the first appearance of an inflammatory arthritis code in the primary care record. At least 12 months of continuous registration before the diagnosis date was required to ensure only index diagnoses were captured. People with new inflammatory arthritis diagnostic codes who had received prescriptions for conventional synthetic DMARDs (eg, methotrexate) or biological DMARDs (eg, adalimumab) 60 days or more before their first rheumatology appointment were deemed not to be new diagnoses and were excluded from analyses (n=4880). For individuals in whom the inflammatory arthritis subdiagnosis subsequently changed (eg, from undifferentiated inflammatory arthritis to rheumatoid arthritis), the most recent subdiagnosis was selected as the final diagnosis.
Baseline sociodemographic characteristics and comorbidities were described without inferential statistics for the inflammatory arthritis cohort (at the time of diagnosis) and the reference population (at April 1, 2019), as follows: age, sex, ethnicity (White, Asian or Asian British, Black, mixed or other), deprivation (IMD quintiles: from 1, most deprived, to 5, least deprived), smoking status (current, former, never), obesity (categorised according to the most recent BMI), hypertension, diabetes, stroke, chronic cardiac disease, chronic respiratory disease, chronic liver disease, cancer, and chronic kidney disease (defined as an estimated glomerular filtration rate 2 or a diagnostic code for end-stage renal failure). Further details of comorbidity definitions and codelists are included in the appendix (p 11).
Approval to undertake this study under the remit of service evaluation was obtained from King's College Hospital NHS Foundation Trust. No further ethical approval was required as per UK Health Research Authority guidance. An information governance statement is included in the appendix (p 12).
Outcomes
The incidence of inflammatory arthritis diagnoses was calculated by dividing the number of new inflammatory arthritis diagnoses in primary care during each study year (April 1, 2019, to March 31, 2020; April 1, 2020, to March 31, 2021; April 1, 2021, to March 31, 2022) by the number of people in the reference population.
For people within the inflammatory arthritis cohort who had their first rheumatology outpatient attendance captured and who had at least 12 months of available follow-up, we documented the following outcomes: median time (in days) from primary care referral to initial rheumatology assessment; median time (in days) from initial rheumatology assessment to first prescription of a conventional synthetic DMARD in primary care; and choice of first conventional synthetic DMARD. Among people who had an initial rheumatology assessment, we additionally recorded the method (in-person or virtual) of consultation.
In England, guidelines recommend that individuals who present to their general practitioner with symptoms suggestive of a new inflammatory arthritis diagnosis should be referred to a rheumatology specialist, and rheumatology assessment should occur within 3 weeks of referral.
14
NICE Rheumatoid arthritis in over 16s.
,
19
NICE Rheumatoid arthritis in over 16s.
,
20
NICE Spondyloarthritis in over 16s: diagnosis and management.
Specialist assessment usually occurs in a rheumatology outpatient service affiliated with a hospital. Where indicated, DMARDs are initiated by the rheumatology specialist in secondary care (dispensed by hospital pharmacies). Once established on a stable dose, prescribing of conventional synthetic DMARDs typically transitions to primary care prescribing (dispensed by community pharmacies) as a shared-care responsibility between primary and secondary care.
21
Ledingham J
Gullick N
Irving K
et al.
BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs.
We defined the initial rheumatology assessment as the date of first attendance at a rheumatology outpatient clinic (defined by the "410" treatment function code
22
NHS Digital NHS Data model and dictionary.
). If the first appointment was not captured within 12 months before the index diagnostic code appeared in the primary care record, it was looked for within 60 days after the index diagnosis. We defined the primary care referral date as the last primary care assessment (virtual or in-person) before the first rheumatology appointment.
We defined the prescription of a conventional synthetic DMARD in primary care as at least one prescription issued for methotrexate (oral or subcutaneous), hydroxychloroquine, sulfasalazine, or leflunomide. Only primary care prescriptions were captured; prescriptions dispensed by hospital pharmacies were not captured. An upper limit of 12 months after the first rheumatology appointment was used for prescriptions, to minimise bias from unequal follow-up time between individuals entering the cohort at different times.
Statistical analysis
Assessment and treatment outcomes were presented by year and by region (categorised into the nine Nomenclature of Territorial Units for Statistics level 1 regions within England
23
Office for National Statistics NUTS level 1 (January 2018) full clipped boundaries in the United Kingdom.
). Interrupted time-series analyses were used to estimate the impact of the pandemic on the proportion of patients with incident inflammatory arthritis (averaged by month) who: (1) were assessed by rheumatology within 3 weeks of primary care referral; and (2) were prescribed a conventional synthetic DMARD in primary care within 6 months of initial rheumatology assessment. Trends in these outcomes were compared before and after the first COVID-19 lockdown in England (March, 2020) using single-group interrupted time-series analyses.
24
Conducting interrupted time-series analysis for single- and multiple-group comparisons.
Newey-West standard errors with five lags were used to account for autocorrelation between observation periods.
Python 3.8 was used for data management. Stata version 16 was used for statistical analyses. As the primary objective of our analyses was descriptive, no correction for multiple hypothesis testing was performed. For statistical disclosure control, we rounded frequency counts to the nearest 5 and redacted non-zero counts below 6. For conventional synthetic DMARD prescribing in individuals with axial spondyloarthritis, only overall counts were presented (ie, not by region or study year) due to small numbers. Code for data management and analysis is shared openly for review and reuse under MIT open license. Detailed pseudonymised patient data are potentially reidentifiable and therefore are not shared.
Patient and public involvement
OpenSAFELY has a publicly available website through which we invite patients or members of the public to contact us about this study or the broader OpenSAFELY project.
Role of the funding source
The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.
Results
Between April 1, 2019, and March 31, 2022, there were 31 280 incident inflammatory arthritis diagnoses recorded in primary care from a reference population of 17 683 500 people aged 18 years or older. Of new inflammatory arthritis diagnoses, 19 085 (61·0%) were rheumatoid arthritis, 6825 (21·8%) were psoriatic arthritis, 3970 (12·7%) were axial spondyloarthritis, and 1400 (4·5%) were undifferentiated inflammatory arthritis. A flow diagram of study populations is shown in the appendix (p 8).
Baseline characteristics of people with incident inflammatory arthritis, compared with the reference population, are shown in the table. The mean age at diagnosis of people with inflammatory arthritis was 55·4 years (SD 16·6): 60·4 years (15·4) for rheumatoid arthritis, 48·6 years (14·4) for psoriatic arthritis, 43·2 years (15·6) for axial spondyloarthritis, and 55·2 years (17·3) for undifferentiated inflammatory arthritis. 18 615 (59·5%) of 31 280 patients with inflammatory arthritis were female (12 385 [64·9%] of 19 085 patients with rheumatoid arthritis; 3675 [53·8%] of 6825 patients with psoriatic arthritis; 1750 [44·1%] of 3970 patients with axial spondyloarthritis; and 805 [57·5%] of 1400 patients with undifferentiated inflammatory arthritis). 22 925 (88·3%) of 25 960 patients with inflammatory arthritis (and available data) were White (13 825 [87·2%] of 15 850 patients with rheumatoid arthritis; 5175 [90·9%] of 5690 patients with psoriatic arthritis; 2900 [88·5%] of 3275 patients with axial spondyloarthritis; and 1025 [89·5%] of 1145 patients with undifferentiated inflammatory arthritis).
TableBaseline demographics and comorbidities for people with incident inflammatory arthritis diagnoses, overall and separated into subdiagnoses, compared with the reference population
Counts have been rounded to the nearest 5, to reduce the risk of disclosure; as such, column totals might differ from the sum of the individual variables. HbA1c=glycated haemoglobin.
People with inflammatory arthritis were more likely to be overweight or obese than the general population (69·8% vs 62·6%); more likely to have a smoking history (62·1% vs 52·1%); and more likely to have hypertension (28·8% vs 21·3%), diabetes (15·5% vs 9·6%), chronic cardiac disease (9·5% vs 6·7%), or chronic respiratory disease (8·2% vs 4·0%).
The monthly incidence of recorded inflammatory arthritis diagnoses is shown in figure 1 and the appendix (p 2). Between March and April, 2020 (the start of the first COVID-19 lockdown in England), monthly inflammatory arthritis diagnoses decreased by 39·7%, from 0·52 to 0·31 per 10 000 adults (from 920 diagnoses in March, 2020, to 555 in April, 2020). This was followed by an increase in inflammatory arthritis diagnoses after June, 2020, approaching prepandemic levels by October, 2020. On a background of monthly variations in numbers of diagnoses, the two largest subsequent decreases in inflammatory arthritis diagnoses occurred between December, 2020, and January, 2021 (16·4%; from 915 to 765 diagnoses) and between December, 2021, and January, 2022 (30·3%; from 990 to 690 diagnoses)—coinciding with rising COVID-19 cases in England—before returning to prepandemic levels by the end of the study period. Similar patterns were observed for female and male patients (appendix p 9).
Figure 1Incidence of inflammatory arthritis diagnoses recorded in primary care during each month of the study period
Show full caption
The vertical dashed line corresponds to the onset of the first COVID-19 lockdown in England (March, 2020).
The incidence of combined inflammatory arthritis diagnoses by study year was 6·4 per 10 000 adults between April 1, 2019, and March 31, 2020; 5·1 per 10 000 between April 1, 2020, and March 31, 2021; and 6·1 per 10 000 between April 1, 2021, and March 31, 2022. For rheumatoid arthritis, the incidence decreased from 3·9 per 10 000 adults between April 1, 2019, and March 31, 2020, to 3·2 per 10 000 between April 1, 2020, and March 31, 2021, increasing to 3·7 per 10 000 between April 1, 2021, and March 31, 2022. Similar patterns were observed for psoriatic arthritis, axial spondyloarthritis, and undifferentiated inflammatory arthritis, and when separated by sex (appendix pp 3–4).
Of 31 280 incident inflammatory arthritis diagnoses, 20 385 (65·2%) had data captured on their first rheumatology appointment, of whom 19 720 (96·7%) had a primary care appointment captured in the preceding year. The median time from the initial rheumatology appointment to an inflammatory arthritis code appearing in the primary care record was 14 days (IQR 0–84). Of 19 720 patients with data on their first rheumatology appointment and preceding primary care appointment, 13 405 (68·0%) had at least 12 months of available follow-up to enable analyses of assessment times and conventional synthetic DMARD prescribing.
The median time from primary care referral to initial rheumatology assessment was 20 days (IQR 9–38). The median assessment time was shorter for rheumatoid arthritis (17 days; IQR 8–33) than psoriatic arthritis (24 days; IQR 12–49) or axial spondyloarthritis (28 days; IQR 12–69), and similar to undifferentiated inflammatory arthritis (19 days; IQR 8–38).
The median time to rheumatology assessment was shorter for patients first assessed after the onset of the pandemic (18 days; IQR 8–35; n=6025) than for patients first assessed before the pandemic (21 days; IQR 9–41; n=7380). Using interrupted time-series analyses, we compared monthly trends in the proportion of patients assessed by rheumatology within 3 weeks of referral (figure 2). Improvements in assessment times began before the pandemic and continued during the pandemic, with no significant differences in overall trends: trend pre-March 2020, 0·054% improvement per year (95% CI 0·023 to 0·086); trend post-March 2020, 0·063% improvement per year (95% CI 0·026 to 0·099); difference in trends, 0·009% per year (95% CI –0·043 to 0·060; p=0·73).
Figure 2Interrupted time series analysis demonstrating trends in the proportion of patients with incident inflammatory arthritis who were assessed by rheumatology within 3 weeks of primary care referral
Show full caption
Single time point dots represent monthly averages. The vertical dashed line corresponds to the onset of the first COVID-19 lockdown in England (March, 2020).
Rheumatology assessment times varied by region (figure 3 and appendix p 5). In the year before the pandemic, the North East of England had the highest proportion of patients assessed within 3 weeks (200 [58·0%] of 345), whereas London had the lowest proportion (170 [45·9%] of 370). Assessment times improved across all regions of England after April, 2020, albeit to varying degrees. Improvement was most apparent in London, where the proportion of patients assessed within 3 weeks increased from 170 (45·9%) of 370 to 140 (59·6%) of 235.
Figure 3Time from primary care referral to initial rheumatology assessment for people with incident inflammatory arthritis, overall and separated by region in England
Show full caption
The horizontal bars represent the mean proportion of patients with incident inflammatory arthritis who were assessed within 3, 6, or >6 weeks of referral. The year before the onset of the COVID-19 pandemic (Year 1: April 1, 2019, to March 31, 2020) and after (Year 2: April 1, 2020, to March 31, 2021) are compared for each region.
Data on the consultation medium used for initial rheumatology visits were available for 6675 (49·8%) of 13 405 patients. Of those with available data, the proportion of patients assessed via telephone or telemedicine increased from ten (0·3%) of 3425 before April, 2020, to 815 (25·1%) of 3250 in the year commencing April, 2020.
8625 (64·3%) of 13 405 patients were prescribed conventional synthetic DMARDs in primary care within 12 months of their first rheumatology appointment. Conventional synthetic DMARD prescribing varied by diagnosis (appendix p 6): 6665 (76·9%) of 8670 patients with incident rheumatoid arthritis were prescribed conventional synthetic DMARDs within 12 months, compared with 1625 (54·8%) of 2965 patients with psoriatic arthritis, 95 (7·5%) of 1275 patients with axial spondyloarthritis, and 240 (48·5%) of 495 patients with undifferentiated inflammatory arthritis. The median time from initial rheumatology assessment to prescription of a conventional synthetic DMARD in primary care was 92 days (IQR 42–172) for rheumatoid arthritis; 112 days (IQR 50–194) for psoriatic arthritis; 118 days (IQR 53–216) for axial spondyloarthritis, and 131 days (IQR 56–217) for undifferentiated inflammatory arthritis.
In interrupted time-series analysis models, the proportion of patients prescribed conventional synthetic DMARDs in primary care within 6 months of their first rheumatology appointment decreased from 275 (50·0%) of 550 to 230 (43·8%) of 525 between February, 2020, and March, 2020. This was followed by a return to prepandemic levels from May, 2020, onwards. Comparing prescribing trends before March, 2020 to after May, 2020, the observed trends were not significantly different (figure 4): trend pre-March, 2020: 0·014% reduction per year (95% CI –0·041 to 0·014); trend post-May, 2020: 0·025% improvement per year (95% CI –0·012 to 0·050); difference in trends, 0·038% per year (95% CI –0·0006 to 0·077; p=0·053).
Figure 4Interrupted time series analysis demonstrating trends in the proportion of patients with incident rheumatoid arthritis, psoriatic arthritis, or undifferentiated inflammatory arthritis who were prescribed csDMARDs in primary care within 6 months of initial rheumatology assessment
Show full caption
Single time point dots represent monthly averages. Trend lines are shown before March, 2020 (the onset of the first COVID-19 lockdown in England), and after May, 2020 (ie, after the two outlier months of March and April, 2020). A sensitivity analysis, including March and April, 2020, is shown in the appendix (p 10). csDMARD=conventional synthetic disease-modifying antirheumatic drug.
The proportion of patients with rheumatoid arthritis, psoriatic arthritis, or undifferentiated inflammatory arthritis prescribed conventional synthetic DMARDs in primary care varied markedly by region (figure 5 and appendix p 7). Before the pandemic, 515 (53·9%) of 955 patients in South West England were prescribed a conventional synthetic DMARD within 3 months of their first rheumatology appointment (760 [79·6%] of 955 within 12 months), compared with 135 (21·4%) of 630 patients in North West England (395 [62·7%] of 630 within 12 months). During the pandemic, there were no consistent changes in conventional synthetic DMARD prescribing nationally, with treatment delays improving in some regions and worsening in others.
Figure 5Time from initial rheumatology assessment to first prescription of a csDMARD in primary care for people with incident rheumatoid arthritis, psoriatic arthritis, or undifferentiated inflammatory arthritis; overall and separated by region in England
Show full caption
The horizontal bars represent the mean proportion of patients with incident inflammatory arthritis who were prescribed csDMARDs within 3, 6, and 12 months of their first rheumatology outpatient assessment. The year before the onset of the COVID-19 pandemic (Year 1: April 1, 2019, to March 31, 2020) and after (Year 2: April 1, 2020, to March 31, 2021) are compared for each region. csDMARD=conventional synthetic disease-modifying antirheumatic drug.
In the year before April, 2020, 2990 (63·5%) of 4705 first conventional synthetic DMARD prescriptions in primary care were for methotrexate, compared with 2175 (56·7%) of 3835 in the year after April, 2020; 60 (1·3%) of 4705 were for leflunomide before versus 40 (1·0%) of 3835 after April, 2020; 970 (20·6%) of 4705 were for hydroxychloroquine before versus 860 (22·4%) of 3835 after April, 2020; and 685 (14·6%) of 4705 were for sulfasalazine before versus 760 (19·8%) of 3835 after April, 2020.
Discussion
In this study, we have demonstrated the feasibility of using OpenSAFELY—a secure, population-level health dataset—to benchmark care quality for inflammatory arthritis. Our findings closely reflect those reported in the existing national audit of inflammatory arthritis care in England, without the need for manual data entry. We found that the number of recorded inflammatory arthritis diagnoses decreased by 40% early in the pandemic. For people who were referred, there was no evidence that rheumatology assessment times were affected by the pandemic. The proportion of patients prescribed conventional synthetic DMARDs in primary care was similar before and during the pandemic, with substantial underlying regional variation.
The 40% decrease in inflammatory arthritis diagnoses in the early pandemic is similar to what has been reported for other physical and mental health conditions.
4
Williams R
Jenkins DA
Ashcroft DM
et al.
Diagnosis of physical and mental health conditions in primary care during the COVID-19 pandemic: a retrospective cohort study.
We observed subsequent decreases in inflammatory arthritis diagnoses that coincided with rising COVID-19 cases. With these decreases, the return to prepandemic levels occurred more quickly, suggesting the NHS and patient behaviour adapted as the pandemic progressed. Interestingly, no rebound in inflammatory arthritis diagnoses (ie, above prepandemic levels) was observed as of March, 2022, implying that a substantial burden of undiagnosed inflammatory arthritis remains as a consequence of the pandemic.
Rheumatology assessment times in our study closely match what has been reported in the existing national audit of inflammatory arthritis in England (NEIAA). In our study, between April, 2019, and April, 2020, 52% of patients were assessed by rheumatology within 3 weeks of referral; th...
What’s next for rheumatoid arthritis and cannabis? The GrowthOp One-and-a-half million people in the United States suffer from rheumatoid arthritis (RA). In fact, The Arthritis Foundation estimates that three times as many ...
Comments
Post a Comment