4. Introduction
● Rheumatoid arthritis (RA) is one of the commonest autoimmune and inflammatory
diseases, which means that your immune system attacks healthy cells in your body
by mistake, causing inflammation (painful swelling) in the affected parts of the
body.RA affects about 1% of the population worldwide.
● The prevalence of RA differ widely among different countries, while it is 1% in North
America, it decreases to 0.2- 0.3% in China, Japan, north-west Greece, rural Africa
and Egypt.
● PCPs face many challenges in diagnosing RA due to confusion in identifying
symptoms and using the correct diagnostic modalities for diagnosing RA, and
therefore, that contributes to delay referring patients with RA. So, this research
seeks to raise awareness among PCPs about the correct diagnostic modalities for
diagnosis of RA and the common symptoms that RA patients are exposed to
through cross-sectional study to identify modifiable barriers to early referral of
suspected RA patients among PCPs in Port Said governorate.
6. Aim and objectives
● Aim
Raising the awareness of primary care physicians surrounding
diagnosis of rheumatoid arthritis.
● Objectives
1. To assess the confidence in diagnosing rheumatoid arthritis
among primary care physicians in Port Said governorate.
2. To determine the barriers in diagnosing and referring patients
with suspected rheumatoid arthritis among primary care physicians
in Port Said governorate.
8. Methods
The study included 80
participants, with age
ranging from 26 to 48
years old. There were 43
females and 37 males.
There were two types of
primary care physicians:
46 family medicine and
34 general practitioners.
A cross-sectional study
was conducted in PHC
units in Port Said
governorate to assess
confidence and barriers in
diagnosing RA.
Data was collected
from primary care
physicians in Port Said
governorate by
proportional non-
random convenient
sampling.
Subjects Study design &
Study population
Sampling
procedure
9. Methods
Data was collected by a structured self-
administered questionnaire. The
questionnaire was filled out privately by
each primary care physician.
Questions evaluated
1. PCPs confidence in diagnosing RA and
recognizing synovitis
2. what PCPs felt were the most
important symptoms in diagnosing RA
3. what they felt were the most
important features in making a
decision to refer a patient with
suspected RA
4. whether they referred patients with
suspected RA immediately or
requested further tests first
5. their access to secondary care
rheumatology
6. what they felt were the challenges in
making an RA diagnosis
Data collection Questionnaire
Statistical analysis
Data was coded then SPSS software
version 26 was used for data processing.
All data were summarized descriptively,
using mean (S.D.), median [(IQR)] and
number (percentage) where appropriate
based on data type, and distributions. The
associations was evaluated using linear
regression models.
11. Access to Rheumatology: Forty six (57.5%) PCPs had access to
dedicated early arthritis clinics. The median (IQR) VAS rating for ease of
access to secondary care rheumatology was 7 (4-9), indicating that most
PCPs considered they had moderate ease of access
PCPs had access
PCPs had no
access
Access to Rheumatology
57.5%
42.5%
0
2
4
6
8
10
12
14
16
0 1 2 3 4 5 6 7 8 9 10
Ease of access to Rheumatology
Count
Ease of access
12. Challenges: key clinical features
0.00% 20.00% 40.00% 60.00% 80.00% 100.00% 120.00%
Pain in small joints (e.g. PIP, MCP, MTP)
Positive anti-CCP antibody
Positive rheumatoid factor
Swelling in small joints (e.g. PIP, MCP, MTP)
Early morning stiffness (> 60 minutes)
Indicatehow importanceare the followingin makinga diagnosis of RA
1= least important;5= most important
5 4 3 2 1
PCPs identified the following
five as the most important in
diagnosing RA: Pain in small
joints, positive anti- cyclic
citrullinated peptide (CCP),
Positive rheumatoid factor,
Swelling in small joints and Early
morning stiffness ( > 60
minutes)
13. Referral decision: Only 9 (11.5%) PCPs would refer suspected RA
immediately to secondary care; 71 (88.75%) preferred to organize
further tests to inform referral decisions. Of the PCPs who would
organize further tests, the most frequently requested was RF (71
PCPs; 88.75%)
14. Association between PCPs time since qualification
and confidence.
In a linear regression model, which
included confidence in recognizing joint
swelling due to synovitis dependent
variable and time since qualification (in
years) as the independent variable, a
significant association was observed
(P=0.047), suggesting that PCPs
confidence in recognizing synovitis
increases as more clinical experience is
accrued. The effect was moderate with a
β-value of 0.223, indicating that per 13-
year increase in the time since
qualification, the confidence in
recognizing swelling due to synovitis VAS
increased by 1 (out of a possible 10 units).
16. Discussion
Our self-administrated questionnaire found that when Egyptian PCPs suspect a patient
has RA, the majority (88.75%) request investigations to support their clinical opinion
before referral which augments their dependence on investigations rather than the
clinical features to carry out a decision. Consequently, most PCPs cannot meet the NICE
quality standard of referring patients with persistent synovitis within 3 days. Meeting this
quality standard requires a paradigm shift in the primary care approach to inflammatory
arthritis referrals, with patients presenting with synovitis being referred on clinical
grounds without waiting for the results of investigations. As our questionnaire showed
that PCPs have a good knowledge of the clinical features of RA (with most correctly
identifying Pain and swelling in small joints as well as early morning stiffness as the most
important symptoms/signs) this change in practice should be achievable.
17. Discussion
We found an over-reliance on RF testing in primary care, undertaken by 88.75% of those
PCPs requesting tests before referral which augments that most of PCPs don’t know
that in sometimes, investigations maybe misleading.
Another major source of delay in suspected RA patients being seen lies with secondary
care services failing to see primary care referrals promptly. Our study suggests that this
is an ongoing issue, with 42.5% of PCPs reporting no access to early arthritis clinics, and
38.75% rating their ease of access to rheumatology as being ≤5 out of 10. The need to
minimize secondary care delay is also addressed in the NICE RA Quality Standards.
19. Conclusion
Once RA is suspected, rapid referral to a rheumatologist is essential to start early
treatment. The signs and symptoms of RA not specifically and can look like the signs and
symptoms of other inflammatory joint diseases. There should be clear guidelines that
help primary care physician to suspect the disease hence to avoid long delay before
hospital referral. To the best of our knowledge and according to some widespread
research gates, the current study done at primary care units is the first in Egypt to
analyze the barriers in diagnosing and referring patients with suspected RA among PCPs.
It must be borne in mind that this study was only conducted on a small group of
physicians as there is a small number of PCPs in primary care units in Port Said
governorate and some PCPs were busy to fill the questionnaire.
21. Recommendations
1. There should be clear guidelines for PCPs to follow, our suggestion is EULAR/ ACR
classification for early diagnosis of RA.
2. Increasing the number of early arthritis clinics and their ability to accommodate
patients to receive larger number of patients and to facilitate communication with
rheumatologists.
3. Raising awareness of PCPs about the importance of clinical features to make an
accurate decision rather than investigations which may be misleading sometimes.
4. Following up the referrals and detecting the barriers which delay the referrals to
control them.
5. Raising awareness about RA symptoms for RA patients and the importance of early
diagnosis of RA through campaigns as the S-factor campaign (an Arthritis Research
UK/National RA Society delivered campaign promoting the need for patients to
consult their PCP early for symptoms of RA(44)) and its impact on their practice.
