Clinical, Economic, and Humanistic Burden Associated With Delayed Diagnosis of Axial Spondyloarthritis: A Systematic Review

Yi, Esther; Ahuja, Amit; Rajput, Tanvi; George, Aneesh Thomas; Park, Yujin

doi:10.1007/s40744-020-00194-8

Cited by 90 publications

(85 citation statements)

References 80 publications

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“…This artefact disappears in fixed-effects models, which were not used in this study due to high heterogeneity between the studies. We did not review the impact of delay to diagnosis as this was recently reviewed by Yi et al [5].…”

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

“…Those with longer delays to diagnosis also report greater work disability, unemployment and healthcare costs [5]. Although the impact of delay is well described, potential causes of delay (i.e., how delay can be improved) are not.…”

Section: Introductionmentioning

confidence: 99%

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Systematic review and meta-analysis of diagnostic delay in axial spondyloarthritis

Zhao¹,

Pittam²,

Harrison³

et al. 2020

Preprint

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Background . Delay to diagnosis in axial spondyloarthritis (axSpA) is longer than many other rheumatic diseases. Prolonged delay has been shown to associate with poorer outcomes including functional impairment and quality of life. Our aims were to describe 1) global variation in delay to diagnosis, 2) factors associated with delay, and 3) differences in diagnostic delay between axSpA and psoriatic arthritis (PsA).Methods . We searched Medline, PubMed, EMBASE and Web of Science using a predefined protocol in accordance with PRISMA guidelines. Delay to diagnosis was defined as years between age at symptom onset and age at diagnosis. We pooled mean diagnostic delay using random-effects inverse variance meta-analysis. We examined variations in pooled estimates using pre-specified subgroup analyses and sources of heterogeneity using meta-regression.Results. A total of 54 studies reported mean diagnostic delay in axSpA patients. The pooled mean delay was 6.8 years (95% confidence interval 6.2 to 7.3) with high levels of heterogeneity. Delay to diagnosis did not improve over time when stratifying results by year of publication. Studies from high-income countries (defined by the World Bank) reported longer delay than those from middle-income countries. Factors consistently reported to be associated with longer delay were: lower education levels, younger age at symptom onset and absence of extra-articular manifestations. Pooled estimate for diagnostic delay from 8 PsA studies was significantly shorter, at 2.6 years (95%CI 1.6 to 3.6).Conclusion. For axSpA patients, delay to diagnosis remains unacceptably prolonged in many parts of the world, although some countries have reported remarkable improvements. Patient factors (education) and disease presentation (age at onset and extra-articular manifestations) should inform awareness campaigns to improve delay. Targets for improvement should aim to resemble delays in other spondyloarthritis patients.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Systematic review and meta-analysis of diagnostic delay in axial spondyloarthritis

Zhao¹,

Pittam²,

Harrison³

et al. 2020

Preprint

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show abstract

“…This artefact disappears in xed-effects models, which were not used in this study due to high heterogeneity between the studies. We did not review the impact of delay to diagnosis as this was recently reviewed by Yi et al [5]. Meta-regression examines relationships between summary data and should not be interpreted as traditional hypothesis testing of individual patient data.…”

Section: Discussionmentioning

confidence: 99%

“…There is abundant evidence that diagnostic delay is associated with worse functional impairment, greater radiographic progression, poorer quality of life and reduced response to treatment [5,6]. Those with longer delays to diagnosis also report greater work disability, unemployment and healthcare costs [5]. Although the impact of delay is well described, potential causes of delay (i.e., how delay can be improved) are not.…”

Section: Introductionmentioning

confidence: 99%

Systematic review and meta-analysis of diagnostic delay in axial spondyloarthritis

Zhao

Pittam

Harrison

et al. 2020

Preprint

View full text Add to dashboard Cite

Background. Delay to diagnosis in axial spondyloarthritis (axSpA) is longer than many other rheumatic diseases. Prolonged delay has been shown to associate with poorer outcomes including functional impairment and quality of life. Our aims were to describe 1) global variation in delay to diagnosis, 2) factors associated with delay, and 3) differences in diagnostic delay between axSpA and psoriatic arthritis (PsA).Methods. We searched Medline, PubMed, EMBASE and Web of Science using a predefined protocol in accordance with PRISMA guidelines. Delay to diagnosis was defined as years between age at symptom onset and age at diagnosis. We pooled mean diagnostic delay using random-effects inverse variance meta-analysis. We examined variations in pooled estimates using pre-specified subgroup analyses and sources of heterogeneity using meta-regression.Results. A total of 64 studies reported mean diagnostic delay in axSpA patients. The pooled mean delay was 6.7 years (95% confidence interval 6.2 to 7.2) with high levels of heterogeneity. Delay to diagnosis did not improve over time when stratifying results by year of publication. Studies from high-income countries (defined by the World Bank) reported longer delay than those from middle-income countries. Factors consistently reported to be associated with longer delay were: lower education levels, younger age at symptom onset and absence of extra-articular manifestations. Pooled estimate for diagnostic delay from 8 PsA studies was significantly shorter, at 2.6 years (95%CI 1.6 to 3.6). Conclusion. For axSpA patients, delay to diagnosis remains unacceptably prolonged in many parts of the world, although some countries have reported remarkable improvements. Patient factors (education) and disease presentation (age at onset and extra-articular manifestations) should inform awareness campaigns to improve delay. Targets for improvement should aim to resemble delays in other spondyloarthritis patients.

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Axial Spondyloarthritis

Bittar,

Deodhar

2024

JAMA

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ImportanceAxial spondyloarthritis is an immune-mediated inflammatory condition involving the sacroiliac joints, spine, and peripheral joints. It affects approximately 1% of adults in the US and is associated with impaired physical function and reduced quality of life.ObservationsInflammatory chronic back pain characterized by gradual onset starting before age 45 years, prolonged morning stiffness, improvement with exercise, and lack of improvement with rest is the most common symptom of axial spondyloarthritis and affects more than 80% of patients. Patients with axial spondyloarthritis may also have inflammatory arthritis in large peripheral joints (most commonly knees) in an oligoarticular, asymmetric fashion; inflammation at tendon insertions (enthesitis); inflammatory eye disease (uveitis); psoriasis; and inflammatory bowel disease. The pathogenesis of axial spondyloarthritis may involve genetic predisposition, gut microbial dysbiosis, and entheseal trauma, with immune cell infiltration of the sacroiliac joints and entheseal insertion areas in the spine. There are currently no diagnostic criteria for axial spondyloarthritis. The diagnosis, often delayed 6 to 8 years after symptom onset, is based on history (ie, inflammatory back pain [sensitivity, 74%-81%; specificity, 25%-44%]), laboratory findings (human leukocyte antigen B27–positive [sensitivity, 50%; specificity, 90%] and elevated C-reactive protein level [sensitivity, 35%; specificity, 91%]), and imaging findings consisting of sacroiliitis on plain radiography (sensitivity, 66%; specificity, 68%) or magnetic resonance imaging (sensitivity, 78%; specificity, 88%). First-line treatments are physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs). However, less than 25% of patients achieve complete symptom control with NSAIDs. Approximately 75% of patients require biologic drugs (tumor necrosis factor inhibitors [anti-TNF agents], interleukin 17 inhibitors [anti–IL-17 agents]) or targeted synthetic disease-modifying antirheumatic agents (Janus kinase [JAK] inhibitors) to reduce symptoms, prevent structural damage, and improve quality of life. Clinical trials reported that anti-TNF agents significantly improved ASAS20 (measure of pain, function, and inflammation) in 58% to 64% of patients compared with 19% to 38% for placebo. Similar outcomes were attained with anti–IL-17 agents (48%-61%, vs 18%-29% with placebo) and JAK inhibitors (52%-56%, vs 26%-29% with placebo). Anti-TNF agents, anti–IL-17 agents, and JAK inhibitors have been associated with reduced radiographic progression of axial spondyloarthritis.ConclusionsAxial spondyloarthritis predominantly affects the sacroiliac joints and spine but is also associated with extraskeletal manifestations such as uveitis, psoriasis, and inflammatory bowel disease. Physical therapy and NSAIDs are first-line treatments, but most patients require therapy with biologics (anti-TNF or anti–IL-17 agents) or JAK inhibitors to achieve improvement in signs and symptoms, inflammation control, and reduced progression of structural damage.

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Clinical, Economic, and Humanistic Burden Associated With Delayed Diagnosis of Axial Spondyloarthritis: A Systematic Review

Cited by 90 publications

References 80 publications

Systematic review and meta-analysis of diagnostic delay in axial spondyloarthritis

Systematic review and meta-analysis of diagnostic delay in axial spondyloarthritis

Systematic review and meta-analysis of diagnostic delay in axial spondyloarthritis

Axial Spondyloarthritis

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