AGREEMENT BETWEEN REFERRING PHYSICIANS AND RHEUMATOLOGISTS AND PREDICTORS OF INFLAMMATORY ARTHRITIS: ANALYSIS BASED ON 8 YEARS OF EXPERIENCE IN AN EARLY ARTHRITIS CLINIC

Background: Early recognition of patients with arthritis is a crucial opportunity for optimal outcome. The Early Arthritis Clinic (EAC) of our department was created in 2012 to ensure a prompt access of these patients to efficient medical care. Patients may be referred based on a set of clinical criteria with less than 12 months duration and laboratory parameters: arthritis, inflammatory arthralgias, squeeze test, morning stiffness > 30 minutes, rheumatoid factor (RF), erythrocyte sedimentation rate (ESR)>30mm/h and C-reactive-protein>0.5mg/dL (CRP). Objectives: To assess the level of agreement between the referring physician and the rheumatologist, regarding the presence of each of the six referral criteria and to identify predictors of inflammatory arthritis. Methods: Cross sectional study including patients aged ≥ 18-year-old observed in the EAC between January 2012 and October 2019. Subjects who were referred to the EAC by a rheumatologist and those without available referral letter/medical records from the first visit to the EAC were excluded. Demographic data, provenience, referral criteria (presence/absence) and the final diagnosis [presence or not of an inflammatory rheumatic disease (IRD)] were collected from medical records. For the six referral criteria, the agreement between the referring physician and the rheumatologist was assessed using the Cohen’s Kappa. The presence of each referral criteria was compared between patients with and without an IRD using χ2 tests. Variables with p<0.1 or clinically relevant were included in forward stepwise multivariable logistic regression analysis to identify possible predictors for IRD. The statistical analysis was performed using SPSS® v21 and p <0.05 was considered statistically significant. Results: 376 patients (70% female; mean age (±SD) 56.3±16.2 years) were included. Most patients were referred from primary care (84%); the remaining 16% include those referred from emergency department and other hospital specialties. We diagnosed an inflammatory arthritis in 62% (n = 232) of the patients. Table 1 shows the level of agreement between the referring physician and the rheumatologist, regarding the presence of the referral criteria. Table 1. Agreement between the referring physician and the rheumatologist, regarding the presence of the referral criteria. Referral criteria Kappa p Arthritis 0.23 0.05 Squeeze test 0.09 0.04 Inflammatory arthralgias 0.11 0.04 Morning stiffness 0.18 0.04 RF 0.27 0.04 ESR 0.26 0.04 CRP 0.25 0.04 ANA 0.02 0.47 ANA- antinuclear antibodies; CRP- C-reactive-protein; ESR-erythrocyte sedimentation rate; RF-Rheumatoid factor In univariable analysis (IRD Vs non-IRD), inflammatory arthralgias (74% Vs 93%, p=0.01), squeeze test (24% Vs 55%, p=0.01), morning stiffness (49% Vs 63%, p=0.05), ESR (63% Vs 46%, p=0.01), CRP (62% Vs 48%, p=0.04) were associated to IRD. In multivariable analysis, only ESR (OR 5.0 [95% CI 1.9-13.0], p < 0.05) and inflammatory arthralgias (OR 0.15 [95% CI 0.04-0.52], p < 0.05) remained as predictors of IRD. Conclusion: Agreement between the referring physicians and the rheumatologist regarding then presence/absence of the referral criteria was poor in all clinical criteria and fair in laboratory criteria. Elevated ESR was an independent predictor of IRD and the description of inflammatory arthralgias was negatively correlated with IRD. These findings suggest the need to clarify the referral criteria used and to improve education among the physicians referring patients to the EAC. Disclosure of Interests: Luisa Brites: None declared, LILIANA SARAIVA: None declared, Ana Rita Cunha: None declared, Helena Assunção: None declared, Tânia Santiago: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Catia Duarte: None declared Citation: Ann Rheum Dis, volume 79, supplement 1, year 2020, page 254Session: Rheumatoid arthritis - prognosis, predictors and outcome (Poster Presentations)