Access to the Rheumatologist for Early Arthritis Patients: What are the Determinants of Delayed Specialized Care? Results from the ESPOIR Cohort

EULAR recommends a rapid referral to rheumatologist for early arthritis (EA) patients, ideally within 6 weeks after disease onset.
PURPOSE: To assess the delay experienced by EA patients included in the national prospective observational ESPOIR cohort to have access to specialized rheumatologic care. To identify the determinants associated with optimal non-delayed care as defined by EULAR guidelines.
METHODS: 813 patients with EA were included into the cohort between 2002 and 2005. Inclusion criteria were: 18 to 70 years old; more than 2 swollen joints for more than 6 weeks and less than 6 months; suspected or confirmed diagnosis of RA. RTO-delay was defined as the time interval between the first arthritis-related symptom to the first visit to rheumatologist. Determinants associated with a delayed specialized care were analysed by stepwise linear regression.
RESULTS: Main patients characteristics were: Female 77%; mean age 48 ±13 years; mean HAQ 1.0 ±0.7; swollen joint count 7 ±5; tender joint count 8 ±7; DAS28 5.2 ±1.5; ESR 29 ±25 mm/1 hr; CRP 22 ±34 mg/L, IgM RF+ 47%, anti-CCP+ 39%; satisfaction to ACR criteria 74%, structural damage 14%.
The mean delay for EA patients to consult a general practitioner (GP) was 26 ±41 days (median 15) and to visit a rheumatologist was 76 ±77 days (median 60). Only 375 (46.2 %) patients were able to access specialized care within the recommended 6-week timeframe.
In multivariate analysis, factors associated with a longer RTO-delay are presented in the table:

	Coefficient	[95% Conf. Interval]	p
Disease characteristics
. Intermittent arthritis	14.03	[2.48; 25.58]	0.017
. Explosive versus progressive onset	-24.57	[-37.05; -12.10]	0.000
. Polyarthritis versus oligoarthritis	-6.09	[-12.97; 0.78]	0.082
. Functional disability on HAQ	-8.08	[-15.63; -0.53]	0.036
Health care system organization
. East region	-23.24	[-41.20; -5.29]	0.011
. South west region	-19.63	[-35.07; -4.18]	0.013
. GP density	8.67	[-3.53; 20.87]	0.163
. Indirect access to specialist through GP	16.17	[1.05; 31.28]	0.036
. Rheumatologist density	37.67	[12.14; 63.20]	0.004

Besides arthritis characteristics (i.e., mild or intermittent symptoms), several factors related to the organization of health care resources, such as physician demography and indirect access to specialists, are associated with a long and suboptimal care of EA patients.
CONCLUSIONS: Even in a country with public national and universal health coverage, significant disparities were identified in the care of EA patients. These inequities might be related to medical demography variations across regions or to differences in physician network efficiency.

 B. Fautrel, None.