The Need for an Early Arthritis Clinic
Rheumatoid arthritis (RA) is a chronic inflammatory disease, characterized by synovial hyperplasia, abnormal cellular and humoral immune responses and joint destruction that often leads to significant disability and increased mortality . A delay in early diagnosis and treatment of the inflammatory arthritides can result in joint destruction with consequent disability  and psychosocial dysfunction . RA is also often associated with comorbidities including cardiovascular disease and osteoporosis . RA therefore is associated with substantial economic costs to the patients, their families and society . The establishment of an early inflammatory arthritis clinic (EAC) in the Greater Rochester Community can facilitate early diagnosis and treatment of RA with the goal of preventing joint damage and subsequent disability.
A majority of patients with new onset rheumatoid arthritis experience significant delays in early diagnosis and optimal care . There often is a delay in referral of patients with inflammatory arthritis to the rheumatologists. Some of the reasons for the delay include the following: primary care physicians (PCPs) may have not received adequate training to recognize early inflammatory arthritis; PCPs may be unaware of the availability of new medications that can adequately treat these ailments and finally because PCPs may have experienced long delays in obtaining rheumatology appointments for their patients. The latter has been particularly true to the Greater Rochester area due to a severe shortage of practicing rheumatologists in the area for the past several years. PCPs who do suspect a diagnosis may also be uncomfortable or unable to prescribe disease modifying agents/ biologic agents used in the treatment of RA.
Evidence-Based/Best Practice Innovation
RA is associated with progressive joint destruction and deformity with the majority of patients developing erosions within the first couple of years . Early therapy with use of disease-modifying anti-rheumatic drugs (DMARDs) may improve clinical outcomes in patients with recent onset of RA compared with delayed treatment . Multiple clinical trials have demonstrated that even a brief delay in starting DMARD therapy can negatively impact radiographic outcome. A recent trial suggested that treatment with DMARDs within 15 days of presentation was associated with a better outcome after 2 years compared with delayed treatment (median 123 days after presentation) . Indeed, the American College of Rheumatology (ACR) has recommended that initiation of DMARDs should not be delayed beyond 3 months of diagnosis .
There is increasing evidence that the very early phase of synovitis in patients destined to develop RA (within the first 12 weeks of symptoms) represent a pathologically distinct stage of disease . These findings suggest that very early intervention may have a qualitatively different effect compared with later intervention. Early diagnosis and aggressive treatment has therefore become the cornerstone for management of rheumatoid arthritis [16-20].
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