January 30, 2020
2 min read

Pre-diagnosis period in PsA marked by musculoskeletal issues, increased health care use

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Lihi Eder

A significant proportion of patients with psoriatic arthritis experience a prodromal period, as early as 5 years prior to diagnosis, characterized by musculoskeletal symptoms and an increase in health care use and costs, according to data published in Arthritis Care & Research.

“PsA is a heterogeneous disease that can present in various clinical manifestations, such as synovitis, enthesitis, dactylitis and spondylitis,” Lihi Eder, MD, PhD, of the University of Toronto and Women’s College Hospital, and colleagues wrote. “Some of these features can present with only minimal findings on physical examination, and the differentiation from other conditions, such as osteoarthritis, can be challenging. Furthermore, unlike RA and lupus, PsA has no reliable diagnostic biomarkers.”

“These factors, along with the lack of awareness of PsA among patients and primary care physicians, and limited access to specialty care contribute to delays in the diagnosis of PsA,” they added. “Better information regarding the pre-diagnosis phases of PsA is required in order improve our understanding of how to address these gaps in care. Such data, however, are limited particularly in the primary-care setting.”

To compare health care use for musculoskeletal symptoms during the 5-year period prior to a PsA diagnosis to that of individuals with no prior inflammatory arthritis, within a primary care setting, Eder and colleagues analyzed information in the Electronic Medical Records Primary Care (EMRPC) database. First, the researchers used the data in the EMRPC from Ontario, Canada, to create a matched cohort of patients with PsA, as well as individuals without inflammatory arthritis. According to the researchers, the total EMRPC includes data on 400,000 patients from 350 primary care physicians, from 1998 to 2016.

A significant proportion of patients with PsA experience a prodromal period, as early as 5 years prior to diagnosis, characterized by musculoskeletal symptoms and an increase in health care use and costs, according to data.
Source: Adobe

Eder and colleagues included 462 patients with PsA, all aged 20 years and older and registered in the EMRPC by April 2016, and 2,310 comparators matched based on age and sex. Prospective comparators were excluded if they had prior spondyloarthritis, ankylosing spondylitis or rheumatoid arthritis. Study outcomes included health care use and costs associated with nonspecific musculoskeletal symptoms during a 5-year period prior to a diagnosis of PsA.

According to the researchers, the likelihood that a patient with PsA had reported to a primary care physician for nonspecific musculoskeletal symptoms in the year immediately prior to their diagnosis was high (OR = 2.14; 95% CI, 1.73-2.64). Eder and colleagues added that the OR was similarly elevated throughout the 5 years preceding the eventual diagnosis.

In addition, the OR associated with other musculoskeletal-related health care use — including musculoskeletal specialists visits, joint injections, joint imaging and ED visits — were higher among patients with PsA as early as 5 years prior to the diagnosis. Total health care cost also increased gradually in patients with PsA, compared with those without, from a mean of CAD $4,873, 5 years prior to the diagnosis, to CAD $6,995, 1 year prior to the diagnosis. Meanwhile, heath care costs for the comparators remained largely stable, at approximately CAD $2,500.

“This study supports the notion that a prodromal phase, that is characterized by nonspecific musculoskeletal symptoms, occur in a significant proportion of the patients,” Eder told Healio Rheumatology. “These result in increased utilization of health care, such as visits to family physicians and the performance of diagnostic tests ultimately, leading to increased health care costs. These findings are important since they highlight the potential for early diagnosis of psoriatic arthritis by identifying this pattern of symptoms in patients with psoriasis.” – by Jason Laday

Disclosure: The researchers report no relevant financial disclosures.