Introduction
Patients with giant cell arteritis (GCA) often require a long duration of steroid therapy. Therefore, steroids should only be commenced when the diagnosis is highly suspected, following a thorough history and blood results to match. Equally, the availability of fast-track pathways will prevent the long-term steroid burden for patients who do not have GCA. Our department's fast-track pathway is still in development, and we aimed to assess the quality of GCA referrals and their outcomes before and during the first wave of the COVID-19 pandemic.
Methods
We retrospectively reviewed all case notes of GCA referrals between 1 April and 30 September in 2019 and 2020. The referral letters were assessed for the inclusion of GCA symptoms, the blood results and the treatments prescribed. The clinic letters were reviewed to determine the interval between patient referral and rheumatology appointment and the outcome, which was the decision to continue or stop the prednisolone.
Results
As illustrated in Table 1, the number of new patients and the proportion of GCA referrals were similar. Interestingly, we found many similarities between these two periods.
Table 1.
Giant cell arteritis referrals and outcomes before and during the COVID-19 pandemic
| Year | 2019 | 2020 |
|---|---|---|
| Total number of new rheumatology patients, n | 744* | 717* |
| Total number of suspected GCA referrals, n (%) | 22 (0.03)* | 15 (0.02)* |
| Female, n (%) | 16 (73) | 9 (60) |
| White – British, n (%) | 19 (86) | 9 (60) |
| Age, years, median (range) | 69 (50-87) | 71 (40-85) |
| The number of GCA referrals from GP, n (%) | 14 (63) | 9 (60) |
| The number of referrals which stated GCA symptoms as either a positive or negative finding, n (%): | ||
| i. Polymyalgia rheumatica | 7 (32) | 7 (47) |
| ii. Jaw claudication | 13 (59)* | 10 (67)* |
| iii. Headaches | 19 (86) | 12 (80) |
| iv. Scalp tenderness | 16 (73) | 12 (80) |
| v. Visual symptoms | 18 (82)* | 13 (87)* |
| The number of referrals which included blood results, n (%) | 19 (86)* | 12 (80)* |
| The number of referrals which stated the results of inflammatory markers, n (%): | ||
| i. C-reactive protein (CRP) | 15 (68)* | 7 (47)* |
| ii. Erythrocyte sedimentation rate (ESR) | 19 (86)* | 10 (67)* |
| iii. Both CRP and ESR | 15 (68) | 5 (33) |
| The number of referrals which stated the start date of prednisolone, n (%) | 17 (77) | 9 (60) |
| The number of patients commenced on appropriate prednisolone dose; 60 mg (with visual symptoms) or 40 mg (without), n (%) | 11 (50)* | 9 (60)* |
| The number of patients who had a PPI (proton pump inhibitor) prescribed, n (%) | 20 (91) | 14 (93) |
| The number of patients who had calcium/vitamin D tablets prescribed, n (%) | 8 (36)* | 7 (47)* |
| The interval between the date of referral and the first rheumatology appointment, days, range (median) | 2–103 (34)* | 2–161 (13)* |
| The number of patients in which a decision was made to continue with steroids following the first appointment, n (%) | 10 (45)* | 7 (47)* |
In terms of the inclusion of GCA symptoms as either a positive or negative finding, jaw claudication was the second least mentioned symptom despite being the most specific for GCA.1 Moreover, not all referral letters commented on visual symptoms despite irreversible blindness being one of the major complications.2 In terms of blood results, less than 90% of referral letters included the results of inflammatory markers and erythrocyte sedimentation rate was favoured over C-reactive protein. Less than two-thirds of patients were commenced on the appropriate prednisolone dose and most patients were not started on calcium/vitamin D tablets.
We also found significant delays in both periods, with the interval exceeding 3 months between patient referral and rheumatology review. Finally, the proportion of patients who had their steroids discontinued following their first rheumatology appointment was more than 50%.
Conclusion
Our findings suggest a minimal effect of the COVID-19 pandemic on the quality and quantity of GCA referrals to our hospital. The constant variable was the lack of a fast-track assessment pathway. Our perspective as a district hospital is reflective of other UK hospitals that do not yet have fast-track pathways. Furthermore, only six out of 16 sites (37.5%) in our region, north-west England, have GCA fast-track pathways in place.3
These findings highlight the importance of improving awareness on the management of GCA. Our recommendations include using a GCA-specific referral template to improve the quality of referrals (Fig 1), promoting the use of the British Society for Rheumatology guideline and encouraging other rheumatology departments to develop or improve their GCA fast-track assessment pathways.2 This report led to the startling revelation that the issues identified from these results did not arise from the COVID-19 pandemic but rather from other factors that existed prior to and persisted through it.
Fig 1.
Referral pro forma.
References
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