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A comparison of giant cell arteritis referrals and outcomes during the COVID-19 pandemic: experience from a district general hospital in the UK

Adlan Wafi Ramli, Susannah Argyropoulos and Surabhi Wig
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DOI: https://doi.org/10.7861/clinmed.22-4-s69
Clin Med July 2022
Adlan Wafi Ramli
ABolton NHS Foundation Trust, Bolton, UK
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Susannah Argyropoulos
ABolton NHS Foundation Trust, Bolton, UK
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Surabhi Wig
ABolton NHS Foundation Trust, Bolton, UK
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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.

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Table 1.

Giant cell arteritis referrals and outcomes before and during the COVID-19 pandemic

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.
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Fig 1.

Referral pro forma.

  • © Royal College of Physicians 2022. All rights reserved.

References

  1. ↵
    1. Mehta P
    , Sattui SE, van der Geest KSM, et al. Giant cell arteritis and COVID-19: similarities and discriminators. A systematic literature review. J Rheumatol 2021;48:1053–59.
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Mackie SL
    , Dejaco C, Appenzeller S, et al. British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis: executive summary. Rheumatology (Oxford) 2020;59:487–94.
    OpenUrl
  3. ↵
    1. Sharp CA
    , Little J, Shahbaz A, et al. P013 Driving improvement through audit: impact of 2017 regional audit and survey upon giant cell arteritis services in 2020. Rheumatology (Oxford) 2021;60(Supplement 1):keab247.012.
    OpenUrl
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A comparison of giant cell arteritis referrals and outcomes during the COVID-19 pandemic: experience from a district general hospital in the UK
Adlan Wafi Ramli, Susannah Argyropoulos, Surabhi Wig
Clinical Medicine Jul 2022, 22 (Suppl 4) 69-70; DOI: 10.7861/clinmed.22-4-s69

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A comparison of giant cell arteritis referrals and outcomes during the COVID-19 pandemic: experience from a district general hospital in the UK
Adlan Wafi Ramli, Susannah Argyropoulos, Surabhi Wig
Clinical Medicine Jul 2022, 22 (Suppl 4) 69-70; DOI: 10.7861/clinmed.22-4-s69
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