The latest National Early Inflammatory Autoimmune Diseases Audit reveals persistent delays in patient presentation, wide regional variation in remission rates and a high burden of mental health symptoms among those newly diagnosed. The audit’s clinical lead Dr Elizabeth Price, NEIAA clinical lead, discusses how the findings underscore the need for earlier recognition of inflammatory rheumatic disease, improved access to psychological support and continued efforts to meet national treatment standards.

The British Society for Rheumatology (BSR)’s National Early Inflammatory Autoimmune Diseases Audit (NEIAA) – formerly known as the National Early Inflammatory Arthritis Audit – offers unique insight into the incidence and distribution of patients with new autoimmune inflammatory disease and evaluates the quality of care against National Institute for Health and Care Excellence (NICE) quality standards for new rheumatoid arthritis.

Commissioned by the Healthcare Quality Improvement Partnership as part of the National Clinical Audit and Patient Outcomes Programme, the NEIAA aims to improve the quality of care for people living with rheumatic diseases by collecting demographic and care quality data on all eligible newly diagnosed patients over the age of 16 in rheumatology departments across England, Wales and, from April 2025, in Jersey.

The NEIAA has been running since May 2018, when the initial eligibility criteria for data collection included suspected early inflammatory arthritis. Since April 2023, only patients with confirmed early inflammatory arthritis have been included and, as of September 2023, the criteria were further extended to include patients with connective tissue diseases (CTD) and vasculitides.

Data on waiting times, time to treatment, patient-reported outcome measures (PROMs), and clinical response to treatment are collected over the first 12 months of care for all those recruited.

PROMs data cover gender, ethnicity, symptom duration, musculoskeletal health, wellbeing, and ability to work and perform regular activities.

For the latest NEIAA cycle, 7,565 patients with early inflammatory arthritis, 1,008 with CTD and 804 with vasculitis were recruited, with improved audit participation and 96% of eligible Trusts submitting data. The audit has broad reach and captures a representative population: 62% of participants were female, reflecting the recognised predominance in many autoimmune conditions. At the same time, other demographic and ethnic characteristics closely mirrored the background population.

What did the latest NEIAA reveal?

We know from the early years of the audit that starting treatment with disease-modifying anti-rheumatic drugs within six weeks of presentation, in line with NICE recommendations, leads to significant improvements in outcomes at three and 12 months.

Continuous audit is known to improve performance over time, and the latest published national report confirms that this standard is met in 60% of patients in England and Wales.

The latest NEIAA audit found that patients with early arthritis are delaying presentation to their healthcare provider. Nationally, 38% of people had symptoms for more than six months at the time of referral; this matters because outcomes are better for those seen promptly and who start treatment early in the course of their disease.

Patients who have not yet contacted a healthcare professional are challenging to target. In the future, we at the BSR hope to work with patient organisations to raise awareness of the importance of early presentation for inflammatory rheumatic disease. Once patients do present to primary care, referrals are prompt – nationally, 53% are referred within three days, and 43% are seen within three weeks.

Remission rates at three months vary substantially by Trust and region, but the national rate was 33%. Early remission rates can be difficult to interpret because of variations in practice and steroid use, as well as incomplete data. We know that early remission improves outcomes, and one of our key future aims is to improve national remission rates by reducing this variation and improving standards.

Subpopulations and mental health impact

Within the NEIAA audit, a subpopulation of 479 individuals with axial spondyloarthritis was younger than the broader population, more likely to be male, and included a higher proportion of individuals from minority ethnic backgrounds. Patients also tended to have a longer disease duration before diagnosis, with 30% having symptoms for more than five years.

The audit also measured performance for giant cell arteritis (GCA) against the national standards. As GCA is a potential medical emergency, the median time from presentation in primary care to referral was zero days, and the median time from referral to assessment was three days, as recommended in the BSR GCA guidance, although 25% of patients reported waiting more than eight days.

The NEIAA has identified a significant burden of anxiety and depression among patients with newly diagnosed arthritis, with 42% reporting symptoms three months after diagnosis. Rates are generally lower in the south-west and east of England and highest in London and the south-east.

Evidence shows that those starting treatment for their arthritis within six weeks have better mental health outcomes – another reason to improve compliance with standards.

To complement the patient-level data, the audit also collected organisational metrics. These confirmed good access to physiotherapy but poor access to psychology services.

Recommendations arising from the latest NEIAA

Based on findings from the last audit cycle, we have made several recommendations.

Specific funding is needed to raise awareness of the importance of early presentation with symptoms of inflammatory rheumatic disease. We also encourage integrated care boards, health boards and commissioners to use the NEIAA data to identify variations in care to support improvements.

We are working to improve the visibility of PROMs to identify patients who would benefit from additional mental health support and recommend that these measures are integrated into clinical pathways.

We must continue to get the message across that early treatment makes a difference to patients' psychological and physical health and improves outcomes. We also need to ensure that axial spondyloarthritis is considered as a potential diagnosis and referred early.

We plan to embed more quality measures into future audits to help rheumatology services demonstrate they are providing high-quality care to their patients.

Author

Elizabeth Price MBBCh PhD
National Early Inflammatory Autoimmune Diseases Audit clinical lead and consultant rheumatologist, Great Western Hospital NHS Foundation Trust, Swindon, UK