AB1309 INTEGRATING ULTRASONOGRAPHY IN A FAST TRACK GIANT CELL ARTERITIS PATHWAY ENHANCES SERVICE PROVISION AND IS COST-EFFECTIVE
Authors: E. Ntatsaki, S. Premraj, D. Ioannidis, V. Vassiliou, S. Mansfield Smith
Journal: Annals of the Rheumatic Diseases (2024)

<h3>Background:</h3> Giant cell arteritis (GCA) is the most prevalent form of adult vasculitis, with potentially significant risks including blindness. Early detection and prompt initiation of treatment are therefore imperative. According to the 2018/2023 EULAR recommendations [1,2], urgent specialist review should be undertaken in suspected cases with ultrasonography as first line imaging. <h3>Objectives:</h3> In our hospital, a standardized referral pathway for GCA was previously lacking, resulting in patients being directed to various clinics, including acute medicine, emergency department, rheumatology, or ophthalmology. An audit conducted over 18 months in 2018 revealed a significant delay in specialist review and reaching a GCA diagnosis. In 2021, we established a rapid access referral pathway for direct specialist review, offering protected one-stop slots in rheumatology or ophthalmology. This pathway also incorporates the use of a dedicated score for assessing GCA risk (GCAPS) and vascular ultrasonography. The objectives of our work were to: 1)Examine referral times for suspected GCA patients 2)Improve the percentage of suspected GCA cases undergoing confirmatory tests, particularly ultrasound or temporary artery biopsy (TAB). 3)Evaluate cost-effectiveness for the introduction of ultrasonography <h3>Methods:</h3> We retrospectively audited using electronic health records our new GCA referrals from January 2022 to June 2023, and compared these to the 2018 data. <h3>Results:</h3> A total of 44 patients were identified and included in this analysis (women=29, mean age=68). In 2023, 89% of patients were reviewed within three days from referral, marking a significant increase from the previous rate of 47%. Additionally, in 2023, patients underwent specialist review within a median of 2 days, in stark contrast to the 19 days observed in 2018. Notably, 100% of our patients underwent diagnostic testing, compared to 79% recorded previously (see Table 1). Among new referrals, 34% received a GCA diagnosis. Of the 40 patients who underwent ultrasound, 27% had positive, 25% equivocal, and 48% negative findings. For the remaining 4 patients, GCA was ruled out without need for ultrasound/biopsy. Seventeen patients underwent biopsy, with 24% receiving a positive diagnosis for GCA. Among referred cases, 52% exhibited high GCAPs scores, while 32% displayed normal inflammatory markers. Considering the data shown in Table 1, and assuming a cost for TAB of Euro €700 and cost for ultrasound of €115 (costs adjusted for 2024 from [3]), with the Fast Track ultrasound supported clinic there is an overall reduction of €294 per patient, or 42%. The ultrasound approach costing €16,270 Euro per 40 patients vs €28,000 Euro with TAB for all patients- even allowing for 38% of patients requiring both tests in the ultrasound pathway. <h3>Conclusion:</h3> The fast-track referral pathway implemented enabled prompt review of our patients. These findings highlight the increased safety provided to suspected GCA patients through a specialized Fast Track GCA assessment clinic equipped with ultrasonography. Furthermore, this approach resulted in a notable decrease in the necessity for temporal artery biopsies and thus was cost-effective, saving €294 (42%) per patient. <b>Table 1.</b> Comparing the 2018 and 2023 data following the Fast Track GCA clinic with ultrasonography. The Fast Track clinic has enabled a faster and more complete service for the patients, enhancing safety in a cost-effective manner. <h3>REFERENCES:</h3> [1] Hellmich B et al. 2018 Update of the EULAR recommendations for the management of large vessel vasculitis. Ann Rheum Dis. 2020 Jan;79(1):19-30. DOI: 10.1136/annrheumdis-2019-215672. Epub 2019 Jul 3. [2] Dejaco C et al. EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice: 2023 update. Ann Rheum Dis. 2023 Aug 7:ard-2023-224543. DOI: 10.1136/ard-2023-224543. [3] Luqmani R et al. The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): a diagnostic accuracy and cost-effectiveness study. Health Technol Assess. 2016 Nov;20(90):1-238. DOI: 10.3310/hta20900. <h3>Acknowledgements:</h3> <b>NIL.</b> <h3>Disclosure of Interests:</h3> <b>None declared.</b>