National Early Inflammatory Arthritis Audit Supplementary Report 2020
Source: data.gov.uk (2024-10-11)

National Early Inflammatory Arthritis Audit (NEIAA). The purpose of the NEIAA is to improve the quality of care for people living with inflammatory arthritis by measuring care provided to patients against the seven quality statements set out in NICE quality standard 33 (2013 version). 

The audit assesses seven key metrics of care provided for people with new symptoms of arthritis attending rheumatology services for the first time:

1. How quickly do primary care health professionals refer people suspected to have inflammatory arthritis?
2. How soon after referral are people seen in secondary care? 
3. How long does it take to start treatment?
4. Do patients receive timely education about their condition? 
5. Are treatment targets set and agreed?
6. Do patients have access to emergency advice? 
7. Are annual reviews taking place?

More information can be found on the audit website (www.arthritisaudit.org.uk)

National Early 
Inflammatory Arthritis 
Audit (NEIAA)
Supplementary report presenting data captured 
at 12 months and results from data linkages 
(Enrolment window: 8 May 2018-7 May 2019)
June 2020
© 2020 Healthcare Quality Improvement Partnership (HQIP) 


3
List of tables	
4
List of figures	
4
Acknowledgements
5
Introduction
6
Executive summary	
7
Key findings	
8
Interpreting the NEIAA report	
9
Data quality	
11
Headlines: Quality standard 7	
12
Headlines: Treatment response	
15
Headlines: Patient-reported outcomes	
17
Headlines: Unplanned admissions	
21
Headlines: Joint replacements and mortality	
23
Conclusions
25
Next steps	
25
Appendices 	
26
Appendix 1: 	Glossary	
26
Appendix 2: 	Governance membership	
27
Project Working Group	
27
Patient Panel	
27
Senior Governance Group	
27
Contents

4
Table 1. 	
Standards of care
Table 2. 	
Annual review performance across regions
Table 3. 	
Disease outcomes at 12 months across regions
Table 4. 	
Hospital admission rates by region
Table 5. 	
Joint replacements by region
Table 6. 	
Regional mortality
List of tables
Figure 1. 	 Regional QS 7 performance
Figure 2. 	 Regional breakdown across annual review components
Figure 3. 	 Use of high-cost drugs by region
Figure 4a.  Patient-reported outcomes: disability (HAQ)
Figure 4b. 	Patient-reported outcomes: MSK-HQ
Figure 4c.  Patient-reported outcomes: mental health
Figure 5a. 	Work outcomes at diagnosis
Figure 5b. 	Work outcomes at three months
Figure 5c.  Work outcomes at 12 months
List of figures

5
Acknowledgements
This report was prepared by members of the National Early Inflammatory Arthritis Audit 
(NEIAA) operations team, using data provided by patients and staff within the NHS or 
private hospitals. The continued success of this national clinical audit is due to the hard work 
and commitment of the rheumatology clinical community. We are very grateful to all the 
clinical and administrative staff and patients who support and contribute to the NEIAA.
Healthcare Quality Improvement Partnership
The NEIAA is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as 
part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). The HQIP  
is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing 
and National Voices. Its aim is to promote quality improvement in patient outcomes, and to 
increase the impact that clinical audit, outcome review programmes and registries have on 
healthcare quality in England and Wales. The HQIP holds the contract to commission, 
manage and develop the NCAPOP, comprising over 40 projects covering care provided to 
people with a wide range of medical, surgical and mental health conditions. The programme 
is funded by NHS England, the Welsh Government and, with some individual projects, other 
devolved administrations and crown dependencies.
Net Solving
Established in 2001, Net Solving has spent over a decade perfecting the art of clinical data 
collection. It has revolutionised the way clinical data collection is conducted by pioneering the 
move to integrated online data collection methods, leveraging the latest technology to provide 
highly accurate data collection and analysis. Its market-leading platform CaseCapture™ is 
the culmination of 15 years’ experience in creating many of the largest clinical data collection 
web tools in the UK and worldwide. Net Solving is wholly committed to its continuing work 
with the British Society for Rheumatology (BSR) on the NEIAA project.
King’s College London
The Centre for Rheumatic Diseases at King’s College London has provided methodological 
and analytical support for the NEIAA from its outset. It has identified outliers using statistically 
robust methods and produced the tables and figures in this report. 

1. How quickly do primary care health professionals refer people suspected to have
inflammatory arthritis?
2. How soon after referral are people seen in secondary care?
3. How long does it take to start treatment?
4. Do patients receive timely education about their condition?
5. Are treatment targets set and agreed?
6. Do patients have access to emergency advice?
7. Are annual reviews taking place?
The audit also assesses how inflammatory arthritis affects people’s day-to-day function, 
mobility, sleep, wellbeing and ability to work.
In October 2019, the NEIAA published its first annual report. At the time of reporting, 
insufficient data were available to report on the seventh metric (annual reviews), as most 
patients would have had less than 12 months of follow-up. The purpose of this 
supplementary report is to provide information on this seventh metric alongside 12-month 
clinician- and patient-reported outcome data. Linkage to NHS Digital enables reporting for 
the first time on unplanned hospitalisations, joint replacements and all-cause mortality. 
*The quality statements have been updated: there are now five, rather than seven
Introduction
The purpose of the NEIAA is to improve the quality of care for people living with 
inflammatory arthritis by measuring care provided to patients against the seven quality 
statements* (QS) set out in NICE quality standard 33 (QS 33). 
The NEIAA collects information on all new patients over the age of 16 seen for the first time 
in specialist rheumatology departments with suspected inflammatory arthritis in England 
and Wales.
The audit assesses seven key metrics of care:
National Early Inflammatory Arthritis Audit (NEIAA)
6

7
Executive summary
This report covers information about the first 12 months of specialist care for all patients with 
rheumatoid pattern inflammatory arthritis (including psoriatic arthritis of the rheumatoid 
type). This includes both clinician- and patient-reported outcomes at baseline, three and 12 
months. 
The report provides information on national and regional performance against QS 7, as well 
as unplanned hospital admissions, joint replacements and mortality. As the NEIAA dataset 
matures, the data obtained from data linkages will provide robust measures of clinical 
outcomes to add to the clinician- and patient-reported outcomes.
For this report the outcomes of patients enrolled into the audit between 8 May 2018 and  
7 May 2019 who have had 12-month information returned were examined. Any 12-month data 
received up to 1 December 2019 have been included.

1.  There is evidence of substantial reduction in disease burden, as measured by clinician 
Disease Activity Scores (DASs) and patient-reported outcomes (PROs), over the first 12 
months of care in all regions of England and Wales.
2.  In total, 779/1,448 (54%) patients were in remission 12 months after diagnosis.
3.  Patients treated with disease-modifying anti-rheumatic drugs (DMARDs) within six weeks 
of referral had a greater chance of being in remission at 12 months: odds ratio (OR) 1.36, 
95% confidence interval (CI) 1.04 to 1.77.
4.  PRO data show improvements in measures of disability, mental health and ability to work. 
Over 12 months of specialist care, Musculoskeletal Health Questionnaire (MSK-HQ) scores 
increased by over 12 units, double the minimum clinically important difference.
5.  Targeted treatment was started within 12 months of specialist care in 15% of patients. The 
term targeted therapy in rheumatology implies the group of high-cost specialist drugs such 
as anti-Tumour Necrosis Factor (TNF) and Janus Kinase (Jak) inhibitors. We used to term 
these ‘biologics’, but the launch of the JAK inhibitors complicates things as technically they 
are not biologics, hence the use of the new term.
6.  Clinicians reported that an annual review was performed for only 43% of patients. This is 
an area which needs further work to understand the reasons and implications. 
7.  Data linkage to hospital episodes statistics (HES) and mortality data has shown, for the 
first time, that within the first 12 months of diagnosis of inflammatory arthritis:
a. There is a high burden of unplanned admissions
b. There are relatively low levels of joint replacement and mortality
8.  Despite the positive headlines, it is important to acknowledge that substantial regional 
variation has been shown in both QS performance and outcomes, including remission 
rates, use of high-cost drugs and unplanned admissions.
Key findings
8
National Early Inflammatory Arthritis Audit (NEIAA)

9
Interpreting the NEIAA report
Hospital/unit/Trust participation
All Trusts/Health Boards providing secondary rheumatology care and seeing patients with 
suspected early inflammatory arthritis (EIA) were eligible to participate. Rheumatology 
outpatient activity data from NHS Digital and the NWIS enabled us to identify all eligible 
Trusts/Health Boards. NEIAA participation is a contractual requirement for all Trusts/Health 
Boards in England and Wales, but the project still relies on clinician goodwill for active 
engagement. As previously highlighted, some bias is possible: departments with less resource 
and lower historical engagement in quality improvement activities may have found it more 
challenging to take part. 
Case ascertainment
All patients aged 16 or over who were first seen in a specialist rheumatology service with 
suspected EIA between 8 May 2018 and 7 May 2019 were eligible. The annual report published 
in October 2019 presents recruitment rates for Trusts/Health Boards. There is currently no 
external method to assess case ascertainment, so sampling bias is possible. Given the better 
than anticipated levels of recruitment in year one, and the demographic similarities of the 
sample compared to other large EIA cohorts, it is believed that any sampling bias is small and 
does not impact on the validity of the findings. 
Data quality and completeness
In order to keep the quality of data high, all information was entered via an online portal. This 
prompted users to complete mandatory fields, as well as checking fields such as NHS number 
and postcode to ensure they were credible. 
Analysis methodology
The report contains performance data for rheumatology services across England and Wales, 
with breakdown by region1. The previous annual report has provided descriptive analyses of 
patient characteristics across each region, funnel graphs to show performance variation at 
Trust/Health Board level, and details of individual Trust/Health Board data. This report 
provides information on national and regional performance using horizontal box plots. 
Data linkage
Deterministic matching to NHS Digital and the NWIS of all patients with EIA with a valid  
NHS number was performed to link to hospital episodes (including joint replacements) and 
mortality for England and Wales. No patients were flagged as opt-outs in England or Wales.
1 Regions defined by the BSR divisions.

10
Statement 1
People with suspected persistent synovitis affecting the small joints 
of the hands or feet, or more than one joint, are referred to a 
rheumatology service within three working days of presentation
Statement 2
People with suspected persistent synovitis are assessed in a 
rheumatology service within three weeks of referral
Statement 3
People with newly diagnosed RA are offered conventional disease-
modifying anti-rheumatic drug (cDMARD) monotherapy within 
three months of onset of persistent symptoms
Statement 4
People with RA are offered educational and self-management 
activities within one month of diagnosis
Statement 5
People who have active RA have their C-reactive protein (CRP)  
and disease activity measured monthly in specialist care until they 
are in remission or have low disease activity
Statement 6
People with RA and disease flares or possible drug-related  
side-effects receive advice within one working day of 
contacting the rheumatology service
Statement 7
People with RA have a comprehensive annual review that is 
coordinated by the rheumatology service
Standards used
This audit assesses achievement of the NICE QS 33 statements for care of patients over 
the age of 16 with rheumatoid arthritis (RA). Details of the standards of care set out in the 
statements can be found in Table 1.
Table 1. Standards of care
For this report, only QS 7 is reported on.
Clinical outcomes
The NEIAA reports on clinician- and patient-reported outcomes. Clinicians complete disease 
activity assessments at baseline, three and 12 months. Patients are asked to complete 
patient-reported measures at corresponding time points. 
The patient-reported measures capture the impact of disease using the Musculoskeletal Health 
Questionnaire (MSK-HQ), disability using the Health Assessment Questionnaire (HAQ), mental 
health impact using the four-item Patient Health Questionnaire Anxiety and Depression 
Screener (PHQ4ADS), and work using the Work Productivity and Activity Index (WPAI). 
Patients can return information through one of three mechanisms: online data entry via the 
patient audit website (www.myarthritisaudit.org.uk), direct entry with the healthcare 
provider in the clinic, or completion of paper forms which are entered online by the clinical 
team.
Governance including patient involvement
The NEIAA has an independent Patient Panel, whose view was sought on the data analysis 
plan, and whose Chair and Deputy Chair sit on the Project Working Group. The NEIAA Senior 
Governance Group, convened by BSR and including representatives of  patient-focused 
charities, provided methodological oversight and has approved analysis plans. 
Small numbers policy
Data for Trusts/Health Boards that have enrolled fewer than five patients into the audit have 
not been included in this report.

11
Data quality
Data completeness and missing data
Clinicians and patients were able to submit data for the 12-month review at any time 
between 10 and 14 months from the date of first assessment. Any 12-month data submitted 
by 1 December 2019 are included in this report. 
At the time of preparation, 7,493 patients with a confirmed diagnosis of EIA had been 
recruited to the audit within the 12 months from 8 May 2018 until 7 May 2019. Of these, 3,296 
patients had been registered more than 12 months ago. Of these patients, 1,524/3,296 
(46%) had 12-month audit information returned. PRO information was available for 
629/1,524 (41%) patients. 
A total of 6,745/7,493 (90%) patients had NHS numbers that could be used for linkage with 
NHS Digital or NWIS data. 
Data accuracy
Data collected for this audit include self-reported information from Trusts/Health Boards  
as well as linked data from NHS Digital and the NWIS. At present the NEIAA is reliant on 
organisations submitting self-reported findings honestly and does not have any means to 
externally verify the information submitted. All data fields are checked to ensure plausible 
values. You can view our data analysis plan here.

12
Headlines: Quality standard 7
What are we measuring?
We are measuring whether patients had had an annual review 12 months after diagnosis. 
Additional information was gathered when an annual review had taken place.
Definition and methods
We collected information for individual patients via a clinician questionnaire approximately 12 
months after diagnosis. Clinicians were sent reminders at 12 months to notify them that the 
information was due. We accepted a two-month window either side of the 12-month time 
point for data collection. We did not gather information on where the annual review took 
place (i.e. in the primary or secondary care setting), but simply whether the review had been 
performed. 
If an annual review had taken place, we asked whether three specific components were 
included: an assessment of bone health (e.g. FRAX score), a cardiovascular risk assessment 
(e.g. QRISK3) and an assessment of disability (e.g. HAQ score). We did not record actual 
scores.
What did we find?
In total, 1,524 patients from the first year of data collection had data returned on annual 
review status (see Table 2). Of these, 648 (43%) had an annual review undertaken and 876 
(57%) had not (see Figure 1). Data were not yet returned or missing for 1,772/3,296 (54%) 
patients recruited more than 12 months ago. Regional variation in annual review completion 
ranged from 15% in London to 68% in the East Midlands.
Of people who did have an annual review, 407/648 (63%) included a bone health assessment, 
cardiac risk assessment and disability. Only 96/648 (15%) had all three components assessed. 
Table 2 shows the regional variation. The individual components are reported as a percentage 
of those people who had an annual review completed (see also Figure 2). There was no clear 
pattern concerning which components of the annual review were included.
Table 2. Annual review performance across regions
Region
Total 
reported
Annual 
review
Cardiac risk 
assessed
Bone health 
assessed
Disability 
assessed
National
1523
43%
35%
41%
40%
Northeast
80
40%
47%
59%
34%
Northwest
224
35%
31%
56%
38%
Yorkshire & Humber
153
52%
28%
27%
38%
East Midlands
155
68%
32%
51%
53%
West Midlands
205
49%
22%
42%
38%
East of England
133
41%
36%
25%
16%
London
151
15%
39%
61%
43%
Southeast
214
43%
43%
26%
36%
Southwest
141
42%
48%
40%
40%
Wales
67
34%
43%
35%
87%

13
Figure 1. Regional QS 7 performance
Figure 2. Regional breakdown across annual review components
34
42
43
15
41
49
68
52
35
40
43
0%
20%
40%
60%
80%
Percentage of patients having annual review
Wales
Southwest
Southeast
London
East of England
West Midlands
East Midlands
Yorkshire & Humber
Northwest
Northeast
National
Quality statement 7
0%
20%
40%
60%
80%
100%
Percentage of patients
Wales
Southwest
Southeast
London
East of England
West Midlands
East Midlands
Yorkshire & Humber
Northwest
Northeast
National
Annual review components
Cardiac risk
Bone health
Disability

14
National Early Inflammatory Arthritis Audit (NEIAA)
What does this mean?
We can only comment on the patients who have had information returned for their 12-
month assessment. However, considering only those for whom we have information, a 
majority of clinicians reported that an annual review had not been undertaken. When 
clinicians indicated that an annual review had been done, it frequently did not include all 
three of the domains this audit assessed (bone health, cardiovascular risk assessment and 
disability review). 
Further investigation of the reasons for these findings is warranted as there are many 
potential explanations. It is possible that there are differences in the interpretation of the 
NICE guideline, or differences in the interpretation of the NEIAA question. Further work is 
needed to understand what processes are in place/being implemented for annual reviews 
and the obstacles to providing this service to patients.
Why is this important?
RA increases cardiovascular risk, fracture risk and the risk of disability. The goal of 
rheumatology care is to minimise any adverse outcomes linked to the disease. An annual 
review has been a recommendation from NICE for many years, in recognition of the 
importance of delivering a structured and individualised review to highlight specific risks  
and care needs. Patient organisations have strongly supported the value of this process  
to patients and questioned to what extent it has been made available to patients. 

15
Headlines: Treatment response 
What are we measuring?
The disease activity of patients with rheumatoid pattern disease was assessed with the 
Disease Activity Score (DAS28) at baseline and after three and 12 months of follow-up. Data 
on the baseline and three-month time points were published in the first annual report. This 
report presents the 12-month information. 
In addition, we report on the proportion of people escalated to targeted therapies 
(e.g. biologics) by 12 months.
Definition and methods
The DAS28 is a composite measure that incorporates objective measures of inflammation 
(number of swollen joints and laboratory markers of inflammation [CRP or ESR]) as well as 
patient measures (tender joint count and global rating scale of symptom severity). Scores 
range from 0 to 10, with remission defined as scores below 2.6, low disease activity as 2.6–3.2, 
moderate disease 3.2–5.1, and severe disease >5.1.
The European League Against Rheumatism (EULAR) DAS28 response is a validated measure 
of treatment response, incorporating both the baseline and follow-up DAS28 scores to 
stratify patients into ‘good response’, ‘moderate response’ and ‘no response’ groups. 
Multivariable logistic regression was used to describe associations with remission at 12 months.
What did we find?
Data were available to calculate disease activity on 1,448/1,524 (95%) patients (see Table 
3). At 12 months, 779/1,448 (54%) patients were in a state of disease remission. The 
breakdown according to EULAR response is shown in Table 3. Remission rates vary across 
regions, with lower rates in the Northwest and Wales, and the highest attainment of 
remission in the Southeast. 
Data were available on transition to targeted therapy in all 1,524 patients. Only 229/1,524 
(15%) patients were started on a targeted therapy by 12 months (see Figure 3). Transition to 
a targeted therapy ranged between 10% in Yorkshire & Humber and 20% in the Southeast 
and East of England. Targeted therapies include biologic DMARDs and Janus kinase (JAK) 
inhibitors, and are considered high-cost relative to cDMARDs.
Table 3. Disease outcomes at 12 months across regions
Region
Total 
reported
Remission
EULAR good 
response
EULAR 
moderate 
response
EULAR no 
response
National
1447
54%
57%
22%
21%
Northeast
77
62%
61%
29%
10%
Northwest
202
48%
54%
25%
21%
Yorkshire & Humber
140
51%
54%
23%
23%
East Midlands
152
56%
55%
25%
20%
West Midlands
200
52%
57%
22%
21%
East of England
125
55%
61%
19%
20%
London
145
43%
49%
24%
27%
Southeast
204
62%
62%
15%
23%
Southwest
137
59%
60%
20%
20%
Wales
65
54%
66%
22%
13%

16
Figure 3. Use of high-cost drugs by region
What does this mean?
DAS28 remission rates at 12 months are good, with a greater proportion in remission than is 
seen in most contemporary clinical trials. The variation is substantial, however, and suggests 
that there are important differences in outcome depending upon where a person is treated. 
The use of targeted therapies also varies substantially by region. The differences are not 
explained by differences in disease severity (either at baseline or during follow-up), 
suggesting variation in practice. 
Why is this important?
Clinical outcomes are the ultimate measure of the value and impact of care. It is important 
to understand the relationship between process and clinical outcomes, and measuring both 
via the NEIAA will improve our understanding. 
Remission is the ultimate clinical target. NEIAA data show that patients treated with DMARDs 
within six weeks of referral (QS 3) had a greater chance of remission at 12 months: OR 1.42; 95% 
CI 1.14 to 1.76. Starting treatment within six weeks of referral was nine times more likely (OR 9.0; 
95% CI 7.9 to 10.2) if the first appointment occurred within three weeks of referral (QS 2). 
In an adjusted model male gender was associated with an increased chance of remission  
(OR 1.7, 95% CI 1.3 to 2.2). Comorbidity and socioeconomic deprivation were both associated 
with a reduced chance of remission. One unit increase on the Rheumatic Disease 
Comorbidity Index (RDCI) was associated with an OR of 0.8 (95% CI 0.7 to 0.9). One decile 
change on the Index of Multiple Deprivation (IMD) was associated with a reduced OR of  
0.93 (95% CI 0.89 to 0.97).
The data also show that, after 12 months of care, there is regional variation in outcomes and 
a significant number of patients fail to achieve clinical response. More work is required to 
close the gap in achieving remission and treatment response across regions. Targeted 
treatments have been a major advance in the treatment of inflammatory arthritis resistant 
to cDMARDs. Targeted treatment options include biologics, e.g. Tumour Necrosis factor 
(TNF) inhibitors and JAK inhibitors and represent a class of drugs that are high cost. There 
are restrictions imposed by NICE on their use, but they should be available to all patients 
with treatment-resistant disease within a 12-month interval from diagnosis. There are likely 
to be many reasons for the substantial variations in use shown by the NEIAA data, and this 
variation warrants further investigation.
18
13
20
13
20
11
13
10
17
16
15
0%
10%
20%
Percentage of patients on targeted therapy by 1 year
Wales
Southwest
Southeast
London
East of England
West Midlands
East Midlands
Yorkshire & Humber
Northwest
Northeast
National
Targeted therapy use

17
Headlines: Patient-reported outcomes
What are we measuring?
PROs capturing information on disease impact, functional impairment, mental health and 
work impacts were collected.
Definition and methods
Data were collected from patients with a confirmed diagnosis of RA pattern EIA from their 
first assessment within specialty services and again after three and 12 months of follow-up. 
Patients could complete information either online via the patient portal or using printed 
questionnaires available in clinic from the rheumatology department.
PRO data collected:
Musculoskeletal Health Questionnaire (MSK-HQ)
This is a 15-item questionnaire evaluating symptom impact. It is validated for use across 
several MSK health conditions. A score is calculated from the first 14 items and ranges from 0 
to 56, with higher scores indicating better MSK health. 
Health Assessment Questionnaire (HAQ)
This is a 10-item questionnaire developed four decades ago to measure disability. Scores 
range from 0 to 3, with higher scores indicating worse functional status. 
Mental Health (PHQ4ADS)
These are the two questionnaires (PHQ2 and GAD2) that are the standard screening tools 
recommended for use in the NHS to identify people who have significant depression or 
anxiety. Each measure contains two items, with a score from 0 to 6. The combined score 
(PHQ4ADS) is a summation of the two components, where higher scores indicate a greater 
likelihood of mental health comorbidity.
Work status and impact
Impact is assessed using the Work Productivity and Activity Index (WPAI). Absenteeism is 
calculated as the number of hours missed as a percentage of total hours contracted to work. 
Presenteeism is the degree to which a patient’s health impacts on their performance at work. 
Overall impairment incorporates both absenteeism and presenteeism.
What did we find?
PROs were available for 629/1,524 (41%) of patients. On average, patients reported 
improvements over 12 months across all domains evaluated (disease impact, physical 
function, mood, work). The figures below provide the details for each outcome. 
MSK-HQ scores improved (see Figure 4b) from a mean of 25.6 at baseline to 37.4 at 12 
months, a change well above the minimum clinically important difference (MCID) of 5.5 for 
the measure. In parallel, disability levels reduced over the period, with a mean difference 
between baseline and 12 months of 0.41, almost double the MCID of 0.22 (see Figure 4a). 
Mental health comorbidity was frequent (see Figure 4c), with almost half (48.9%) of 
patients screening positive on the combined PHQ2/GAD2 tool at diagnosis. By 12 months, 
only 26.5% screened positive, which is only marginally above the background population rate.
Overall work impairment (see Figure 5) reduced from 31.9% at baseline to 23.5% at 12 
months. While this demonstrates substantial improvement, it is below the estimated MCID of 
20% for this measure.

18
Figure 4a. Patient-reported outcomes: disability (HAQ)
Figure 4b. Patient-reported outcomes: MSK-HQ
Figure 4c. Patient-reported outcomes: mental health
1.10
0.82
0.69
0
0.5
1.0
1.5
2.0
2.5
Baseline
3 months
12 months
HAQ
25.6
34.6
37.4
Baseline
3 months
12 months
MSK−HQ
0
16
24
32
40
48
8
48.9
30.2
26.5
Baseline
3 months
12 months
Proportion of patients screening positive for mental health comorbidity
0
10
20
30
40
50

19
Figure 5a. Work outcomes at diagnosis
31.9
43.8
18.9
0
10
20
30
40
50
Percentage work and daily impairment
Work impact amongst people in work at diagnosis
Absenteeism
Presenteeism
Overall impairment
0
10
20
30
40
50
27.2
33.0
9.3
Percentage work and daily impairment
Absenteeism
Presenteeism
Overall impairment
Figure 5b. Work outcomes at three months
Work impact amongst people in work at three months
0
10
20
30
40
50
Percentage work and daily impairment
23.5
25.2
3.8
Absenteeism
Presenteeism
Overall impairment
Figure 5c. Work outcomes at 12 months
Work impact amongst people in work at 12 months

20
Only the national statistics can be presented here due to the low volume of data available 
thus far but, as with other NEIAA assessments of care, regional variation in PROs is evident 
so work still needs to be done to reduce variation. 
What does this mean?
These data provide a great source of optimism, demonstrating the benefits of NHS care, with 
some striking improvements across England and Wales as a whole. This is one of the largest 
studies to demonstrate such remarkable improvements across the domains of PROs. 
Why is this important?
The NEIAA patient-reported measures provide information about disease impact across a 
breadth of domains, encompassing both physical and mental health as well as impact on work. 
It is essential that our clinical targets translate into improved quality of life for patients and that 
we are assessing measures that are important to patients.
Historically, collection of PROs and, in particular, mental health and work information is 
infrequent in routine practice.
There is a recognised association between work loss and absenteeism with inflammatory 
arthritis. Work loss is a cause of worse mental and physical health, loss of financial independence 
and loss of status and purpose in society. Measuring and offering support early in the disease 
course is essential to help patients remain in the workforce.
This audit highlights the importance of mental health comorbidity. The wider agenda for 
parity of esteem across physical and mental health is particularly relevant to patients with 
inflammatory arthritis, who experience a significantly greater burden of mental health 
comorbidity than the general population.
There is much room for improvement, but the NEIAA has triggered data capture directly from 
patients and shown that it is possible to collect this information to guide management decisions, 
making this an important step forward for the rheumatology community and its patients.

21
Headlines: Unplanned admissions
What are we measuring?
How often are patients admitted to hospital for unplanned care following a diagnosis of EIA?
Definition and methods
All patients with a confirmed diagnosis of EIA with a valid NHS number uploaded to the 
NEIAA were linked to NHS Digital and the NWIS. The number of unplanned admissions 
(including attendances at emergency departments) was recorded. Event rates per 1000 
patient years were calculated. Cox proportional hazards models were used to describe 
associations with unplanned admissions.
What did we find?
In total, 343 patients had an unplanned admission (see Table 4). The national unplanned 
admission rate was 159 per 1000 person years (95% CI 143 to 177), with rates ranging from 
112 in the Southeast to 207 in the East Midlands. 
Table 4. Hospital admission rates by region
Region
Unplanned admission 
rate / 1000 person years
Lower 95% CI
Upper 95% CI
National
158.8
142.9
176.5
Northeast
153.1
98.8
237.3
Northwest
171.3
131.8
222.5
Yorkshire & Humber
196.4
144.1
267.7
East Midlands
206.6
150.4
284.0
West Midlands
128.2
89.6
183.4
East of England
150.0
104.3
215.9
London
145.7
104.6
203.0
Southeast
111.8
79.9
156.4
Southwest
166.5
119.6
231.9
Wales
197.6
134.5
290.2

22
National Early Inflammatory Arthritis Audit (NEIAA)
What are we measuring?
Approximately 1 in 7 people diagnosed with EIA will have an unplanned admission within 12 
months of diagnosis. In an adjusted analysis, the only patient characteristic that predicted 
hospitalisation was the presence of comorbidity (hazard ratio: 1.3 per unit RDCI change; 
95% CI 1.1 to 1.4).
Why is this important?
Unplanned admissions represent a need for prompt medical review and an unpredictable 
demand for NHS support. People with newly diagnosed inflammatory arthritis may need  
to be seen urgently in hospital for a number of reasons (flares of arthritis, complications  
of treatment [side-effects, infections], inter-current illnesses or for unrelated medical 
problems) and these data provide clear evidence of variation in rates of unplanned 
admissions across regions. 
The association with comorbidity is important, as this varies by region and is therefore 
an important contextual factor when considering site-level variation.
This is the first time that anyone has reported on admission data for an EIA cohort in this 
manner. The information provides an important benchmark against which performance  
can be measured in the future.
This report does not explore reasons for hospitalisation, although work is ongoing to explore 
specific patterns in admission, in particular looking at infections.

23
Headlines: Joint replacements and mortality
What are we measuring?
We have measured (a) how often patients require joint replacement surgery and 
(b) mortality rates within 12 months of diagnosis of EIA.
Definition and methods
All patients with a confirmed diagnosis of EIA with a valid NHS number uploaded to the NEIAA 
were linked to NHS Digital and the NWIS. The number of hip or knee joint replacements  
as well as any deaths were recorded. Event rates per 1000 patient years were calculated. 
What did we find?
In total, 19 people had a joint replacement (see Table 5), corresponding to a rate of  
8/1000 per year (95% CI 5 to 13). The highest rate was observed in the West Midlands, and 
three regions (East Midlands, East of England and Wales) reported no joint replacements. 
Table 5. Joint replacements by region
In total, 42 deaths occurred (see Table 6), corresponding to a mortality rate of 18/1000 per 
year (95% CI 14 to 25). Mortality was highest in the Northeast, and lowest in London.
Region
Joint replacements / 
1000 person years
Lower 95% CI
Upper 95% CI
National
8.3
5.3
13.1
Northeast
7.3
1.0
51.8
Northwest
5.7
1.4
22.9
Yorkshire & Humber
9.3
2.3
37.1
East Midlands
0.0
West Midlands
24.4
11.0
54.3
East of England
0.0
London
11.9
3.8
36.8
Southeast
9.4
3.0
29.2
Southwest
9.1
2.3
36.6
Wales
0.0

24
Table 6. Regional mortality
Based upon the limited numbers of events accrued to date, numbers are too low for the 
NEIAA to present Trust/Health Board level event rates for joint replacement and mortality 
(as no individual Trust/Health Board has had >5 events).
What does this mean?
Very few people have joint replacements in the first 12 months after diagnosis, which is to be 
expected given that joint damage such that replacement is required takes time to 
accumulate. It is important to recognise that several factors contribute to joint 
replacements, including clinical need for surgery and access to surgery. Areas where no joint 
replacements were undertaken could reflect a lack of need or long waiting times for surgery. 
The mortality data are crude estimates, and do not account for case mix. Demographics and 
comorbidity are important to consider, e.g. London has the youngest population of all regions. 
Why is this important?
Inflammatory arthritis has long been associated with a need for joint replacement surgery 
and reduced life expectancy. General epidemiological studies have suggested a trend towards 
fewer joint replacements and a mortality rate that is approximately that of the general 
population in recent years. The low numbers of events across England and Wales as a whole 
suggest that this trend is being seen in practice and is reassuring. It is vital, however, that we 
continue to review these data and work towards good outcomes being translated to all 
patients in England and Wales.
Region
Mortality / 1000 
person years
Lower 95% CI
Upper 95% CI
National
18.4
13.6
24.9
Northeast
29.2
11.0
77.8
Northwest
20.0
9.5
42.0
Yorkshire & Humber
27.8
12.5
61.8
East Midlands
15.3
4.9
47.4
West Midlands
20.2
8.4
48.5
East of England
19.5
7.3
51.9
London
3.9
0.6
28.0
Southeast
18.8
8.4
41.8
Southwest
16.2
6.1
43.0
Wales
7.1
1.0
50.2

25
Conclusions
•  The NEIAA has been hugely successful in terms of engagement, with far higher recruitment 
numbers than anticipated. In addition, the capture of PROs has been above expectations, 
even 12 months after first appointment
•  Available data suggest a problem in delivering annual reviews for most people with 
inflammatory arthritis
•  The disease burden of inflammatory arthritis is high, although there is evidence of 
substantial improvement over the first 12 months of care in all regions of England and 
Wales
•  Relatively low numbers of patients progress to targeted treatment within 12 months of 
their first specialist assessment
•  There is a high burden of unplanned admissions within the first 12 months of receiving a 
diagnosis of an inflammatory arthritis. Work is needed to understand what the drivers are 
for these and to ascertain whether they are avoidable
•  The joint replacement and mortality data provide insight into some of the most impactful 
measures available to an early arthritis population
•  As the NEIAA dataset matures, the data obtained from data linkages will provide robust 
measures of clinical outcomes to add to the clinician- and patient-reported outcomes
•  The data provide detailed information needed for local units to understand their 
performance and support quality improvement activity
•  Substantial regional variation has been shown for all aspects of care presented in this report
Next steps
The audit will continue to collect information on early arthritis care across the NHS. 
Future reporting will incorporate 12-month outcome data alongside the baseline and 
three-month results.
Strategies for quality improvement are outlined in the NEIAA quality improvement plan.

National Early Inflammatory Arthritis Audit (NEIAA)
26
Appendices
Appendix 1: Glossary
BSR 	
British Society for Rheumatology
cDMARD 
conventional disease-modifying anti-rheumatic drug
CI 	
confidence interval
CRP 	
C-reactive protein
DAS 	
Disease Activity Score
DMARD 	
disease-modifying anti-rheumatic drug
EIA 	
early inflammatory arthritis
ESR 	
erythrocyte sedimentation rate
EULAR 	
European League Against Rheumatism
GAD2 	
Generalised Anxiety Disorder 2
HAQ 	
Health Assessment Questionnaire
HQIP 	
Health Quality Improvement Partnership
IMD 	
Index of Multiple Deprivation
IQR 	
interquartile range
JAK 	
Janus kinase
MCID	
minimum clinically important difference
MSK-HQ 	
Musculoskeletal Health Questionnaire
NCAPOP 	
National Clinical Audit and Patient Outcomes Programme
NEIAA 	
National Early Inflammatory Arthritis Audit
NHS 	
National Health Service
NICE 	
National Institute for Health and Care Excellence
NWIS 	
NHS Wales Informatics Service
OR 	
odds ratio
PHQ2	
Patient Health Questionnaire 2
PHQ4ADS	
Patient Health Questionnaire 4 Anxiety and Depression Screener
PRO 	
patient-recorded outcome
QS 	
quality statement
RA 	
rheumatoid arthritis
RDCI	
Rheumatic Disease Comorbidity Index
SD 	
standard deviation
WPAI 	
Work Productivity and Activity Index

Appendix 2: Governance membership
Project Working Group 
Dr Jo Ledingham (Chair)
Dr Elizabeth MacPhie (Deputy Chair)
Paul Amlani-Hatcher
Prof Fiona Cramp
Martin Cripps 
Jessica Ellis
Dr Jill Firth
Dr James Galloway
Dr Ian Giles
Fowzia Ibrahim
Dr Flora McErlane
Sallie Nicholas
David Pickles
Dr Raj Sengupta
Dr Charlotte Sharp
Roger Stevens
Prof Karen Walker-Bone
Dr Mark Yates
Patient Panel
Paul Amlani-Hatcher (Chair)
Roger Stevens (Deputy Chair)
Thomas Esterine
Heidi Lempp (Patient Liaison Expert)
Christine Lowe
Hannah Maltby
Carol Simpson
Yvonne Spencer
Kate Wilkins
Ruth Williams
Senior Governance Group
Dr Elizabeth Price (Chair)
Ali Rivett (Deputy Chair)
Ailsa Bosworth
Martin Cripps
Dr Benjamin Ellis
Jessica Ellis
Dr James Galloway
Sasha Hewitt
Tasneem Hoosain
Clare Jacklin
Dr Peter Lanyon
Dr Jo Ledingham
Dr Gary MacFarlane
Dr Elizabeth MacPhie
Sallie Nicholas
Dr Ayas Syed
Sarah Walker
Dale Webb
27

British Society 
for Rheumatology
Bride House
18-20 Bride Lane
London, EC4Y 8EE
xx-xxxx-xxxx
xxx@xxx.xx
rheumatology.org.uk
 BSR-NEIAA-JUN20