Disclosure(s): No financial relationships with ineligible companies to disclose
Background/Purpose: Psoriatic arthritis (PsA) remains widely underdiagnosed and misdiagnosed worldwide, leading to delays in appropriate management and increased disease burden. While diagnostic delay has been extensively studied in axial spondyloarthritis (axSpA), there remains a significant research gap in understanding delays specific to PsA. This study aims to examine the extent and consequences of diagnostic and referral delays in PsA and their impact on radiographic outcomes. Methods: We systematically searched PubMed, Web of Science, and Scopus from inception until March 16, 2025, following PRISMA guidelines (Fig.1) to identify observational studies reporting diagnostic delay in PsA. Studies were included if they diagnosed PsA patients based on the CASPAR classification criteria, confirmed diagnosis by a rheumatologist or self-reported physician diagnosis. Diagnostic and referral delays were extracted if reported as mean (SD) or median (IQR). Meta-analysis was conducted using Review Manager software 5.4 (RevMan), employing random- and fixed-effects models using the inverse variance method. Heterogeneity was assessed using I² statistics following Cochrane guidelines. Results: A total of 20 observational studies were included encompassing 23,894 participants, with 15 contributing to the meta-analysis encompassing 22,749 participants. The pooled mean diagnostic delay was 31.24 months (95% CI: 22.48, 40.00) using a random-effects model, with considerable heterogeneity (I² = 100%) (Fig. 2). The mean referral delay was analyzed using both fixed- and random-effects models, with the random-effects model yielding a pooled mean referral delay of 21.69 months (95% CI: 15.02, 28.35) and the fixed-effects model yielding 15.32 months (95% CI: 13.98, 16.67), with considerable heterogeneity (I² = 92%) (Fig. 2). Patients with prolonged diagnostic delay had significantly increased odds of radiographic damage. The fixed-effects model yielded a pooled OR of 2.80 (95% CI: 2.31, 3.39), while the random-effects model showed an OR of 2.54 (95% CI: 1.58, 4.09). Heterogeneity for both was moderate (I² = 49%) (Fig. 2). Studies indicated substantial geographic variation in diagnostic delay, with reports ranging from 6.55 months in India to over 62.4 months in Italy (Fig. 3). Conclusion: This is the first systematic review and meta-analysis that explores diagnostic and referral delays in PsA, and their relationship to radiographic joint damage. This meta-analysis confirmed that both diagnostic and referral delays in psoriatic arthritis are statistically and clinically significant, with longer delays linked to an increased risk of radiographic joint damage. These delays reflect gaps in disease recognition and care coordination. Improving early detection, particularly in primary care and dermatology settings, and streamlining referral pathways to rheumatology are essential in reducing structural damage and improving patient outcomes.
