¿Se derivan adecuadamente las espondiloartropatías desde primaria a especializada?

Assessment of SpondyloArthritis International Society (ASAS) Consensus on Spanish Nomenclature for Spondyloarthritis

OBJECTIVE

To develop a consensus to standardize the use of Spanish terms, abbreviations and acronyms in the field of spondyloarthritis (SpA).

METHODS

An international task force comprising all native Spanish-speaking Assessment of SpondyloArthritis International Society (ASAS) members, the executive committee of Grupo para el estudio de la Espondiloartritis de la Sociedad Española de Reumatología (GRESSER), two methodologists, two linguists from the Real Academia Nacional de Medicina de España (RANM) and two patients from the Spanish Coordinator of Spondylitis Associations (CEADE) was established. A literature review was performed to identify the conflicting terms/abbreviations/acronyms in SpA. This review examined written sources in Spanish including manuscripts, ICF and ICD, guidelines, recommendations and consensuses. This was followed by a nominal group meeting and a three-round Delphi. The recommendations from the RANM based on the Panhispanic dictionary were followed throughout the process.

RESULTS

Consensus was reached for 46 terms, abbreviations or acronyms related to the field of SpA. A Spanish translation was accepted for 6 terms and 6 abbreviations to name or classify the disease, and for 6 terms and 4 abbreviations related to SpA. It was agreed not to translate 15 acronyms into Spanish. However, when mentioning them, it was recommended to follow this structure: type of acronym in Spanish and acronym and expanded form in English. With regard to 7 terms or abbreviations attached to acronyms, it was agreed to translate only the expanded form and a translation was also selected for each of them.

CONCLUSIONS

Through this standardization, it is expected to establish a common use of the Spanish nomenclature for SpA. The implementation of this consensus across the community will be of substantial benefit, avoiding misunderstandings and time-consuming processes.

Evaluation of multiple referral strategies for axial spondyloarthritis in the SPondyloArthritis Caught Early (SPACE) cohort

BACKGROUND

Several models have been proposed to refer patients with possible axial spondyloarthritis (axSpA) to a rheumatologist. Our aim was to evaluate performance of these models in a single cohort.

METHODS

13 referral models found in the literature were evaluated in the Leiden SPondyloArthritis Caught Early (SPACE) cohort, which includes patients with back pain (≥3 months, ≤2 years, onset <45 years; n=261) referred to a rheumatology outpatient clinic. Imaging was not considered as a referral parameter. Performance of the strategies was evaluated (sensitivity, specificity, positive likelihood ratio (LR+)) using diagnosis by a rheumatologist as an external standard. For secondary analyses, fulfilment of the Assessment in SpondyloArthritis international Society (ASAS) axSpA criteria was used as an external standard.

RESULTS

In total, 107/261 patients were diagnosed with axSpA. Most models performed well regarding sensitivity and specificity. The MASTER strategy showed a balanced sensitivity/specificity with the highest LR+. The ASAS and Brandt I strategies are the most sensitive strategies. Using classification by ASAS axSpA criteria as the external standard gave comparable results. Most patients missed by the strategies fulfilled the imaging arm of the ASAS axSpA criteria.

CONCLUSIONS

Most referral models performed well, although patients in SPACE have already been referred, which may have led to overestimation of performance. If no patient is to be missed, the ASAS strategy would be most preferable. If the number of referrals needs to be limited, the MASTER strategy seems to perform best. The 'ideal' referral strategy may be different from country to country, due to differences in healthcare structure and prevalence of referral parameters such as human leucocyte antigen-B27.

Centre characteristics determine ambulatory care and referrals in patients with spondyloarthritis

OBJECTIVE

To describe the variability in rheumatology visits and referrals to other medical specialties of patients with spondyloarthritis (SpA) and to explore factors that may influence such variability.

METHODS

Nation-wide cross-sectional study performed in 2009-2010. Randomly selected records of patients with a diagnosis of SpA and at least one visit to a rheumatology unit within the previous 2 years were audited. The rates of rheumatology visits and of referrals to other medical specialties were estimated-total and between centres-in the study period. Multilevel regression was used to analyse factors associated with variability and to adjust for clinical and patient characteristics.

RESULTS

1168 patients' records (45 centres) were reviewed, mainly ankylosing spondylitis (55.2 %) and psoriatic arthritis (22.2 %). The patients had incurred in 5908 visits to rheumatology clinics (rate 254 per 100 patient-years), 4307 visits to other medical specialties (19.6 % were referrals from rheumatology), and 775 visits to specialised nurse clinics. An adjusted variability in frequenting rheumatology clinics of 15.7 % between centres was observed. This was partially explained by the number of faculties and trainees. The adjusted intercentre variability for referrals to other specialties was 12.3 %, and it was associated with urban settings, number of procedures, and existence of SpA dedicated clinics; the probability of a patient with SpA of being referred to other specialist may increase up to 25 % depending on the treating centre.

CONCLUSION

Frequenting rheumatology clinics and referrals to other specialists significantly varies between centres, after adjustment by patient characteristics.

Quality standards for rheumatology outpatient clinic. The EXTRELLA project

INTRODUCTION

In recent years, outpatient clinics have undergone extensive development. At present, patients with rheumatic diseases are mainly assisted in this area. However, the quality standards of care are poorly documented.

OBJECTIVE

To develop specific quality criteria and standards for an outpatient rheumatology clinic.

METHOD

The project was based on the two-round Delphi method. The following groups of participants took part: scientific committee (13 rheumatologists), five nominal groups (45 rheumatologists and 12 nurses) and a group of discussion formed by 9 patients. Different drafts were consecutively generated until a final document was obtained that included the standards that received a punctuation equal or over 7 in at least 70% of the participants.

RESULTS

148 standards were developed, grouped into the following 9 dimensions: a) structure (22), b) clinical activity and relationship with the patients (34), c) planning (7), d) levels of priority (5), e) relations with primary care physicians, with Emergency Department and with other clinical departments, f) process (26), g) nursing (13), h) teaching and research (13) and i) activity measures (8).

CONCLUSION

This study established specific quality standards for rheumatology outpatient clinic. It can be a useful tool for organising this area in the Rheumatology Department and as a reference when proposing improvement measures to health administrators.

General practitioners' perceptions of their ability to identify and refer patients with suspected axial spondyloarthritis: a qualitative study

OBJECTIVE

To explore the knowledge, beliefs, and experiences of general practitioners (GP) about inflammatory back pain (IBP) and axial spondyloarthritis (axSpA) and potential barriers for referral of patients suspected of having axSpA.

METHODS

A qualitative study involving semistructured interviews with GP was conducted. Transcripts of the interviews were independently read and annotated by 2 readers. Illustrative themes were identified and a coding system to categorize the data was developed.

RESULTS

Ten GP (all men; mean age 49 yrs) were interviewed. All could adequately describe "classic" ankylosing spondylitis (AS) and mentioned chronic back pain and/or stiffness as key features. All GP thought that AS is almost exclusively diagnosed in men. Six GP knew that there is a difference between mechanical back pain and IBP, but could recall only a limited number of variables indicative of IBP, such as awakening night pain (4 GP), insidious onset of back pain (1 GP), improvement with movement (1 GP), and (morning) stiffness (2 GP). Two GP mentioned peripheral arthritis as other SpA features, none mentioned dactylitis or enthesitis. GP awareness of associated extraarticular manifestations was low. Most GP expressed that (practical) referral measures would be useful.

CONCLUSION

GP are aware of "classic", but longterm features of axSpA. Knowledge about the disease spectrum and early detection is, however, limited. Addressing these issues in training programs may improve recognition of axSpA in primary care. This may ultimately contribute to earlier referral, diagnosis, and initiation of effective treatment in patients with axSpA.