Regional Differences in Diagnosis Journey and Healthcare Utilization: Results from the International Map of Axial Spondyloarthritis (IMAS)

INTRODUCTION

To assess differences in the diagnosis journey and access to care in a large sample of patients with axial spondyloarthritis (axSpA) from around the world, included in the International Map of Axial Spondyloarthritis (IMAS).

METHODS

IMAS was a cross-sectional online survey (2017-2022) of 5557 unselected patients with axSpA from 27 countries. Across five worldwide geographic regions, the patient journey until diagnosis and healthcare utilization in the last 12 months prior to survey were evaluated. Univariable and multivariable linear regression was used to analyze factors associated with higher healthcare utilization.

RESULTS

Of 5557 participants in IMAS, the diagnosis took an average of 7.4 years, requiring more than two visits to HCPs (77.7% general practitioner and 51.3% rheumatologist), and more than two diagnostic tests [67.5% performed human leukocyte antigen B27 (HLA-B27), 64.2% x-ray, and 59.1% magnetic resonance imaging (MRI) scans]. North America and Europe were the regions with the highest number of healthcare professional (HCP) visits for diagnosis, while the lowest number of visits was in the Asian region. In the previous 12 months, 94.9% (n = 5272) used at least one healthcare resource, with an average of 29 uses per year. The regions with the highest healthcare utilization were Latin America, Europe, and North America. In the multiple linear regression, factors associated with higher number of healthcare utilization were younger age (b =  - 0.311), female gender (b = 7.736), higher disease activity (b = 1.461), poorer mental health (b = 0.624), greater functional limitation (b = 0.300), greater spinal stiffness (b = 1.527), and longer diagnostic delay (b = 0.104).

CONCLUSION

The diagnosis of axSpA usually takes more than two visits to HCPs and at least 7 years. After diagnosis, axSpA is associated with frequent healthcare resource use. Younger age, female gender, higher disease activity, poorer mental health, greater functional limitation, greater spinal stiffness, and longer diagnostic delay are associated with higher healthcare utilization. Europe and North America use more HCP visits and diagnostic tests before and after diagnosis than the other regions.

Advanced practice physiotherapists in Scottish primary care: Axial Spondyloarthropathy epidemiology, time to diagnosis, and referrals to rheumatology

OBJECTIVES

(1) Generate empirical knowledge of a Musculoskeletal (MSK) Advanced Practice Physiotherapist (APP) Service in Scottish Primary Care; (2) Identify the incidence and baseline time to diagnosis of Axial Spondyloarthropathy (AxSpA); (3) Identify APP Rheumatology referral fulfilment of the NICE 2017 Guidelines and Spondylarthritis Diagnosis Evaluation (SPADE) Tool; (4) Calculate APP Rheumatology referral conversion rates for AxSpA diagnosis and further investigation; (5) Contribute towards the current body of literature for informing analysis of MSK APP services within Scottish Primary Care.

METHODS

An audit and evaluation approach was undertaken over a 3-year period (May 2019-April 2022). Relevant clinical cases from the whole-service data-set were identified and analysed, using retrospective electronic healthcare record review and descriptive statistical techniques.

RESULTS

A total of 37,656 primary care MSK APP consultations took place, with N = 19 suspected AxSpA referrals made to Rheumatology. N = 6 cases of AxSpA were diagnosed by a Rheumatologist (31.6%). The mean age of individuals diagnosed with AxSpA was 39.6 ± 8.8, and 66.7% (4/6) were female. Mean time to diagnosis was 3.4 years, and incidence per-10,000 person-years was 1.6. Compliance of referrals with the NICE 2017 Guidelines and SPADE Tool Criteria was 78.9%. Of those diagnosed with AxSpA, 66.7% met both referral criterion sets.

CONCLUSION

Those referred by an MSK APP from primary care had a 5.1 year shorter time to diagnosis than the previous reported UK average of 8.5 years. APPs identified relevant AxSpA features in referring to Rheumatology, and supported effective implementation of the local secondary care pathway.

Diagnostic delay in axial spondylarthritis: A lost battle?

Diagnostic delay in axial spondylarthritis (axSpA) remains an unacceptable worldwide problem; with evidence suggesting significant detrimental impact both clinically on the individual, and economically on society. There is therefore, a need for global action across various healthcare professions that come into contact with patients living, and suffering, with undiagnosed axSpA. Recent estimates of the median diagnostic delay suggest that globally, individuals with axSpA wait between 2 and 6 years for a diagnosis - revealing a clear benchmark for improvement. This timespan presents a window of opportunity for earlier diagnosis and intervention, which will likely improve patient outcomes. This review describes the current diagnostic delay as estimated across countries and over time, before presenting evidence from published strategies that may be implemented to improve this delay across primary and secondary care, including for specialties treating extra-musculoskeletal manifestations of axSpA (ophthalmology, gastroenterology, dermatology). Ongoing campaigns tackling delayed diagnosis in axSpA are also highlighted.

A UK survey evaluation of First Contact Practitioners' and musculoskeletal physiotherapists' confidence, recognition, and referral of suspected axial spondyloarthritis

BACKGROUND

Axial Spondyloarthritis is an inflammatory disease associated with significant diagnostic delays. Steen et al. (2021) found inadequate consideration of axial Spondyloarthritis (axSpA) in physiotherapists back pain assessments. Since the previous survey, increased professional education on axSpA has occurred and First Contact Practitioners (FCPs), now widely established in General Practice, are key in supporting earlier recognition.

OBJECTIVES

(1) To re-evaluate physiotherapists' and evaluate FCPs' awareness, knowledge, and confidence in screening for and recognising features of axSpA and criteria prompting referral to rheumatology. (2) To compare these results to previous research (Steen et al., 2021).

DESIGN

As per Steen et al. (2021), an online survey was undertaken combining back pain vignettes (reflecting axSpA, non-specific low back pain [NSLBP] and radicular syndrome) and questioning on features of suspected axSpA.

RESULTS

165 surveys were analysed. Only 73% (n = 120/165) of respondents recognised the axSpA vignette compared to NSLBP 91% (n = 80/88) and radicular syndrome 88% (n = 68/77). An improvement in axSpA recognition was demonstrated compared with previous data. FCPs performed slightly better with 77% (n = 67/87) of respondents recognising the axSpA vignette. Adequate awareness of national referral guidance was evident in only 55% of 'clinical reasoning' and 6% of 'further subjective screening' responses. There was still misplaced confidence in recognising clinical features of axSpA compared to knowledge levels shown, including high importance given to inflammatory markers.

CONCLUSION(S)

Musculoskeletal physiotherapists demonstrate some improved knowledge and awareness of axSpA compared with previous study findings. Consideration of axSpA is still not universal in musculoskeletal physiotherapists' or FCPs' approaches to persistent back pain assessments and awareness of national referral guidance remains limited. This study highlights the continued need for professional education. Enhanced knowledge of screening and referral criteria in musculoskeletal clinical practice would support earlier diagnosis and better outcomes.

Patient Survey Exploring the Burden of Inflammatory Back Pain in Patients With Uveitis

Background  In the UK, diagnostic delays remain a challenge in axial spondyloarthritis (axSpA). Studies have shown that acute anterior uveitis is the most common extra-articular manifestation associated with axSpA. As part of a National Axial Spondyloarthritis Society (NASS) Aspiring to Excellence quality improvement project, this study aimed to ascertain the burden of inflammatory back pain (IBP) in patients attending a uveitis clinic and to establish the number of these patients who had not been referred to a rheumatologist, thereby contributing to the diagnostic delay. The secondary aims were to explore the factors contributing to the diagnostic delay. Methods  A 22-question patient survey was created to identify the burden of back pain in patients attending a specialist uveitis clinic at a London NHS Trust. Participants were recruited when attending their clinic appointments. Survey content included patient demographics and whether they had experienced back pain for longer than three months. The Berlin Criteria was used to identify the presence of inflammatory back pain, and it was also ascertained whether participants had a previous diagnosis of axSpA. Participants were asked if they had seen any healthcare professionals regarding their back pain and the total number of consultations they had had with each profession. Results  A cohort of 50 patients who attended the uveitis clinic at the Royal Free London NHS Trust completed the survey between February and July 2022. The mean age of the respondents was 52 years with a mean length of time with uveitis of 6.57 years. Of them, 64% were female and 36% were male. Forty per cent (40%) of participants (20 respondents) reported experiencing back pain for more than three months and 12% (six respondents) had a diagnosis of axSpA. Of those who reported back pain for more than three months, the mean age of onset of back pain was 28.6 years. Of the 14 participants (28%) who had back pain and were not diagnosed with axSpA, nine (18%) fulfilled the Berlin criteria for IBP. All participants had seen a GP or allied health professional specifically for their back pain. On average, respondents had seen two allied healthcare professionals, but only 40% (eight) of respondents with back pain had been seen by a rheumatologist. Conclusions  In this study, the data highlights that inflammatory back pain is common in patients with uveitis and the majority of patients with inflammatory back pain had not been referred to a rheumatology service and potentially have undiagnosed axSpA. Contributing factors to this potential delay in diagnosis include a lack of awareness of axSpA and its presenting features and associated conditions and a lack of onward referral for a specialist rheumatology opinion. This highlights the need for public, patient and healthcare professional education and the development of timely referral pathways to reduce delays in diagnosis.

Axial Spondyloarthritis and Diagnostic Challenges: Over-diagnosis, Misdiagnosis, and Under-diagnosis

PURPOSE OF REVIEW

This article aims to review the challenges in axial spondyloarthritis diagnosis and identify the possible contributing factors.

RECENT FINDINGS

The inability to reach an accurate diagnosis in a timely fashion can lead to treatment delays and worse disease outcomes. The lack of validated diagnostic criteria and the misuse of the currently available classification criteria could be contributing. There is also significant inter-reader variability in interpreting images, and the radiologic definitions of axial spondyloarthritis continue to be re-defined to improve their positive predictive value. The role of inflammatory back pain features, serologic biomarkers, genetics, and their diagnostic contribution to axial spondyloarthritis continues to be investigated. There is still a significant amount of delay in the diagnosis of axial spondyloarthritis. Appreciating the factors that contribute to this delay is of utmost importance to close the gap. It is similarly important to recognize other conditions that may present with symptoms that mimic axial spondyloarthritis so that misdiagnosis and wrong treatment can be avoided.

Social Media Use Among Members of the Assessment of Spondyloarthritis International Society: Results of a Web-Based Survey

BACKGROUND

The use of social media in health care may serve as a beneficial tool for education, information dissemination, telemedicine, research, networking, and communications. To better leverage the benefits of social media, it is imperative to understand the patterns of its use and potential barriers to its implementation in health care. A previous study in 2016 that investigated social media use among young clinical rheumatologists (≤45 years) and basic scientists showed that there was substantial social media use among them for social and professional reasons. However, there is a limited inquiry into social media use in different areas of rheumatology, such as spondyloarthritis.

OBJECTIVE

We aimed to explore the motivations, barriers, and patterns of social media use among an international group of experts in spondyloarthritis.

METHODS

We distributed a web-based survey via email from March 2021 to June 2021 to 198 members of the Assessment of Spondyloarthritis International Society. It contained 24 questions about demographic characteristics, patterns of current social media use, and perceptions of utility. Univariable and multivariable logistic regression analyses were performed to identify the characteristics associated with use trends.

RESULTS

The response rate was 78.8% (156/198). Of these, 93.6% (146/156) of participants used at least one social media platform. Apart from internet-based shopping and entertainment, the use of social media for clinical updates (odds ratio [OR] 6.25, 95% CI 2.43-16.03) and research updates (OR 3.45, 95% CI 1.35-8.78) were associated with higher social media consumption. Among the respondents, 66% (103/156) used social media in a work-related manner. The use of social media for new web-based resources (OR 6.55, 95% CI 2.01-21.37), interaction with international colleagues (OR 4.66, 95% CI 1.21-17.90), and establishing a web-based presence (OR 4.05, 95% CI 1.25-13.13) were associated with higher levels of consumption for work-related purposes. Time investment, confidentiality concerns, and security concerns were the top 3 challenges to a wider adoption of social media.

CONCLUSIONS

Most respondents (103/156, 66%) use social media in a work-related manner. Professional development, establishing a web-based presence, and international collaboration were associated with higher use. Challenges to social media adoption should be addressed to maximize its benefits.

The frequency of sacroiliitis on MRI in subjects over 55 years of age

OBJECTIVE

To evaluate the frequency of sacroiliitis in older subjects.

MATERIALS AND METHODS

Consecutive MRI examinations of the sacroiliac joints (SIJs) performed for suspected sacroiliitis (2005-2019) in patients ≥ 18 years were retrospectively evaluated for the presence of active/structural lesions and were categorized for the presence/absence of sacroiliitis. Clinical and imaging parameters were compared between subjects with sacroiliitis according to age groups < 40 years, 40-55, and > 55 years. Clinical parameters including inflammatory back pain (IBP) and other spondyloarthritis (SpA) features were retrieved from the medical records.

RESULTS

A total of 431 patients with SIJs MRI were evaluated: median age, 44 [IQR 35-54]; female:male 267(62%):164(38%). Sacroiliitis was diagnosed in 89 (20.6%) subjects-median age, 41 years [IQR 32-54], 52% females- and was equally prevalent among the different age groups: > 40 years old, 23.6%; 40-55, 20%; and > 55 years old, 17%, p = 0.43, with active/structural lesions equally dispersed. Older patients (> 55) started suffering from back pain at an older age and had a longer delay in diagnosis. Gender distribution, the presence of IBP, and other SpA features were no different in patients < 45 and > 55 years of age.

CONCLUSIONS

The frequency of sacroiliitis on SIJs-MRI in subjects > 55 years is similar to its frequency in younger subjects and is associated with the same type and magnitude of active and structural MRI lesions. Clinical parameters such as IBP and additional SpA features are similarly prevalent in older and younger subjects suggesting they suffer from the same disease and differing only in age of presentation.

Development and test–retest reliability of a screening tool for axial spondyloarthritis

Background

People with axial Spondyloarthritis (axSpA) suffer from lengthy diagnostic delays of ~7 years. The usage of screening tools to identify axSpA patients in primary care can reduce diagnostic delays by facilitating early referral to rheumatologic care. The purpose of this study was to examine the psychometric properties of a potential screening tool for patients with axSpA.

Method

Content validity was evaluated by soliciting feedback from 7 rheumatologists regarding the relevance and content representativeness of the proposed screening questions. For the test-retest study, participants ≥18 years of age with chronic back pain (≥3 months) without a diagnosis of mechanical or inflammatory back pain (n = 91) were e-recruited through ResearchMatch. Participation included completing identical baseline and follow-up questionnaires ~14 days apart. Weighted quadratic kappa was used to measure test-retest reliability between the two ratings of the ordinal scales. Construct validity was examined using exploratory factor analysis (EFA) and items with factor loadings ≥0.6 were extracted. Scale dimensionality and simplified factorial solutions were measured using Kaiser’s criteria (Eigenvalue >1). Cronbach’s alpha was used to measure internal consistency.

Results

Most participants were women, non-Hispanic white, and had at least some college education, with a mean age of 45 years. On average, the age at onset of back pain was 31 years. Eleven questions yielded test–retest reliabilities ranging from 0.6 to 0.76. Results from EFA extracted two factors relating to: 1) how pain affects daily life functioning and 2) whether pain improves with movement. Internal consistency was high for questions evaluating how pain affects life, with a Cronbach’s alpha of 0.81. Following assessment for validity and reliability, the questionnaire was revised to create the 6-item screening tool.

Conclusions

The 6-item SpA-SED screening tool designed to identify potential cases of axSpA was found to have good test–retest reliability and high internal consistency.

Prevalence of Inflammatory Back Pain in a Low-Income Population

BACKGROUND

Inflammatory back pain (IBP) is a major criterion in identifying axial spondyloarthritis. Whether socioeconomic issues impact prevalence of IBP assessed using standardized questionnaires has not been assessed. We determined IBP prevalence and performance of IBP questionnaires in a low-income, low-literacy population.

METHODS

Individuals were interviewed in Fortaleza, Brazil, for the prevalence of IBP using Calin's, Berlin, and ASAS IBP questionnaires; monthly family income (US dollars), literacy (>/≤8 school years [SYs]), and smoking habit (present/absent) were registered.

RESULTS

Two hundred nineteen individuals were included (mean age, 38.2 ± 12.9 years), 110 (50.2%) men, 58 (26.4%) White, and 38 (17.3%) smokers. Overall, 152 (69.4%) declared

CONCLUSIONS

This is the first report on IBP prevalence in a low-income, low-literacy population. Chronic back pain was highly prevalent with almost 15% having IBP using ASAS criteria. Inflammatory back pain prevalence looked similar using ASAS and Berlin criteria; values were higher using Calin's criteria. Literacy or income did not influence IBP prevalence in this population, which was higher among women. The higher prevalence of IBP using Calin's criteria in this population should be taken into account as it might impact studies aiming to determine prevalence of axial spondyloarthritis in clinical studies in this scenario.

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MESH Headings

• Adult
• Back Pain/epidemiology
• Brazil/epidemiology
• Female
• Humans
• Male
• Middle Aged
• Poverty
• Prevalence
• Spondylarthritis/epidemiology
• Surveys and Questionnaires

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Affiliation(s)

Jobson Lopes de Oliveira From the Department of Internal Medicine, Faculty of Medicine, Universidade Federal do Ceará, Fortaleza, Brazil
Guilherme Ferreira Maciel da Silva From the Department of Internal Medicine, Faculty of Medicine, Universidade Federal do Ceará, Fortaleza, Brazil
Igor Albuquerque Nogueira From the Department of Internal Medicine, Faculty of Medicine, Universidade Federal do Ceará, Fortaleza, Brazil
Artur Queirós Azevedo From the Department of Internal Medicine, Faculty of Medicine, Universidade Federal do Ceará, Fortaleza, Brazil
Xenofon Baraliakos Rheumazentrum Ruhrgebiet Herne, Ruhr-University Bochum, Bochum, Germany
Francisco Airton Castro Rocha From the Department of Internal Medicine, Faculty of Medicine, Universidade Federal do Ceará, Fortaleza, Brazil

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Changes in ankylosing spondylitis incidence, prevalence and time to diagnosis over two decades

Objectives

To assess changes in ankylosing spondylitis (AS) incidence, prevalence and time to diagnosis, between 1998 and 2017.

Methods

Using UK GP data from the Clinical Practice Research Datalink, we identified patients diagnosed with AS between 1998 and 2017. We estimated the annual AS incidence, prevalence and length of time from first recorded symptom of back pain to rheumatology referral and diagnosis.

Results

We identified 12 333 patients with AS. The incidence declined from 0.72 (±0.14) per 10 000 patient-years in 1998 to 0.39 (±0.06) in 2007, with this decline significant only in men, then incidence rose to 0.57 (±0.11) in 2017. By contrast, prevalence increased between 1998 and 2017 (from 0.13%±0.006 to 0.18%±0.006), rising steeply among women (from 0.06%±0.05 to 0.10%±0.06) and patients aged ≥60 (from 0.14%±0.01 to 0.26%±0.01). The overall median time from first symptom to rheumatology referral was 4.87 years (IQR=1.42–10.23). The median time from first symptom to diagnosis rose between 1998 and 2017 (from 3.62 years (IQR=1.14–7.07) to 8.31 (IQR=3.77–15.89)) and was longer in women (6.71 (IQR=2.30–12.36)) than men (5.65 (IQR=1.66–11.20)).

Conclusion

AS incidence declined significantly between 1998 and 2007, with an increase between 2007 and 2017 that may be explained by an improvement in the recognition of AS or confidence in diagnosing AS over time, stemming from increased awareness of inflammatory back pain and the importance of early treatment. The rising AS prevalence may indicate improved patient survival. The persisting delay in rheumatology referral and diagnosis remains of concern, particularly in women.

Early identification of axial spondyloarthritis in a multi-ethnic Asian population

INTRODUCTION/OBJECTIVES

To address the diagnostic delay in axial spondyloarthritis (axSpA), we have cross-culturally adapted the Hamilton axSpA questionnaire, a self-administered screening questionnaire, in the Singapore population. In this study, we compared the performance of various scoring methods for this questionnaire in detecting axSpA.

METHOD

The questionnaire was self-administered by eligible subjects. Scoring methods included method A, the original questionnaire scoring, and methods B-E, scoring developed based on the Assessment of SpondyloArthritis International Society (ASAS) criteria for inflammatory back pain (IBP) and the referral, classification and both referral and classification of axSpA, respectively. The reference standard was diagnosis by a rheumatologist. Since the ASAS criteria-based scoring methods were mainly based on clinical axSpA features, self-report and rheumatologist-assessment of clinical axSpA features were also compared in subjects with axSpA.

RESULTS

Of 1418 subjects (age: 54 ± 14 years, female: 73%) recruited, 46 were diagnosed with axSpA by a rheumatologist. Sensitivities of methods A-E were 35%, 61%, 63%, 48% and 83%, respectively. Self-report of clinical axSpA features exceeded rheumatologist-assessment for arthritis (83 vs 26%), good response to NSAIDs (37 vs 30%), enthesitis (35 vs 30%), dactylitis (20 vs 2%) and family history for axSpA (13 vs 4%). The reverse was true for IBP (41 vs 63%) and uveitis (4 vs 15%).

CONCLUSIONS

A self-administered questionnaire using the ASAS referral and classification criteria-based scoring yielded relatively high sensitivity in detecting axSpA in subjects newly referred to rheumatology clinics. This supports its evaluation as a screening and referral tool in the general population in future studies. Key Points • A self-administered questionnaire could be used as a screening and referral tool. • ASAS referral and classification criteria-based scoring yielded relatively high sensitivity. • Inaccurate perception of clinical axSpA features was observed in axSpA patients.

Human motion capture for movement limitation analysis using an RGB-D camera in spondyloarthritis: a validation study

A human motion capture system using an RGB-D camera could be a good option to understand the trunk limitations in spondyloarthritis. The aim of this study is to validate a human motion capture system using an RGB-D camera to analyse trunk movement limitations in spondyloarthritis patients. Cross-sectional study was performed where spondyloarthritis patients were diagnosed with a rheumatologist. The RGB-D camera analysed the kinematics of each participant during seven functional tasks based on rheumatologic assessment. The OpenNI2 library collected the depth data, the NiTE2 middleware detected a virtual skeleton and the MRPT library recorded the trunk positions. The gold standard was registered using an inertial measurement unit. The outcome variables were angular displacement, angular velocity and lineal acceleration of the trunk. Criterion validity and the reliability were calculated. Seventeen subjects (54.35 (11.75) years) were measured. The Bending task obtained moderate results in validity (r = 0.55-0.62) and successful results in reliability (ICC = 0.80-0.88) and validity and reliability of angular kinematic results in Chair task were moderate and (r = 0.60-0.74, ICC = 0.61-0.72). The kinematic results in Timed Up and Go test were less consistent. The RGB-D camera was documented to be a reliable tool to assess the movement limitations in spondyloarthritis depending on the functional tasks: Bending task. Chair task needs further research and the TUG analysis was not validated. Comparation of both systems, required software for camera analysis, outcomes and final results of validity and reliability of each test.

Physiotherapists' awareness, knowledge and confidence in screening and referral of suspected axial spondyloarthritis: A survey of UK clinical practice

BACKGROUND

Axial spondyloarthritis (axSpA) is an inflammatory disease associated with significant diagnostic delays and is commonly missed in assessments of persistent back pain.

OBJECTIVE

To explore musculoskeletal physiotherapists' awareness, knowledge and confidence in screening for signs, symptoms and risk factors of suspected axSpA and criteria for rheumatology referral.

DESIGN

An online UK survey was undertaken combining back pain vignettes (reflecting axSpA, non-specific back pain and radicular syndrome) and questioning on features of suspected axSpA. Recruitment utilised online professional forums and social media. Data analysis included descriptive statistics and conceptual content analysis for free text responses.

RESULTS

132 survey responses were analysed. Only 67% (88/132) of respondents identified inflammatory pathologies as a possible cause of persistent back pain. Only 60% (79/132) recognised the axSpA vignette compared to non-specific low back pain (94%) and radicular syndrome (80%). Most suspecting axSpA would refer for specialist assessment (77/79; 92%). Awareness of national referral guidance was evident in only 50% of 'clinical reasoning' and 20% of 'further subjective screening' responses. There was misplaced confidence in recognising clinical features of axSpA (≥7/10) compared to knowledge levels shown, including high importance given to inflammatory markers and human leucocyte antigen B27 (median = 8/10).

CONCLUSIONS

Musculoskeletal physiotherapists may not be giving adequate consideration to axSpA in back pain assessments. Awareness of national referral guidance was also limited. Professional education on screening and referral for suspected axSpA is needed to make axSpA screening and referral criteria core knowledge in musculoskeletal clinical practice, supporting earlier diagnosis and better outcomes.

Educational needs and challenges in axial spondyloarthritis

PURPOSE OF REVIEW

Axial spondyloarthritis (axSpA) affects 0.5-1% of the population in many regions of the world. This review summarizes the challenges in medical education around axSpA with attention to evidence around delayed diagnosis, clinician familiarity with typical axSpA features, such as inflammatory back pain and adherence to accepted management principles.

RECENT FINDINGS

Clinicians who commonly manage patients with chronic back pain or other typical axSpA features are not consistently aware of the concept of inflammatory back pain and common extra-spinal manifestations. Further, clinicians may not be familiar with the nonradiographic spectrum of axSpA. Management of patients with possible axSpA does not consistently follow principles that would establish an axSpA diagnosis, and diagnosis of axSpA remains delayed by 6-7 years on average, with evidence suggesting management disparities on the basis of sex and race in some cases. Referral recommendations have increased the probability of axSpA diagnosis up to about 40% and, may complement educational efforts in axSpA.

SUMMARY

Educational efforts in axSpA should focus on providing front-line clinicians with a better understanding of inflammatory back pain, the nonradiographic form of axSpA, and accepted principles in axSpA management.

Inflammatory back pain: a concept, not a diagnosis

PURPOSE OF REVIEW

The concept of inflammatory back pain (IBP) describes a cohort of patients with chronic back pain (CBP) who have distinct clinical characteristics, rather than being a diagnosis in and of itself. IBP is a common and important feature of axial spondyloarthritis (axSpA) but this is not the only differential. This review examines the utility of IBP in both primary and secondary care settings.

RECENT FINDINGS

There are a number of suggested referral strategies for patients with suspected axSpA that include IBP. These strategies attempt to strike a balance between ensuring potential axSpA patients are not overlooked, whilst simultaneously not overwhelming secondary care services. Their success relies on the clinicians who first encounter these patients being familiar with IBP as a concept; however, it is still poorly recognized by many healthcare professionals. IBP may be helpful as part of a referral strategy; however, other clinical features, laboratory investigations and radiology must be incorporated for the final diagnostic outcome in axSpA.

SUMMARY

Delayed diagnosis is a major clinical problem in axSpA and is associated with worse clinical outcomes. When recognized and utilized correctly, IBP can be a useful tool to promote prompt referral to rheumatology services.

Primary care physician perspectives on screening for axial spondyloarthritis: A qualitative study

BACKGROUND

Many patients with axial spondylarthritis (axSpA) experience lengthy diagnostic delays upwards of 14 years. (5-14 years). Screening tools for axSpA have been proposed for use in primary care settings, but whether this approach could be implemented into busy primary care settings remains unknown.

OBJECTIVE

To solicit feedback from primary care physicians regarding questions from the Inflammatory Back Pain Assessment: the Assessment of Spondyloarthritis International Society (ASAS) Expert Criteria and gain insight about barriers and facilitators for implementing axSpA screening in primary care.

METHODS

Guided by Consolidated Criteria for reporting Qualitative Research (COREQ-criteria), we recorded, transcribed, and analyzed in-depth interviews with eight family medicine physicians and ten internists (purposeful sampling) using immersion/crystallization techniques.

RESULTS

Few physicians reported awareness of existing classification criteria for axSpA, and many reported a lack of confidence in their ability to distinguish between inflammatory and mechanical back pain. From three domains, 10 subthemes emerged: 1) typical work-up of axSpA patients in primary care, with subthemes including the clues involved in work-up and role of clinical examinations for axSpA; 2) feedback on questions from the Inflammatory Back Pain Assessment: ASAS Expert Criteria, with subthemes to evaluate contents/questions of a potential screening tool for axSpA; and 3) implementation of the screening tool in primary care settings, with subthemes of perceived barriers including awareness, time, other conditions to screen, rare disease, and lack of structured questionnaire for back pain and perceived facilitators including workflow issues and awareness.

CONCLUSIONS

Primary care physicians believed that an improved screening instrument and a strong evidence-base to support the need for screening for axSpA are required. The implementation of axSpA screening into a busy primary care practice requires integration into the practice workflow, with use of technology suggested as a possible way to improve efficiency.

Value-Based Healthcare in Rheumatology: Axial Spondyloarthritis and Beyond

PURPOSE OF REVIEW

This review examines axial spondyloarthritis (axSpA) and the wider field of rheumatology through a value-based healthcare (VBHC) lens. VBHC is focused on ensuring patients receive high quality care to improve outcomes and reduce unnecessary costs.

RECENT FINDINGS

There are many opportunities to apply the principles of VBHC in axSpA. These include the appropriate utilization of diagnostic investigations, such as HLA-B27 and magnetic resonance imaging, assessing outcomes meaningful to patients, and optimizing care pathways. Multidisciplinary care may improve value, and reduced specialist review and medication tapering may be appropriate. Increasing the value of the care we provide to patients can occur across domains and directly and indirectly improves patient outcomes. Taking the time to integrate principles of VBHC into our practice will allow us to justifiably gain and maintain access to diagnostic and therapeutic advances for the benefit of all our patients.

Axial spondyloarthritis 10 years on: still looking for the lost tribe

Despite the publication of various recommendations, quality standards and referral strategies to promote early diagnosis in axial SpA (axSpA) over the last decade, there remains a significant delay to diagnosis, leading to a lost tribe of undiagnosed, untreated patients with persistent back pain and axSpA symptoms. This review discusses the various factors contributing to diagnostic delay in axSpA, while providing recommendations to improve the diagnostic pathway, for example use of the online Spondyloarthritis Diagnosis Evaluation (SPADE) tool (http://www.spadetool.co.uk/). Significant shortcomings exist at both the primary and secondary care level, with healthcare professionals often lacking knowledge and awareness of axSpA. Myths regarding the classical signs and symptoms still prevail, including the perception of axSpA as a male disease, only occurring in individuals who are HLA-B27 positive with raised inflammatory markers. Individuals within this lost tribe of undiagnosed patients are likely lacking adequate treatment and are thereby at risk of worse clinical outcomes. It is therefore vital that public health initiatives are implemented to improve education of healthcare professionals and to ensure early specialist referral, to ultimately improve the lives of patients with axSpA.

BSR Spondyloarthritis Course, 27 February 2020. Spondyloarthritis: pathogenesis, diagnosis and management

High-quality continuous medical education is essential to maintain excellence in health-care delivery, upskilling professionals and improving patient outcomes. This is particularly relevant when addressing rare disease groups, such as the spondyloarthritides, a group of heterogeneous inflammatory conditions that affect joints and other organs, such as the skin, bowel and eye. Professional bodies, such as the British Society for Rheumatology (BSR), are well placed to deliver this type of education. In 2020, the BSR ran a dedicated SpA course aimed at rheumatology health-care professionals wishing to update their basic knowledge of SpA with a review of the latest advances in the field. Here, we summarize the proceedings of the meeting and discuss the value of such an initiative.

The ambiguity of sciatica as a clinical diagnosis: A case series

Sciatica as a clinical diagnosis is nonspecific. A diagnosis of sciatica is typically used as a synonym for lumbosacral radiculopathy. However, the differential for combined low back and leg pain is broad, and the etiology can be one several different conditions. The lifetime prevalence of sciatica ranges from 12.2% to 43%, and nonsuccessful outcomes of treatment are prevalent. Nurse practitioners and other primary care clinicians often have minimal training in differential diagnosis of the complex causes of lower back and leg pain, and many lack adequate time per patient encounter to work up these conditions. Differentiating causes of low back and leg pain proves challenging, and inadequate or incomplete diagnoses result in suboptimal outcomes. Chiropractic care availability may lessen demands of primary care with respect to spinal complaints, while simultaneously improving patient outcomes. The authors describe three patients referred from primary care with a clinical diagnosis of sciatica despite differing underlying pathologies. More precise clinical terminology should be used when diagnosing patients with combined low back and leg pain. Nurse practitioners and other clinicians' triage, treat, and determine appropriate referrals for low back and leg pain. Multidisciplinary care including chiropractic may add value in settings where patients with lower back and leg pain are treated.

Awareness of axial spondyloarthritis among chiropractors and osteopaths: findings from a UK Web-based survey

Objective

Chiropractors and osteopaths are important professional partners in the management of axial spondyloarthritis (axSpA). In view of recent advances in diagnosis and treatment, we sought to understand their current knowledge and working practices.

Methods

A Web-based survey was advertised to chiropractors and osteopaths via the Royal College of Chiropractors and the Institute of Osteopathy.

Results

Of 382 completed responses [237 chiropractors (62%) and 145 osteopaths (38%)], all were familiar with AS, but only 63 and 25% were familiar with the terms axSpA and non-radiographic axSpA, respectively. Seventy-seven per cent were confident with inflammatory back pain. Respondents routinely asked about IBD (91%), psoriasis (81%), acute anterior uveitis (49%), peripheral arthritis (71%), genitourinary/gut infection (56%), enthesitis (30%) and dactylitis (20%). Eighty-seven per cent were aware of the association between axSpA and HLA-B27. Only 29% recognized that axSpA was common in women. Forty per cent recommend an X-ray (pelvic in 80%) and, if normal, 27% would recommend MRI of the sacroiliac joints and whole spine. Forty-four per cent were aware of biologic therapies. Forty-three per cent were confident with the process of onward referral to rheumatology via the general practitioner (GP). The principal perceived barrier to onward referral was reluctance by the GP to accept their professional opinion.

Conclusion

Overall knowledge of ankylosing spondylitis is good, but the term axSpA is poorly understood. Specific learning needs include gender preponderance, awareness of acute anterior uveitis and the availability of biological therapies. There is lack of confidence in the onward referral process to rheumatology via the GP.

Knowledge of features of inflammatory back pain in primary care in the West Midlands: a cross-sectional survey in the United Kingdom

KEY MESSAGES

There is a relative lack of confidence among GPs in the assessment and management of IBP vs. mechanical back pain. A simple screening tool for SpA, applicable in primary care urgently needs to be developed. It is reasonable for patients with symptoms suggestive of inflammatory back pain to be referred to secondary care without further investigations. The objective of this study was to assess current practice of our local general practitioners (GPs) in using clinical features, as well as radiological and laboratory investigations to assess patients with IBP. An online, observational questionnaire-based survey was done in 10 West Midlands CCGs including disparate geographical and socioeconomic areas. The survey consisted of 23 questions based on Calin, Berlin and ESSG Criteria for spondyloarthropathies. GPs were asked to rate the importance of a range of symptoms as indications of IBP IBP (10 point scale, range 1-10), and what their views were on which were the most important treatments for patients with suspected inflammatory back pain(4 point scale, range 1-4). The 4 most important symptoms for predicting inflammatory back pain according to our local cohort of GPs were 'morning stiffness' 'sleep disturbances caused by back pain' 'insidious onset' and 'age of onset' < 45. Among the treatment options, NSAIDs were ranked as the most important treatment option for IBP. DMARDS were rated as the next most important treatment option, ahead of physiotherapy and anti-TNF therapy. This study has highlighted relative lack of confidence among GPs in the assessment of IBP. Whether this reflects a need for education or poor performance of these questions in primary care populations requires further study.

A truly complementary approach: A qualitative exploration of complementary and alternative medicine practitioners' views of treating ankylosing spondylitis

OBJECTIVE

Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease in which individuals experience a long delay to diagnosis. Prior to diagnosis, individuals report frequent use of complementary and alternative medicine (CAM) therapies. While popularly used, there is a dearth of knowledge concerning the experiences of CAM practitioners in terms of treating individuals with AS. Addressing this knowledge gap, the present study provides a detailed exploration of how UK-based CAM practitioners treat individuals with AS.

METHODS

Semi-structured telephone interviews were conducted with eight UK-based CAM practitioners, (four males), aged 45-69 years. CAM practitioners were recruited across a range of CAM therapies and years of CAM practice experience (8-46 years).

RESULTS

Thematic analysis resulted in the identification of three themes to characterize the data. Themes comprised: (i) the whole picture; (ii) alarm bells; and (iii) a common language. Themes highlighted CAM practitioner adoption of a holistic, yet individualized approach to treating individuals with AS, despite a general sense of lack of knowledge concerning AS among CAM practitioners. Notably, results indicated a desire of CAM practitioners to work more collaboratively with mainstream health providers to provide more joined-up care for individuals with AS.

CONCLUSION

CAM practitioners emphasized the benefits of CAM to focus on providing effective symptom management when used in conjunction, rather than in opposition to, mainstream healthcare. Adoption of a more holistic approach to AS management by CAM practitioners may empower clients to become more aware of symptoms, thus potentially reducing delays in receiving a formal diagnosis of AS.

GPs' patterns of clinical assessment when faced with a patient suspected for spondyloarthritis: a prospective educational intervention study

Background

Timely recognition and referral of patients with spondyloarthritis (SpA) is challenging due to the frequent unawareness of the clinical picture.

Aim

To identify clinical assessment patterns of GPs and GP-residents when facing a patient suspected of having SpA, and to determine which components of clinical assessment were most prevalent prior to referral to the rheumatologist and whether targeted education could positively influence pattern recognition.

Design & setting

Prospective multicentre educational intervention study in primary care practices in the Netherlands.

Method

GPs and GP-residents were visited in two rounds by standardised patients (SPs) simulating axial or peripheral SpA (dactylitis). Between these rounds, an educational intervention regarding SpA took place for part of the participants. SPs completed a case-specific checklist inquiring about disease-related items and items on physical examination.

Results

Sixty-eight participants (30 GPs and 38 GP-residents) were included and 19 (28%) received the educational intervention. In round 1, about half of the participants asked at least one question to differentiate between an inflammatory or mechanical origin of the back pain or peripheral complaint; on average, <15% asked for extra-articular manifestations. After education, GP-residents inquired more about the presence of extra-articular manifestations and family history of axial SpA; this pattern was also observed in the GPs and GP-residents who correctly referred the SP. In the peripheral SpA case, the observed gain was less evident when compared to the axial SpA case.

Conclusion

Pattern recognition of patients suspected for SpA by GP(-residents) is essential for referral to a rheumatologist and can be improved by education.

High Prevalence of Undiagnosed Axial Spondyloarthritis in Patients with Chronic Low Back Pain Consulting Non-Rheumatologist Specialists in Belgium: SUSPECT Study

INTRODUCTION

Diagnosis of axial spondyloarthritis (SpA) can be delayed for several years mainly because of low awareness of axial SpA among non-rheumatologists who are the first interlocutors of potential SpA patients. One strategy to decrease the delay between appearance of first symptoms and diagnosis of axial SpA and to allow early management of the disease is to provide the non-rheumatologists with tools to identify patients requiring prompt referral to rheumatologists. This study was designed to evaluate in a real-world setting whether screening patients with chronic low back pain who consult physical medicine and rehabilitation (PMR) physicians, orthopedists, and ophthalmologists is useful in detecting axial SpA.

METHODS

During this non-interventional cross-sectional study, data from 161 patients with chronic back pain, consulting an orthopedist, PMR physician, or ophthalmologist were collected during a single visit. Any patient who presented with at least four out of five symptoms of inflammatory back pain (IBP) and at least one additional SpA feature were to be referred to a rheumatologist. Analysis was purely descriptive.

RESULTS

IBP was diagnosed in approximately half of the patients (89 patients) and 72 of them met the referral criteria. A total of 117 patients were finally referred to a rheumatologist and axial SpA was diagnosed for 37 of them.

CONCLUSIONS

The high prevalence of undiagnosed axial SpA in patients with chronic back pain visiting PMR physicians, orthopedists, and ophthalmologists suggests that these healthcare professionals may play a key role in the strategy developed to shorten the delay observed in the formal diagnosis of SpA.

FUNDING

Abbvie.

Study protocol for a cluster randomized controlled trial to evaluate a referral strategy for axial spondyloarthritis in young primary care patients with chronic low back pain; an impact study

BACKGROUND

Axial spondyloarthritis (axSpA) is a disabling inflammatory joint disease with chronic low back pain (CLBP) as leading symptom. Recognizing axSpA in the large amount of CLBP patients is difficult for general practioners (GP). This evaluation aims to assess the effect of a referral strategy for axSpA in young primary care patients with CLBP by comparing the use of the strategy with usual care. The effect is measured at three different levels; by patient reported outcomes (the clinical effect), process and costs evaluation.

METHODS/DESIGN

This study design is a cluster randomized controlled trial with GP as clusters. GPs throughout the Netherlands are invited to participate and randomized to either the intervention or the control group. Patients from participating GPs are invited to participate if they have ever been registered with low back pain, without radiation (ICPC L03) and aged 18-45 years. To be included in the study, patients need to have current low back pain and chronic low back pain (>12 weeks). In the intervention arm a referral strategy for axSpA will be applied in CLBP patients, in the control arm care as usual will be provided for CLBP patients. The referral strategy consists of four easy to use variables. All are questions about the back pain complaints of the patients. Data is prospectively collected in an online database at baseline (T0), 4 months (T1), 12 months (T2) and 24 months (T3). After time point T1 (4 months) patients from the control group will also receive the intervention i.e. the application of a referral strategy for axSpA. The effect of the referral strategy is measured at three different levels, by patient outcomes (e.g. pain scores, quality of life), process measures (e.g. number of axSpA diagnoses by rheumatologists) and by costs (work productivity and health care resources use). Our primary outcome is the Roland Morris Disability Questionnaire after 4 months, secondary outcomes are pain and quality of life. Costs will be assessed before and after the use of the referral strategy, to estimate if the use of the strategy will lead to a reduction in health care costs and improvement in work participation.

DISCUSSION

It is anticipated that using the axSpA referral strategy for primary care CLBP patients will increase the quality of life of CLBP patients, will result in more (correct) diagnoses of axSpA by the rheumatologists, and will be cost-effective. Ultimately, the results of this study may contribute to the startup of a national implementation of the axSpA referral strategy to identify timely CLBP patients with axSpA.

TRIAL REGISTRATION

NCT01944163 , date of registration; September 6, 2013 (Clinicaltrials.gov).

Spinal Mobility in Axial Spondyloarthritis: A Cross-Sectional Clinical Study

OBJECTIVE

Research concerning spinal mobility in axial spondyloarthritis (axSpA) has focused on ankylosing spondylitis (AS), and data on the clinical diagnosis of undifferentiated spondyloarthritis (USpA) are limited. The objective was to study differences in spinal mobility between axSpA subgroups AS and USpA, including gender differences.

METHODS

A total of 183 patients with axSpA from a rheumatology clinic were included in the study. The earliest recorded spinal mobility measures (cervical rotation/flexion/extension/lateral flexion, tragus-to-wall distance, vital capacity, chest expansion, thoracic flexion, thoracolumbar flexion, lateral spinal flexion, lumbar flexion and intermalleolar distance) were obtained by specialized physiotherapists. Differences between subgroups were analysed using analysis of covariance, controlled for gender and disease duration.

RESULTS

In the USpA group (n = 57), the mean [standard deviation (SD)] age was 41.6 (11.4) years, and disease duration was 13 (10.6) years, with 54% men. In the AS group (n = 126), the mean (SD) age was 48.4 (13.5) years, and disease duration 24.6 (13.3) years, with 77% men. Spinal mobility was less restricted in USpA versus AS patients (p ≤ 0.05), with a median (interquartile range) tragus-to-wall distance of 11 (10-12) cm versus 13 (11.3-18.5) cm; thoracolumbar flexion 9 (7-10) cm versus 6.5 (4-9) cm; lateral spinal flexion 29 (25-36) cm versus 21.3 (12-31) cm; lumbar flexion 4.5 (3.5-5.0) cm versus 3.5 (2.0-4.5) cm and intermalleolar distance 113 (102-121) cm versus 101 (86-114) cm. There were no differences between the subgroups in cervical mobility, vital capacity, chest expansion or thoracic flexion, and there were few gender differences, besides anthropometric measures.

CONCLUSION

Patients with USpA and AS had similar cervical and chest mobility, while thoracic and lumbar mobility were more severely restricted in AS. There were few gender differences in either subgroup. Further studies, to understand the full impact of USpA on spinal mobility, are needed. Copyright © 2016 John Wiley & Sons, Ltd.

[Differential diagnosis between mechanical and inflammatory lower back pain, therapy options]

The article presents the differential diagnosis between mechanical and inflammatory lower back pain based on clinical and paraclinical evidence. The results of comparative studies of amtolmetinum guacilum (AMG) and celecoxib, as well the CORONA study of its efficacy and cardiovascular safety in ankylosing spondylitis, are also discussed.

Education improves referral of patients suspected of having spondyloarthritis by general practitioners: a study with unannounced standardised patients in daily practice

OBJECTIVES

To evaluate the practice performance of general practitioners (GPs) and GP residents in recognising and referring patients suspected for having axial or peripheral spondyloarthritis (SpA), and to investigate the influence of education on this performance.

METHODS

GP (residents) were visited in two rounds by standardised patients (SPs) simulating axial SpA, peripheral SpA or carpal tunnel syndrome (CTS) with in between an educational intervention on SpA for part of the participants. Participants were unaware of the nature of the medical problem and study purpose. CTS was included as diversionary tactic. The primary outcome was ≥40% improvement in (considering) referral of the SPs with SpA to the rheumatologist after education. Secondary outcomes included ordering additional diagnostic tests, correct recognition of SpA and identification of variables contributing to this.

RESULTS

68 participants (30 GPs and 38 GP residents) were included, of which 19 received education. The primary outcome was met. A significantly higher proportion of GP (residents) from the intervention group referred patients to the rheumatologist compared with the control group after education (change scores, axial SpA +71% vs +15% (p<0.01); peripheral SpA +48% vs 0% (p<0.001)). Participants who received education, more frequently correctly recognised SpA compared with controls (change scores, axial SpA +50% vs -5% (p<0.001); peripheral SpA +21% vs 0% (p=0.01).

CONCLUSIONS

Recognition and referral of patients suspected for having SpA by GP (residents) is low, but targeted education markedly improved this. This supports the development of educational initiatives to improve recognition of SpA and hence referral to a rheumatologist.

Delayed diagnosis of ankylosing spondylitis in a Japanese population

OBJECTIVES

This study was conducted to evaluate the period from symptom onset to diagnosis of ankylosing spondylitis (AS) in Japanese patients and to examine possible reasons for delayed diagnosis.

METHODS

Seventy-two consecutive patients with AS were studied. Diagnostic delay was defined as the gap between the first spondyloarthropathic symptom and diagnosis of AS according to the modified New York criteria.

RESULTS

The mean patient ages at disease onset and diagnosis were 25.6 ± 11.3 and 33.3 ± 13.2 years old, respectively, resulting in diagnostic delay of 6.7 years. The number of medical institutions to which patients were referred before diagnosis was 2.4, and orthopedic surgeons were most commonly visited (62%). Non-specific low back pain or lumbar spondylitis (33%) and degenerative arthritis (28%) were the primary diagnoses preceding that of AS. Absence of articular symptoms significantly correlated with diagnostic delay. The patients with disease onset on year 2000 or later had significantly shorter periods until diagnosis than those before 2000 (3.6 vs. 7.5 years).

CONCLUSIONS

The present study showed a marked diagnostic delay among Japanese patients with AS. Although it has been improved, continuing medical education focusing on inflammatory back pain in adolescent is required for early diagnosis of AS.

Assessment of spinal pain

Spinal pain or back pain is a very common symptom that can have many reasons. The most studied location is low back pain, and it is considered to be nonspecific in the majority of cases. Only a small proportion of patients have axial inflammation as the major cause of their back complaints with chronic inflammatory back pain (IBP) as the most prominent clinical feature of spondyloarthritis (SpA). The recognition of IBP and patients with axial spondyloarthritis (axSpA) is challenging in primary care, and it is important to further facilitate the early diagnosis of SpA. Proposals for improving the referral of patients with a possible diagnosis of axSpA include clinical parameters, human leukocyte antigen (HLA) B27, and imaging parameters. Imaging is crucial for the visualization, objective validation, and understanding of back pain. Numerous diseases such as degenerative disk disease, degenerative changes in the intervertebral (facet) joints and the associated ligaments, spinal instability, herniation of the intervertebral disk, and spinal stenosis have to be differentiated in interpreting imaging of the spine. The sacroiliac joints and the spine are of major importance for the diagnosis and classification of axSpA. Conventional radiographs and magnetic resonance imaging (MRI) are the most important imaging technologies for visualization of structural changes such as syndesmophytes and axial inflammation such as sacroiliitis and spondylitis. The pathogenesis of axSpA is largely genetically determined. HLA B27 has the strongest contribution to the total genetic burden, but other major contributors such as endoplasmic reticulum aminopeptidase (ERAP)-1 and interleukin (IL)-23R have also been identified.

The journey to diagnosis in AS/axial SpA: the impact of delay

OBJECTIVES

The aim of the present study was to conduct an in-depth exploration of the 'journey' to diagnosis of people with ankylosing spondylitis (AS)/axial spondyloarthritis (Axial SpA) to gain insights into the experience, potential barriers and facilitators in this process.

METHODS

The present qualitative study, embedded within a prospective longitudinal cohort study, was located within an interpretive phenomenological paradigm. Ten people newly diagnosed with AS/axial SpA, reporting an average of 10.1 [standard deviation (SD) 7.3] years between experiencing symptoms and diagnosis, participated in semi-structured interviews. The interviews were recorded, transcribed and analysed thematically. Ethical approval and informed consent were obtained.

RESULTS

Analysis identified four key themes: 'What's going on?' described the process associated with trying to understanding a changing body experience complicated by variability and the severity of back pain experienced. 'Fighting for a diagnosis' provided insights into the process of having to 'fight' to be believed and feeling dismissed by healthcare professionals. 'Being adrift' explored the negative psychological consequences associated with a search for a diagnosis. 'The start of a journey' described the relief associated with receiving a diagnosis, juxtaposed against emotions associated with the diagnosis of a long-term degenerative condition.

CONCLUSIONS

The delay in diagnosis experienced may be associated with lack of familiarity and knowledge of AS/axial SpA in the population and in healthcare professionals, and creates a multiplicity of problems, including psychological distress. Clinicians therefore need to consider the potential impact of a person's 'journey to diagnosis' on clinical management once a diagnosis has been made.

A novel evidence-based detection of undiagnosed spondyloarthritis in patients presenting with acute anterior uveitis: the DUET (Dublin Uveitis Evaluation Tool)

BACKGROUND

To date, there are no formal guidelines or referral pathways for acute anterior uveitis (AAU) patients developed or endorsed by any international or national societies. The objective of our study was to develop and validate an assessment algorithm for referral from ophthalmologists of appropriate AAU patients to rheumatology that will aid the early diagnosis of the spondyloarthropathy (SpA).

METHODS

All consecutive patients attending the emergency department of local ophthalmology hospital with AAU, but who did not have a known diagnosis of SpA, were eligible to participate in this study. Patients with any other known cause of AAU were excluded. Two independent cohorts were enrolled. Test algorithm and Dublin Uveitis Evaluation Tool (DUET) algorithm (revised form of test algorithm) were used in these cohorts to identify patients as SpA suspects and non-SpA controls, respectively.

RESULTS

STUDY PHASE-1. ALGORITHM DEVELOPMENT COHORT (n=101): After rheumatologic evaluation of the entire cohort, 41.6% (n=42) had undiagnosed SpA. Our test algorithm was noted to have: sensitivity 100% and specificity 53.5%. Further regression analysis resulted in the development of the DUET algorithm which made the following improvements: sensitivity 95%, specificity 98%, positive likelihood ratio (LR) 56.19, and negative LR 0.04. STUDY PHASE-2. DUET ALGORITHM VALIDATION COHORT (n=72): After rheumatologic evaluation of the cohort, 40% (n=29) were diagnosed with SpA, with the following performance of DUET algorithm-sensitivity 96%, specificity 97%, positive LR 41.5 and negative LR 0.03.

CONCLUSIONS

Approximately 40% of patients presenting with idiopathic AAU have undiagnosed SpA. A simple to apply algorithm is described with excellent sensitivity and specificity.

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.

Association of HLA-B27 status and gender with sacroiliitis in patients with ankylosing spondylitis

Objective: To observe the influence of human leucocyte antigen B27 (HLA-B27) status and gender on sacroiliitis on computed tomography (CT) in ankylosingspondylitis (AS).

Methods: We reviewed the archived medical records of the AS inpatients admitted in the Rheumatology Department of the First Affiliated Hospital of Wenzhou Medical University during the period from January 2007 through January 2013 and finally 386 patients were included in the study. The severity of sacroiliitis on CT was evaluated according to the grading used in the modified New York criteria for AS. Two-way classification analysis of variance (ANOVA) was employed to examine the effect of HLA-B27 status and gender on age at disease onset. The impact of HLA-B27 and gender on sacroiliitis on CT was tested by univariate and multivariate logistic regression analyses.

Results: There were 350 HLA-B27 positive patients (90.7%) and 36 HLA-B27 negative patients (9.3%). The ANOVA test indicated that HLA-B27 positive patients and male patients respectively had an earlier age at disease onset than HLA-B27 negative patients and female patients. The logistic regression analysis indicated that positive HLA-B27 status (OR 2.601, p=0.004) and male gender (OR 1.923, p=0.004) were significant predictors of worse sacroiliitis. In addition, elevated ESR (OR 2.181, p=0.013) and longer disease duration (OR 1.100, p<0.001) contributed to worse sacroiliitis likewise.

Conclusion: Positive HLA-B27 status and male gender are associated with worse sacroiliitis on CT, acting as predictors of sacroiliitis. Elevated ESR and longer disease duration also contribute to worse sacroiliitis. Meanwhile, positive HLA-B27 status and male gender are associated with earlier age at disease onset.

Validation of a patient self-reported screening questionnaire for axial spondyloarthropathy in a UK Population

STUDY DESIGN

Cross-sectional cohort study.

OBJECTIVE

The aim of this study was to develop and validate a patient-completed screening questionnaire for axial spondyloarthropathy for use in the United Kingdom.

SUMMARY OF BACKGROUND DATA

Axial spondyloarthropathy (axial SpA) can be difficult to diagnose in the early stages of disease, leading to diagnostic delay and morbidity. Existing population screening tools lack sensitivity or have not been validated in the UK population.

METHODS

Questionnaires were sent to 295 patients with definite ankylosing spondylitis (meeting modified New York criteria), nonradiographical axial SpA (sacroiliitis on magnetic resonance imaging), or mechanical back pain. Responses from 190 patients were analyzed. Binary logistic regression was used to develop a model differentiating inflammatory from mechanical pain.

RESULTS

The final model (male sex, onset of symptoms by age 33 years, no radiation of pain, pain gets better as day goes on, pain increases with rest, and personal history of iritis) correctly classified 86% of cases with Nagelkerke R = 0.486. A numerical score (with 1 point assigned for each feature present) was calculated and receiver operating characteristic curve was constructed, with area under the curve of 0.911 (95% confidence interval: 0.87-0.96). A score of ≥3/6 had sensitivity of 75.6% and specificity of 87.9% for inflammation.

CONCLUSION

We have developed a model that differentiates patients with ankylosing spondylitis/axial SpA from those with mechanical spinal disease and can be used as a self-completed screening tool.

Differential diagnosis and management of ankylosing spondylitis masked as adhesive capsulitis: a resident's case problem

STUDY DESIGN

Resident's case problem.

BACKGROUND

Ankylosing spondylitis is a potentially debilitating seronegative spondyloarthropathy, with inflammatory low back pain as the most commonly reported symptom. In the absence of low back pain, identification of other diagnostic criteria or associated impairments and joint involvement, such as involvement of the hip or shoulder, may be beneficial.

DIAGNOSIS

A 32-year-old man with right shoulder pain and decreased range of motion was referred with a diagnosis of adhesive capsulitis. He had been managed by multiple healthcare providers for 3 years before being referred to a physical therapist. Glenoid labral pathology was evident on prior magnetic resonance imaging, which had led to a persistent focus on the shoulder. The evaluation by the physical therapist revealed significant mobility deficits in the cervical, thoracic, and lumbar spine. Radiographs and laboratory tests were ordered and a referral was made to rheumatology after the initial physical therapy assessment. The diagnostic work-up confirmed the diagnosis of ankylosing spondylitis and led to multidisciplinary management of the disease.

DISCUSSION

Low back pain is often the primary symptom of ankylosing spondylitis later in the disease process. Earlier indicators of ankylosing spondylitis, such as severely impaired mobility and spine stiffness, may help guide detection in the absence of spinal pain. In this case, an appropriate diagnosis led to improvement in the management strategy of what might have appeared to be unrelated shoulder pain. Early differential diagnosis is important, as emerging interventions show promise when used earlier in the disease process.