General Practitioners’ Perceptions of Their Ability to Identify and Refer Patients with Suspected Axial Spondyloarthritis: A Qualitative Study

2014 ◽  
Vol 41 (5) ◽  
pp. 897-901 ◽  
Author(s):  
Marloes van Onna ◽  
Simone Gorter ◽  
Aniek van Meerendonk ◽  
Astrid van Tubergen
Keyword(s):  
Back Pain ◽  
Qualitative Study ◽  
General Practitioners ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis ◽  
Inflammatory Back Pain ◽  
Coding System ◽  
Disease Spectrum ◽  
Insidious Onset ◽  
Mechanical Back Pain

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.

scholarly journals SAT0380 ENHANCING RHEUMATOLOGY REFERRALS AMONG INFLAMMATORY BOWEL DISEASE PATIENTS WITH SUSPECTED AXIAL SPONDYLOARTHRITIS

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 1138.2-1138
Author(s):  
C. S. E. Lim ◽  
M. Tremelling ◽  
L. Hamilton ◽  
A. Macgregor ◽  
K. Gaffney
Keyword(s):  
Back Pain ◽  
Musculoskeletal Pain ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis ◽  
Inflammatory Back Pain ◽  
Aminosalicylic Acid ◽  
Research Support ◽  
Clinical Probability ◽  
Asas Criteria ◽  
History Of

Background:Axial spondyloarthritis (axSpA) is associated with inflammatory bowel disease (IBD). In IBD patients, the clinical probability of axSpA increases in those with chronic back pain (CBP) whose symptoms started before the age of forty-five years old. In practice, this should trigger a rheumatology review especially if accompanied by other symptoms suspicious of inflammatory disease. However, in any health system, the goal of identifying all possible cases need to be balanced with the practical realisation of the finite resources available.Objectives:The study aimed to define the clinical characteristics of a subgroup of IBD patients who are routinely managed in secondary care who have an increased clinical probability for axSpA. Identification of these characteristics may help improve the quality and specificity of referrals to Rheumatology from Gastroenterology clinics.Methods:An analytical cross-sectional study was undertaken. Consecutive IBD patients attending routine Gastroenterology clinics were sent a modified validated back pain questionnaire. The questionnaire included the presence or absence of a previous diagnosis of axSpA; components of validated inflammatory back pain criteria; diagrams to indicate the location of back pain and other musculoskeletal pain; personal and family history of known axSpA manifestations; and details of their IBD course, activity and treatment.IBD patients, with back pain duration > 3 months with onset before 45 years were considered to have a medium diagnostic probability (MDP) for axSpA. MDP-positive IBD patients were compared with MDP-negative IBD patients and logistic regression was used to model the association with clinical features.Results:Four hundred and seventy consecutive IBD patients (mean age 54 years; 46% male) were surveyed. Two hundred and nine patients (59%) replied, of whom 191 patients (69%) consented to participate. One hundred and seventy-three (91%) of those who consented had a valid completed questionnaire and were included for data analysis. Of these, 74% had Ulcerative Colitis and 26% had Crohn’s disease. Their mean age was 58 years, 39% male. Mean age at IBD diagnosis was 39 years, mean IBD disease duration 19 yrs. CBP (back pain greater than three months) was reported by 76%. Inflammatory back pain fulfilling Calin, Berlin, ASAS criteria was seen in 23%, 29%, and 15% respectively. In addition, 80% reported peripheral musculoskeletal pain. Self-reported personal history of enthesitis, reactive arthritis (ReA), acute anterior uveitis (AAU), skin psoriasis (PSO) and dactylitis were 50%, 30%, 24%, 15% and 0% respectively. Self-reported family history of IBD, ReA, PSO, axSpA and AAU were 60%, 36%, 22%, 11%, and 1% respectively.Ninety-one (53%) patients were MDP-positive and 82 (47%) patients were MDP-negative. The clinical characteristics associated with MDP (adjusted for age at invitation) were: the presence of inflammatory back pain using ASAS criteria [OR 8.84 (1.61,48.67); p=0.01], longer interval between symptom onset and gastroenterologist diagnosis of IBD [OR 1.09 (1.03,1.16); p=0.005], and use of rectal topical 5-aminosalicylic acid [OR 3.27 (1.11,9.68); p=0.03].Conclusion:Chronic back pain and peripheral musculoskeletal pain are common in a secondary care IBD population. In IBD patients, with back pain duration > 3 months and onset before 45 years, the presence of inflammatory back pain, longer diagnostic delay of IBD and the use of rectal topical 5-aminosalicylic acid were associated with a higher clinical probability of axSpA. The identification of these clinical features may not only improve the quality and specificity of Rheumatology referrals from Gastroenterology in this subgroup of patients but also lends real world evidence to current ASAS-endorsed recommendations for early referral of patients with a suspicion of axial spondyloarthritis.Disclosure of Interests:Chong Seng Edwin Lim Grant/research support from: AbbVie - Research support/grant but NOT for this study., Mark Tremelling: None declared, Louise Hamilton: None declared, Alexander Macgregor: None declared, Karl Gaffney Grant/research support from: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Consultant of: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Speakers bureau: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma

scholarly journals Identifying patients with axial spondyloarthritis in primary care: how useful are items indicative of inflammatory back pain?

2011 ◽  
Vol 70 (10) ◽  
pp. 1782-1787 ◽  
Author(s):  
A Braun ◽  
E Saracbasi ◽  
J Grifka ◽  
J Schnitker ◽  
J Braun
Keyword(s):  
Primary Care ◽  
Back Pain ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis ◽  
Age At Onset ◽  
Inflammatory Back Pain ◽  
Single Item ◽  
Inflammatory Drugs ◽  
Waking Up ◽  
Key Questions

BackgroundThe value of clinical items defining inflammatory back pain to identify patients with axial spondyloarthritis (SpA) in primary care is unclear.ObjectiveTo identify predictive clinical parameters for a diagnosis of axial SpA in patients with chronic back pain presenting in primary care.MethodsConsecutive patients aged <45 years (n=950) with back pain for >2 months who presented to orthopaedic surgeons (n=143) were randomised based on four key questions for referral to rheumatologists (n=36) for diagnosis.ResultsThe rheumatologists saw 322 representative patients (mean age 36 years, 50% female, median duration of back pain 30 months). 113 patients (35%) were diagnosed as axial SpA (62% HLA B27+), 47 (15%) as ankylosing spondylitis (AS) and 66 (21%) as axial non-radiographic SpA (nrSpA). Age at onset ≤35 years, improvement by exercise, improvement with non-steroidal anti-inflammatory drugs, waking up in the second half of the night and alternating buttock pain were identified as most relevant for diagnosing axial SpA by multiple regression analysis. Differences between AS and nrSpA were detected. No single item was predictive, but ≥3 items proved useful for good sensitivity and specificity by receiver operating characteristic modelling.ConclusionThis study shows that a preselection in primary care of patients with back pain based on a combination of clinical items is useful to facilitate the diagnosis of axial SpA.

Advancing Early Identification of Axial Spondyloarthritis: An Interobserver Comparison of Extended Role Practitioners and Rheumatologists

2019 ◽  
Vol 47 (4) ◽  
pp. 524-530 ◽  
Author(s):  
Laura Passalent ◽  
Christopher Hawke ◽  
Daeria O. Lawson ◽  
Ahmed Omar ◽  
Khalid A. Alnaqbi ◽  
...  
Keyword(s):  
Back Pain ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis ◽  
Age Of Onset ◽  
Clinical Information ◽  
Models Of Care ◽  
Clinical Impression ◽  
Written Form ◽  
Mechanical Back Pain ◽  
Magnetic Resonance Imaging Mri

Objective.To compare clinical impression and confidence of extended role practitioners (ERP) with those of rheumatologists experienced in axial spondyloarthritis (axSpA) according to (1) evaluation of patients with chronic back pain assessed for axSpA; and (2) magnetic resonance imaging (MRI) recommendation for further investigation of these patients.Methods.Patients with ≥ 3 months of back pain and age of onset < 45 years were referred for axSpA evaluation. An ERP assessed consecutive patients and recorded standardized clinical information in written form. Three rheumatologists subsequently evaluated each patient based on the recorded information. Patients were classified as having axSpA or mechanical back pain based on clinical and investigative findings. Level of confidence was noted for classification and MRI indication. Agreement between assessors was evaluated using percentage agreement and κ coefficient.Results.Fifty-seven patients were assessed. Interobserver agreement of clinical impression for all raters was moderate (κ = 0.52). Agreement of clinical impression between ERP and rheumatologists ranged between 71.2% (κ = 0.41) and 79.7% (κ = 0.57). Agreement of clinical impression among rheumatologists ranged from 74.1% (κ = 0.49) to 79.7% (κ = 0.58). All rater agreement for MRI indication was fair (κ = 0.37). ERP agreement with rheumatologist for MRI recommendation ranged from 64.2% (κ = 0.32) to 75% (κ = 0.48). Agreement for MRI indication among rheumatologists ranged from 62.9% (κ = 0.27) to 74% (κ = 0.47). Confidence in clinical impression was similar among all practitioners.Conclusion.ERP with specialty training in inflammatory arthritis demonstrate clinical impressions comparable with those of rheumatologists in the assessment of axSpA. Incorporation of such roles into existing models of care may assist in early detection of axSpA.

scholarly journals MRI compared with low-dose CT scanning in the diagnosis of axial spondyloarthritis

2019 ◽  
Vol 39 (4) ◽  
pp. 1295-1303 ◽  
Author(s):  
Lusi Ye ◽  
Yuncai Liu ◽  
Qinqin Xiao ◽  
Ledan Dong ◽  
Caiyun Wen ◽  
...  
Keyword(s):  
Back Pain ◽  
Sacroiliac Joint ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis ◽  
Significant Proportion ◽  
High Specificity ◽  
Ct Scanning ◽  
Conventional Radiography ◽  
Plain Radiography ◽  
Inflammatory Back Pain

Abstract Objectives To compare the performance of conventional radiography, ldCT, and MRI in the diagnosis of sacroiliitis in suspected axial spondyloarthritis (axSpA). Methods Patients presenting with > 3 months chronic back pain were assessed by axSpA-experienced rheumatologists and diagnosed as axSpA or not; axSpA patients were then considered nr-axSpA or AS using plain radiography. Non-axSpA patients were recruited as controls, and divided into non-inflammatory and inflammatory groups on the basis of inflammatory back pain and/or CRP/ESR elevation. Clinical variables, pelvic radiography, sacroiliac joint (SIJ) ldCT, and SIJ MRI were obtained. Results A total of 121 patients were included and had SIJ radiography and ldCT, of whom 71 additionally had an SIJ MRI. These included 23 non-inflammatory controls, 21 inflammatory controls, 32 nr-axSpA cases, and 45 AS cases. Fourteen of 32 (44%) nr-axSpA patients had positive ldCT scans, 21/24 (88%) had MRI-BMO, and 11/24 (46%) had MRI-structural lesions. ldCT had high specificity with only 1/23 (4%) non-inflammatory controls being positive. MRI-BMO had the highest sensitivity for nr-axSpA, but compared with ldCT lower specificity, with 5/15 (33%) of non-inflammatory controls being positive, and similar sensitivity for AS (20/22 (91%) vs 44/44 for ldCT). Conclusions ldCT identifies evidence of radiographic change in a significant proportion of nr-axSpA cases and is highly specific for axSpA. MRI-BMO lesions are more sensitive than either conventional radiography or MRI-structural assessment for axSpA. The relative position of these imaging modalities in screening for axSpA needs to be reconsidered, also taking into account the costs involved.Key Points• ldCT is more sensitive for erosions or sclerosis in axSpA than plain radiography, with 44% of patients with nr-axSpA having evidence of AS-related sacroiliac joint changes on ldCT.• MRI-structural lesions are no more sensitive but are less specific for AS than ldCT.• MRI-BMO is the most sensitive test for nr-axSpA of the modalities tested but is less specific for axSpA than for ldCT.

scholarly journals AB0892-HPR PATIENT PERSPECTIVES ON PROVIDER PRACTICES LEADING TO AN AXIAL SPONDYLOARTHRITIS DIAGNOSIS: A QUALITATIVE STUDY

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 1469.2-1470
Author(s):  
K. Lapane ◽  
C. Dubé ◽  
K. Ferrucci ◽  
S. Khan ◽  
K. A. Kuhn ◽  
...  
Keyword(s):  
Back Pain ◽  
Qualitative Study ◽  
Focus Groups ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis ◽  
Diagnostic Delay ◽  
Primary Care Providers ◽  
The United States ◽  
Research Support ◽  
The Impact

Background:People with Axial Spondyloarthritis (axSpA) experience a diagnostic delay between 7 to 10 years. (1-5) This delay contributes to increased depression and desperation in searching for an appropriate diagnosis. (6) Consequently, people with axSpA experience impaired physical function, structural damage, and overall worsened quality of life than those who experience a timely diagnosis. (7)Objectives:To gain knowledge and understand patients’ experiences with healthcare providers in diagnosis of axSpA.Methods:Using qualitative study design, we conducted six focus groups, with a total of 26 participants with a confirmed diagnosis of axSpA by rheumatologists from three different geographic locations: Worcester, MA, Aurora, CO and Philadelphia, PA. Focus groups were audio recorded and approximately 2 hours in duration. The focus groups were transcribed, deidentified, cleaned and stored in a secure location. NVivo software was used to code the data using a coding scheme which emerged from the focus group discussion topics. For intercoder reliability, two researchers coded the data and generated summary reports for data analysis.Results:Patients described their frustrating journeys to diagnosis and attributed the lengthy diagnosis delays to a multitude of factors. These elements include, lack of definitive diagnostic test, disease characteristics, lack of primary care providers’ awareness of axSpA, time, and trust. Patients felt that their physicians dismissed their complaints or would describe their symptoms as psychosomatic. The health care system also contributed to their diagnostic delays, including the lengthy referral process to a rheumatologist and the short clinical appointments. Patients believe that to reduce diagnostic delay, physicians must work with their patients; listening and believing their patients while allotting time for patients to discuss their experiences. In addition, patients believe earlier referral to a rheumatologist, and HLA-B27 genetic testing would decrease the diagnostic delay of axSpA.Conclusion:In this study, patients desire definitive testing in clinical practice for earlier diagnosis of axSpA. Additionally, more education regarding the guidelines to diagnose axSpA and earlier referral to rheumatologists might be needed. Until this is feasible, patients seek clinicians who will work with them until a diagnosis is made, listening, and believing their experiences and symptoms.References:[1]Deodhar A, Mease P, Reveille J, Curtis J, Karunaratne P, Malhotra K. Prevalence of axial spondyloarthritis among undiagnosed chronic back pain patients in the United States [abstract]. Ann Rheum Dis. 2014;73:198-199.[2]Deodhar A, Mease PJ, Reveille JD, et al. Frequency of Axial Spondyloarthritis Diagnosis Among Patients Seen by US Rheumatologists for Evaluation of Chronic Back Pain. Arthritis Rheumatol. 2016;68(2326-5205 (Electronic)):1669–1676.[3]Garrido-Cumbrera M, Poddubnyy D, Gossec L, et al. The European Map of Axial Spondyloarthritis: Capturing the Patient Perspective-an Analysis of 2846 Patients Across 13 Countries. Curr Rheumatol Rep. 2019;21(1534-6307 (Electronic)):19.[4]Redeker I, Callhoff J, Hoffmann F, et al. Determinants of diagnostic delay in axial spondyloarthritis: an analysis based on linked claims and patient-reported survey data. Rheumatology (Oxford) 2019;58(1462-0332 (Electronic)):1634–1638.[5]Strand V, Singh JA. Evaluation and Management of the Patient With Suspected Inflammatory Spine Disease. Mayo Clin Proc 2017;92(1942-5546 (Electronic)):555–564.[6]Martindale J. The impact of delay in diagnosing ankylosing spondylitis/axial SpA. . Rheumatology. 2014;53.[7]Yi EA-O, Ahuja A, Rajput T, George AT, Park Y. Clinical, Economic, and Humanistic Burden Associated With Delayed Diagnosis of Axial Spondyloarthritis: A Systematic Review. Rheumatol Ther 2020(2198-6576 (Print)):65-87.Disclosure of Interests:Kate Lapane: None declared, Catherine Dubé Grant/research support from: Novartis, as personnel on such studies, Katarina Ferrucci: None declared, Sara Khan: None declared, Kristine A. Kuhn Consultant of: UCB, Eli Lilly, Novartis, Grant/research support from: Pfizer, Alexis Ogdie Consultant of: Abbvie, Amgen, BMS, Celgene, Corrona, Gilead, Janssen, Lilly, Novartis, Pfizer, UCB, Grant/research support from: Pfizer to Penn, Novartis to Penn, Amgen to Forward/NDB, Esther Yi Employee of: Novartis Pharmaceuticals, Jonathan Kay Consultant of: AbbVie, Inc.; Boehringer Ingelheim GmbH; Celltrion Healthcare Co. Ltd.; Jubilant Radiopharma; Merck & Co.,Inc.; Pfizer Inc.; Samsung Bioepis; Sandoz Inc.; Scipher Medicine; UCB, Inc., Grant/research support from: (paid to UMass Medical School) Gilead Sciences Inc.; Novartis Pharmaceuticals Corp.; Pfizer Inc., Shao-Hsien Liu Grant/research support from: Novartis

scholarly journals Diagnostic accuracy of inflammatory back pain for axial spondyloarthritis in rheumatological care

RMD Open ◽  
2018 ◽  
Vol 4 (2) ◽  
pp. e000825 ◽  
Author(s):  
Denis Poddubnyy ◽  
Johanna Callhoff ◽  
Inge Spiller ◽  
Joachim Listing ◽  
Juergen Braun ◽  
...  
Keyword(s):  
Primary Care ◽  
Back Pain ◽  
Diagnostic Accuracy ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis ◽  
Final Diagnosis ◽  
Inflammatory Back Pain ◽  
Likelihood Ratios ◽  
High Prevalence ◽  
Selection Parameter

ObjectiveInflammatory back pain (IBP), the key symptom of axial spondyloarthritis (axSpA), including ankylosing spondylitis, has been proposed as a screening test for patients presenting with chronic back pain in primary care. The diagnostic accuracy of IBP in the rheumatology setting is unknown.MethodsSix rheumatology centres, representing secondary and tertiary rheumatology care, included routinely referred patients with consecutive chronic back pain with suspicion of axSpA. IBP (diagnostic test) was assessed in each centre by an independent (blinded) rheumatologist; a second (unblinded) rheumatologist made the diagnosis (axSpA or no-axSpA), which served as reference standard.ResultsOf 461 routinely referred patients, 403 received a final diagnosis. IBP was present in 67.3%, and 44.6% (180/403) were diagnosed as axSpA. The sensitivity of IBP according to various definitions (global judgement, Calin, Berlin, Assessment of SpondyloArthritis international Society criteria for IBP) was 74.4%–81.1 % and comparable to published figures, whereas the specificity was unexpectedly low (25.1%–43.9%). The resulting positive likelihood ratios (LR+) were 1.1–1.4 and without major differences between sets of IBP criteria. The presence of IBP according to various definitions increased the probability of axSpA by 2.5%–8.4% only (from 44.6% to 47.1%–53.0%).ConclusionsThe diagnostic utility of IBP in the rheumatology setting was smaller than expected. However, this was counterbalanced by a high prevalence of IBP among referred patients, demonstrating the effective usage of IBP in primary care as selection parameter for referral to rheumatology. Notably, this study illustrates potential shifts in specificity and LR+ of diagnostic tests if these tests are used to select patients for referral.

Evaluation of 2 Screening Strategies for Early Identification of Patients with Axial Spondyloarthritis in Primary Care

2011 ◽  
Vol 38 (11) ◽  
pp. 2452-2460 ◽  
Author(s):  
DENIS PODDUBNYY ◽  
JANIS VAHLDIEK ◽  
INGE SPILLER ◽  
BEATE BUSS ◽  
JOACHIM LISTING ◽  
...  
Keyword(s):  
Primary Care ◽  
Back Pain ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis ◽  
Age At Onset ◽  
Positive Family History ◽  
Screening Method ◽  
Inflammatory Back Pain ◽  
Care Level ◽  
Primary Care Level

Objective.To evaluate 2 referral strategies for axial spondyloarthritis (SpA) in patients with chronic low back pain at the primary care level.Methods.Referral physicians (n = 259) were randomly assigned to either Strategy 1 or Strategy 2 in order to refer patients with chronic back pain (duration > 3 months), age at onset of back pain < 45 years, and no diagnosis of axial SpA, to a cooperating rheumatologist (n = 43). According to Strategy 1, suitable patients were referred if at least 1 of the following screening criteria was present: inflammatory back pain, HLA-B27, or sacroiliitis detected by imaging. According to Strategy 2, patients were referred if 2 out of 5 criteria were positive: the same 3 criteria from Strategy 1 and additionally a positive family history of ankylosing spondylitis (AS) or a good treatment response to nonsteroidal antiinflammatory drugs. The final diagnosis of the rheumatologist was used as the “gold standard.”Results.In total, 560 consecutively referred patients were included in the analysis. Among 318 patients referred by Strategy 1, 41.8% (95% CI 36.5%–47.3%) were diagnosed with definite axial SpA. Among 242 patients referred by the second strategy, definite axial SpA was diagnosed in 36.8% (95% CI 31.0%–43.0%) of the cases.Conclusion.Both referral strategies demonstrated comparable performance in identification of patients with axial SpA. Strategy 1 might be preferred as an easy and reliable screening method for axial SpA at the primary care level.

Alternative diagnoses in patients with chronic back pain not diagnosed with axial spondyloarthritis: data from the SPACE cohort

2017 ◽  
pp. annrheumdis-2017-212175
Author(s):  
Zineb Ez-Zaitouni ◽  
Robert B M Landewé ◽  
Désirée van der Heijde ◽  
Floris A van Gaalen
Keyword(s):  
Back Pain ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis
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