Axial Spondyloarthritis: Validation of an Inter-Professional Model of Care

Christopher Hawke¹, Laura Passalent^2,3, Anthony V. Perruccio⁴, Kala Sundararajan⁵, Nigil Haroon⁶, Robert D Inman⁷ and Y. Raja Rampersaud⁸, ¹Toronto Western Hospital, University of Toronto, Toronto, ON, Canada, ²Allied Health, Toronto Western Hospital, Toronto, ON, Canada, ³Physical Therapy, University of Toronto, Toronto, ON, Canada, ⁴Orthopaedic Surgery, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, ⁵Orthopaedic Research Department, Toronto Western Hospital, Toronto, ON, Canada, ⁶Rheumatology, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada, ⁷Immunlogy and Institute of Medical Science, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada, ⁸Orthopaedic Surgery and Neurosurgery, University Health Network and University of Toronto, Toronto, ON, Canada

Meeting: 2015 ACR/ARHP Annual Meeting

Date of first publication: September 29, 2015

Keywords: Interdisciplinary rheumatology team and spondylarthritis

Session Information

Date: Sunday, November 8, 2015

Title: Health Services Research Poster I: Diagnosis, Management and Treatment Strategies

Session Type: ACR Poster Session A

Session Time: 9:00AM-11:00AM

Background/Purpose:

Early detection of axial Spondyloarthritis (axSpA) is challenging given the lack of pathognomonic clinical findings. Clinical overlap with mechanical back pain leaves axSpA a poorly recognized disease entity. Given that effective treatments are now available, early detection of axSpA is critical. To enable primary care detection, the aim of this study was to evaluate an inter-professional model of care (MOC) for detection of axSpA with respect to three essential screening elements: 1) assignment to high vs low risk groups on the basis of clinical characteristics of patients; 2) agreement on mechanical versus inflammatory back pain; 3) interpretation of radiographic sacroiliitis.

Methods:

Patients with >3 months of back pain and age of onset ≤45 years were referred to the program. Exclusion criteria included: leg dominant pain, neurological symptoms, or an established diagnosis of an inflammatory condition. A comprehensive examination was completed by an Advanced Practice Physiotherapist (APP). Investigations included: HLA B27, CRP, ESR, and radiographs of the SI joints. Patients completed an initial assessment with an APP and were subsequently reviewed by a Rheumatologist with experience in axSpA. The APP and Rheumatologist independently categorized each patient’s risk of axSpA into ‘low’, ‘medium’, or ‘high’ as well as the risk of mechanical back pain. Each patient’s radiographs were interpreted independently by the APP and the Rheumatologist. Final axSpA diagnosis was determined by the Rheumatologist using the Assessment of Spondyloarthritis (ASAS) criteria.

Results:

A total of 123 patients were evaluated using the inter-professional MOC. Fifty-nine percent were female, with a mean age of 35.5 years (±9.6 years). Mean duration of back pain was 7.2 years (+/-8.5, range 3 months to 37 years). Agreement of risk categorization between APP and Rheumatologist was 79.7%, with Kappa coefficient= 0.57 (CI 0.38-0.77). Sensitivity and specificity for the APP (versus final diagnosis) was 71.4% (CI 30.3-94.9%) and 75% (CI 61.9-84.9%) respectively; with a positive predictive value of 25% (CI 9.6-49.4%) and negative predictive value of 95.7% (CI 84.3-99.3%). Radiographic interpretation for the presence of sacroiliitis, as per modified New York Criteria (mNYC), was fair to moderate (Kappa=0.39 left, Kappa=0.42 right) between the APP and Rheumatologist. Patients assigned by the APP and Rheumatologist to the low and high risk groups did not differ with respect to the following: age, gender, inflammatory back pain, extra articular features, family history, HLA B27 status, ESR, CRP, or radiographic sacroiliitis.

Conclusion:

Using the ASAS criteria and Rheumatologists’ final diagnosis as a gold standard, an inter-professional MOC demonstrated high negative predictive value and fair agreement with radiographic interpretation for sacroiliitis consistent with the literature. No significant differences were identified between clinical characteristics when assigning risk scores for axSpA. These preliminary findings suggest that an inter-disciplinary team is an effective MOC when screening for axSpA and represents a possible model for earlier detection within primary care.

Disclosure: C. Hawke, None; L. Passalent, None; A. V. Perruccio, None; K. Sundararajan, None; N. Haroon, None; R. D. Inman, None; Y. R. Rampersaud, None.

To cite this abstract in AMA style:

Hawke C, Passalent L, Perruccio AV, Sundararajan K, Haroon N, Inman RD, Rampersaud YR. Axial Spondyloarthritis: Validation of an Inter-Professional Model of Care [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). https://acrabstracts.org/abstract/axial-spondyloarthritis-validation-of-an-inter-professional-model-of-care/. Accessed .

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