Background/Purpose: Early recognition is crucial in improving outcomes in patients with axial spondyloarthritis (axSpA).  Despite this, there exists long delay between symptom onset and rheumatology diagnosis, with an average interval of 8 years. Compounding this issue is uncertainty regarding initial axSpA screening and referral practices amongst primary care providers. The purpose of this study was to examine the knowledge, screening and referral practices for suspected axSpA within primary care.

Methods: Primary care physicians (MDs), physiotherapists (PTs), chiropractors (DCs) and nurse practitioners (NPs), licensed and registered with an Ontario regulatory college or professional association, were sent an electronic questionnaire via their respective professional institutions using Survey Monkey™ from September 2017 to September 2018. The questionnaire was developed based on our results from a qualitative study of primary care axSpA screening and referral practices conducted in 2016 and was piloted by ten primary care practitioners to strengthen face and content validity, clarity, relevance and format. The questionnaire addressed: i) knowledge of clinical and investigative features of axSpA; ii) awareness of axSpA screening tools and iii) referral practices for evaluation of suspected axSpA. Univariate statistics were used to address the above objective. All data analyses were conducted on SAS version 9.4.

Results: In total there were 276 respondents: MDs (44.5%), DCs (34%), PTs (19%) and NPs (2.4%). 93.1% worked in urban settings. 61.8% indicated > 10 years of primary care experience. In terms of clinical knowledge, the following were considered “very important” when assessing suspected axSpA: morning stiffness lasting > 30 minutes (81.9%); presence of HLA B27 (66.7%); evaluation of acute phase reactants (46.4%) and radiographs (spine and pelvis) (45.3%). Most respondents “never used” or “were not familiar” with axSpA screening tools (80%). The majority of MDs (90.9%) indicated they would “always” or “often” refer to rheumatology. PTs (90.5%) and DCs (88.0%) would “always” or “often” refer back to the patient’s MD to facilitate further investigation and/or referral, as they are not legislated to directly refer to medical specialists in the province of Ontario.  Travel (28.8%) and prolonged wait times (53.2%) were identified as referral barriers. DCs and PTs indicated legislative issues pertaining to scope of practice as a barrier to assessing patients with suspected axSpA (82.2%, 50.0%, respectively).

Conclusion: The majority of primary care practitioners demonstrate reasonable knowledge of clinical features for suspected axSpA; however there is little awareness of axSpA screening tools. Although the majority of MDs refer their patients with suspected axSpA for rheumatology consultation, prolonged wait times were identified as a substantial barrier. PTs and DCs, who are also first contact healthcare providers, identified barriers to axSpA screening and referral related legislative scope of practice, that if mitigated, could allow for better early detection of axSpA.   The results of this study may inform targeted education of primary care practitioners to improve early recognition of axSpA.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/axial-spondyloarthritis-knowledge-screening-and-referral-practices-amongst-primary-care-providers/