Background/Purpose: There is a dearth of literature exploring challenges faced by rheumatologists in the referral, diagnosis, management, and monitoring of patients with suspected axial spondyloarthritis (axSpA) worldwide. Our study aims to understand such challenges faced by rheumatologists in the Gulf countries.

Methods: A cross-sectional online survey was conducted among practicing rheumatologists in six countries using 35-close ended questions. Items underwent refinement using a sensibility assessment framework and were pilot-tested among 12 rheumatologists, and followed international survey reporting guidelines. The survey assessed demographic characteristics, referral patterns, diagnostic features, monitoring practices, and management challenges related to axSpA. Descriptive statistics were applied and normalized average scores were computed for ranking questions and converted into percentages. Data collection occurred between April and May 2021.

Results: A total of 188 responses were received and analyzed (response rate 50.6% during COVID pandemic). Most respondents were consultants (68.1%), practiced in tertiary governmental hospitals (52.7%) and located in urban settings (95.1%) (Table 1). A majority (88.6%) reported delayed presentation of axSpA patients, primarily due to low disease awareness among primary care physicians (55.8%) and absence of validated referral criteria (35.0%), Figure 1. Orthopedists, family physicians, and internists were among the top referring specialties. Nearly half of respondents believed that non-rheumatology specialists are reluctant to refer their axSpA patients to a rheumatologist.Diagnostic challenges were reported by 65.5% of respondents, especially in patients with atypical symptoms or limited access to HLA-B27 testing and advanced imaging. Only 28.8% experienced difficulty ordering or interpreting HLA-B27, primarily due to test unavailability (66.7%), or perceived low prevalence of HLA-B27 in their patient population (31%). The majority (76.6%) had access to a musculoskeletal radiologist to read X-rays and MRIs. Trust in radiology reports of sacroiliac X-rays and MRI for assessing suspected axSpA was generally moderate to high.Figure 2 illustrates the preferred frequency of monitoring various axSpA disease metrics across different time intervals, including those rarely or never used.About 47% and 31.5% of respondents reported difficulties in tracking patient-reported outcomes and physical exam findings, respectively—mainly due to busy schedule and lack of a nurse to support. In terms of management, patient non-adherence due to fear of drug side effects (44.1%) or symptom improvement (43.1%) were leading obstacles. Only 12% had access to a rheumatology-trained nurse. Physiotherapy was considered to be usually useful by 45.2% of rheumatologists.

Conclusion: This is the first comprehensive study from the Middle East and North Africa region to explore clinical practices and challenges in the referral, diagnosis, management, and monitoring of axSpA among rheumatologists. Delays in diagnosis and referral suggest the need for educational initiatives targeting non-rheumatologists, and improved multidisciplinary support.

Table 1: Participants’ demographics

Figure 1. Perceived challenges and referral patterns in axial spondyloarthritis care: (A) Delays in referral to rheumatology, (B) Specialties most frequently referring patients, (C) Reasons for referral reluctance from non-rheumatologists, and (D) Diagnostic challenges.

Figure 2: Frequency of monitoring disease metrics perceived by rheumatologists

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/practice-patterns-and-barriers-in-the-referral-management-and-monitoring-of-axial-spondyloarthritis-insights-from-an-online-survey-of-rheumatologists/