Background/Purpose: This analysis compares referral patterns and diagnostic tools for axial spondyloarthritis (axSpA) used by rheumatologists working in academic centers and in community clinical practice settings.

Methods: The MAXIMA (Management of Axial SpA International and Multicentric Approaches) survey asked respondents questions pertaining to referral, diagnosis, and management of patients with axSpA. The survey was completed anonymously online by participants from 42 countries in Europe, Latin America, and North America. The MAXIMA survey was funded by Abbott Laboratories and conducted by a third-party vendor with guidance and approval of the questionnaire by a steering committee of SpA experts. None of the participants were compensated for completing the survey. 

Results: 500 surveys were completed by 141 rheumatologists in academic practice settings (28%) and 359 rheumatologists in community practice settings (72%). Only 58% of academic rheumatologists compared to 72% of clinical rheumatologists agreed that the concept of axial SpA is clear to the rheumatology community. However, responses to various questions about referral and diagnostic work-up for patients with axSpA were generally similar in both practice settings (table). The majority of respondents (87%) reported that primary care providers referred patients with chronic back pain for 3 months and onset <45 yrs old; 47% of respondents received referrals from other specialists such as dermatologists, gastroenterologists, and ophthalmologists. Other than chronic and inflammatory back pain, referrals from non-rheumatology specialists were triggered by the occurrence of uveitis (82%), inflammatory bowel disease (48%) and skin lesions (46%). At the time of referral to the rheumatologist, 48% of patients have symptoms for ≥3 yrs. The ASAS criteria (85%) were cited as the most common classification criteria that guide respondents in the diagnosis of axSpA in clinical practice, compared to the modified New York criteria for AS (23%), ESSG (8%), and Amor (6%). In terms of diagnostic work-up, approximately half systematically request HLA-B27 typing. MRI of the sacroiliac joints is the most commonly used imaging test, closely followed by pelvic x-rays.

Conclusion: Results of the MAXIMA survey show general agreement in referral patterns and use of diagnostic tools by rheumatologists in academic and clinical practice settings when evaluating patients for axSpA. Half of the patients are still being seen by rheumatologists several years after onset of symptoms, which indicates the need for appropriate early referral.

 

Table. Response rates in MAXIMA survey regarding SpA referral patterns and diagnosis
Question	Rheumatology Practice Setting		Overall N=500
	Academic Center N=141	Community Clinical Practice N=359
Patients with back pain ≥3 mo, <45 yrs old
Source of referralsa
Primary care provider	82	89	87
Physiotherapist	18	30	27
Private office rheumatologist	22	18	19
Other specialistb	50	46	47
Duration of symptoms
<1 yr	9	10	10
1–2 yrs	36	45	42
3–4 yrs	41	30	33
>5 yrs	14	15	15
Triggers of past referrals from other specialists
Uveitis	81	82	82
Chronic back pain	69	64	65
IBP	38	44	42
Skin lesions	47	45	46
Nail lesions	23	30	28
Inflammatory bowel disease	45	49	48
Diagnosis in daily practice
Classification guides used for diagnosis of axSpA in practice
ASAS	92	83	85
Modified New York criteria for AS	21	24	23
ESSG	4	10	8
HLA-B27 typing performed routinely	49	50	49
Imaging tests used
MRI sacroiliac joint	92	93	93
Pelvic x-ray	88	85	86
Spinal x-ray	71	78	76
MRI spine	56	58	57
aRespondents may have indicated >1 source of referrals. bOther specialist = dermatologist, gastroenterologist, ophthalmologist. AS, ankylosing spondylitis; ASAS, Assessments in Spondyloarthritis International Society; axSpA, axial spondyloarthritis; ; BASDAI, Bath AS Disease Activity Index; ESSG, European Spondylarthropathy Study Group; IBP, inflammatory back pain; mo, months; MRI, magnetic resonance imaging; SpA, spondyloarthritis; yr, year.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/referral-patterns-and-diagnosis-of-patients-with-axial-spondyloarthritis-results-of-an-international-survey/