Background/Purpose: Emerging models of care in rheumatology are using non-physician health care professionals to assess patients with suspected inflammatory arthritis with the aim to improve early detection and access to care. Such models of care have been recently implemented for early identification of axial spondyloarthritis (SpA). The primary objective of this study was to compare the clinical impression and confidence of advanced practice physiotherapists (APP), having specialized training in inflammatory arthritis, with rheumatologists experienced in axial SpA according to: 1) the evaluation of patients with chronic back pain being assessed for axial SpA and 2) MRI recommendation for further investigation of the above patients. 

Methods: Patients with more than 3 months of back pain with onset prior to the age of 45 years and attending community primary care or high risk clinics (e.g. gastroenterology or ophthalmology) were referred for axial SpA evaluation. Two APPs and three rheumatologists evaluated each patient’s history, physical examination, laboratory studies and plain radiographs.  Patients were classified as either axial SpA or mechanical back pain (MBP) based on the above clinical and investigative findings.  Level of confidence in the clinical impression and recommendation for obtaining an MRI for further investigation were noted.   Agreement between assessors was evaluated using percent agreement and Cohen’s Kappa coefficient. 

Results: Of 57 patients assessed, 56% were referred through community care pathways. The majority (56.1%) of patients was male and the mean (±SD) age was 38.5 years (±12.2). Overall interobserver agreement of clinical impression for all raters was moderate (Κ=0.52).  Agreement of clinical impression between the APPs and rheumatologists ranged between 71.2% (Κ=0.41; 95% CI: 0.17-0.67) and 79.7% (Κ=0.57; 95% CI: 0.35-0.79). Agreement of clinical impression amongst rheumatologists ranged from 74.1% (Κ=0.49; 95% CI: 0.26-0.71) and 79.7% (Κ=0.58; 95% CI: 0.37-0.8). All rater agreement for recommendation of MRI showed fair agreement (Κ=0.37).  The APP agreement with rheumatologist for MRI recommendation ranged from 64.2% (Κ-0.31, 95% CI: 0.13-0.55) and 75% (Κ=0.48, 95% CI: 0.23-0.72).  Agreement to recommend MRI amongst rheumatologists ranged from 62.9% (Κ=0.27, 95% CI: 0.02-0.52) and 74% (Κ=0.47, 95% CI: 0.24-0.71). Confidence in clinical impression was similar amongst all practitioners (APPs median score 7/10; rheumatologists median score 6/10).

Conclusion: APPs with specialty training in inflammatory arthritis demonstrate comparable case ascertainment as rheumatologists in the assessment of axial SpA.  Utilization of such advanced practice roles may assist in improving the early detection of axial SpA, thereby facilitating early treatment and improving overall outcomes in this patient population.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/a-comparison-of-interobserver-agreement-between-advanced-practice-physiotherapists-and-rheumatologists-in-the-detection-of-axial-spondyloarthritis/