Background/Purpose:

Early diagnosis is critical for optimal management of patients with inflammatory arthritis. Axial spondyloarthritis (AxSpA) has the longest delay in diagnosis among inflammatory joint diseases. Timely access to rheumatological assessment is particularly challenging in remote areas.

Objectives: To evaluate the impact of an alternate model of care on detection of AxSpA in remote areas and determine patient satisfaction with the model.

Methods:

To improve access to assessment of AxSpA, a satellite inter-professional AxSpA screening clinic (SpASC) was established 1000 kilometers away from the parent spondylitis clinic. Two Advanced Practice Physiotherapists (APPs) with extended scope training in inflammatory arthritis provided standardized assessment onsite for patients with chronic back pain of more than 3 months duration and onset less than age 50. Patients with a previous diagnosis of SpA or those with leg-dominant pain were excluded. A telemedicine platform (OTN) allowed for APPs to consult with the staff Rheumatologist at the parent site at the end of the assessment.

The following investigations were obtained prior to the assessment: X-rays of the pelvis, lumbar, and cervical spine; testing for HLA B27, CRP and ESR levels.

The APP and Rheumatologist independently diagnosed patients as; AxSpA, non-specific back pain or other. The Rheumatologist and APP rated the probability of AxSpA as low, medium or high, scoring confidence of the classification on a 0-10 Likert scale. Radiographs of the sacroiliac joints were scored independently by the APP and rheumatologist using New York grading. For patients thought likely to have AxSpA despite non-diagnostic X-rays, an MRI was ordered. Access was measured by wait time in days and by the geographic area of patients based on postal code. Each patient that attended the satellite clinic was asked to complete a multidimensional patient satisfaction questionnaire.

Results:

In this analysis, 43 patients who completed the study protocol were assessed. Another 17 patients are awaiting MRI. The patients had a mean age of 36.8 (IQR 27.5-41) years and 28 (68.3%) were female. Nine (20.9%) patients were diagnosed with AxSpA (5 Ankylosing Spondylitis and 4 non-radiographic AxSpA). Thirty-two (74.4%) had non-specific back pain. One patient (2.3%) had a pedicle fracture and one (2.3%) was referred to a specialist clinic, with a subsequent diagnosis of lupus.

Diagnostic agreement between the APP and Rheumatologist was moderate-good (kappa 0.63 (0.38-0.87)). Median wait times were 162 days (July 2016, IQR, 69-176 days) and 131 days (March 2017, IQR, 99-180 days). With local wait time up to 2 years. Of the 60 patients seen in the clinic 47 (78%) travelled less than 50km to the clinic, with 13 (21.6%) travelling between 120-350kms.

Twenty-three patients (51%) returned satisfaction questionnaires after the consultation: 21 (95%) either agreed or strongly agreed that overall they were satisfied with the consultation.

Conclusion:

Establishing a satellite clinic with ACPAC-trained APPs consulting rheumatologists via telemedicine can offer improved access to care and effective diagnosis of AxSpA. Overall, patients were satisfied and accepting of the alternative consultation process.

« Back to 2017 ACR/ARHP Annual Meeting

ACR Meeting Abstracts - https://acrabstracts.org/abstract/a-multidisciplinary-telemedicine-program-for-identification-of-spondyloarthritis-in-medically-underserviced-communities/