Background/Purpose:  For the axial spondyloarthritis (SpA) population, early recognition is crucial in preventing major morbidity. Despite this, there exists an unacceptably long delay between the onset of symptoms and diagnosis, with an average wait time of 8 years between the commencement of back pain and time when patients are diagnosed by a rheumatologist. Compounding this issue is the uncertainty that exists with respect to initial screening and referral practices amongst primary care practitioners for adults with suspected axial SpA. The purpose of this study was to explore the screening and referral practices for suspected axial SpA in adults with chronic back pain amongst primary care physicians (PCPs), physiotherapists (PTs), chiropractors (DCs) and nurse practitioners (NPs) working in community practice in the province of Ontario, Canada.

Methods:  Semi-structured key informant (KI) interviews were conducted with PCPs, PTs, DCs and NPs working in community practice. Interviews were conducted with KIs to address: 1) screening practices for axial SpA; and 2) referral practices for adults with suspected axial SpA. Interviews were conducted in-person or over the telephone. All interviews were recorded and transcribed verbatim. Interview transcripts were analyzed using a compare and contrast analysis by coding groups of words that addressed the research objectives. Two members of the research team undertook this exercise independent of each other and then met to reconcile an understanding of emergent themes. Groups of words with similar meaning were organized into themes. The themes were organized into two main categories: Screening Practices and Referral Practices. NVIVO V9 was used to assist with organization of codes.

Results:  A total of 17 interviews were conducted: PCPs (5); PTs (3); DCs (6) and NPs (3). Practice locations for KIs were primarily urban (14 urban; 3 rural). Mean years of practice of key informants was 9.3 years (range, 1-22 years). Overall, 3 themes were identified related to Screening Practices for axial SpA: 1) knowledge of clinical manifestations of axial SpA; 2) role of investigations in early diagnosis, and 3) lack of awareness of assessment guidelines and screening tools. Themes related to Referral Practices included: 1) optimization of technology; 2) referral barriers, and 3) legislative hurdles.

Conclusion:  Most primary care practitioners had a general understanding of the clinical manifestations of axial SpA; however, knowledge deficits existed related to rare clinical presentations and the role of investigations in early identification of the disease. With respect to referral practices, there are opportunities to address system-level barriers, including more extensive use of technology (e.g. use of online consultations and electronic referral templates). Our research has identified a number of opportunities for implementation of quality improvement initiatives and indication for collaboration with policy makers and other stakeholders, including patients. These results may be incorporated into a wider research initiative to gain better insight into primary care screening and referral practices for adults with suspected axial SpA.

ACR Meeting Abstracts - https://acrabstracts.org/abstract/adult-axial-spondyloarthritis-screening-and-referral-practices-amongst-primary-care-physicians-physiotherapists-chiropractors-and-nurse-practitioners-results-from-a-qualitative-study/