Session Type: Poster Session (Sunday)
Session Time: 9:00AM-11:00AM
Background/Purpose: Early recognition of axial spondyloarthritis (axSpA) in primary care (PC) is difficult due to the high prevalence of low back pain resulting in a major delay for a diagnosis of axSpA. Recently we proposed a 2-step referral strategy (1) which concentrates on patients ≤45 years with chronic back pain who are to be referred to a rheumatologist if fulfilling 2 of 3 features: buttock pain, improvement by movement, psoriasis (Step 1), or, in case of ≤1 feature, positive testing for HLA-B27 (Step 2). We prospectively evaluated this 2-step referral strategy in PC.
Methods: Consecutive patients ≤45 years who presented in PC to general practitioners or orthopedic surgeons working in PC with back pain lasting ≥2 months who had not been diagnosed before received questionnaires (Q1) relevant for the referral process. Thereafter, the PC physician asked the same questions in a separate questionnaire (Q2), including the decision on HLA-B27 testing. All patients were then referred to two experienced rheumatologists in a tertiary center who performed a complete workup including clinical, laboratory and imaging with radiographs and magnetic resonance imaging (MRI) examinations before their final diagnosis of axSpA or non-SpA (Q3).
Results: A total of 320 patients (mean age 35.9±10.3 years) was recruited. The proposed referral strategy (prS) was fulfilled by 127 patients in Q1 (39.7%), 160 in Q2 (50%), 102 by both, Q1 and Q2 (31.9%), and 83 with either Q1 or Q2 (25.9%). Overall, 47 patients were diagnosed with axSpA by the rheumatologist at Q3 (14.7%), 66% of which were male, mean age 34.7±10.1 years, 70.2% HLA-B27 positive, mean CRP 0.8±1.4mg/dl, mean ASDAS 3.2±0.8, mean BASDAI 5.1±2.0. Of these, 37 patients had fulfilled the prS in Q1 or Q2 (78.7%), and 31 in both Q1 and Q2 (66%), respectively. In the latter, the HLA-B27 prevalence was significantly higher (27/31, 87.1%) as compared to patients diagnosed with axSpA at Q3 but who did not fulfill the prS in Q1 and Q2 (5/16, 31.3%) (p< 0.001). The sensitivity and specificity of the prS was 78.7% and 69.2% in Q1, 78.7% and 62.2% in Q2, and in both, Q1 and Q2, 66% and 74%, respectively. AxSpA patients correctly identified by the prS in Q1 and Q2, were significantly more frequently positive for HLA-B27 and CRP and fulfilled more frequently the ASAS definition of inflammatory back pain in Q3.
Conclusion: A simple two-step referral strategy using a combination of clinical features for identifying axSpA patients in PC without laboratory and imaging examinations was confirmed in a large population from daily practice. This strategy performed well as selection for referral at the patient and PC physician level.
- Braun A et al, ARD 2011
To cite this abstract in AMA style:Baraliakos X, Tsiami S, morzeck d, Fedorov K, Kiltz U, Braun J. Early Recognition of Patients with Axial Spondyloarthritis by Using a Practical Referral System – Evaluation of the Recently Proposed 2-step Strategy [abstract]. Arthritis Rheumatol. 2019; 71 (suppl 10). https://acrabstracts.org/abstract/early-recognition-of-patients-with-axial-spondyloarthritis-by-using-a-practical-referral-system-evaluation-of-the-recently-proposed-2-step-strategy/. Accessed November 26, 2020.
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ACR Meeting Abstracts - https://acrabstracts.org/abstract/early-recognition-of-patients-with-axial-spondyloarthritis-by-using-a-practical-referral-system-evaluation-of-the-recently-proposed-2-step-strategy/