Background/Purpose: Timely recognition and referral of patients with spondyloarthritis (SpA) is challenging due to the insidious disease onset and frequently unawareness of the clinical picture by primary care physicians. The aims of this study were to assess the current practice performance of general practitioners (GPs) and GP-residents in recognizing SpA, and to investigate the influence of education on this performance.

Methods: All GP-residents and their supervising GPs were visited in two rounds by standardized patients (SPs) during their regular outpatient clinic, simulating axial SpA (axSpA), peripheral SpA (perSpA) (i.e. dactylitis) or carpal tunnel syndrome (CTS), respectively. Participants were unaware of the nature of the medical problem and purpose of the study. CTS was included as a diversionary tactic. Each case was simulated by a male and a female, in random order, according to a predefined schedule. After the 1st round, half of the GP-residents were educated about SpA, as part of the GP specialty training without referring to the actual study. The other half of the GP-residents and all GPs served as controls. Next, all participants were visited by SPs again in the 2nd round. Participants ranked their differential diagnosis based on their probabilities (rank order: 1=most likely to 3=less likely) and indicated whether referral to a hospital physician would be appropriate. Descriptive statistics and chi-square tests were used to analyse the data.

Results: Sixty-eight (38 GP-residents (mean age 27.9 yrs, 32% male) and 30 GPs (mean age 52.5 yrs, 80% male) participated. Both rounds of SP-encounters were completed by 61 (90%) and 59 (87%) participants for the axSpA and perSpA case, respectively. Table 1 shows that axSpA was ranked as the no. 1 diagnosis by 12/61 (20%) participants, whereas perSpA was correctly diagnosed by none of participants in the 1st round. Participants who received the educational intervention, were more likely to rank axSpA and perSpA as the no. 1 diagnosis in the 2nd round when compared to the control group (axSpA 72% vs. 14% (p<0.001); perSpA 21% vs 3% (p=0.017)). All 18 participants, who received the educational intervention, listed axSpA in their differential diagnosis in the 2nd round and were more likely to refer the patient or considered referral to the rheumatologist optional (axSpA 77% vs. 25% (p<0.001); perSpA 53% vs. 5% (p<0.001)).

Conclusion: Patients with SpA are not adequately recognized by general practitioners. Providing an educational programme to GP-residents markedly improved the recognition of SpA and referral of patients with SpA to the rheumatologist.

Table 1. Pre- and post-intervention results of the educational and control group regarding diagnosis and referral of patients suspected for axial and peripheral spondyloarthritis