Article
Performance of an online self-referral questionnaire compared to a physician based referral approach to identify patients with a high probability of axial spondyloarthritis: results from the OptiRef study
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Authors
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Fabian Proft
- Charité – Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie, Rheumatologie, Berlin
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Laura Spiller
- Charité – Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie, Rheumatologie, Berlin
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Mikhail Protopopov
- Charité – Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie, Rheumatologie, Berlin
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Valeria Rios Rodriguez
- Charité – Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie, Rheumatologie, Berlin
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Burkhard Muche
- Charité – Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie, Rheumatologie, Berlin
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Rademacher Judith
- Charité – Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie, Rheumatologie, Berlin
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Susanne Lüders
- Charité – Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie, Rheumatologie, Berlin
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Anne-Katrin Weber
- Charité – Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie, Rheumatologie, Berlin
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Inge Spiller
- Charité – Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie, Rheumatologie, Berlin
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Joachim Sieper
- Charité – Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie, Rheumatologie, Berlin
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Denis Poddubnyy
- Charité – Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie, Rheumatologie, Berlin
| Published: | February 5, 2019 |
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Outline
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Background: The diagnostic delay in axial spondyloarthritis (axSpA) has been reported to be 9 years and still remains unacceptably high. One of the major reasons for this delay is a late referral of patients with suspicion of axSpA by primary care (PC) physicians dealing with patients with chronic back pain (CBP). Physician-based referral programs have performed well in recognition of patients with high probability of axSpA among CBP patients. However, there is still an unmet need for patients who do not receive a referral recommendation to a rheumatologists because of lack of awareness on the PC level. The objective of this study was to develop and evaluate an online self-referral tool for CBP patients and suspicion of axSpA.
Methods: Patients with CBP were included in the Identification of the Optimal Referral Strategy for Early Diagnosis of Axial Spondyloarthritis (OptiRef) Study and assessed by a rheumatologist if they either 1) were referred by a physician using the Berlin referral tool (CBP>3 months and CBP onset<45 years of age + at least 1 of the following 3 parameters: inflammatory back pain (IBP), HLA-B27 positivity, sacroiliitis on imaging), or 2) completed an online referral tool (www.bechterew-check.de) and indicated the presence of CBP>3 months with CBP onset<45 years of age + at least 1 additional SpA parameter (IBP symptoms, good response to NSAID´s, peripheral symptoms suggestive of arthritis/enthesitis, HLA-B27 positivity, elevated CRP, psoriasis, inflammatory bowel disease, uveitis, SpA-familyhistory). Rheumatologist then performed a structured assessment of SpA features and made the diagnosis of axSpA/non-axSpA.
Results: A total of 339 patients were included in the study: 162 patients (47.8%) were referred by a physician and 177 patients (52.2%) entered the study via the online self-referral tool. A total of 60 patients (37%) in the physician-referral group and 33 patients (18.6%) in the self-referral group were finally diagnosed with axSpA (p<0.001). The main patient characteristics are shown in Table 1 [Fig. 1]. Patients who were included via the online referral tool had a longer symptom duration, were more often females, less often HLA-B27 positive and had less often elevated CRP as compared to physician-referred patients. Furthermore, the physician global assessment of disease activity done by a rheumatologist was significantly lower in the self-referred group. In patients diagnosed with axSpA there were no significant differences concerning demographics, clinical features or disease activity parameters between the two groups, except of HLA-B27, which was significantly more often positive in subjects referred by a physician (p<0.001).
Conclusion: The self-referral strategy resulted in the diagnosis of axSpA in 19% of the patients as compared to 37% with a referral done by a physician. However, the proportion of axSpA among self-referred patients was clearly higher than the expected 5% prevalence of axSpA in patients with CBP. The online self-referral tool can be used, therefore, in addition to a physician based referral program to improve the early diagnosis and to increase awareness of axSpA.
