gms | German Medical Science

47. Kongress der Deutschen Gesellschaft für Rheumatologie (DGRh), 33. Jahrestagung der Deutschen Gesellschaft für Orthopädische Rheumatologie (DGORh), 29. Jahrestagung der Gesellschaft für Kinder- und Jugendrheumatologie (GKJR)

04.09. - 07.09.2019, Dresden

Early recognition of patients with axial spondyloarthritis by using a practical referral system – evaluation of the recently proposed 2-step strategy

Meeting Abstract

  • Xenofon Baraliakos - Rheumazentrum Ruhrgebiet, Herne
  • Styliani Tsiami - Rheumazentrum Ruhrgebiet, Herne
  • Doris Morzeck - Rheumazentrum Ruhrgebiet, Ruhr-Universität Bochum, Herne
  • Kirill Fedorov - Rheumazentrum Ruhrgebiet, Herne
  • Uta Kiltz - Rheumazentrum Ruhrgebiet und Ruhr-Universität Bochum, Herne
  • Jürgen Braun - Rheumazentrum Ruhrgebiet, Herne

Deutsche Gesellschaft für Rheumatologie. Deutsche Gesellschaft für Orthopädische Rheumatologie. Gesellschaft für Kinder- und Jugendrheumatologie. 47. Kongress der Deutschen Gesellschaft für Rheumatologie (DGRh), 33. Jahrestagung der Deutschen Gesellschaft für Orthopädische Rheumatologie (DGORh), 29. Jahrestagung der Gesellschaft für Kinder- und Jugendrheumatologie (GKJR). Dresden, 04.-07.09.2019. Düsseldorf: German Medical Science GMS Publishing House; 2019. DocSpA.39

doi: 10.3205/19dgrh248, urn:nbn:de:0183-19dgrh2482

Published: October 8, 2019

© 2019 Baraliakos et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. See license information at http://creativecommons.org/licenses/by/4.0/.


Outline

Text

Background: Axial spondyloarthritis (axSpA) in primary care (PC) is difficult to recognize due to the high prevalence of low back pain in the general population. The results is a significant delay for a diagnosis of axSpA. A 2-step referral strategy has been recently proposed (Braun A, et al. ARD. 2011), concentrating on patients ≤45 years with chronic back pain to be referred to a rheumatologist if fulfilling 2/3 features: buttock pain, improvement by movement, psoriasis (Step 1), or, in case of ≤1 feature, positive testing for HLA-B27 (Step 2). Here we prospectively evaluate this 2-step referral strategy in PC under real-life conditions.

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 (39.7%), 160 (50%) and 102 (31.9%) in Q1, Q2 and both, respectively, while 83 patients fulfilled either Q1 or Q2 (25.9%). A total of 47 (14.7%) patients were diagnosed with axSpA by the rheumatologist at Q3 (66% male, mean age 34.7±10.1 years, 70.2% HLA-B27 positive, mean CRP 0.8±1.4mg/dl). Of these, 37 (78.7%) patients had fulfilled the prS in Q1 or Q2, and 31 (66%) in both Q1 and Q2, 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: This study confirms the feasibility a simple referral strategy using a combination of clinical features for identifying axSpA patients in PC without laboratory and imaging examinations. This strategy performed already well at the early patient and PC physician level just based on a symptom-based questionnaire.

This work was supported by an unrestricted Grant by Novartis Pharma GmbH, Germany