The spondyloarthritides (SpA) are a very heterogeneous group of diseases where suboptimal patient assessment has been observed in routine clinical practice.1–6 Thus, the EmAR II study, for example, showed that in the assessment of patients with SpA, approximately 60% of medical records did not include an evaluation of possible joint involvement.7 Similarly, 87% of the records also showed no joint index, and 84% did not show a functional index. Studies in other countries have described a similar scenario.3

The ONLY TOOLS study was designed with these data in mind, and created an assessment checklist for patients with SpA in order to standardise and more strictly monitor the disease and comorbidities, and to help identify high risk and response factors.8 Subsequently, the Práctica Madrid project was launched, in which the aforementioned checklist was implemented in routine clinical practice, and which demonstrated on its first analysis that it is feasible and that it significantly improves the assessment of patients with SpA.

On the other hand, although axial SpA (axSpA) and psoriatic arthritis (PsA) are included in the SpA group, they have different characteristics, even beyond joint involvement. Patients with PsA show a higher percentage of cardiovascular involvement, metabolic syndrome or cancer compared to other forms of SpA.9 However, these findings should not influence patient assessment, but should serve to reinforce their collection. Therefore, the aim of this sub-study was to analyse the baseline data regarding patient assessment and changes in data collection comparatively between patients with axSpA and PsA within the Práctica Madrid project.

Six hospitals and 11 rheumatologists participated. A total of 83 and 68 medical histories pre and post implementation of the checklist were reviewed. The patient characteristics of both samples were similar, with a median age at diagnosis of 43 and 40 years, respectively, and an interquartile range (p25–75) of 33–51 and 32–48, respectively. About half of the patients were male. The proportion of patients with axSpA and PsA was comparable (40.2% and 44.8% pre-implementation, 47.6% and 47.8% post-implementation). Eight percent of the patients with axSpA also had peripheral involvement, and none of the patients with PsA had axial involvement.

At baseline (Tables 1 and 2) we highlight that, except for some variables such as nail involvement or uveitis, the general trend is towards a lower percentage of recording in patients with PsA compared to those with axSpA.

On the other hand, in general, implementation increased the recording of almost all variables in all patients, regardless of the SpA subtype. Specifically, in patients with axSpA (Table 1) there was a significant increase in the recording of alcohol consumption in the clinical history (51% vs 90%), as well as some extra-articular manifestations such as diarrhoea or inflammatory bowel disease (IBD) and urethritis, comorbidities such as diabetes mellitus (69% vs 93%), hyperlipidaemia (66% vs 100%), depression, obesity or gout/hyperuricaemia, and the following physical examination data: weight (12% vs 63%), height (9% vs 63%) and blood pressure (9% vs 56%). The recording of other disease-related parameters also increased, such as physician global assessment (PGV) (36% vs 76%) and patient global assessment (PGV) (51% vs 90%), and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) (62% vs 86%).

In the case of PsA (Table 2), the parameters whose recording in medical records increased significantly were alcohol consumption (46% vs 87%), comorbidities such as high blood pressure (HBP) (66% vs 93%), diabetes mellitus (53% vs 93%), and hyperlipidaemia (64% vs 90%), cardiovascular disease (42% vs 65%) and gout/hyperuricaemia (38% vs 62%), and almost all physical examination parameters, such as chest expansion (23% vs 50%), cervical rotation (20% vs 53%), weight (35% vs 62%), height (21% vs 62%) and blood pressure (23% vs 71%). The same was true of the PGA (23% vs 71%), the PtGA (48% vs 78%) and the Bath Ankylosing Spondylitis Functional Index (BASFI) (36% vs 64%).

Comparatively, as at the baseline, the trend is towards a higher percentage of collection in axSpA than in PsA (Tables 1 and 2). On the other hand, we also note that post-implementation, in both groups, there are variables that continue to be collected in nearly 50% of the records, or even less, such as the presence of depression, chest expansion or Ankylosing Spondylitis Disease Activity Score (ASDAS).

The checklist developed for the ONLY TOOLS project was considered in this sub-analysis of the Práctica Madrid study. The results obtained have shown that the implementation of a specific checklist improves, in general terms, the assessment of patients with axSpA as well as with PsA. Furthermore, it has been observed that in the PsA subgroup, pre- and post-implementation of the checklist, the percentage of collection of relevant variables is clearly insufficient. Finally, and despite the increase observed after the implementation of this action framework, the collection of some variables continues to be low in both groups. Although in a study designed for a different purpose (adherence to a treat-to-target strategy protocol, with patients with SpA and RA), Lesuis et al.10 found that after the implementation of an assessment protocol they went from collecting 9% of cases to 20%. Although the trend is upwards, these figures are much lower than those collected in this study.

Since the EmAR II study, conducted in 2009–2010, which found poor recording in the daily practice of assessment of patients with SpA, many national and international recommendations have been published and various projects have been developed to improve the management of patients with SpA.1,11–14 The data collected at the baseline in the Práctica Madrid project in 2018 show an increase in the collection of variables in the assessment of patients with axSpA and PsA, suggesting a positive effect of all the activities discussed, which clearly continues to improve after the implementation of the checklist, regardless of the subgroup.

Despite the improvement mentioned in the collection of variables, there continues to be suboptimal evaluation of processes of high prevalence or impact, such as depression,4 or of activity and function parameters, such as chest expansion, ASDAS or Disease Activity Score 28 (DAS28). In the current framework of SpAs, where referral is the main objective and where decisions are made through holistic and patient-centred assessment, the emphasis should continue to be on improving the assessment of patients with axSpA especially in PsA, despite the good results obtained.

This study is not free of limitations, mainly related to the small sample size and the representativeness of the sample. It is evident that the study of 83 medical records before the implementation of the checklist and 68 after its implementation may seem, at first glance, insufficient to detect an effect. However, despite this reduced number, significant differences have been found in various variables, indicating that the effect is large enough to be detected in small samples and that larger samples would predictably ratify the results observed. On the other hand, and in order to avoid overestimation of the effect, in the post-implementation phase of the tool, different patients to those in the first phase were selected, in order to avoid an excess of variables in previously selected patients. Secondly, the design used, with the selection of centres with different characteristics and resources, aims to ensure the representativeness of the sample. Despite these considerations, it is clear that this analysis could be a first point of departure for the proposed objective that would justify conducting a study with a greater number of patients and centres.

This project was conducted with the collaboration of the Rheumatology Society of the Community of Madrid (SORCOM).

E.L. has received funding for research projects from Roche, MSD, Pfizer, Abbvie, BMS, UCB, Actelion, Celgene, Grunenthal and Sanofi. E.R.A. has received funding for research projects and courses from GSK, Abbvie, MSD and Celgene. E.R. has received funding for courses from Pfizer, Abbvie, Novartis, Roche, Lilly, Janssen and Asacpharma. The remaining authors have no conflict of interests to declare.