In routine clinical practice, it is recommended that patients with spondyloarthritis (SpA) be evaluated according to clinical signs, symptoms and acute-phase reactants,1,2 for example the Bath Ankylosing Spondylitis Disease Activity Index, C-reactive protein or the Ankylosing Spondylitis Disease Activity Score, which combines the 2 aspects (both subjective assessment of the patient and the acute-phase reactants).3 The same occurs with psoriatic arthritis (PsA).2

However, despite the availability of a number of Spanish and international guidelines for the evaluation of SpA including PsA, the EmAR II study, conducted in Spain,4 demonstrated that, in the assessment of SpA patients, approximately 60% of their medical records do not include an assessment of possible joint involvement or overall evaluation of the patient. In 87%, no joint score is recorded and, in 84%, there is no mention of a functional score. Distinct factors may contribute to this situation. At the present time, there is great pressure on health professionals that does not favor the evaluation and systematic collection of data. Moreover, there is a great variability in the assessment variables recorded for these patients (number, characteristics, feasibility, validation, etc.). This means that the outpatient follow-up of these individuals may not be optimal.5

These facts justify the need to design realistic strategies that contribute to improving the quality of clinical practice in order that these patients receive integrated care.4 On the basis of the above aspects, the purpose of this project was to draw up a normalization tool (a framework for action, in the form of a checklist of items to be considered in visits to the rheumatologist, for an adequate assessment of the patient) to enhance the evaluation in routine practice of patients with axial SpA and PsA, for the aim of standardizing and achieving a stricter control of the disease, favoring the identification of high-risk factors and responses, as well as control of comorbidities.

We drafted a checklist to evaluate SpA patients, with differentiated markers for patients with axial SpA and PsA, and their periodicity, as well as other specifications (Fig. 1). It includes sociodemographic variables, like the date of birth and sex (risk factor for the risk of radiographic progression and a determinant of a good response to biological therapy.

Fig. 1.

Checklist for the evaluation of patients with axial spondyloarthritis and psoriatic arthritis.

(1.12MB).

Concerning personal history, we documented, among other data, allergies, profession/employment status and use of tobacco (another risk factor affecting radiographic progression). Likewise, we recorded the date of symptom onset, the date of the diagnosis, related family history, enthesitis, dactylitis, extra-articular manifestations and the presence of inflammatory lower back pain. In the group of PsA patients, we included peripheral involvement, cutaneous symptoms and nail involvement.

With respect to comorbidities, we considered only those that had been diagnosed, such as hypertension, gastric ulcers and osteoporosis. As biomarkers, we included human leukocyte antigen (HLA) B27 and, specifically, in PsA, rheumatoid factor and anti-cyclic citrullinated peptide antibodies.

For patients with PsA, the physical examination included a study of synovitis in an upper and a lower limb and dactylitis, as well as a study of the skin and nails. Those with axial SpA underwent examinations of hip mobility, modified Schöber test, chest expansion and cervical rotation.

On the other hand, patient weight, height, body mass index, abdominal circumference and arterial blood pressure should be determined yearly in PsA patients and, as a measure of “excellence”, in the case of those with SpA.

With respect to clinical control, for axial SpA, the checklist includes the physician global assessment, the Bath Ankylosing Spondylitis Functional Index and the Disease Activity Score in 28 joints in the case of polyarticular involvement, aside from the Ankylosing Spondylitis Disease Activity Score and the Bath Ankylosing Spondylitis Disease Activity Index as determinants of a good response to biological therapy, and the former, moreover, as a risk factor of radiographic progression. In the case of PsA, the patient global assessment and morning joint stiffness are also evaluated.

Ancillary tests that should be performed in the control of axial SpA are complete blood count, erythrocyte sedimentation rate, routine laboratory tests, urinalysis and C-reactive protein (a determining factor of a good response to biological therapy and of radiographic progression). As a measure of excellence, it was decided to include 25-OH vitamin D and bone densitometry. In PsA patients, urinary uric acid should also be determined and, as a measure of excellence, the lipid profile, as well. With regard to imaging studies, plain radiography of the pelvis, spine and sacroiliac joints (and peripheral joints in patients with PsA) helps to monitor risk factors for radiographic progression. A radiograph of the pelvis enables a proper assessment of the sacroiliac joints and the hips, making it unnecessary to X-ray these structures. Magnetic resonance of the sacroiliac joints serves as a marker of radiographic progression, and is also related to the response to biological therapy. Thus, the decision was made to include it.

Finally, this checklist incorporates a section on treatments.

The work group for the study of SpA of the Spanish Society of Rheumatology has developed a practical and simple checklist, achieved by consensus. It is adapted to the characteristics of Spanish outpatient clinics, and is based on a review of the literature and the opinion of experts for the assessment of patients with axial SpA and PsA in routine clinical practice.

A number of studies have shown that adherence to the recommendations for the evaluation of patients with SpA and PsA is highly variable, either because of a lack of time, motivation or knowledge, or because of the considerable number of the variables and their characterists.2,5–8

In addition to standardizing routine clinical practice, the drafting of this checklist was to facilitate the identification of different risk profiles in patients (response to biological therapies,9 radiographic progression,10,11, etc.) and aid in improving our approach to their comorbidities.12 With these “warning signs” the effort is made to stress the need for greater awareness and control in these patients. It includes all the variables recommended in the Spanish and international guidelines and is presented in a simple form so that its use is feasible, either printed out or incorporated into the electronic medical record.1,2 Thus, although these items are familiar to rheumatologists, providing them in an orderly and accessible way that is easy to employ should be an incentive for its implementation. This should contribute to a better control, adaptation of the resources utilized and facilitation of an integrated management of complex patients and serve as a tool to resolve the detected needs.5

The project has several limitations. For example, a possible limitation could be derived from the representativeness of the panelists, making it difficult to generalize and compare the suggested ideas. To avoid these limitations, we contacted rheumatologists from different centers in Spain to ensure demographic representativeness. Another limitation could be derived from the election of the items included in the checklist; although the failure to mention a relevant variable does not appear to be probable, new ones can be defined during every patient visit. We have not performed a real implementation of the checklist to determine whether or not its use is truly feasible and whether it enhances the care of patients with axial SpA, but this will be the object of future projects.

The design of a checklist as a tool for standardization might improve normalization and evaluation in the outpatient clinic. It could lead to a stricter control of the disease, identification of risk profiles and the control of comorbidities in routine clinical practice. At the present time, a project is underway for the introduction and assessment of the use of this checklist.

The project was financed by the Spanish Foundation of Rheumatology.

EL has received funding for research projects from AbbVie, Roche, MSD, Pfizer, Gebro, UCB, Grünenthal, Sobi, Celgene and Eisai. The remaining authors declare they have no conflicts of interest.