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Of this amount&#44; 22&#46;8&#37; &#40;&#8364;4&#44;641&#46;00&#41; corresponds to direct costs &#40;hospitalisations and pharmacological treatment&#41;&#46; 43&#46;5&#37; &#40;&#8364;8&#44;845&#46;00&#41; corresponds to costs due to home modifications and informal carers and 33&#46;6&#37; &#40;&#8364;6&#44;843&#46;00&#41; to indirect costs&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> Patients with axSpA often experience limitations in their social relationships&#44; especially in the work environment&#44; as they require more time off work&#46; It has been estimated that work productivity losses due to axSpA are equivalent to &#8364;3&#44;851&#47;patient-year&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">As with other chronic immune-mediated inflammatory diseases&#44; diagnosis and treatment involve different specialties and levels of care&#44; and therefore the review of the care process and multidisciplinary treatment has been prioritised to ensure integrated&#44; person-centred care&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In recent years&#44; quality certifications have spread due to their usefulness in reducing unnecessary variability&#44; increasing diagnostic and therapeutic appropriateness&#44; contributing to person-centred care and establishing the basis for making decisions based on the results&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> In diseases such as axSpA&#44; in which diagnostic uncertainty and comorbidities concur&#44; certification can be a tool that contributes to achieving greater efficiency in the therapeutic effort of the different levels&#44; moving towards comprehensive care&#46; These tools are based on the idea that if the means &#40;structure&#41; and organisation &#40;processes&#41; are agreed as adequate and the objectives &#40;results&#41; are clearly set and monitored&#44; the quality of care received by patients will be improved&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">This study was designed to establish the basis for a certification model to help reduce unnecessary clinical variability in specialised axSpA treatment units within rheumatology services&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">Qualitative study that sought to establish by consensus quality standards that could be used in a certification process applying the mixed methodology of self-assessment by the axSpA unit and external assessment &#40;audit&#41;&#44; which was called the SpACE project&#46; The study was conducted between July 2019 and January 2020&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Two face-to-face sessions and up to three rounds via virtual channels were conducted to establish a sufficient degree of consensus to identify relevant&#44; acceptable and responsive quality standards&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Participants</span><p id="par0045" class="elsevierStylePara elsevierViewall">A total of 22 professionals from the specialties of rheumatology&#44; ophthalmology&#44; gastroenterology&#44; traumatology&#44; family medicine&#44; physiotherapy and nursing and 4 experts in quality management and certification systems participated&#46; The selection of participants was based on their specialised training and at least 10 years of previous experience in their field of expertise&#44; taking into account that they have provided care to patients along the axial spondylitis care pathway&#46; All agreed to participate in the study after being informed of the objectives and methodology&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Procedure</span><p id="par0050" class="elsevierStylePara elsevierViewall">First&#44; a pragmatic review was carried out in the PubMed&#44; Scopus&#44; PEDro and Cochrane databases&#44; using the terms&#58; back pain&#44; physical therapy&#44; ankylosing spondyloarthritis&#44; non radiographic axial spondyloarthritis&#44; axial spondyloarthritis&#44; quality of care&#44; costs&#44; service delivery and organisation&#46; We proceeded in the same way with meta-search engines to search for information in grey literature &#40;publications on websites&#44; reports or recommendations produced by scientific societies&#41;&#46; Finally&#44; a mAnnual search was performed on the websites of the following organisations and societies&#58; Ministerio de Sanidad&#44; Consumo y Bienestar Social&#44; Sociedad Espa&#241;ola de Reumatolog&#237;a&#44; European League Against Rheumatism&#44; American College of Rheumathology and National Institute for Health and Care Excellence&#46; Papers potentially relevant to quality assessment or detailing its structure&#44; functions and necessary resources were selected&#46; We also searched for documentation of studies that described the resources use by this type of units in contrast with a non-monographic &#40;standard&#41; consultation&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Secondly&#44; a qualitative consensus study was carried out among expert professionals&#46; This involved two face-to-face sessions and a phase of individual work and discussion by electronic means&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In the first face-to-face session&#44; the participants answered the following questions&#58; how is correct care of the patient with axSpA achieved&#63; are the necessary means available&#63;&#44; is health education carried out&#63;&#44; and what differentiates quality care&#63; Their answers allowed a first draft of quality standards to be established&#44; grouped into dimensions or areas to be explored&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">For each quality standard&#44; name&#44; definition&#44; purpose&#44; standard threshold&#44; numerator&#47;denominator&#44; source of information&#44; method of assessment and bibliography were considered&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Through virtual channels&#44; consensus was sought among the experts to identify those standards that met the requirements of being relevant and measurable from current information systems&#46; In the last face-to-face session&#44; participants reviewed the relevance&#44; feasibility and degree of acceptance of the proposed standard for inclusion in the public health system&#46; A priori consensus was considered to be reached when an indicator was rated higher than 8&#46;0 &#40;scale of 0&#11036;10&#44; with 10 representing high relevance and feasibility&#41;&#46; Finally&#44; the working group discussed the basis of the certification scheme&#44; including&#58; performance-based compliance levels&#44; procedure for self-assessment through a platform &#40;<a href="http://www.space-cert.es/">http&#58;&#47;&#47;www&#46;space-cert&#46;es</a>&#41; and conditions for external assessment &#40;including conditions for the setting up of an auditor panel&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The certification proposal was articulated in 4 levels &#40;non-certified&#44; certified&#44; advanced certified and excellence certified&#41;&#46; To establish this classification the experts considered the difficulties in practice in satisfying each indicator&#44; so that the advanced and excellence certificates represented a higher level of achievement in the direction indicated by each indicator&#46; To achieve the certificate level&#44; it was required to meet the full set of standards at the &#11027;certified&#11069; level&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">As a result of the literature review&#44; 37 possible quality standards were obtained&#46; During the initial session&#44; the expert panel reviewed this initial proposal to define quality standards&#46; At the end of the meeting a total of 32 standards were established to be reviewed by the members of the expert panel&#46; In the discussion phase&#44; 14 standards were agreed upon&#44; which were grouped into 4 dimensions &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; These dimensions ranged from patient assessment to patient satisfaction and safety&#44; multidisciplinary care and treatment outcomes&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The standards corresponded to structure &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#44; care process &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#41; and effectiveness&#44; safety and patient experience outcomes &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#41;&#46; Eleven standards &#40;79&#37; of the certification standards&#41; had to be assessed by auditing a random selection of medical records&#59; the remaining standards to be assessed by the existence or not of documentation or protocols to determine compliance with the criterion&#46; For this phase of certification&#44; it was recommended to apply batch sampling to determine whether the established quality standards were adequately and sufficiently met&#46; The main advantage of this method is that it allows a small number of the total batch to be evaluated in order to accept or reject based on the result&#46; For this process 3<span class="elsevierStyleHsp" style=""></span>h were considered necessary&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The self-assessment will be performed by a coordinator of the centre and will be the result of consensus among the staff of the rheumatology service&#46; The application for quality certification is initiated by registering on the platform &#40;<a href="http://www.space-cert.es/">http&#58;&#47;&#47;www&#46;space-cert&#46;es&#47;</a>&#41; designed ad hoc to capture all the necessary information&#44; including the evidence justifying the self-assessment&#46; The information included on the website corresponds only to the results of the self-assessment and not to patient data&#44; in order to comply with legal regulations&#46; The results of this self-assessment allow the service to apply an internal audit and implement improvement plans or corrective actions when advisable&#46; Finally&#44; the result of the self-assessment is externally contrasted during the external audit process&#44; a review process that is also reflected in the platform&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">A set of relevant&#44; acceptable and sensitive quality standards is presented&#44; agreed upon by rheumatology specialists with complementary profiles&#44; which will lay the foundations for a future certification process for units caring for patients with axSpA&#46; There is no history in the literature of proposals for standards for the certification of units that care for patients with axSpA&#46; SpACE certification can contribute to homogenising clinical variability in the different axSpA services and achieve the implementation of the minimum necessary to care for people with this diseased&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The methodology used is similar to that used in other studies with similar objectives&#44; although focused on other rheumatologic diseases&#44; such as the case of psoriatic arthritis with the so-called QUANTUM project&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The certification of care units has been linked to improvements in quality of care and prognosis of new onset by facilitating early diagnosis and treatment&#44; optimising the use of resources &#40;both human and material&#41; for routine clinical practice in the medium and long term&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> The provision of multidisciplinary care involving different professionals is linked to better clinical outcome&#46; Other studies have shown an increase in quality of life and well-being with nursing consultations to assess inflammatory activity&#44; and improved health education&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">This approach&#44; in addition to reducing unnecessary variability&#44; has other advantages&#46; First&#44; it can be expected to contribute to the provision of agreed minimum resource requirements and to the establishment of a greater number of specialised units in hospitals&#46; Second&#44; it should promote the identification of areas for improvement in services&#44; or what corrective actions need to be implemented&#44; to provide better value care&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a> Third&#44; it stimulates improvements in outcomes by establishing benchmarking systems linked to the external recognition that comes with quality certification&#46; Finally&#44; having units recognised by third parties makes it easier for them to participate in national and international clinical trials&#44; as they have a proven structure and operating processes&#44; allowing comparison of results&#46;</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Limitations</span><p id="par0115" class="elsevierStylePara elsevierViewall">This proposal has been developed within the framework of the Spanish health system&#46; The proposed standards may not be generalised to other countries&#46; The planned self-assessment and external evaluation require a pilot study to test the operability of the procedure and the application designed to facilitate this certification&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0120" class="elsevierStylePara elsevierViewall">In conclusion&#44; SpACE is a proposal for a certification standard&#44; the result of consensus&#44; which seeks to ensure the necessary basic equipment and improve organisational processes&#44; coordination between levels and health outcomes for patients diagnosed with axSpA&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Funding</span><p id="par0125" class="elsevierStylePara elsevierViewall">Novartis funded this research project&#46; No Novartis employees were involved in the design&#44; execution&#44; data capture&#44; interpretation of results and drawing of conclusions of this study&#46; Responsibility for the study rests entirely with the authors&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interests</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Axial spondyloarthritis is an immune-mediated disease with a high cost&#44; diagnostic delay and associated complications that makes it a particularly important condition&#46; This work aims to establish a certification standard &#40;SpACE Project&#41; for monographic consultations in its diagnosis and treatment&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Qualitative study of consensus&#44; through the technique of the nominal group&#46; First&#44; a pragmatic review of the literature was carried out&#46; Second&#44; professionals involved throughout the care process &#40;rheumatology&#44; ophthalmology&#44; gastroenterology&#44; traumatology&#44; family medicine&#44; physical therapy&#44; and nursing&#41; were included&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Thirty-seven possible standards were extracted from the pragmatic review of the literature&#46; During the consensus phase only those standards with high feasibility and importance in the care process were prioritized&#46; Finally&#44; the group of 26 experts agreed on the inclusion of 14 standards&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion and conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">SpACE is a consensus-based certification standard that seeks to improve health outcomes and more integrated care&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La espondiloartritis axial es una enfermedad inmunomediada con un elevado coste&#44; retraso diagn&#243;stico y complicaciones asociadas&#44; lo que la convierte en una enfermedad con especial importancia&#46; Este trabajo busca por consenso establecer un modelo de certificaci&#243;n &#40;Proyecto SpACE&#41; para consultas monogr&#225;ficas en su diagn&#243;stico y tratamiento&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio cualitativo de consenso&#44; a trav&#233;s de la t&#233;cnica del grupo nominal&#46; Primero&#44; fue realizada una revisi&#243;n pragm&#225;tica de la literatura&#46; Segundo&#44; fueron incluidos profesionales involucrados a lo largo del proceso asistencial &#40;reumatolog&#237;a&#44; oftalmolog&#237;a&#44; gastroenterolog&#237;a&#44; traumatolog&#237;a&#44; medicina de familia&#44; fisioterapia y enfermer&#237;a&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Producto de la revisi&#243;n pragm&#225;tica de la literatura fueron extra&#237;dos 37 posibles est&#225;ndares&#46; Durante la fase de consenso solo aquellos est&#225;ndares con una elevada factibilidad e importancia en el proceso asistencial fueron priorizados&#46; Finalmente&#44; el grupo de 26 expertos acord&#243; la inclusi&#243;n de 14 est&#225;ndares&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discusi&#243;n y conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">SpaCE es una norma de certificaci&#243;n&#44; fruto del consenso&#44; que busca mejorar los resultados en salud y una atenci&#243;n m&#225;s integrada&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Garc&#237;a EI&#44; Martin-Delgado J&#44; Queiro R&#44; P&#233;rez Venegas JJ&#44; Gratacos J&#44; Sanz J&#44; et al&#46; Propuesta de norma de certificaci&#243;n de calidad &#171;SpACE&#187; para unidades de tratamiento de pacientes con espondiloartritis axial&#46; Reumatol Clin&#46; 2022&#59;18&#58;299&#11036;303&#46;</p>"
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            "apendice" => "<p id="par0135" class="elsevierStylePara elsevierViewall">SpACE Workgroup&#58; Dr&#46; Ceferino Barbazan &#40;Complejo Hospitalario Universitario de Vigo&#41;&#44; Dr&#46; Fern&#225;ndez Nebro &#40;Hospital General de M&#225;laga&#41;&#44; Dr&#46; Enrique Raya &#40;Hospital Cl&#237;nico San Cecilio de Granada&#41;&#44; Dr&#46; Fernando Rodriguez &#40;Hospital Virgen de la Arrixaca&#41;&#44; Dr&#46; Rom&#225;n Ivorra &#40;Hospital La Fe&#41;&#44; Dra&#46; Emma Beltr&#225;n &#40;Hospital del Mar&#41;&#44; Dr&#46; Carlos Rodriguez Lozano &#40;Hospital Universitario de Gran Canaria Doctor Negr&#237;n&#41;&#44; Dr&#46; Pedro Zarco &#40;Hospital Universitario Fundaci&#243;n Alcorc&#243;n&#41;&#44; Dr&#46; Francisco Javier de Toro &#40;Hospital Universitario de A Coru&#241;a&#41;&#44; Dr&#46; Cristina Fern&#225;ndez Carballido &#40;Hospital Universitario de San Juan de Alicante&#41;&#44; Dr&#46; Xavier Juanola &#40;Hospital de Bellvitge&#41;&#44; Dr&#46; Ignacio Mar&#237;n &#40;Hospital Gregorio Mara&#241;&#243;n&#41;&#44; Dr&#46; Isaac Alarc&#243;n Valero &#40;Parc de Salut Mar&#41;&#44; Dr&#46; Iago Garreta &#40;Hospital de Bellvitge&#41;&#44; Dr&#46; &#253;ngel Bueno &#40;Hospital Universitario Fundaci&#243;n Alcorc&#243;n&#41;&#44; Dr&#46; Juan Ignacio Exp&#243;sito &#40;Hospital Universitario Puerta del Mar&#41;&#44; Ms&#46; Gloria Gonzalez &#40;Universidad de C&#225;diz&#41;&#44; Ms&#46; Lidia Valencia &#40;Hospital de Bellvitge&#41;&#46;</p>"
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Standard&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dimension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Category&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Level&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Definition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Periodicity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Assessment method&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Delay to care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Coordination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Care for patients with suspected inflammatory back pain indicative of a diagnosis of axSpA should not exceed 45 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Referral for rheumatology consultation of patients with suspected axSpA in the previous 6 months will be analysed by the assessor&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consultation with primary care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Coordination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Process&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Advanced certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">There will be channels for consultation established between the 2 services to establish communications&#44; either face-to-face or telematic to support the early diagnosis of the disease&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Annual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The assessor will analyse the evidence provided by the rheumatology service that demonstrates the existence of a stable consultancy system&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment by a pain scale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment and treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In the anamnesis of all patients with a suspected diagnosis of axSpA or already diagnosed and under follow-up&#44; a scale will be applied to assess the degree of pain perceived by the patient&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Each consultation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The assessor shall analyse the existence of an assessment of the presence of pain through the application of objective measures such as BASDAI&#44; EVA or ASDAS&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment of functional capacity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment and treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Advanced certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In patients with suspected axSpA and in their follow-up by the rheumatologist&#44; an adult functional capacity assessment scale will be applied in the anamnesis of all patients attending consultation&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The assessor will check for the presence of an assessment of functional ability using the BASFI scale&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment of spinal mobility&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment and treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In patients with suspected axSpA and in their follow-up by the rheumatologist&#44; assessment of spinal mobility should be recorded in the patient&#39;s history&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The presence of an assessment of spinal mobility shall be analysed by the assessor&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinimetry and assessment of the patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment and treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Excellence certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Proportion of patients with axSpA followed up in the clinic with a complete clinical evaluation&#44; including questionnaires with the patient&#39;s perspective&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The assessor will analyse the medical history for evidence of spondylometry&#44; assessment of pain&#44; fatigue and mobility using scales&#44; as well as peripheral joint counts in mixed forms and extra-articular manifestation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment of remission or low activity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment and treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Proportion of patients with axSpA achieving remission or low activity with therapeutic regimes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The presence of a remission or low activity phase &#40;BASDAI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>4 and&#47;or ASDAS-PCR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>2&#44;1 or an alternative measure&#41; in patients with a therapeutic plan of more than 6 months duration shall be analysed by the assessor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment of extraarticular manifestations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment and treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In patients with suspected axSpA and in the follow-up of those already diagnosed&#44; the presence of extra-articular manifestations will be assessed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Each consultation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The assessor shall analyse whether the presence of extra-articular manifestations has been evaluated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Access to magnetic resonance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Coordination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Structure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Excellence certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The rheumatology service will have direct access to request MRI tests to confirm&#47;rule out the presence of sacroiliitis and spondylitis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Six-monthly&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The number of requests made before 30 days shall be analysed by the assessor taking into consideration the total of the specific agenda of sacroiliac MRI requests&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Radiographic follow-up of axSpA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment and treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Advanced certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients with axSpA should have regular radiographic follow-up to assess structural damage based on disease activity and severity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Annual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The assessor shall analyse the radiographic follow-up&#44; understood as the existence of compliance with the baseline radiographic protocol and its follow-up compliance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multidisciplinary care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Coordination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Process&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A multidisciplinary care protocol will exist in the rheumatology department&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Annual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The assessor shall verify the existence of a multidisciplinary care protocol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Education in health plans&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Person and patient safety-centred care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Outcome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Advanced certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Proportion of diagnosed patients with axSpAa who receive health education&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Annual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The assessor shall analyse the presence of an assessment&#44; preferably by the nurses&#44; through a specific health education programme&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patient satisfaction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Person and patient safety-centred care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Outcome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Excellence certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Systematic collection of patient satisfaction with the process of care for axSpA by the rheumatology department&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Annual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The assessor should verify the completion of patient satisfaction surveys &#40;and 80&#37; shall score &#11301;4 on 5-step scales&#41; by the rheumatology service to its users&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Adverse event reporting system&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Person and patient safety-centred care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Process&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Excellence certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rheumatology professionals should actively participate in the reporting of safety incidents in the adverse event reporting system established in the centre&#44; the SiNAPS programme&#44; which allows preventive measures to be taken to avoid new incidents in the future due to the same causes&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Annual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The existence of the reporting system and its outcomes shall be analysed by the assessor&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Standards for the certification of treatment units for patients with axial spondyloarthritis&#46;</p>"
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                    0 => array:2 [
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                        0 => array:2 [
                          "etal" => true
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                            0 => "S&#46; Mu&#241;oz-Fern&#225;ndez"
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                            2 => "T&#46; Cobo-Ib&#225;&#241;ez"
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                          "etal" => false
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                      "titulo" => "Impact of comorbidity on physical function in patients with ankylosing spondylitis and psoriatic arthritis attending rheumatology clinics&#58; results from a cross-sectional study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Fern&#225;ndez-Carballido"
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                            2 => "C&#46; Garc&#237;a-G&#243;mez"
                            3 => "S&#46; Casta&#241;eda"
                            4 => "C&#46; Gonz&#225;lez-Juanatey"
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                      "Revista" => array:5 [
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                      "titulo" => "The journey of the non-radiographic axial spondyloarthritis patient&#58; the perspective of professionals and patients"
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                        0 => array:2 [
                          "etal" => false
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                  ]
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                    0 => array:2 [
                      "doi" => "10.1007/s10067-020-05269-z"
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                        "tituloSerie" => "Clin Rheumatol"
                        "fecha" => "2021"
                        "volumen" => "40"
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                        "paginaFinal" => "600"
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                0 => array:2 [
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                      "titulo" => "Management of psoriasis and psoriatic arthritis in a combined dermatology and rheumatology clinic"
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                          "etal" => false
                          "autores" => array:5 [
                            0 => "N&#46;F&#46; Velez"
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                            3 => "E&#46;A&#46; Mody"
                            4 => "A&#46;A&#46; Qureshi"
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                    0 => array:2 [
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                      "titulo" => "The burden of ankylosing spondylitis in Spain"
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                          "etal" => false
                          "autores" => array:6 [
                            0 => "G&#46; Kobelt"
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                            2 => "J&#46; Mulero"
                            3 => "J&#46; Gratacos"
                            4 => "A&#46; Pocovi"
                            5 => "E&#46; Collantes-Estevez"
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Quality certification standard proposal ⬓SpACE⬽ for axial spondyloarthritis treatment units
Propuesta de norma de certificación de calidad «SpACE» para unidades de tratamiento de pacientes con espondiloartritis axial
Emilio Ignacio Garcíaa, Jimmy Martin-Delgadob,
Corresponding author
jimmy.martind@umh.es

Corresponding author.
, Ruben Queiroc, José Javier Pérez Venegasd, Jordi Gratacose, Jesús Sanzf, Antonio Torrésg, José Joaquín Mirah,i,j, on behalf of the Grupo SpaCE
a Universidad de Cádiz, Cádiz, Spain
b Grupo de Investigación Atenea, Fundación para el Fomento de la Investigación Sanitaria y Biomédica (FISABIO), Sant Joan d⬢Alacant, Alicante, Spain
c Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
d Hospital Universitario Virgen Macarena, Sevilla, Spain
e Consorci Corporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain
f Hospital Puerta de Hierro, Majadahonda, Madrid, Spain
g Sociedad Española de Calidad Asistencial, Oviedo, Spain
h Departamento de Salud Alicante-Sant Joan d⬢Alacant, Sant Joan d⬢Alacant, Alicante, Spain
i Universidad Miguel Hernández, Elche, Alicante, Spain
j Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Alicante, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Axial spondyloarthritis &#40;axSpA&#41; is a chronic inflammatory disease that characteristically affects the sacroiliac and spine joints&#44; causing pain and functional limitation&#46; It is a chronic form of arthritis with an estimated incidence of 7 new cases per 100&#44;000 populationa&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">AxSpA has its onset between the ages of 20 and 40&#44; with an evolution in flare-ups of inflammation of the joints of the spine&#44; or of other joints such as the shoulders&#44; hips&#44; knees or ankles&#46; Patients with this condition have a high number of concomitant diseases&#44; such as uveitis&#44; psoriasis or inflammatory bowel disease&#44; as well as comorbidities such as osteoporosis&#44; obesity&#44; hypertension&#44; hypercholesterolemia&#44; anxiety&#44; depression&#44; sleep disorders or fibromyalgia&#59; all of which can impair their functional capacity and quality of life&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2&#11036;6</span></a> In most cases&#44; the diagnosis of axSpA is delayed mainly due to its insidious onset&#44; its low prevalence and the fact that it is not always recognised by the non-rheumatology physician&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> This delay may prevent treatment in the early stages and may be responsible for aggravation of the disease&#44; increased structural damage and loss of mobility&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The estimated total annual cost per patient with axSpA is &#8364;20&#44;328&#46;00&#46; Of this amount&#44; 22&#46;8&#37; &#40;&#8364;4&#44;641&#46;00&#41; corresponds to direct costs &#40;hospitalisations and pharmacological treatment&#41;&#46; 43&#46;5&#37; &#40;&#8364;8&#44;845&#46;00&#41; corresponds to costs due to home modifications and informal carers and 33&#46;6&#37; &#40;&#8364;6&#44;843&#46;00&#41; to indirect costs&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> Patients with axSpA often experience limitations in their social relationships&#44; especially in the work environment&#44; as they require more time off work&#46; It has been estimated that work productivity losses due to axSpA are equivalent to &#8364;3&#44;851&#47;patient-year&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">As with other chronic immune-mediated inflammatory diseases&#44; diagnosis and treatment involve different specialties and levels of care&#44; and therefore the review of the care process and multidisciplinary treatment has been prioritised to ensure integrated&#44; person-centred care&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In recent years&#44; quality certifications have spread due to their usefulness in reducing unnecessary variability&#44; increasing diagnostic and therapeutic appropriateness&#44; contributing to person-centred care and establishing the basis for making decisions based on the results&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> In diseases such as axSpA&#44; in which diagnostic uncertainty and comorbidities concur&#44; certification can be a tool that contributes to achieving greater efficiency in the therapeutic effort of the different levels&#44; moving towards comprehensive care&#46; These tools are based on the idea that if the means &#40;structure&#41; and organisation &#40;processes&#41; are agreed as adequate and the objectives &#40;results&#41; are clearly set and monitored&#44; the quality of care received by patients will be improved&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">This study was designed to establish the basis for a certification model to help reduce unnecessary clinical variability in specialised axSpA treatment units within rheumatology services&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">Qualitative study that sought to establish by consensus quality standards that could be used in a certification process applying the mixed methodology of self-assessment by the axSpA unit and external assessment &#40;audit&#41;&#44; which was called the SpACE project&#46; The study was conducted between July 2019 and January 2020&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Two face-to-face sessions and up to three rounds via virtual channels were conducted to establish a sufficient degree of consensus to identify relevant&#44; acceptable and responsive quality standards&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Participants</span><p id="par0045" class="elsevierStylePara elsevierViewall">A total of 22 professionals from the specialties of rheumatology&#44; ophthalmology&#44; gastroenterology&#44; traumatology&#44; family medicine&#44; physiotherapy and nursing and 4 experts in quality management and certification systems participated&#46; The selection of participants was based on their specialised training and at least 10 years of previous experience in their field of expertise&#44; taking into account that they have provided care to patients along the axial spondylitis care pathway&#46; All agreed to participate in the study after being informed of the objectives and methodology&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Procedure</span><p id="par0050" class="elsevierStylePara elsevierViewall">First&#44; a pragmatic review was carried out in the PubMed&#44; Scopus&#44; PEDro and Cochrane databases&#44; using the terms&#58; back pain&#44; physical therapy&#44; ankylosing spondyloarthritis&#44; non radiographic axial spondyloarthritis&#44; axial spondyloarthritis&#44; quality of care&#44; costs&#44; service delivery and organisation&#46; We proceeded in the same way with meta-search engines to search for information in grey literature &#40;publications on websites&#44; reports or recommendations produced by scientific societies&#41;&#46; Finally&#44; a mAnnual search was performed on the websites of the following organisations and societies&#58; Ministerio de Sanidad&#44; Consumo y Bienestar Social&#44; Sociedad Espa&#241;ola de Reumatolog&#237;a&#44; European League Against Rheumatism&#44; American College of Rheumathology and National Institute for Health and Care Excellence&#46; Papers potentially relevant to quality assessment or detailing its structure&#44; functions and necessary resources were selected&#46; We also searched for documentation of studies that described the resources use by this type of units in contrast with a non-monographic &#40;standard&#41; consultation&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Secondly&#44; a qualitative consensus study was carried out among expert professionals&#46; This involved two face-to-face sessions and a phase of individual work and discussion by electronic means&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In the first face-to-face session&#44; the participants answered the following questions&#58; how is correct care of the patient with axSpA achieved&#63; are the necessary means available&#63;&#44; is health education carried out&#63;&#44; and what differentiates quality care&#63; Their answers allowed a first draft of quality standards to be established&#44; grouped into dimensions or areas to be explored&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">For each quality standard&#44; name&#44; definition&#44; purpose&#44; standard threshold&#44; numerator&#47;denominator&#44; source of information&#44; method of assessment and bibliography were considered&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Through virtual channels&#44; consensus was sought among the experts to identify those standards that met the requirements of being relevant and measurable from current information systems&#46; In the last face-to-face session&#44; participants reviewed the relevance&#44; feasibility and degree of acceptance of the proposed standard for inclusion in the public health system&#46; A priori consensus was considered to be reached when an indicator was rated higher than 8&#46;0 &#40;scale of 0&#11036;10&#44; with 10 representing high relevance and feasibility&#41;&#46; Finally&#44; the working group discussed the basis of the certification scheme&#44; including&#58; performance-based compliance levels&#44; procedure for self-assessment through a platform &#40;<a href="http://www.space-cert.es/">http&#58;&#47;&#47;www&#46;space-cert&#46;es</a>&#41; and conditions for external assessment &#40;including conditions for the setting up of an auditor panel&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The certification proposal was articulated in 4 levels &#40;non-certified&#44; certified&#44; advanced certified and excellence certified&#41;&#46; To establish this classification the experts considered the difficulties in practice in satisfying each indicator&#44; so that the advanced and excellence certificates represented a higher level of achievement in the direction indicated by each indicator&#46; To achieve the certificate level&#44; it was required to meet the full set of standards at the &#11027;certified&#11069; level&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">As a result of the literature review&#44; 37 possible quality standards were obtained&#46; During the initial session&#44; the expert panel reviewed this initial proposal to define quality standards&#46; At the end of the meeting a total of 32 standards were established to be reviewed by the members of the expert panel&#46; In the discussion phase&#44; 14 standards were agreed upon&#44; which were grouped into 4 dimensions &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; These dimensions ranged from patient assessment to patient satisfaction and safety&#44; multidisciplinary care and treatment outcomes&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The standards corresponded to structure &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#44; care process &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#41; and effectiveness&#44; safety and patient experience outcomes &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#41;&#46; Eleven standards &#40;79&#37; of the certification standards&#41; had to be assessed by auditing a random selection of medical records&#59; the remaining standards to be assessed by the existence or not of documentation or protocols to determine compliance with the criterion&#46; For this phase of certification&#44; it was recommended to apply batch sampling to determine whether the established quality standards were adequately and sufficiently met&#46; The main advantage of this method is that it allows a small number of the total batch to be evaluated in order to accept or reject based on the result&#46; For this process 3<span class="elsevierStyleHsp" style=""></span>h were considered necessary&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The self-assessment will be performed by a coordinator of the centre and will be the result of consensus among the staff of the rheumatology service&#46; The application for quality certification is initiated by registering on the platform &#40;<a href="http://www.space-cert.es/">http&#58;&#47;&#47;www&#46;space-cert&#46;es&#47;</a>&#41; designed ad hoc to capture all the necessary information&#44; including the evidence justifying the self-assessment&#46; The information included on the website corresponds only to the results of the self-assessment and not to patient data&#44; in order to comply with legal regulations&#46; The results of this self-assessment allow the service to apply an internal audit and implement improvement plans or corrective actions when advisable&#46; Finally&#44; the result of the self-assessment is externally contrasted during the external audit process&#44; a review process that is also reflected in the platform&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">A set of relevant&#44; acceptable and sensitive quality standards is presented&#44; agreed upon by rheumatology specialists with complementary profiles&#44; which will lay the foundations for a future certification process for units caring for patients with axSpA&#46; There is no history in the literature of proposals for standards for the certification of units that care for patients with axSpA&#46; SpACE certification can contribute to homogenising clinical variability in the different axSpA services and achieve the implementation of the minimum necessary to care for people with this diseased&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The methodology used is similar to that used in other studies with similar objectives&#44; although focused on other rheumatologic diseases&#44; such as the case of psoriatic arthritis with the so-called QUANTUM project&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The certification of care units has been linked to improvements in quality of care and prognosis of new onset by facilitating early diagnosis and treatment&#44; optimising the use of resources &#40;both human and material&#41; for routine clinical practice in the medium and long term&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> The provision of multidisciplinary care involving different professionals is linked to better clinical outcome&#46; Other studies have shown an increase in quality of life and well-being with nursing consultations to assess inflammatory activity&#44; and improved health education&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">This approach&#44; in addition to reducing unnecessary variability&#44; has other advantages&#46; First&#44; it can be expected to contribute to the provision of agreed minimum resource requirements and to the establishment of a greater number of specialised units in hospitals&#46; Second&#44; it should promote the identification of areas for improvement in services&#44; or what corrective actions need to be implemented&#44; to provide better value care&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a> Third&#44; it stimulates improvements in outcomes by establishing benchmarking systems linked to the external recognition that comes with quality certification&#46; Finally&#44; having units recognised by third parties makes it easier for them to participate in national and international clinical trials&#44; as they have a proven structure and operating processes&#44; allowing comparison of results&#46;</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Limitations</span><p id="par0115" class="elsevierStylePara elsevierViewall">This proposal has been developed within the framework of the Spanish health system&#46; The proposed standards may not be generalised to other countries&#46; The planned self-assessment and external evaluation require a pilot study to test the operability of the procedure and the application designed to facilitate this certification&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0120" class="elsevierStylePara elsevierViewall">In conclusion&#44; SpACE is a proposal for a certification standard&#44; the result of consensus&#44; which seeks to ensure the necessary basic equipment and improve organisational processes&#44; coordination between levels and health outcomes for patients diagnosed with axSpA&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Funding</span><p id="par0125" class="elsevierStylePara elsevierViewall">Novartis funded this research project&#46; No Novartis employees were involved in the design&#44; execution&#44; data capture&#44; interpretation of results and drawing of conclusions of this study&#46; Responsibility for the study rests entirely with the authors&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interests</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Material and methods"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Participants"
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            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Procedure"
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          ]
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        6 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Results"
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        7 => array:3 [
          "identificador" => "sec0030"
          "titulo" => "Discussion"
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            0 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Limitations"
            ]
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        8 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Conclusions"
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        9 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Funding"
        ]
        10 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Conflict of interests"
        ]
        11 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2020-11-09"
    "fechaAceptado" => "2021-04-05"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1511760"
          "palabras" => array:3 [
            0 => "Spondyloarthritis"
            1 => "Accreditation"
            2 => "Quality assurance of health care"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1511759"
          "palabras" => array:3 [
            0 => "Espondiloartritis"
            1 => "Acreditaci&#243;n"
            2 => "Garant&#237;a de la calidad de atenci&#243;n de salud"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Axial spondyloarthritis is an immune-mediated disease with a high cost&#44; diagnostic delay and associated complications that makes it a particularly important condition&#46; This work aims to establish a certification standard &#40;SpACE Project&#41; for monographic consultations in its diagnosis and treatment&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Qualitative study of consensus&#44; through the technique of the nominal group&#46; First&#44; a pragmatic review of the literature was carried out&#46; Second&#44; professionals involved throughout the care process &#40;rheumatology&#44; ophthalmology&#44; gastroenterology&#44; traumatology&#44; family medicine&#44; physical therapy&#44; and nursing&#41; were included&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Thirty-seven possible standards were extracted from the pragmatic review of the literature&#46; During the consensus phase only those standards with high feasibility and importance in the care process were prioritized&#46; Finally&#44; the group of 26 experts agreed on the inclusion of 14 standards&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion and conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">SpACE is a consensus-based certification standard that seeks to improve health outcomes and more integrated care&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background and objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Materials and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Discussion and conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La espondiloartritis axial es una enfermedad inmunomediada con un elevado coste&#44; retraso diagn&#243;stico y complicaciones asociadas&#44; lo que la convierte en una enfermedad con especial importancia&#46; Este trabajo busca por consenso establecer un modelo de certificaci&#243;n &#40;Proyecto SpACE&#41; para consultas monogr&#225;ficas en su diagn&#243;stico y tratamiento&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio cualitativo de consenso&#44; a trav&#233;s de la t&#233;cnica del grupo nominal&#46; Primero&#44; fue realizada una revisi&#243;n pragm&#225;tica de la literatura&#46; Segundo&#44; fueron incluidos profesionales involucrados a lo largo del proceso asistencial &#40;reumatolog&#237;a&#44; oftalmolog&#237;a&#44; gastroenterolog&#237;a&#44; traumatolog&#237;a&#44; medicina de familia&#44; fisioterapia y enfermer&#237;a&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Producto de la revisi&#243;n pragm&#225;tica de la literatura fueron extra&#237;dos 37 posibles est&#225;ndares&#46; Durante la fase de consenso solo aquellos est&#225;ndares con una elevada factibilidad e importancia en el proceso asistencial fueron priorizados&#46; Finalmente&#44; el grupo de 26 expertos acord&#243; la inclusi&#243;n de 14 est&#225;ndares&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discusi&#243;n y conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">SpaCE es una norma de certificaci&#243;n&#44; fruto del consenso&#44; que busca mejorar los resultados en salud y una atenci&#243;n m&#225;s integrada&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Antecedentes y objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Materiales y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Discusi&#243;n y conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:2 [
      0 => array:3 [
        "etiqueta" => "&#9504;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The names of the SpACE group members are listed in <a class="elsevierStyleCrossRef" href="#sec0055">Appendix A</a>&#46;</p>"
        "identificador" => "fn0005"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Garc&#237;a EI&#44; Martin-Delgado J&#44; Queiro R&#44; P&#233;rez Venegas JJ&#44; Gratacos J&#44; Sanz J&#44; et al&#46; Propuesta de norma de certificaci&#243;n de calidad &#171;SpACE&#187; para unidades de tratamiento de pacientes con espondiloartritis axial&#46; Reumatol Clin&#46; 2022&#59;18&#58;299&#11036;303&#46;</p>"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:3 [
            "apendice" => "<p id="par0135" class="elsevierStylePara elsevierViewall">SpACE Workgroup&#58; Dr&#46; Ceferino Barbazan &#40;Complejo Hospitalario Universitario de Vigo&#41;&#44; Dr&#46; Fern&#225;ndez Nebro &#40;Hospital General de M&#225;laga&#41;&#44; Dr&#46; Enrique Raya &#40;Hospital Cl&#237;nico San Cecilio de Granada&#41;&#44; Dr&#46; Fernando Rodriguez &#40;Hospital Virgen de la Arrixaca&#41;&#44; Dr&#46; Rom&#225;n Ivorra &#40;Hospital La Fe&#41;&#44; Dra&#46; Emma Beltr&#225;n &#40;Hospital del Mar&#41;&#44; Dr&#46; Carlos Rodriguez Lozano &#40;Hospital Universitario de Gran Canaria Doctor Negr&#237;n&#41;&#44; Dr&#46; Pedro Zarco &#40;Hospital Universitario Fundaci&#243;n Alcorc&#243;n&#41;&#44; Dr&#46; Francisco Javier de Toro &#40;Hospital Universitario de A Coru&#241;a&#41;&#44; Dr&#46; Cristina Fern&#225;ndez Carballido &#40;Hospital Universitario de San Juan de Alicante&#41;&#44; Dr&#46; Xavier Juanola &#40;Hospital de Bellvitge&#41;&#44; Dr&#46; Ignacio Mar&#237;n &#40;Hospital Gregorio Mara&#241;&#243;n&#41;&#44; Dr&#46; Isaac Alarc&#243;n Valero &#40;Parc de Salut Mar&#41;&#44; Dr&#46; Iago Garreta &#40;Hospital de Bellvitge&#41;&#44; Dr&#46; &#253;ngel Bueno &#40;Hospital Universitario Fundaci&#243;n Alcorc&#243;n&#41;&#44; Dr&#46; Juan Ignacio Exp&#243;sito &#40;Hospital Universitario Puerta del Mar&#41;&#44; Ms&#46; Gloria Gonzalez &#40;Universidad de C&#225;diz&#41;&#44; Ms&#46; Lidia Valencia &#40;Hospital de Bellvitge&#41;&#46;</p>"
            "etiqueta" => "Appendix A"
            "identificador" => "sec0055"
          ]
        ]
      ]
    ]
    "multimedia" => array:1 [
      0 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Standard&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dimension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Category&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Level&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Definition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Periodicity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Assessment method&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Delay to care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Coordination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Care for patients with suspected inflammatory back pain indicative of a diagnosis of axSpA should not exceed 45 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Referral for rheumatology consultation of patients with suspected axSpA in the previous 6 months will be analysed by the assessor&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consultation with primary care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Coordination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Process&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Advanced certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">There will be channels for consultation established between the 2 services to establish communications&#44; either face-to-face or telematic to support the early diagnosis of the disease&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Annual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The assessor will analyse the evidence provided by the rheumatology service that demonstrates the existence of a stable consultancy system&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment by a pain scale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment and treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In the anamnesis of all patients with a suspected diagnosis of axSpA or already diagnosed and under follow-up&#44; a scale will be applied to assess the degree of pain perceived by the patient&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Each consultation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The assessor shall analyse the existence of an assessment of the presence of pain through the application of objective measures such as BASDAI&#44; EVA or ASDAS&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment of functional capacity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment and treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Advanced certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In patients with suspected axSpA and in their follow-up by the rheumatologist&#44; an adult functional capacity assessment scale will be applied in the anamnesis of all patients attending consultation&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The assessor will check for the presence of an assessment of functional ability using the BASFI scale&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment of spinal mobility&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment and treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In patients with suspected axSpA and in their follow-up by the rheumatologist&#44; assessment of spinal mobility should be recorded in the patient&#39;s history&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The presence of an assessment of spinal mobility shall be analysed by the assessor&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinimetry and assessment of the patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment and treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Excellence certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Proportion of patients with axSpA followed up in the clinic with a complete clinical evaluation&#44; including questionnaires with the patient&#39;s perspective&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The assessor will analyse the medical history for evidence of spondylometry&#44; assessment of pain&#44; fatigue and mobility using scales&#44; as well as peripheral joint counts in mixed forms and extra-articular manifestation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment of remission or low activity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment and treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Proportion of patients with axSpA achieving remission or low activity with therapeutic regimes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The presence of a remission or low activity phase &#40;BASDAI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>4 and&#47;or ASDAS-PCR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>2&#44;1 or an alternative measure&#41; in patients with a therapeutic plan of more than 6 months duration shall be analysed by the assessor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment of extraarticular manifestations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment and treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In patients with suspected axSpA and in the follow-up of those already diagnosed&#44; the presence of extra-articular manifestations will be assessed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Each consultation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The assessor shall analyse whether the presence of extra-articular manifestations has been evaluated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Access to magnetic resonance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Coordination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Structure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Excellence certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The rheumatology service will have direct access to request MRI tests to confirm&#47;rule out the presence of sacroiliitis and spondylitis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Six-monthly&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The number of requests made before 30 days shall be analysed by the assessor taking into consideration the total of the specific agenda of sacroiliac MRI requests&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Radiographic follow-up of axSpA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessment and treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Advanced certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients with axSpA should have regular radiographic follow-up to assess structural damage based on disease activity and severity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Annual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The assessor shall analyse the radiographic follow-up&#44; understood as the existence of compliance with the baseline radiographic protocol and its follow-up compliance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multidisciplinary care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Coordination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Process&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A multidisciplinary care protocol will exist in the rheumatology department&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Annual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The assessor shall verify the existence of a multidisciplinary care protocol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Education in health plans&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Person and patient safety-centred care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Outcome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Advanced certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Proportion of diagnosed patients with axSpAa who receive health education&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Annual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The assessor shall analyse the presence of an assessment&#44; preferably by the nurses&#44; through a specific health education programme&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patient satisfaction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Person and patient safety-centred care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Outcome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Excellence certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Systematic collection of patient satisfaction with the process of care for axSpA by the rheumatology department&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Annual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The assessor should verify the completion of patient satisfaction surveys &#40;and 80&#37; shall score &#11301;4 on 5-step scales&#41; by the rheumatology service to its users&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Adverse event reporting system&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Person and patient safety-centred care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Process&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Excellence certified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rheumatology professionals should actively participate in the reporting of safety incidents in the adverse event reporting system established in the centre&#44; the SiNAPS programme&#44; which allows preventive measures to be taken to avoid new incidents in the future due to the same causes&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Annual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The existence of the reporting system and its outcomes shall be analysed by the assessor&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2902548.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Standards for the certification of treatment units for patients with axial spondyloarthritis&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
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Idiomas
Reumatología Clínica (English Edition)
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