Spondyloarthritis (SPA) is a group of rheumatic diseases that share many clinical, radiological, and genetic and epidemiology characteristics, which clearly distinguishes them from other inflammatory diseases of the musculoskeletal system, especially rheumatoid arthritis (RA), which has a pattern that differs by having distinct joint and extraarticular manifestations, absence (seronegative) of serum rheumatoid factor and a strong association with the major histocompatibility antigen class I, HLA-B27, in most cases. Furthermore, there is evidence from studies in humans and in animal models that suggest the involvement of bacteria or bacterial products in its ethiopathogenesis.1

Currently, the group includes ankylosing spondylitis (AS), reactive arthritis, psoriatic arthritis subgroups, arthritis associated with inflammatory bowel disease, a subgroup of juvenile idiopathic arthritis and undifferentiated spondyloarthritis. Its clinical spectrum is broad and heterogeneous, expressed with varying intensity in each of the diseases that make up the group.

The prevalence of ESPA is not low, affecting 1.9% of the general population.2 In Spain, the National Spondyloarthropathy Validation Study3 showed an average prevalence of 13% in patients consulting rheumatology services, ranging from 8% to 16% among the different Spanish regions. It is estimated that the SPA, a young persons disease, involves an average annual loss of 62 working days per patient. In 20% of patients with these diseases, it leads to a career change, another 20% retires from any professional activity, and 27% attains permanent4 disability status. It is therefore a relatively high prevalence diseases and an important social load. However, so far they have not been given the same attention as other rheumatic diseases such as RA and osteoporosis.

Although today there are new classification criteria for an earlier SPA diagnosis,5,6 it is true that until recently diagnostic criteria required the presence of signs which, by their nature, are late, such as radiological sacroiliitis or decreased mobility,7 which could induce delays in diagnosis and limit their use for early diagnosis, among others problems.8 The average delay in diagnosis of SPA in Spain is known from the REGISPONSER project and averages over six years,9 a phenomenon that is similar to other countries.10 This delay is due to both the insidious onset of the disease and the application of criteria which require the presence of “advanced changes” and the fact that SPA are not well-known to the non-specialist, both due to problems of academic training and because sometimes they lack adequate support in rheumatology. Until recent years, early diagnosis may have had less value, given the absence of effective treatment measures. Currently, treatment response in autoimmune diseases has greatly improved and is spreading to SPA. In addition, there are more effective treatments that could alter the progression of structural lesions and progression to ankylosing disease.11

The Spanish Foundation of Rheumatology (FER) in 2009 designed the Esperanza (Hope) Program, a clinical pathway (CP) for early SPA that integrates primary and specialty care, which aims to reduce the variability in clinical practice, facilitating early diagnosis, improved training of general practitioners and specialists, optimizing health resources and stimulating research. Prior to the development of the CP, and after the problems was identified with the launch of a similar program in 2004 for RA (SERAP12 Program), the Spanish Foundation for Rheumatology (FER) conducted a qualitative study to explore the level of knowledge of the CP between primary care physicians (PCP), assessing difficulties in its inception, the motivations and obstacles to the acceptance of a CP, with assessment of knowledge in SPA and evaluating the needs and expectations of primary care in these diseases, in order to incorporate this information in planning programs for management and increasing their chances of success.

The main objective of qualitative research techniques is not to empirically prove the facts, but to analyze and interpret the meanings, motivations and behaviors related to such events. For the purpose of this study, given its exploratory nature, it was considered that the most appropriate technique was conducting focus groups. We developed a typological box to identify the profiles of participating physicians to ensure the diversity of views and the number of groups that would be necessary. A profile of the participants was established that would allow applying surveys to PCP of the national health system, which included different age groups, different number of years in practice, different sexes and diverse population areas (rural and urban). It was also considered necessary to allow groups to know the different situation in terms of geographical area, as there are differences in this respect after the transfer of the management of the health system to autonomous regions. Specifically, it was considered important to understand the systems differing aspects in Basque, Catalan and Andalusian regions. Were conducted 5 focus groups (two in Madrid, two in Barcelona and one in Seville).

The focus groups were composed of between 6 and 8 PCP and held within a week, consecutively, in rooms that were eligible for this type of groups, with a neutral environment in the structurally and symbolically. The speech was recorded entirely in audio and video, transcribed verbatim and analyzed semiologically. In Bilbao, given the difficulty of organizing focus groups with audiovisual recording, three key informants were selected to allow the box to complete the typological profile in terms of age, years of experience, participation and collaboration with the rheumatology CP. Interviewers were experts and followed an index map that reproduced the terms of discussion. Both groups and the interviewers completed the collection of the information when it was confirmed that the recording had been saturated, i.e. when new comments were redundant and added nothing new. The moderation of groups and the interviews were conducted by sociologists and experts outside the project with qualitative techniques, both for data collection and analysis. Semiological analysis was performed with the help of the Nudist Live program identifying categories and codes, using the inductive method.13

There are different motivations for receiving CP plans related to the age and experience of the PCP, which determine two distinct profiles of professionals: (a) young: proactive, entrepreneurial, interested in training and in the activities to improve their resume, interested in new proposals to improve health care and selfless attitude towards financial rewards, (b) Veterans: passive, disillusioned with new health reform proposals, uninterested in training and only incentivized by financial rewards. The “youth” and “seniority” are identified more by the motivations that move the PCP and their degree of “burn out” than biological age.

The motivations for the benefit of those plans were of different types, related with transcendent, intrinsic, extrinsic and/or management aspects.

The intrinsic aspects were of particular value in the profile of the “young” PCP and posed the possibility of training and research, the ability to rotate one month a year in a hospital service and self-satisfaction of a job well done; “It would be very interesting to do training” (Barcelona/Madrid).

“The self-satisfaction of doing a good job as a doctor and thinking about the good of the patient” (Barcelona/Madrid): “It would be nice to rotate one month a year in a hospital service, if you looking for an answer for your query” (Barcelona).