Axial Spondyloarthritis (SpA) is a chronic inflammatory disease that primarily affects the spine and sacroiliac joints, which basically evolves from an unaffected form (non radiological axial SpA) to another with radiographic sacroiliitis (ankylosing spondylitis [SA]) and can be known using on conventional X-rays.1,2

It has been estimated that its prevalence is about 0.7%.3 It is a known fact that the disease commonly debuts insidiously, usually before 40 years of age, with chronic inflammatory low back pain. Axial SpA and AS can be diagnosed using a series of simple clinical and radiological criteria, based on the HLA B27. However, it can take between 7 and 9 years after the onset of symptoms until a diagnosis is established.4,5

This delay in diagnosis leads to a delay in establishing the most appropriate treatment for each patient and the adverse consequences of untreated disease may diminish the quality of life of the patient, causing prolonged sick leave and increasing the economic burden of the process, in addition to promoting structural damage associated with the presence of untreated disease in the first years of evolution.6,7 That is why strategies are being designed for referral of early stage patients with axial symptoms to Rheumatology clinics, which would help shorten diagnosis time and optimize the therapeutic management of these patients in the earliest stages of4,8–12 disease.

The RADAR study12 found that inflammatory LBP is the most commonly used criterion and, simultaneously, the one that yielded the most results, in order to establish a mechanism for referral from primary care (PC) to Rheumatology. There is, however, no consensus recommendation with PC to specify what criteria must be evaluated in a patient with chronic back pain in order to decide an appropriate referral to Rheumatology.

The ultimate objective of this document is to improve the quality of care for patients with chronic, inflammatory low back pain and SpA by creating validated and easy to use resource that does not interrupt the consultation and that ultimately benefits the patient. This resource should include criteria for suspicion, research algorithms and recommendations for referral to Rheumatology. The target group who should use this resource are primary care physicians (PCP).

A modified RAND methodology13 was used, with group discussions and14 Delphi technique to evaluate the degree of acceptance of the recommendations and the preference criteria.

A panel of 4 SpA expert rheumatologists and 4 PCP, all Spaniards, moderated by a methodologist, held a meeting to determine the scope, users and the set of existing criteria, and to identify the difficulties of assessment and referral of patients with suspected SpA. The group followed the following script: (1) what are the available criteria for suspecting/referring inflammatory back pain? (2) how are the available criteria evaluated? (3) what is the current referral process and the systematic evaluation of low back pain in primary care?, weighing the difficulty of assessing the criteria available in this context, (4) what parameters allow an informed selection of the criteria to recommend?, and (5) solutions or necessities to improve the implementation of criteria (training, research, etc.).

In order to document the suitability of recommendations and facilitate the decisions of the panelists, a systematic review of the literature on low back pain in primary care was undertaken and the results were condensed into evidence tables. This review identified existing criteria and those proposed by the panel, as well as their performance. In particular, the objective was to understand their sensitivity and specificity, as they would become screening instruments. The search strategy for the review is available in an Annex 1; it basically included synonyms for “Spondyloarthritis AND Low back pain AND (sensitivity and specificity) AND primary care.” The panelists were queried on the ease of collecting the data in PC, in particular if the data is included in the usual history and whether the criterion can be interpreted correctly, that is, if there is a good agreement between what Rheumatologists and PCP think.

All of the information collected was summarized in a report and a survey format was prepared for the vote by 25 professionals, including rheumatologists and PCP. The first Delphi round was used to prioritize items and gather comments and views on the proposals, and the second to define the degree of agreement. The conflicting items (under agreement or excessive variability) were discussed and reformulated for the second round. Each recommendation comes as a result with an average degree of agreement in the second round. The full study was conducted throughout 2013.

A literature search was conducted and a second, manual search of the publications obtained led researchers to 12 studies which were retrieved for detailed review. Evidence tables were built by extracting performance parameters of different clinical features in the diagnosis of SpA (Table 1). Table 2 summarizes the reproducibility and diagnostic performance parameters described by Rudwaleit et al. in 2004 from15 different studies. The Annex 1 also includes a table in which the data available for each criterion proposed by the panel is summarized.

The recommendations are presented and discussed below in tabular format (Table 3), each accompanied with the degree of agreement (0–10) and an algorithm (Fig. 1).

Fig. 1.

Algorithm for referral of patients with inflammatory back pain. According to the algorithm, the referral of patients under 45 years of age with chronic back pain should be done in 4 phases defined by key questions, extra questions, physical examination and laboratory tests. The components of each of these phases are described in the text.

(0.41MB).

The new classification criteria Assessment of Spondyloarthritis International Society should permit better and earlier identification of patients suffering from axial SpA, both those with radiographic evidence of sacroiliac affection (ankylosing spondylitis) as those without radiographic involvement (non radiological axial spondyloarthritis)18,19; however, this must be accompanied by a referral of patients to a rheumatologist in earlier stages. That is why we must have strategies suitable for this purpose. The main protagonists for specialist referral of patients of cases suspected of SpA are the PCP. The difficulty of making a correct derivation in cases of suspicion of SpA in patients with chronic axial pain from primary care is evident, since this type of pain is a common reason for consultation20,21 and can be related to many other causes besides16 SpA. So far, most of the guidelines, recommendations and protocols for referral of patients suspected of SpA were designed by rheumatologists, and PCP could or could not follow them depending on various circumstances.22 Since the participation in their elaboration of many hospitals and primary health care facilities in our country, and the subsequent publication of this data in the RADAR study,12 the need to design strategies for referral from PC with the participation of both rheumatologists as well as PCP became apparent.

In the expectation of seeking consensus among rheumatologists and PCP for the preparation of this document, professionals from both levels of care, who showed interest in inflammatory lumbar pathology, contributed to its development. However, we must not forget that the primary beneficiary of health is the user-patient, so this document should be submitted for the assessment of patients with SpA. Similarly, it is understood that this is a document that includes the referral processes, and must be accepted by administrators whose job it is to implant it in clinical practice, and should also be subjected to discussion among these professionals.

The final document is aimed primarily at the PCP, with criteria included for suspected cases, research algorithms and recommendations for referral to Rheumatology, and is designed to be an easy to use resource that does not disrupt consultation and consensus. The starting point is the patient with axial pain with an onset before age 45. From here, we have included key questions and extra questions about inflammatory back pain as well as other musculoskeletal manifestations, extra-articular manifestations, family history and additional tests related to the diagnosis.

In the algorithm, the importance of referral to a rheumatologist in all patients with chronic low back pain of less than 45 is emphasized on those who have features of inflammatory back pain, or signs suggestive of SpA, with HLA B27 positive or elevated CRP, or alteration of X-rays of the sacroiliac joints. The age limit of 45 years, as shown in all published algorithms, can be considered reasonable, if not entirely justified, although it can happen later in life and not always is lower back pain in those under 45 SpA. However, since the prevalence of chronic low back pain is almost double in patients over 45,21 and spondyloarthrosis is the most common cause of back pain in this group, it was felt that raising the age limit would unnecessarily increase referrals.

We want to note two limitations to these recommendations, requiring continued prudence and individualizing their application in patients. To successfully implement this protocol there must be a two-way commitment between PC and Rheumatology regarding information about the patient's condition and its final status. This would imply, however: (1) identifying the Reference area of a consultant (2) reasonable waiting times for referred patients, (3) communication on the final destination of the patient (counterreferral, if appropriate, to the PCP). In addition, some individual characteristics may act as confounding factors, particularly self-medication, which can modify some of the key questions and influence bad decision making.

In conclusion, the referral of patients under 45 years with chronic back pain from PC to Rheumatology should be done if any of these 3 possibilities exist: (1) inflammatory back pain, (2) signs suggestive of SpA (heel pain, arthritis, psoriasis, uveitis, dactylitis, inflammatory bowel disease or family history of SpA), or (3) HLA B27 positive, elevated CRP or pelvic X-ray indicative of sacroiliitis. Strategies should be designed from training and awareness by Rheumatology department to maintain optimal PCP collective collaboration in identifying cases and facilitating Rheumatology department to be prepared to take the lead.

The authors declare no conflict of interest.

This project was made possible by financial and logistical support from Merck Sharp & Dohme, Spain.