The eMAR II study is a study of variability in the treatment of rheumatoid arthritis (RA) and spondyloarthritis (SpA) in Spain. We define variability in clinical practice as the differences within a group of patients in relation to any aspect of the same clinical practice.

Variability of clinical practice is a very common phenomenon in medicine, and is responsible for the improper use of different procedures, with a subsequent unnecessary use of resources and possible collateral damage to the patient and costs for the health system.1–8 These reasons justify the need to understand variability, its determinants and effects, in order to design realistic strategies to help improve the quality of clinical practice.

In this sense, the results of the first study of variability in the treatment of RA in Spain (eMAR I), made 10 years ago, showed a wide variability in the use of different health resources, diagnostic procedures and therapeutic monitoring of patients with RA who, in many cases, is independent of the characteristics of the patient or the severity of the disease.7,8

In the 10 years since the eMAR I, care for RA and other inflammatory joint diseases type has undergone a revolution due to various factors including the availability of new treatments, better understanding of these processes, the growth of rheumatology care in our country and the development of other important research. The eMAR II evaluates the potential impact of these events in the practices of management of RA and in SpA. In the latter group of diseases has been is poorly studied.9,10 The objective of this paper is to describe the variability in the management of SpA in Spain in terms of healthcare resource utilization (physician visits, hospitalizations, etc.) and the use of techniques (radiography, ultrasound, etc.). The results of this study may serve greatly in the constant improvement of management of patients in our country.

Variability in clinical practice refers to the differences we find in it. That is, patients are not always managed the same way. The variability in clinical practice is admissible if, for example, there is no evidence that a particular technique, system or drug is superior to the rest, when the specific characteristics and preferences of patients so require it, or when resources are not available. However, it is unacceptable when it is caused by deficiencies in the skills of the physician, poor organization of the institution, ignorance or a deliberate decision not to use a practices for which there is proven evidence of superiority, which may seriously harm the patient and consume resources unnecessarily.

Although not always easy to prove, it seems that there are differences in management (variability) of SpA (among countries, hospitals, doctors, etc.), More specifically the use of diagnostic, monitoring or drug therapy and rehabilitation. At times it may even appear that, as a result of this variability, improper use of resources may occur, that is, these differences cannot be justified by the severity of illness, patient preferences, and so on.

The data we have presented come from the eMAR II study and allow us to know the use of health resources in patients with SpAs in Spain. Among the variables collected we find visits to physicians and other professionals, hospital admissions, orthopedic surgery, additional tests and the consumption of drugs. They are all important variables in our clinical practice.

On the other hand, random selection of centers and patients makes the results reliably reflect how we are managing health resources in our country and the representativeness of the sample relative to the general population. In addition, we have included community hospitals with under 200 beds and large reference hospitals with more than 1000 beds and other exclusive hospital with additional outpatient care.

As for the results obtained in relation to medical visits, we found that, on average, patients visited the rheumatologist at least 4 times a year. Quite similar results have been found in Germany,12 Canada,13 United States.14 or Brazil,15 although not all of these studies included the full spectrum of SpA.

On the other hand, in relation to visits to other specialists, our study found a median of 2 visits. This information was not collected equally in the published series, so comparison is difficult. However, it is curious that most of them were not requested by the rheumatologist. And although it is possible that other reasons exist for not asking for consultations related to SpA, if we consider that the services most frequently visited in our study were ophthalmology, orthopedics, digestive and dermatology, it is reasonable to assume that many of them really did have a relationship with SpA.

Non-medical consultations made by patients with SpA were generally very low. These include physiotherapy, psychology, social worker or education, and were significantly lower than those reported in other series.13,16 These differences may be due to the fact that their severity was different but in the case of SpA in our country also that these resources were being underused or there was no access to them.

Following hospital admission, they were not very common, being the most common surgery, followed by co-morbidity and disease activity. Less than half were directly related to the ESA. In other countries have reported income rates rather similar to those reported in this trabajo.12 Other studies have also shown that the average hospital stay for these patients is small, one or a few days.16–19

The rate of orthopedic surgery in our study was very low, the most frequent procedure being joint prosthesis, non-prosthetic surgeries and soft tissue surgeries. There were no surgical complications in most cases. Other studies have found low rates of orthopedic surgery in patients with SpA.13,19,20 This is most likely due to the average age of these patients, which was clearly inferior to those with other diseases such as RA or osteoarthritis of the knee and hip.

Finally, in regard to additional laboratory testing, the most frequent were blood count, biochemistry and ESR, with a median of 4. Compared with other studies, our median is slightly inferior,16,21 although a single study that measured the number of laboratory tests per patient per year showed it to be very elevated.15

The most common imaging tests were plain X-rays with axial projection (including cervical, thoracic, lumbar, iliac or pelvis) with a median of one. Other imaging or additional tests were not performed in most patients. The case of skeletal X-rays calls our attention, because on the basis of various consensus and practice guidelines published in our country,9,10,22,23 and used either for the evaluation of the disease or in the context of biological therapies, a greater number of some of them would be expected.

In summary, our work has been detailed the use of healthcare resources by patients with SpA in Spain. Visit data to the rheumatologist and prosthetic surgery are similar to most studies published in our environment, but other aspects concerning the use of health resources are different from what was expected and/or different compared to other countries. Furthermore, these data may contribute to understand and improve organizational aspects of management of SpA in Spanish hospitals.

Protection of human and animal subjects. The authors declare that no experiments were performed on humans or animals for this investigation.

Confidentiality of Data. The authors declare that they have followed the protocols of their work centre on the publication of patient data and that all the patients included in the study have received sufficient information and have given their informed consent in writing to participate in that study.

Right to privacy and informed consent. The authors have obtained the informed consent of the patients and /or subjects mentioned in the article. The author for correspondence is in possession of this document.

eMAR II study was funded by Abbott Laboratories.