Background A substantial number of patients with chronic low back pain (CLBP) have axial spondyloarthritis (axSpA), but early recognition of these patients is difficult for general practitioners (GPs). The Case Finding Axial Spondyloarthritis (CaFaSpA) referral strategy has shown to be able to identify patients with CLBP at risk for axSpA, but its impact on clinical daily practice is yet unknown. Objective To assess the effect of the CaFaSpA referral strategy on pain caused by disability in primary care patients with CLBP. Methods Within this clustered randomized controlled trial 93 general practices were randomized to either the CaFaSpA referral model (intervention) or usual primary care (control). In each group primary care patients between 18 and 45 years with CLBP were included. The primary outcome was disability caused by CLBP, measured with the Roland Morris Disability Questionnaire (RMDQ) at baseline and four months. Secondary outcome was the frequency of new axSpA diagnosis. Descriptive analyses were performed, and a linear mixed-effects model was used. Results In total 679 CLBP patients were included of which 333 patients were allocated to the intervention group and 346 to the control group. Sixty-four percent were female and mean age was 36.2 years. The mean RMDQ score at baseline was 8.39 in the intervention group and

BackgroundA substantial amount of young patients with chronic low back pain (CLBP) have axial spondyloarthritis (axSpA), but early recognition of these patients is difficult for general practitioners (GPs). Recently, the CaFaSpA referral rule has been published and externally validated. It is an easy to use referral strategy that has shown to be able to identify patients with CLBP at high risk for axSpA in a primary care setting. The CaFaSpA referral rule consists of 4 items: inflammatory back pain, family history of axSpA or related disease, good reaction to NSAIDs and duration of back pain ≥5 years. If at least 2 out of 4 items are present, the referral rule is positive and a referral to a rheumatologist is advised.ObjectivesTo assess the effect of the CaFaSpA referral rule on disability in young CBPP patients by comparing it with usual care, using the format of an impact analysis.MethodsA cluster randomized controlled trial with GP practices as clusters. GP practices were randomized to either the intervention (use of the referral strategy) or control (usual care) group. Within these GP practices, patients aged 18–45 years with current CLBP were recruited. The primary outcome was disability caused by low back pain, measured with the Roland Morris Disability Questionnaire (RMDQ) scale 0–24. RMDQ score was obtained at baseline and 4 months after a referral advice was made. A higher RMDQ score means more disability. For statistical analysis a linear mixed effects regression model was used.Results92 primary care practices were randomized, 679 patients participated (64% women, mean age 36.2 years (SD7.5) and median CLBP duration 9 years (IQR 4–15 years). 333 patients were randomized to the intervention group, both groups had similar characteristics at baseline. Sixty percent of participants had a positive referral rule. RMDQ scores are shown in table 1. Sub scores are shown for patients with a positive outcome of the referral rule (PRR) and a negative outcome of the referral rule (NRR). The change in RMDQ score after 4 months in the intervention group was -0.74 (95% confidence interval (CI) -1.31 – -0.18) and in the control group -0.46 (95% CI -0.98 – 0.05). There was no significant difference between groups.ConclusionsCompared with usual care, use of the CaFaSpA referral rule in CLBP patients in a primary care setting did not significantly impact disability in these patients, 4 months after a referral advice was made. Results after 12 and 24 months should be awaited before definitive conclusions about the impact of the CaFaSpA referral rule for axSpA in CLBP patients can be made.Disclosure of InterestNone declared

BackgroundA substantial amount of patients with chronic low back pain (CLBP) have axial spondyloarthritis (axSpA), but early recognition of these patients is difficult for general practitioners (GPs).1 As a result, several referral strategies have been developed to help physicians identify patients at risk for axSpA within the large group of CLBP patients.2 Most referral strategies were developed in secondary care patients. The only referral strategy that was developed and validated in primary low back patients is the CaFaSpA strategy.3 An essential step before implementing referral strategies in daily clinical practice is the execution of an impact analysis.4 ObjectivesThe purpose of this study is to assess the impact of using a referral strategy on patient outcomes in young primary care patients with CLBP at risk for axSPA.MethodsA clustered randomized controlled trial was performed in a primary care setting (ClinicalTrials.gov Identifier: NCT01944163). Each cluster contained the general practices from a single primary care practice and their included patients. Clusters were randomized to either the intervention (use of CaFaSpA referral strategy) or the control group (usual care). Primary outcome was disability caused by CLBP, measured with the Roland Morris Disability Questionnaire (RMDQ) at baseline and 4 months. Secondary outcome was axSpA diagnosis made by a rheumatologist. A linear mixed-effects model was used to analyze mean change in RMDQ score.ResultsIn total 679 patients were included within 93 GP clusters. Sixty-four percent of our study population were female and mean age was 36 years. Median RMDQ score at baseline was 8 (IQR 4-12) in both groups. Compared to baseline, mean RMDQ score decreased by 0.74 points at 4 months (intervention) and by 0.46 points (control) (Fig. 1). This decrease did not significantly differ between groups (p=0.50). Eight percent of the finally referred patients in the intervention group, received an axSPA diagnosis (8%) from the rheumatologist. The median RMDQ among patients who visited the rheumatologist decreased from 8 to 5 after 4 month. This was not statistically significant (p-value=0.17).ConclusionAlthough the CaFaSpA referral strategy did not have an early impact on disability caused by CLBP, it can be used as a screening strategy for GPs to identify axSpA patients.References[1] Jois RN, Macgregor AJ, Gaffney K. Recognition of inflammatory back pain and ankylosing spondylitis in PC. Rheumatology (Oxford) 2008;47:1364-1366.[2] Abawi O, van den Berg R, van der Heijde D, van Gaalen FA. Evaluation of multiple referral strategies for axial spondyloarthritis in the SPondyloArthritis Caught Early (SPACE) cohort. RMD Open 2017 Apr 7;3(1):e000389-2016-000389. eCollection 2017.[3] van Hoeven L, Vergouwe Y, de Buck PD, Luime JJ, Hazes JM, Weel AE. External Validation of a Referral Rule for Axial Spondyloarthritis in Primary Care Patients with Chronic Low Back Pain. PLoS One 2015 Jul 22;10(7):e0131963.[4] Moons KG. Kengne AP, Grobbee DE, Risk prediction models: II. External valid...