Objectives
To design a strategy for early detection and referral of patients with suspected spondyloarthritis (SpA) by primary care physicians (PCP).
Methods
We used a modified RAND/UCLA methodology and systematic review (SR). A discussion group, formed by rheumatologists and PCP, discussed the process map and proposed recommendations and algorithms. These, together with the results of the SR, underwent 2 Delphi rounds to assess acceptance by a large group of users.
Results
The recommendations and grade of agreement are presnted in Table 1).
Table 1
Recommendation
Mean agreement/10
As an entry criterion, we should investigate the presence of inflammatory back pain (IBP) in patients <45 years (1) who attend for chronic back pain as main consultation reason (2); if pain lasts ≥3 months (3) and is perceived by the patient as continuous, while recognizing fluctuations (4).
(1) 8.6(2) 7.6(3) 8.3(4) 7.4
It is recommended to investigate these patients in 4 phases 1) key questions, 2) additional questions, 3) physical examination, and 4) additional tests.
8.4
Refer the patient to rheumatology if1) mainly night pain, defined as pain that wakes the patient, especially in the second part of the night and forces the patient to get up (1),2) pain improves with physical activity and worsens with rest (2).
(1) 8.8(2) 8.0
If the answer to the above questions is negative but suspicion remains, then inquire about the following. If any is positive, refer the patient to rheumatology.– alternating buttock pain/sciatica (1)– gradual onset (2)– pain responds to full–dose NSAIDs, but not to analgesics, and reappears when NSAIDs are stopped (3)– heel pain (4)– arthritis in lower limbs (5)– psoriasis (6), or uveitis (7), or inflammatory bowel disease [IBD] (8)– or family history of psoriasis (10), IBD (11), or ankylosing spondylitis (12).
(1) 7.7(2) 7.0(3) 8.0(4) 7.0(5) 8.0(6) 7.9(7) 8.6(8) 8.1(10) 6.8(11) 6.6(12) 7.4
If all is negative, and doubt remains, consider a physical examination to confirm arthritis or dactylitis.
8.3
The only additional tests that could guide and should be performed by PCP, depending on availability, are– PA sacroiliac X–ray (1),– lab tests: ESR (2), PCR (3) and HLAB27 (4).
(1) 8.4(2) 7.5(3) 7.9(4) 8.3
In areas where access to tests or to their results is limited, doubtful cases should be referred to a rheumatologist without ordering the tests.
7.9
The rheumatology reference service should design feedback strategies to improve referrals.
8.3
To improve the speed of referral, the panel recommends:– to maintain rheumatology waiting lists below reasonable limits (<1 mo.) (1), or– to establish of early SpA units (2). or– to agree on fast tracks in the area (3)
(1) 8.7(2) 8.8(3) 8.3
Conclusions
Any chronic (>3 months) LBP in <45 years patients should be investigated in 4 phases 1) key questions, 2) extra questions, 3) physical examination, and 4) additional tests. They should be referred to rheumatology if having 1) IBP, 2) signs suggestive of SpA, or 3) HLA B27+, elevated CRP, or sacro...
