Background Appropriate identification and referral of patients with symptoms suggestive of axial spondyloarthritis (axSpA) can facilitate earlier diagnosis and management. Understanding current referral practices used by primary care and other health-care providers can identify areas for further education and intervention.
Objectives To compare referral patterns and diagnostic tools for axSpA used by rheumatologists working in academic centers and in community clinical practice settings.
Methods The MAXIMA (Management of Axial SpA International and Multicentric Approaches) survey asked respondents questions pertaining to referral, diagnosis, and management of patients with axSpA. The survey was completed anonymously online by rheumatologists from 42 countries in Europe, Latin America, and North America. The MAXIMA survey was funded by AbbVie and conducted by a third-party vendor with guidance and approval of the questionnaire by a steering committee of SpA experts. Participants were not compensated for completing the survey.
Results 500 surveys were completed by 141 rheumatologists in academic practice settings (28%) and 359 rheumatologists in community practice settings (72%). Only 58% of academic rheumatologists compared to 72% of clinical rheumatologists agreed that the concept of axial SpA is clear to the rheumatology community. However, responses to various questions about referral and diagnostic work-up for patients with axSpA were generally similar in both practice settings. The majority of referrals for patients with chronic back pain for ≥3 months and onset <45 yrs old were from primary care providers; 47% of respondents received referrals from other specialists such as dermatologists, gastroenterologists, and ophthalmologists. Other than chronic and inflammatory back pain, referrals were triggered by the occurrence of uveitis (82%), inflammatory bowel disease (48%) and skin lesions (46%). At the time of referral to the rheumatologist, 48% of patients have symptoms for ≥ 3 yrs. The ASAS criteria (85%) were cited as the most common classification criteria that guide respondents in the diagnosis of axSpA in clinical practice, compared to the modified New York criteria for AS (23%), ESSG (8%), and Amor (6%). In terms of diagnostic work-up, approximately half systematically request HLA-B27 typing. MRI of the sacroiliac joints is the most commonly used imaging test (93%), closely followed by pelvic x-rays (86%).
Conclusions Results of the MAXIMA survey show general agreement in referral patterns and use of diagnostic tools by rheumatologists in academic and clinical practice settings when evaluating patients for axSpA. Half of the patients were referred to rheumatologists for evaluation several years after onset of symptoms, which indicates a need for ways to facilitate earlier referral.
Acknowledgements AbbVie was responsible for the survey funding, analysis, interpretation of data, and writing, reviewing, and approving the publication. Dianne Nguyen is being acknowledged for her significant contribution to this publication in her medical director role at Abbott. Medical writing support was provided by Kathleen V. Kastenholz, PharmD, MS, and Douglas E. Dylla, PhD. of AbbVie.
Disclosure of Interest D. van der Heijde Grant/research support from: AbbVie, Amgen, AstraZeneca, BMS, Centocor, Chugai, Daiichi, Eli-Lilly, GSK, Janssen Biologics, Merck, Novartis, Novo-Nordisk, Otsuka, Pfizer, Roche, Sanofi-Aventis, Schering-Plough, UCB, Vertex, Consultant for: AbbVie, Amgen, AstraZeneca, BMS, Centocor, Chugai, Daiichi, Eli-Lilly, GSK, Janssen Biologics, Merck, Novartis, Novo-Nordisk, Otsuka, Pfizer, Roche, Sanofi-Aventis, Schering-Plough, UCB, Vertex, Employee of: Imaging Rheumatology bv, J. Sieper Grant/research support from: AbbVie, Merck, Pfizer, and UCB, Consultant for: AbbVie, Merck, Pfizer, and UCB, Speakers bureau: AbbVie, Merck, Pfizer, and UCB, D. Elewaut Grant/research support from: AbbVie, Speakers bureau: AbbVie, A. Pangan Shareholder of: AbbVie, Employee of: AbbVie