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Abstract
Background Timely recognition and referral of patients with spondyloarthritis (SpA) is challenging due to the insidious disease onset and frequently unawareness of the clinical picture by primary care physicians.
Objectives The aims of this study were to assess the current practice performance of general practitioners (GPs) and GP-residents in recognizing SpA, and to investigate the influence of education on this performance.
Methods GP-residents and their supervising GPs were visited in two rounds by standardized patients (SPs) during their regular outpatient clinic, simulating axial SpA (axSpA), peripheral SpA (perSpA) (i.e. dactylitis) or carpal tunnel syndrome (CTS), respectively. Participants were unaware of the nature of the medical problem and purpose of the study. CTS was included as a diversionary tactic. Each case was simulated by a male and a female, in random order, according to a predefined schedule. After the 1st round, half of the GP-residents were educated about SpA, as part of the GP specialty training without referring to the actual study. The other half of the GP-residents and all GPs served as controls. Next, all participants were visited by SPs again in the 2nd round. Participants ranked their differential diagnosis based on their probabilities (rank order: 1=most likely to 3=less likely) and indicated whether referral to a hospital physician would be appropriate. The primary outcome was at least 40% improvement in referral of the SPs with SpA by GP residents to the rheumatologist. Descriptive statistics, chi-square and McNemar tests were used to analyse the data. In addition, the difference in change scores between the educational and control group with regard to referral of the SP and correct recognition of SpA was compared.
Results Sixty-eight (38 GP-residents (mean age 27.9 yrs, 32% male) and 30 GPs (mean age 52.5 yrs, 80% male) participated. Both rounds of SP-encounters were completed by 61 (90%) and 59 (87%) participants for the axSpA and perSpA case, respectively. Participants who received education were more likely to refer the patient or considered referral to the rheumatologist optional (change scores, axSpA 71% vs. 15% (P<0.001); perSpA 48% vs. 0% (P<0.001)); Figure 1). AxSpA was ranked as the no. 1 diagnosis by 12/61 (20%) participants, whereas perSpA was correctly diagnosed by none of participants in the 1st round. Participants who received the educational intervention, were more likely to rank axSpA and perSpA as the no. 1 diagnosis in the 2nd round when compared to the control group (change scores, axSpA 50% educational group vs. -5% control group, (P<0.001); perSpA change scores: 21% vs. 0% (P=0.01)). All 18 participants, who received the educational intervention, listed axSpA in their differential diagnosis in the 2nd round.
Conclusions Patients with SpA are not adequately recognized by general practitioners. Providing an educational programme to GP-residents markedly improved the referral of patients with SpA to the rheumatologist and recognition of SpA.
Disclosure of Interest M. Van Onna Consultant for: Janssen-Cilag and UCB, S. Gorter: None declared, B. Maiburg: None declared, G. Waagenaar: None declared, A. van Tubergen Grant/research support from: Pfizer, Roche, Consultant for: AbbVie, MSD, Pfizer, UCB, Janssen-Cilag, Speakers bureau: AbbVie, MSD, UCB, Pfizer