Background Timely recognition and referral of patients with spondyloarthritis (SpA) is challenging due to the insidious disease onset and frequent unawareness of the clinical picture by general practitioners (GPs). In a previous intervention study, we demonstrated that an educational programme targeted at recognition of SpA clearly improves referral of patients suspected for SpA.
Objectives To evaluate (1) the clinical assessment patterns of GPs and GP-residents when facing a patient suspected of having spondyloarthritis (SpA) and (2) the influence of an educational intervention on these clinical assessment patterns.
Methods Alongside the intervention study, data were collected for this present qualitative study. GP (residents) were visited in 2 rounds by standardised patients (SPs) simulating either axial or peripheral SpA. In between, an educational intervention on SpA for half of the GP residents was organized. The other half and all GPs served as controls. Participants were visited by the SPs during their regular outpatient clinic and were unaware of the nature of the medical problem and study purpose. After the visit, SPs completed a case-specific checklist inquiring about disease-related items. These items were categorized into four subgroups: questions regarding (1) differentiation between a mechanical or inflammatory origin of the complaint, (2) presence of swollen joints, back pain or entheseal complaints (3) presence of extra-articular manifestations and (4) family history. Differences in patterns of clinical assessment were explored for the education versus the control group. Descriptive analyses were used to analyse demographic data.
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 axial and peripheral SpA case, respectively.
Axial SpA case (Figure): participants who received education were in round 2, as compared to round 1, somewhat more likely to ask questions about the specific inflammatory character of the complaint. However, the most noticeable gain was seen in questions regarding the presence of extra-articular manifestations and family history of SpA. Despite that controls also tended to ask more questions regarding the inflammatory character of the complaint and family history of SpA in round 2, an evident increase in questions belonging to other subgroups (e.g. extra-articular manifestations) was not observed.
Peripheral SpA case (data not shown): in round 2, GP residents who received the educational intervention asked more questions regarding extra-articular complaints and family history of SpA. However, the observed gain was less evident as compared to the axial SpA case. In the control group, no difference was observed between both rounds.
Conclusions Targeted education can help GPs to improve their history taking and hence pattern recognition of patients suspected for SpA. Focusing on history taking alone already increases the chance of referral to the rheumatologist and targeted education should therefore be offered to all GPs to maximize a successful implementation of a referral strategy in primary care.
van Onna M, et al. RMD Open 2015;1:e000152.
Disclosure of Interest M. Van Onna Consultant for: Janssen-Cilag and UCB, S. Gorter Speakers bureau: UCB, B. Maiburg: None declared, G. Waagenaar: None declared, A. van Tubergen Grant/research support from: Roche, Pfizer, Consultant for: Janssen-Cilag, UCB, Abbvie, MSD, Novartis, Speakers bureau: Abbvie, MSD, UCB, Pfizer