Patients with axial spondyloarthritis (axSpA) are often diagnosed late in their disease course. Offering tools for referral may be helpful in improving early diagnosis. Several initiatives have been performed to study the effect of referral strategies in primary care. The objectives of these referral programs were to identify patients with possible axSpA early, make a correct diagnosis, and to provide the best possible care as early as possible. The yield of these referral programs was found to be high, up to 45% of the patients who were referred suffered from axSpA (1). The use of a referral tool seems therefore useful.
For successful implementation of a referral tool, an important prerequisite is to pay attention to potential barriers for application of this tool in daily practice. Barriers for implementation may be related to the nature of the tool (e.g. feasibility, credibility), the characteristics of the primary care workers (e.g. knowledge, attitude), social context (e.g. opinion of colleagues, culture), organisational context (e.g. resources, time), and economic and political context (e.g. financial arrangements) (2). Interviews and questionnaires can help identifying these barriers.
Multifaceted implementation strategies, tailored to the barriers found and offered in several steps seem to be effective. Examples are use of a combination of the following: education, providing electronic letters or a laminated card with referral criteria and other important SpA features which can contribute to early recognition, writing an overview article in journals for primary care and disseminate these, audit records of routinely collected data and provide feedback, and involving key opinion leaders. Also influencing the environment around the primary care workers may help in increasing awareness, for example by media attention and contacting patient societies and inform them to increase awareness of SpA features among family members.
There is not one unique strategy for successful implementation, because this may depend on local situations. By not addressing the full spectrum of barriers, implementation of a referral tool might fail.
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Disclosure of Interest None Declared