Background The average delay in diagnosis for patients with axial spondyloarthritis (axSpA) is 7 to 10 years. Factors that contribute to this delay are multifactorial and include the lack of diagnostic criteria (although classification criteria exist) for axSpA and the difficulty in distinguishing inflammatory back pain, a key symptom of axSpA, from other highly prevalent forms of low back pain. We sought to describe reasons for diagnostic delay for axSpA provided by primary care physicians. Methods We conducted a qualitative research study which included 18 US primary care physicians, balanced by gender. Physicians provided informed consent to participate in an in-depth interview (< 60 min), conducted in person (n = 3) or over the phone (n = 15), in 2019. The analysis focuses on thoughts about factors contributing to diagnostic delay in axSpA. Results Physicians noted that the disease characteristics contributing to diagnostic delay include: back pain is common and axSpA is less prevalent, slow progression of axSpA, intermittent nature of axSpA pain, and in the absence of abnormal radiographs of the spine or sacroiliac joints, there is no definitive test for axSpA. Patient characteristics believed to contribute to diagnostic delay included having multiple conditions in need of attention, infrequent interactions with the health care system, and “doctor shopping.” Doctors noted that patients wait until the last moments of the clinical encounter to discuss back pain. Problematic physician characteristics included lack of rapport with patients, lack of setting appropriate expectations, and attribution of back pain to other factors. Structural/system issues included short appointments, lack of continuity of care, insufficient insurance coverage for tests, lack of back pain clinics, and a shortage of rheumatologists. Conclusion Primary care physicians agreed that lengthy axSpA diagnosis delays are challenging to address owing to the multifactorial causes (e.g., disease characteristics, patient characteristics, lack of definitive tests, system factors).
Background Many patients with axial spondylarthritis (axSpA) experience lengthy diagnostic delays upwards of 14 years. (5–14 years). Screening tools for axSpA have been proposed for use in primary care settings, but whether this approach could be implemented into busy primary care settings remains unknown. Objective To solicit feedback from primary care physicians regarding questions from the Inflammatory Back Pain Assessment: the Assessment of Spondyloarthritis International Society (ASAS) Expert Criteria and gain insight about barriers and facilitators for implementing axSpA screening in primary care. Methods Guided by Consolidated Criteria for reporting Qualitative Research (COREQ-criteria), we recorded, transcribed, and analyzed in-depth interviews with eight family medicine physicians and ten internists (purposeful sampling) using immersion/crystallization techniques. Results Few physicians reported awareness of existing classification criteria for axSpA, and many reported a lack of confidence in their ability to distinguish between inflammatory and mechanical back pain. From three domains, 10 subthemes emerged: 1) typical work-up of axSpA patients in primary care, with subthemes including the clues involved in work-up and role of clinical examinations for axSpA; 2) feedback on questions from the Inflammatory Back Pain Assessment: ASAS Expert Criteria, with subthemes to evaluate contents/questions of a potential screening tool for axSpA; and 3) implementation of the screening tool in primary care settings, with subthemes of perceived barriers including awareness, time, other conditions to screen, rare disease, and lack of structured questionnaire for back pain and perceived facilitators including workflow issues and awareness. Conclusions Primary care physicians believed that an improved screening instrument and a strong evidence-base to support the need for screening for axSpA are required. The implementation of axSpA screening into a busy primary care practice requires integration into the practice workflow, with use of technology suggested as a possible way to improve efficiency.
Objective To evaluate physical activity and attitudes towards exercise among people with axial and peripheral spondyloarthritis (SpA). Methods Using baseline information from an on-going, longitudinal, prospective SpA cohort study (n=264), self-reported attitudes and beliefs towards exercise were assessed using questionnaires. Total metabolic equivalent (MET) hours of self-reported physical activity per week, time spent in activities, and activity levels were calculated from the Nurses’ Health Study Physical Activity Questionnaire II (NHSPAQ II). Adjusted multivariable linear models estimated the relationship between physical activity and disease status (axial versus peripheral). Results Regardless of predominant anatomic distribution of disease, most participants were well-educated, non-Hispanic white men. Approximately 40% met the United States Department of Health and Human Services physical activity recommendations. Positive attitudes, beliefs, and perceived benefits towards exercise were similar by anatomic distribution of disease. Despite similar MET-hours per week, participants with axial disease had greater concerns regarding discomfort and joint injuries than those with peripheral disease. Compared to those with peripheral SpA (n=201), participants with axial SpA (n=63) spent less time engaging in light and moderate activities (adjusted β in light activity: -1.94 minutes/week, 95% Confidence Interval (CI): -2.96 to -0.93; adjusted β in moderate activity: -1.05 minutes/week, 95% CI: -2.12 to 0.02). Conclusion Participants with axial SpA had greater concerns regarding discomfort and injuries from exercise than those with peripheral SpA. Although no differences in time spent in vigorous activities were observed, participants with axial SpA spent less time than those with peripheral SpA in light to moderate activities.
Background People with axial Spondyloarthritis (axSpA) suffer from lengthy diagnostic delays of ~7 years. The usage of screening tools to identify axSpA patients in primary care can reduce diagnostic delays by facilitating early referral to rheumatologic care. The purpose of this study was to examine the psychometric properties of a potential screening tool for patients with axSpA. Method Content validity was evaluated by soliciting feedback from 7 rheumatologists regarding the relevance and content representativeness of the proposed screening questions. For the test-retest study, participants ≥18 years of age with chronic back pain (≥3 months) without a diagnosis of mechanical or inflammatory back pain (n = 91) were e-recruited through ResearchMatch. Participation included completing identical baseline and follow-up questionnaires ~14 days apart. Weighted quadratic kappa was used to measure test-retest reliability between the two ratings of the ordinal scales. Construct validity was examined using exploratory factor analysis (EFA) and items with factor loadings ≥0.6 were extracted. Scale dimensionality and simplified factorial solutions were measured using Kaiser’s criteria (Eigenvalue >1). Cronbach’s alpha was used to measure internal consistency. Results Most participants were women, non-Hispanic white, and had at least some college education, with a mean age of 45 years. On average, the age at onset of back pain was 31 years. Eleven questions yielded test–retest reliabilities ranging from 0.6 to 0.76. Results from EFA extracted two factors relating to: 1) how pain affects daily life functioning and 2) whether pain improves with movement. Internal consistency was high for questions evaluating how pain affects life, with a Cronbach’s alpha of 0.81. Following assessment for validity and reliability, the questionnaire was revised to create the 6-item screening tool. Conclusions The 6-item SpA-SED screening tool designed to identify potential cases of axSpA was found to have good test–retest reliability and high internal consistency.
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