The IMPACT study: A clustered randomized controlled trial to assess the effect of a referral algorithm for axial spondyloarthritis

Abstract

Background A substantial number of patients with chronic low back pain (CLBP) have axial spondyloarthritis (axSpA), but early recognition of these patients is difficult for general practitioners (GPs). The Case Finding Axial Spondyloarthritis (CaFaSpA) referral strategy has shown to be able to identify patients with CLBP at risk for axSpA, but its impact on clinical daily practice is yet unknown. Objective To assess the effect of the CaFaSpA referral strategy on pain caused by disability in primary care patients with CLBP. Methods Within this clustered randomized controlled trial 93 general practices were randomized to either the CaFaSpA referral model (intervention) or usual primary care (control). In each group primary care patients between 18 and 45 years with CLBP were included. The primary outcome was disability caused by CLBP, measured with the Roland Morris Disability Questionnaire (RMDQ) at baseline and four months. Secondary outcome was the frequency of new axSpA diagnosis. Descriptive analyses were performed, and a linear mixed-effects model was used. Results In total 679 CLBP patients were included of which 333 patients were allocated to the intervention group and 346 to the control group. Sixty-four percent were female and mean age was 36.2 years. The mean RMDQ score at baseline was 8.39 in the intervention group and

Rheum to Diagnosis: A Mixed Methods Study to Uncover Impediments to Accurate Diagnosis of Nonradiographic Axial Spondyloarthritis in the United States

“…Symptoms described by study patients re ect the marked heterogeneity of nr-axSpA. Current efforts to increase awareness of axSpA often emphasize chronic IBP, (19,33,34) and for many patients in this study, persistent back pain was an early and dominant symptom. Yet numerous patients did not have this classic symptom pattern (see Additional le 10).…”

Primary care physician perspectives on screening for axial spondyloarthritis: A qualitative study

“…Patient reported screening approaches (e.g., via online screening or an app) offer an alternative to EMR-based algorithms. Use of a non-invasive, algorithm to find cases of axSpA, based on information contained in the EMR, has been studied using a randomized controlled cluster trial design [ 41 ]. In the intervention arm, the diagnosis of axSpA was ultimately confirmed in 8% of subjects but this approach did not have a short term impact on physical function, as average disability scores were similar in both arms at 4 months [ 41 ].…”

Health and economic outcomes in axial spondyloarhthritis

“…Efforts to reduce this delay have resulted in referral strategies for non-rheumatologists and diagnostic algorithms for rheumatologists. 156,[180][181][182][183][184][185][186][187] In the costeffectiveness analysis in this thesis, which was the first economic evaluation of diagnosis of axSpA in the rheumatology setting (Chapter 8), the focus was on the diagnostic algorithms.…”

“…An important limitation in the existing evidence on referral strategies is that in most studies only the referred population was assessed for axSpA. 181,183,184,187 This precludes firm conclusions on the number and characteristics of especially the false negatives, i.e. the axSpA cases missed by the referrer.…”