Abstract and Introduction
Abstract
The aim of this work was to develop a consensual recommendation under the auspices of the Assessment of SpondyloArthritis international Society (ASAS) for early referral of patients with a suspicion of axial spondyloarthritis by non-rheumatologists. The development of a referral recommendation consisted of four phases: (1) systematic literature review, (2) the first Delphi round aiming at identification of unmet needs and development of a candidate list of referral parameters, (3) the second Delphi round aiming at identification of the most useful combination of referral parameters and (4) final discussion and formal endorsement by ASAS membership. The following consensus on a referral recommendation was achieved as a result of the Delphi processes and final voting: "Patients with chronic back pain (duration ≥3 months) and back pain onset before 45 years of age should be referred to a rheumatologist if at least one of the following parameters is present: Inflammatory back pain; human leucocyte antigen-B27; Sacroiliitis on imaging if available (X-rays or magnetic resonance imaging); Peripheral manifestations (arthritis, enthesitis, dactylitis); Extra-articular manifestations (psoriasis, inflammatory bowel disease, uveitis); Positive family history for spondyloarthritis; Good response to non-steroidal anti-inflammatory drugs; Elevated acute phase reactant." A consensual ASAS-endorsed referral recommendation for patients suspected of having axial spondyloarthritis was developed as a flexible and universal strategy to be used in clinical practice by primary care physicians or non-rheumatology specialists. The practical value of this strategy applied in different settings should be determined in future studies.
Introduction
There is still a substantial gap of 5–8 years between the onset of symptoms and the diagnosis of axial spondyloarthritis (axSpA). One of the major reasons for such a delay is a late referral of patients to a rheumatologist by general practitioners and other physicians encountering patients with back pain. This late referral can be caused by the referring doctor and/or by the patient. The leading clinical manifestation of axSpA is chronic back pain. However, chronic back pain is highly prevalent in the general population and axSpA is responsible for only about 5% of the cases. Obviously, it is not feasible to refer all patients with chronic back pain to a rheumatologist with such a relatively low prevalence of axSpA among chronic back pain patients. A certain kind of a 'filter' based on the presence of features characteristic of axSpA is necessary in order to sufficiently increase the likelihood of axSpA in patients referred to a rheumatologist by non-rheumatologists (ie, general practitioners, orthopaedic surgeons, gastroenterologists, dermatologists). At the same time, such a 'filter' (further called 'referral strategy') should not be too complex in order to make its application feasible by all type of doctors. While several referral strategies have been proposed and tested over the last 10 years, to date a universally accepted referral strategy is still lacking. In this work, we aim to summarise existing data concerning referral strategies for patients suspected of having axSpA and to develop a consensual Assessment of SpondyloArthritis international Society (ASAS)-endorsed recommendation for early referral of this group.