PCPs fall short of rheumatology referral 'sweet spot' for inflammatory back pain
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MAUI, Hawaii — Primary care providers and other nonrheumatologists often ordered inappropriate blood tests in patients with suspected inflammatory back pain, according to a presentation at the 2020 Rheumatology Winter Clinical Symposium.
Eric Ruderman, MD, professor of medicine at the University of Northwestern Feinberg School of Medicine, presented a number of data sets pertaining to axial spondyloarthritis. Early in his talk, he focused on findings presented by Magrey and colleagues that were originally presented at EULAR 2019. This study included 1,690 nonrheumatologists — including primary care providers and nurse practitioners — who were surveyed on topics pertaining to diagnosis and referral of patients with inflammatory back pain (IBP).
Results showed that these physicians saw a median of 100 patients per year with back pain. Criteria for diagnosis of IBP included morning stiffness (61%), sleep difficulty due to back pain (29%), improved back pain with activity (29%) and accompanying buttock pain (16%). “Many of [these providers] knew at least some of the pieces of what constitutes inflammatory back pain, like morning stiffness,” Ruderman said. “Most, though, did not understand factors like sleep pain, pain with activity or buttock pain.”
Among the 59% of these health care providers referred patients for IBP, 13% did so immediately, 49% ordered more assessments and 24% waited for treatment response. Overall, 90% of the patient cohort was referred to a rheumatologist within 2 months. “They did see that patients were generally referred within a reasonable amount of time,” Ruderman said.
The study also included data for the blood tests the nonrheumatologists ordered for patients with suspected IBP. These findings showed that 90% ordered C-reactive protein, more than 89% ordered erythrocyte sedimentation rate or antinuclear antibodies, more than 86% ordered complete blood count or rheumatoid factor, more than 70% ordered HLA-B27 or a complete metabolic panel, and less than 50% ordered citrullinated peptide antibody or fasting glucose.
“This speaks to the fact that we really have more to do in terms of educating our colleagues in primary care to make sure these patients get to us,” Ruderman said.
Arthur Kavanaugh, MD, professor of medicine at the University of California, San Diego, and program chairman for the RWCS meeting, also weighed in on the findings. “They have looked at this in several European clinics, where they actively tried to get patients with inflammatory back pain to rheumatology,” he said. “Those efforts have not been tremendously successful.”
Ruderman suggested that there is a delicate balance between “sending everybody” and sending patients who have a high likelihood of disease. “The sweet spot is going to be anywhere between 25% and 50%,” he said. “But we have to do something to stop them from ordering ANA tests.” – by Rob Volansky
Reference:
Ruderman E. Axial Spondyloarthritis 2019: Year in Review. Presented at RWCS Annual Meeting; Feb. 12-15, 2020; Maui, Hawaii.
Disclosure: Kavanaugh reports associations with AbbVie, Amgen, BMS, Eli Lilly, Gilead, Janssen, Novartis, Pfizer and UCB. Ruderman reports associations with Abbvie, Amgen, Coronna, GSK, Janssen, Lily, Novartis, Pfizer and Treg.