Lack of 'familiarity, awareness' in primary care driving delay in axial SpA diagnosis
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Primary care providers reported a lack of familiarity with axial spondyloarthritis features, contributing to fewer rheumatology referrals and a delay in diagnosis, noted a presenter at the 2021 North American Young Rheumatology Investigator Forum.
“We embarked on this study due to the glaring discrepancy between the population and diagnostic prevalence of axial spondyloarthritis and ankylosing spondylitis in the U.S.,” Swetha Ann Alexander, MBBS, a PGY3 internal medicine resident at the University of Connecticut, told attendees. “The delay between symptom onset and the diagnosis of axial spondyloarthritis has been estimated to be approximately 13 years.
“The delayed and missed diagnosis of axial spondyloarthritis may result from the lack of timely referral of non-rheumatologists,” she noted. “Primary care providers are the main source of referrals for back pain patients to rheumatologists. These inadequate referrals stem from a lack of knowledge, familiarity and awareness of axial spondyloarthritis among non-rheumatology providers who are usually the first line of defense for patients with back pain.”
To determine experience and recognition of axial SpA features among PCPs, Alexander and colleagues distributed a HIPAA-compliant survey to providers (n=138) across multiple academic institutions and affiliated practices. Participants were questioned regarding their demographics, practice settings, practice patterns and knowledge assessment of axial SpA.
According to survey results, 95% of those who completed the questionnaire reported that they were “somewhat familiar” with the term “inflammatory back pain.” Although 42% of respondents reported that they often assess for inflammatory back pain in patients with chronic back pain, 37% of providers reported that they were not comfortable with making the diagnosis.
A majority of the providers did not assess for axial SpA-associated features like peripheral arthritis, psoriasis, inflammatory bowel disease or a family history of SpA, Alexander noted, and more than 75% of providers did not look into features such as enthesitis or uveitis.
“It was interesting to see that the majority of the providers never ordered HLA B27 and C- reactive protein, but 35% did order ANA and Rheumatoid Factor when assessing young patients with chronic back pain,” Alexander said.
The imaging modality of choice among primary care providers was predominantly X-ray of the lumbar spine (76%) with 54% of providers reporting that they rarely or never ordered MRI of the lumbar spine. In addition, 72% rarely or never ordered X-ray of the sacroiliac joint whereas 97% rarely or never ordered an MRI for the sacroiliac joint.
“[The survey] also assessed referral patterns for patients with chronic back pain, and primary care providers were asked to rank the specialty providers in the order in which they would send referrals; rheumatology referrals were ranked lowest,” Alexander said.
In contrast, physical medicine and rehabilitation specialists were ranked highest (61%) followed by orthopedics (16%), spine surgery (12%) and chiropractor specialists (6%).
“Primary care providers are likely not appropriately evaluating chronic back pain patients for axial spondyloarthritis, which likely contributes to the lack of rheumatology referrals and a delay in diagnosis,” Alexander told attendees. “This survey provides us a glimpse into the current real-world practice, thus offering us an opportunity for enhanced education and collaboration to help decrease the delay in diagnosis for axial spondyloarthritis patients and greatly improve their quality of life.”
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