Many physicians who treat patients with chronic back pain lack the knowledge to identify people with axial spondyloarthritis, a chronic inflammatory disorder, and do not routinely screen for it, according to research led by Yale School of Medicine and published recently in The Journal of Rheumatology.
Axial spondyloarthritis affects 1.4% of the population, and symptoms typically begin in young adulthood. Although the condition is relatively common, it is frequently missed, said Abhijeet Danve, MD, MHS, associate professor of medicine (rheumatology, allergy and immunology) and director of the Yale Spondyloarthritis Program, who led the study. People with this disorder are usually not diagnosed for eight to 14 years after the onset of symptoms. These people can develop irreversible damage to their spine or sacroiliac joints and suffer other effects, he said.
Although the condition is relatively common, it is frequently missed.
Abhijeet Danve, MD, MHS
“Uncontrolled inflammation in the body will have deleterious effects on other organ systems and could mean increased risk of heart disease, stroke, blood clot, or hypertension,” he said.
Danve and the other researchers knew that the appropriate patients with chronic back pain, a common symptom of axial spondyloarthritis, are frequently not referred to rheumatologists, who are considered the experts in diagnosis and management of this disease.
“We wanted to see what primary care physicians and other specialists know about this condition, whether they apply the knowledge in routine clinical practice, and also find the barriers to referral to rheumatology,” he said.
The researchers sent a survey to physicians across the U.S. who treat patients with chronic back pain. This included physicians in family and internal medicine, spine surgery and orthopedics, pain management, and physical medicine and rehabilitation. To compare the results, they also surveyed rheumatologists, who are considered experts in this disease.
A total of 750 physicians completed the survey. Most non-rheumatologists (75%) were familiar with inflammatory back pain, and about half (54%) with axial spondyloarthritis, while all rheumatologists were familiar with both.
Most non-rheumatologists (87%) could identify at least half the symptoms associated with inflammatory back pain from a list. But that knowledge did not transfer into their practices. Just 40% of the non-rheumatologists routinely assessed for features of the condition, while all but one of the rheumatologists routinely did.
Axial spondyloarthritis is a challenging condition to diagnose, but the imaging test offering the clearest indication of the condition and that physicians should order first is a pelvic X-ray, Danve said. A surprising finding for him was that only half of the non-rheumatologist physicians knew this.
“If half of the physicians don’t know which imaging test to order, this diagnosis will remain elusive to us, these patients will not be referred to rheumatology, and that will lead to delay in the diagnosis,” he said.
Danve hopes the study helps in designing solutions. For example, rehabilitation and physical medicine specialists were most likely to know to order a pelvic X-ray, and family and internal medicine physicians the least. But family and internal medicine physicians are typically the first to see patients and the most common referral source to rheumatologists, so focusing on them for educational campaigns may be most important, he said.
In addition, the study found that both non-rheumatologists (81%) and rheumatologists (97%) wanted formal referral guidelines for the condition to be developed. Danve and his colleagues in the Spondyloarthritis Research and Treatment Network are developing national guidelines for referral of chronic back pain patients to rheumatologists, which may help improve diagnosis of this condition.
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