Spondyloarthritis Research and Treatment Network Recommendations for the Referral of Adults With Chronic Back Pain
Maureen Dubreuil1,2, Abhijeet Danve3, Jean W Liew1
1Boston University School of Medicine, Boston, Massachusetts.
Objective:
In the United States, axial spondyloarthritis (axSpA) diagnosis is delayed up to 14 years preventing effective management. We convened a multidisciplinary clinician and patient group to develop recommendations for rheumatology referral of adults with chronic back pain.
Methods:
Systematic review (SR) and meta-analysis determined predictive values of clinical, laboratory, and imaging axSpA features for diagnosis. In a Delphi exercise, experts reviewed these test characteristics and voted to gain consensus for inclusion or exclusion in the final recommendations. Features that did not gain consensus were evaluated using discrete choice experiments (DCE). Positive likelihood ratios (+LRs) were used to calculate the probability of axSpA to develop the referral strategy.
Results:
The SR uncovered 28 axSpA features (+LR 0.5-10). There was consensus to include uveitis, elevated erythrocyte sedimentation rate or C-reactive protein, family history of spondyloarthritis, HLA-B27, inflammatory bowel disease, sacroiliitis by imaging, good response to nonsteroidal anti-inflammatory drugs, and psoriasis. DCE allowed exclusion of features with low importance. Experts considered posttest probability of ≥33% appropriate for referral. +LRs were used to generate a scoring system to be used in adults with chronic back pain with onset before age 45 years; a score of ≥3 is considered a threshold for referral to a rheumatologist.
Conclusions:
On behalf of the Spondyloarthritis Research and Treatment Network (SPARTAN), we developed data-driven referral recommendations for adults with chronic back pain to a rheumatologist for evaluation of axSpA. Validation is needed to determine if axSpA is diagnosed in 33% of those referred and if this strategy reduces diagnostic delay.