E042 Referrals for back pain to rheumatology outpatients: time to rethink service delivery?
Authors: Arumalla Nikita , Okoye Emeka , Jones Roseanne , Humby Frances , Subesinghe Sujith , Golding Tess , Garrood Toby , Byng-Maddick Rachel 
Published: April 2024

Abstract

Background/Aims
Diagnostic delay in inflammatory and mechanical back pain (IBP and MBP) is a challenge, leading to time-off-work, mental health deterioration and chronicity of pain. Here we describe referral and follow-up characteristics in patients referred to a rheumatology service with back pain. By identifying these patients earlier and having a more proactive approach we may be able to reduce diagnostic delay and prevent some of this burden.

Methods
All new patients attending rheumatology outpatients at Guys and St Thomas’ Trust in London, UK are routinely sent a digital pre-appointment questionnaire to complete prior to initial visit. Between 21/06/2021 and 20/10/2022, 137 patients referred with back pain completed this questionnaire, which included the Assessment of SpondyloArthritis International Society (ASAS) IBP criteria. Clinical records were reviewed until June 2023.

Results
Our cohort had a mean (SD) age of 40.5(13.5) years, 50% were female and 66% were referred from primary care. Average symptom duration was 5.2(6.1) years. A primary diagnosis of axial spondyloarthritis was made in 41%, 53% were diagnosed with MBP and 6% had MBP on a background of other inflammatory disease. Incomplete data was an issue, with only 54% of the referrals having a CRP result, 50% having an ESR result and 22% with HLAB27 done and result available at referral. Rheumatology requested an MRI spine in 61% of back pain referrals. Of the 38% with a prior MRI, 15% did not have the result available at first rheumatology visit, 21% did not have the correct MRI protocol done and 17% had a further MRI spine done through rheumatology clinic. Overall, 92% of patients had at least one MRI spine done. The referral to new appointment wait time in this cohort was 19.4 (41.4) weeks and new visit to first follow-up visit duration of 18.2(13.0) weeks. Only 18% of patients were referred for back pain physiotherapy prior to being seen in rheumatology, with 20% referred at first rheumatology visit and 38% referred after this time. Of those with MBP, 96% were discharged with 82% being discharged after one follow-up i.e. after reviewing new investigation results.

Conclusion
Delay in time to diagnosis and management of back pain is considerable, with long referral to review and follow-up times and less than 1/5 patients referred for physiotherapy prior to being seen in secondary care. With 92% of patients having at least one MRI spine done, there is a call for front-loading new back pain referrals with appropriate MRI spine imaging at point of vetting along with appropriate blood tests, which we feel would help reduce diagnostic delay and be in line with the UK Getting It Right First Time (GIRFT) programme which advocates that quality care is given first time, every time.

Disclosure
N. Arumalla: None. E. Okoye: None. R. Jones: None. F. Humby: None. S. Subesinghe: None. T. Golding: None. T. Garrood: Shareholder/stock ownership; Serac Healthcare. Honoraria; UCB, Abbvie. Grants/research support; Versus Arthritis, Pfizer, Gilead, Guy’s and St Thomas’ Charity, NHSX. Other; Fresnius-Kabi. R. Byng-Maddick: None.