SAT0338 DELAYED DIAGNOSIS OF ANKYLOSING SPONDYLITIS: RESULTS FROM A SURVEY OF 1690 US PHYSICIANS FROM 10 SPECIALTIES
Authors: Marina Magrey, Esther Yi, Daniel Wolin, Mark Price, Costel Chirila, Eric Davenport, Yujin Park
Journal: Annals of the Rheumatic Diseases (2019)

<h3>Background:</h3> There is a significant delay in the diagnosis of ankylosing spondylitis (AS) in the United States. Several studies have estimated that the time between symptom onset and physician diagnosis is 5-7 years. Diagnosis delay is attributed to nonspecific presentation of chronic back pain, requiring clinical experience to recognize early AS. <h3>Objectives:</h3> To identify obstacles to early diagnosis of AS by assessing the knowledge of nonrheumatology health care providers (HCPs) on inflammatory back pain (IBP) and possible barriers to referral to a rheumatologist. <h3>Methods:</h3> Survey content was first conceptualized based on concept elicitation interviews with HCPs, and questionnaires were developed by the study investigators to identify clinical characteristics, symptom presentation, and diagnostic measures that lead an HCP to suspect IBP and their perspectives on the referral process. The survey was then cognitively tested with HCPs from 10 specialties (family medicine, internal medicine, dermatology, gastroenterology, ophthalmology, orthopedics, chiropractic, pain management, physical therapy, and physiatry), revised, and finalized. HCPs from these 10 specialties were invited to participate in the cross-sectional web-based survey hosted by Survey Sampling International between June 27 and July 20, 2018. HCPs who were currently licensed, actively practicing in the US, and had referred a patient with suspected IBP (except ophthalmology) or referred a patient with uveitis/iritis (ophthalmology only) within the past 12 months were eligible to participate. Descriptive statistics were used to analyze the data. <h3>Results:</h3> Of 2395 HCPs screened, 1690 were eligible and included in our study. Overall, HCPs saw a median of 100 patients with chronic back pain within the past 12 months of the survey. Regarding criteria leading to suspicion of IBP, 61% of HCPs indicated morning stiffness &gt; 30 minutes, 29% sleep disturbance due to back pain, 28% pain that improves with activity, and 16% alternating buttock pain. Among HCPs who would order diagnostic blood work, ≈ 90% selected C-reactive protein, erythrocyte sedimentation rate, antinuclear antibody (ANA), and rheumatoid factor (RF), while 76% selected HLA-B27 (Figure 1). Most HCPs suspected underlying conditions of rheumatoid arthritis (RA; 94%), AS (90%), and psoriatic arthritis (81%) as related to IBP. Almost 40% of HCPs would treat patients with suspected IBP themselves; of these, ≈ 80% would recommend nonsteroidal anti-inflammatory drugs and physical therapy (Figure 2). Regarding referrals, 57% of HCPs would refer patients with suspected IBP to another physician, but only 13% would refer immediately; 49% would perform further evaluations, 24% would wait until initial treatment response, 11% would monitor patient for some time, and 3% would consult with another physician before referring. Upon referral, 90% of HCPs estimated a wait time of up to 2 months for their patient to see another specialist. Of 1670 HCPs queried, 80% indicated that the specialist's expertise in treating autoimmune disease is the most important factor influencing their referral. <h3>Conclusion:</h3> Most HCPs did not recognize IBP criteria in patients with chronic back pain. As most considered RA to be the underlying condition, ANA and RF were ordered as diagnostic workup. Many HCPs opted to treat and monitor patients with suspected IBP before referral, and most reported a wait time of up to 2 months for their patients to see a specialist. <h3>Acknowledgement:</h3> This study was sponsored by Novartis Pharmaceuticals Corporation, East Hanover, NJ. <h3>Disclosure of Interests:</h3> Marina Magrey Grant/research support from: M. Magrey received research funding from AbbVie and UCB for clinical trials, served as a consultant for Novartis, and was a member of advisory boards for Eli Lilly, Novartis, and UCB, Consultant for: M. Magrey received research funding from AbbVie and UCB for clinical trials, served as a consultant for Novartis, and was a member of advisory boards for Eli Lilly, Novartis, and UCB, Esther Yi Consultant for: E. Yi is a postdoctoral fellow at the University of Texas at Austin and Baylor Scott and White Health, providing services to Novartis Pharmaceuticals Corporation., Daniel Wolin Employee of: D. Wolin is an employee of RTI Health Solutions., Mark Price Employee of: M. Price is an employee of RTI Health Solutions., Costel Chirila Employee of: C. Chirila is an employee of RTI Health Solutions., Eric Davenport Employee of: E. Davenport is an employee of RTI Health Solutions., Yujin Park Employee of: Y. Park is an employee of Novartis.