Primary care physician perspectives on barriers to diagnosing axial Spondyloarthritis: a qualitative study

Kate L. Lapane,Catherine Dubé,Shao-Hsien Liu,Jonathan Kay,Esther Yi,Sara Khan,Divya Shridharmurthy,Ariel Beccia

doi:10.1186/s12875-020-01274-y

Abstract

BackgroundThe average delay in diagnosis for patients with axial spondyloarthritis (axSpA) is 7 to 10 years. Factors that contribute to this delay are multifactorial and include the lack of diagnostic criteria (although classification criteria exist) for axSpA and the difficulty in distinguishing inflammatory back pain, a key symptom of axSpA, from other highly prevalent forms of low back pain. We sought to describe reasons for diagnostic delay for axSpA provided by primary care physicians.MethodsWe conducted a qualitative research study which included 18 US primary care physicians, balanced by gender. Physicians provided informed consent to participate in an in-depth interview (< 60 min), conducted in person (n = 3) or over the phone (n = 15), in 2019. The analysis focuses on thoughts about factors contributing to diagnostic delay in axSpA.ResultsPhysicians noted that the disease characteristics contributing to diagnostic delay include: back pain is common and axSpA is less prevalent, slow progression of axSpA, intermittent nature of axSpA pain, and in the absence of abnormal radiographs of the spine or sacroiliac joints, there is no definitive test for axSpA. Patient characteristics believed to contribute to diagnostic delay included having multiple conditions in need of attention, infrequent interactions with the health care system, and “doctor shopping.” Doctors noted that patients wait until the last moments of the clinical encounter to discuss back pain. Problematic physician characteristics included lack of rapport with patients, lack of setting appropriate expectations, and attribution of back pain to other factors. Structural/system issues included short appointments, lack of continuity of care, insufficient insurance coverage for tests, lack of back pain clinics, and a shortage of rheumatologists.ConclusionPrimary care physicians agreed that lengthy axSpA diagnosis delays are challenging to address owing to the multifactorial causes (e.g., disease characteristics, patient characteristics, lack of definitive tests, system factors).

Highlights

The average delay in diagnosis for patients with axial spondyloarthritis is 7 to 10 years
Physicians believed that multiple factors were contributing to the diagnostic delay in axial spondyloarthritis (axSpA)
This study sheds light on the challenges faced by primary care physicians that may contribute to the delay in diagnosing axSpA, which typically presents with the insidious onset of back pain that often is attributed to other, more prevalent conditions [22, 23]

Summary

Introduction

The average delay in diagnosis for patients with axial spondyloarthritis (axSpA) is 7 to 10 years. We sought to describe reasons for diagnostic delay for axSpA provided by primary care physicians. The improvement of delay in diagnosis for axSpA may slow disease progression and avoid or delay serious disability due to the early treatment interventions and access to care [13]. The delay in diagnosis for axSpA is multifactorial including characteristics of the patients, providers, healthcare system, and disease itself. Despite the use of sensitive imaging tool such as magnetic resonance imaging, the delayed diagnosis for patients with non-radiographic axSpA is still significant [14]. Primary care physicians may have difficulty discriminating inflammatory back pain from other types of back pain and may be unaware of other features that are important in making a diagnosis of axSpA

Results

Discussion

Conclusion