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

BACKGROUND: The 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. METHODS: We 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. RESULTS: Physicians 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. CONCLUSION: Primary 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).

Sex Differences in Time to Initiate Nonsteroidal Anti-Inflammatory Drugs or Biologic Disease-Modifying Antirheumatic Drugs Among Patients With Axial Spondyloarthritis.

OBJECTIVE: We evaluated sex differences in time to initiation of receiving nonsteroidal anti-inflammatory drugs (NSAIDs) or biologic disease-modifying antirheumatic drugs (bDMARDs) among patients with axial spondyloarthritis (axSpA). METHODS: Using the 2013 to 2018 IBM MarketScan Database, we identified 174,632 patients with axSpA aged ≥18 years. We evaluated the time between axSpA diagnosis and the first prescription NSAID dispensing (among those with no baseline NSAIDs reception) or bDMARDs infusion/procedure claim (among those who were dispensed two or more different prescription NSAIDs in the baseline period). Adjusted hazard ratios (aHRs) for time to initiation of patients receiving NSAIDs or bDMARDs were computed using survival analyses. Cox proportional hazard models estimated associations between sex and predictors of treatment initiation. RESULTS: Average age at diagnosis was 48.2 years, 65.7% were female, and 37.8% were dispensed one or more NSAIDs before axSpA diagnosis. Of those who did not receive two or more different prescription NSAIDs before diagnosis, NSAID reception was initiated earlier in female patients than in male patients (NSAID reception initiators: female patients (32.9%), male patients (29.3%); aHR 1.14, 95% confidence interval [CI] 1.11-1.16). Among those who received two or more different prescription NSAIDs in the baseline period, 4.2% received a bDMARD, whereas 77.9% continued receiving NSAIDs after diagnosis. Time to bDMARD reception initiation was longer for female patients than for male patients (aHR 0.61, 95% CI 0.52-0.72), but bDMARDs were received sooner among those who received NSAIDs in the baseline period. CONCLUSION: Prescription NSAID reception was more common than initiation of receiving bDMARDs among patients newly diagnosed with axSpA. Female patients appeared more likely to continue receiving NSAIDs after diagnosis, and the time to initiation of receiving bDMARDs was longer for female patients than for male patients.

Postpartum Depression in Reproductive-Age Women With and Without Rheumatic Disease: A Population-Based Matched Cohort Study.

OBJECTIVE: To examine postpartum depression (PPD) among women with axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), or rheumatoid arthritis (RA) in comparison with a matched population without rheumatic disease (RD). METHODS: A retrospective analysis using the 2013-2018 IBM MarketScan Commercial Claims and Encounters Database was conducted. Pregnant women with axSpA, PsA, or RA were identified, and the delivery date was used as the index date. We restricted the sample to women ≤ 55 years with continuous enrollment ≥ 6 months before date of last menstrual period and throughout pregnancy. Each patient was matched with 4 individuals without RD on: (1) maternal age at delivery, (2) prior history of depression, and (3) duration of depression before delivery. Cox frailty proportional hazards models estimated the crude and adjusted hazard ratios (aHR) and 95% CI of incident postpartum depression within 1 year among women with axSpA, PsA, or RA (axSpA/PsA/RA cohort) compared to the matched non-RD comparison group. RESULTS: Overall, 2667 women with axSpA, PsA, or RA and 10,668 patients without any RD were included. The median follow-up time in days was 256 (IQR 93-366) and 265 (IQR 99-366) for the axSpA/PsA/RA cohort and matched non-RD comparison group, respectively. Development of PPD was more common in the axSpA/PsA/RA cohort relative to the matched non-RD comparison group (axSpA/PsA/RA cohort: 17.2%; matched non-RD comparison group: 12.8%; aHR 1.22, 95% CI 1.09-1.36). CONCLUSION: Postpartum depression is significantly higher in women of reproductive age with axSpA/PsA/RA when compared to those without RD.

Development and test-retest reliability of a screening tool for axial spondyloarthritis.

BACKGROUND: People with axial Spondyloarthritis (axSpA) suffer from lengthy diagnostic delays of ~7 years. The usage of screening tools to identify axSpA patients in primary care can reduce diagnostic delays by facilitating early referral to rheumatologic care. The purpose of this study was to examine the psychometric properties of a potential screening tool for patients with axSpA. METHOD: Content validity was evaluated by soliciting feedback from 7 rheumatologists regarding the relevance and content representativeness of the proposed screening questions. For the test-retest study, participants ≥18 years of age with chronic back pain (≥3 months) without a diagnosis of mechanical or inflammatory back pain (n = 91) were e-recruited through ResearchMatch. Participation included completing identical baseline and follow-up questionnaires ~14 days apart. Weighted quadratic kappa was used to measure test-retest reliability between the two ratings of the ordinal scales. Construct validity was examined using exploratory factor analysis (EFA) and items with factor loadings ≥0.6 were extracted. Scale dimensionality and simplified factorial solutions were measured using Kaiser's criteria (Eigenvalue >1). Cronbach's alpha was used to measure internal consistency. RESULTS: Most participants were women, non-Hispanic white, and had at least some college education, with a mean age of 45 years. On average, the age at onset of back pain was 31 years. Eleven questions yielded test-retest reliabilities ranging from 0.6 to 0.76. Results from EFA extracted two factors relating to: 1) how pain affects daily life functioning and 2) whether pain improves with movement. Internal consistency was high for questions evaluating how pain affects life, with a Cronbach's alpha of 0.81. Following assessment for validity and reliability, the questionnaire was revised to create the 6-item screening tool. CONCLUSIONS: The 6-item SpA-SED screening tool designed to identify potential cases of axSpA was found to have good test-retest reliability and high internal consistency.

The disease burden of axial spondyloarthritis: through a gendered lens.

INTRODUCTION: Axial spondyloarthritis (axSpA) affects patients' health-related quality of life (HRQoL). Prior studies have documented gender differences in axSpA across the disease spectrum. Our study aims to assess gender differences on the effects of axSpA on patients' HRQoL. METHOD: A secondary qualitative thematic analysis was conducted using data from in-depth interviews (n = 24) of patients with a rheumatologist-confirmed axSpA diagnosis. This analysis focused on gender and HRQoL themes including activity, occupation, sleep, healthcare system, mental health, medication usage, and relationships. RESULTS: While men on average waited a year longer than women to tell healthcare providers about symptoms (2.5 years men versus 1.6 years women), the interval between first report of symptoms to diagnosis was ~ 2 years longer for women relative to men (7.5 women versus 9.3 years men). Women and men with axSpA shared more similarities than differences regarding the impact of disease on HRQoL including (1) physical health, (2) limited mobility, (3) occupation, (4) sleep, (5) healthcare system obstacles, (6) mental health, (7) medication usage, and (8) relationships. Some women reported being dismissed by doctors due to their gender, and some described the pain experienced during pregnancy and complications during birth. CONCLUSIONS: axSpA adversely impacts HRQoL regardless of gender, but women seeking care for axSpA may experience greater challenges reaching a diagnosis. It is essential that providers recognize impaired HRQoL among men and women with axSpA. Future studies with larger sample sizes are needed to identify aspects of HRQoL to adequately address people with axSpA. Key Points • While men waited on average a year longer to tell their healthcare provider about their symptoms, the diagnostic delay is 2 years longer for women. • Women and men with axSpA have similar experiences regarding impacts on their health-related quality of life. • Some women describe difficulty during pregnancy and being dismissed by doctors due to their gender.

Development of a screening tool to identify patients with axial spondyloarthritis: a cognitive interview study.

OBJECTIVE: To further refine the wording of screening questions and examine their face validity through cognitive interviews with axial spondyloarthritis (axSpA) and chronic mechanical back pain patients. METHODS: In-depth, semi-structured cognitive interviews were conducted with 30 patients (10 axSpA; 20 chronic mechanical back pain patients) to assess the face validity and comprehensibility of the screening questions. The interview protocol focused on 12 questions/domains including participants' feedback/thoughts on the duration of suffering from back pain, age at onset of back pain, pace of back pain development, improvement of pain with movement or rest, nocturnal back pain improving upon awakening, pain in other parts of the body, responsiveness of pain to nonsteroidal anti-inflammatory drug (NSAID) use, history of autoimmune conditions, and domains such as sleep, sitting, and stiffness. The Flesch-Kincaid grade level and Flesch reading ease scores were then analyzed for the revised versions of screening questions. RESULTS: Participants preferred questions that allowed them to provide more details regarding the frequency of their symptoms. Questions were refined for clarity and eliminated if participants considered them to be irrelevant (e.g., NSAIDs). Two sample screeners were derived from twelve questions each with an overall reading grade of 7.5 and reading ease of 65.7%. CONCLUSIONS: It is feasible to design a screening tool that is accessible to most (e.g., reading level) and clear to individuals with back pain. An evidence-based approach to demonstrate the validity of the screening tool will be critical for it to be implemented widely into clinical practice. Key Points • Our study developed two sample screeners that are clear to individuals with back pain and accessible to most with an overall Flesch-Kincaid reading grade of 7.5 and Flesch reading ease of 65.7%. • Questions that were considered irrelevant to participants were eliminated such as responsiveness of pain to nonsteroidal anti-inflammatory drug (NSAID). • It is feasible to design a screening tool that is accessible to most (e.g., reading level) and clear to individuals with back pain.

Comanagement with rheumatology and prescription biologics filled during pregnancy in women with rheumatic diseases: a retrospective analysis of US administrative claims data.

OBJECTIVES: To evaluate comanagement with rheumatology and biological prescriptions filled during pregnancy among women with axial spondyloarthritis (axSpA), rheumatoid arthritis (RA) or psoriatic arthritis (PsA) and to examine factors associated with receiving comanagement with rheumatology during pregnancy. DESIGN: A retrospective analysis of US claims data. SETTING: Commercially insured enrollees using data from the 2013-2018 IBM MarketScan Commercial Claims and Encounters Database. PARTICIPANTS: We identified 4131 pregnant women aged ≤55 years from the 2013-2018 IBM MarketScan Commercial Claims and Encounters Database with an International Classification of Disease, 9th Revision/10th Revision codes for RA, axSpA or PsA, with continuous enrolment at ≥3 months before the date of the last menstrual period (LMP) (index date) and throughout pregnancy. PRIMARY OUTCOMES: Filled biologics (prescriptions and infusions) claims were categorised by 90 days before the LMP and trimester, as were primary care, obstetrician and rheumatological claims. RESULTS: The prevalence of axSpA, RA and PsA was 0.7%, 0.2% and 0.04% among reproductive age women. The average maternal age was 32.7 years (SD 5.7). During pregnancy, 9.1% of those with axSpA (n=2,410) and 56.4% of those with RA/PsA (n=1,721) had a rheumatological claim. Biologics claims were less common among those with axSpA (90 days before LMP: 1.6%, during pregnancy: 1.1%) than those with RA/PsA (90 days before LMP: 11.9%, during pregnancy: 6.9%). Medications during pregnancy included corticosteroids (axSpA: 0.3%, RA/PsA: 2.2%), non-biological disease-modifying antirheumatic drugs (axSpA: 0.2%, RA/PsA: 1.7%), non-steroidal anti-inflammatory drugs (axSpA: 0.2%, RA/PsA: 1.3%) and opioids (axSpA: 0.2%, RA/PsA: 0.6%). Established rheumatological care and biologics claims during the 90 days before LMP showed good prediction accuracy for receiving comanagement with rheumatology during pregnancy (axSpA: area under the receiver operator curve (AUC) 0.73, RA/PsA: AUC 0.70). CONCLUSION: Comanagement with rheumatology during pregnancy occurs infrequently, especially for women with axSpA. Biologics claims during pregnancy may not align with published guidelines. Future research is warranted to improve comanagement with rheumatology during pregnancy.

Disease Burden and Health-Related Quality of Life Among Women and Men with Spondyloarthritis: An Exploratory Analysis of a Population-Based Sample.

Objective: We described the burden of illness and health-related quality of life (HRQoL) in adults with spondyloarthritis (SpA) using a nationally representative sample. Materials and Methods: We identified participants with SpA using the Amor classification criteria (probable: score 5 or definite: ≥6) and complete data on HRQoL from the 2009 to 2010 National Health and Nutrition Examination Survey (n = 231). HRQoL was measured using the Healthy Days Measures including self-rated health status (excellent/very good, good, fair/poor), number of activity-restricted days, and number of unhealthy mental and physical health days in the past month (range: 0-30). Other domains including clinical assessments, comorbidities, physical functioning, and medication use were also explored. Results: Only 39% of the sample met the Amor criteria for definite SpA. Although 58% of those with definite SpA had seen a doctor >3 times in the past year, 2.5% women and 4.1% men had ever been told by a physician that they have ankylosing spondylitis. Among those with definite SpA, racial/ethnic diversity was observed in women (13.6% non-Hispanic Black, 23.2% Hispanic) and men (11.6% non-Hispanic Black, 11.2% Hispanic). Overall, 41.6% women and 49.7% men rated their health as fair/poor. For other HRQoL measures, 25.4% women and 20.4% men reported ≥15 activity-restricted days and 39.7% women and 41.4% men reported ≥15 physically unhealthy days. Conclusion: Both men and women rank health as poor with indications that it affects QoL. Although our small sample size limits definitive statements, we observed trends that warrant further confirmation in larger population-based samples.

The relationship between restless sleep and symptoms of the knee: data from the Osteoarthritis Initiative.

OBJECTIVE: To examine the associations between restless sleep and knee symptoms among individuals with radiographically confirmed KOA. METHODS: Cross-sectional and longitudinal associations were examined using Osteoarthritis Initiative (OAI) data. Participants with radiographic KOA (n = 2517) were asked how often sleep was restless in the past week over the 4 years, and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) was used to measure knee symptoms. Adjusted ß coefficients (aß) and 95% confidence intervals (CI) were derived from generalized estimating equations (GEEs) models stratified by sex. RESULTS: One in 7 participants reported ≥ 3 nights with restless sleep. Cross-sectional analyses indicated that restless sleep 5-7 nights was associated with worse symptoms (Women: pain: aß 1.93, 95% CI 1.12-2.74, stiffness: aß 0.57, 95% CI 0.19-0.94, physical function: aß 5.68, 95% CI 3.09-8.27; Men: pain: aß = 1.85, 95% CI 0.85-2.86; stiffness: aß 0.63, 95% CI 0.15-1.12; physical function: aß 5.89, 95% CI 2.68-9.09) compared with < 1 night. Longitudinal analyses confirmed that more nights with restless sleep were associated with worse pain (P trend = 0.01) and function (P trend = 0.04) in women and physical function in men (P trend = 0.04), although estimates did not meet thresholds for minimal clinically meaningful differences. CONCLUSION: While the analysis of cross-sectional data supported the association between restless sleep and KOA symptoms, such relationships were not confirmed in more robust longitudinal analysis. Further research examining whether sleep quality, duration, or disorders is associated with worsening symptoms in persons with KOA is warranted. Key Points • The prevalence of frequent restless sleep among persons with knee OA is not uncommon. • There were linear trends between frequency of restless sleep and self-reported symptoms of the knee in cross-sectional analyses. • In the more robust longitudinal analysis, despite the statistically significant linear trends observed between frequency of restless sleep and symptoms (women: pain and physical function; men: function), none appeared to reach the a priori selected ranges for minimally clinically relevant differences.

Primary care physician perspectives on screening for axial spondyloarthritis: A qualitative study.

BACKGROUND: Many patients with axial spondylarthritis (axSpA) experience lengthy diagnostic delays upwards of 14 years. (5-14 years). Screening tools for axSpA have been proposed for use in primary care settings, but whether this approach could be implemented into busy primary care settings remains unknown. OBJECTIVE: To solicit feedback from primary care physicians regarding questions from the Inflammatory Back Pain Assessment: the Assessment of Spondyloarthritis International Society (ASAS) Expert Criteria and gain insight about barriers and facilitators for implementing axSpA screening in primary care. METHODS: Guided by Consolidated Criteria for reporting Qualitative Research (COREQ-criteria), we recorded, transcribed, and analyzed in-depth interviews with eight family medicine physicians and ten internists (purposeful sampling) using immersion/crystallization techniques. RESULTS: Few physicians reported awareness of existing classification criteria for axSpA, and many reported a lack of confidence in their ability to distinguish between inflammatory and mechanical back pain. From three domains, 10 subthemes emerged: 1) typical work-up of axSpA patients in primary care, with subthemes including the clues involved in work-up and role of clinical examinations for axSpA; 2) feedback on questions from the Inflammatory Back Pain Assessment: ASAS Expert Criteria, with subthemes to evaluate contents/questions of a potential screening tool for axSpA; and 3) implementation of the screening tool in primary care settings, with subthemes of perceived barriers including awareness, time, other conditions to screen, rare disease, and lack of structured questionnaire for back pain and perceived facilitators including workflow issues and awareness. CONCLUSIONS: Primary care physicians believed that an improved screening instrument and a strong evidence-base to support the need for screening for axSpA are required. The implementation of axSpA screening into a busy primary care practice requires integration into the practice workflow, with use of technology suggested as a possible way to improve efficiency.

Physical Activity and Attitudes Toward Exercise in People With Axial and Peripheral Spondyloarthritis.

OBJECTIVE: To evaluate physical activity and attitudes toward exercise among people with axial (ax-) and peripheral (p-) spondyloarthritis (SpA). METHODS: Using baseline information from an ongoing, longitudinal, prospective SpA cohort study (n = 264), self-reported attitudes and beliefs toward exercise were assessed using questionnaires. Total metabolic equivalent (MET) hours of self-reported physical activity per week, time spent in activities, and activity levels were calculated from the Nurses' Health Study Physical Activity Questionnaire II (NHSPAQ II). Adjusted multivariable linear models estimated the relationship between physical activity and disease status (axial vs peripheral). RESULTS: Regardless of predominant anatomic distribution of disease, most participants were well-educated, non-Hispanic White men. Approximately 40% met the US Department of Health and Human Services physical activity recommendations. Positive attitudes, beliefs, and perceived benefits toward exercise were similar by anatomic distribution of disease. Despite similar MET h/week, participants with axial disease had greater concerns regarding discomfort and joint injuries than those with peripheral disease. Compared to those with pSpA (n = 201), participants with axSpA (n = 63) spent less time engaging in light and moderate activities (adjusted ß in light activity: -1.94 min/week, 95% CI -2.96 to -0.93; adjusted ß in moderate activity: -1.05 min/week, 95% CI -2.12 to 0.02). CONCLUSION: Participants with axSpA had greater concerns regarding discomfort and injuries from exercise than those with pSpA. Although no differences in time spent in vigorous activities were observed, participants with axSpA spent less time than those with pSpA in light to moderate activities.

The Prevalence and Factors Associated with Antiepileptic Drug Use in US Nursing Home Residents.

BACKGROUND: Antiepileptic drugs (AEDs) are commonly used by nursing home residents, both on- and off-label. The landscape of AED use has changed over the past two decades; however, despite this, contemporaneous research on AED use in US nursing home residents is scant. OBJECTIVE: The aim of this study was to estimate the prevalence of AED use, describe prescribing patterns, identify factors associated with AED use, and assess whether these factors differ among AEDs with expanded indications in older adults (i.e. gabapentin, pregabalin, topiramate, and lamotrigine). METHODS: We conducted a cross-sectional study among 549,240 long-stay older residents who enrolled in fee-for-service Medicare and lived in 15,111 US nursing homes on 1 September 2016. Demographics and conditions associated with AED indications, epilepsy comorbidities, and safety data came from the Minimum Data Set Version 3.0 (MDS 3.0). Medicare Part D claims were used to identify AED use. Robust Poisson models and multinomial logistic models for clustered data estimated adjusted prevalence ratios (aPR), adjusted odds ratios (aOR), and 95% confidence intervals (CIs). RESULTS: Overall, 24.0% used AEDs (gabapentin [13.3%], levetiracetam [4.7%], phenytoin [1.9%], pregabalin [1.8%], and lamotrigine [1.2%]). AED use was associated with epilepsy (aPR 3.73, 95% CI 3.69-3.77), bipolar disorder (aPR 1.20, 95% CI 1.18-1.22), pain (aPRmoderate/severe vs. no pain 1.42, 95% CI 1.40-1.44), diabetes (aPR 1.27, 95% CI 1.26-1.28), anxiety (aPR 1.12, 95% CI 1.11-1.13), depression (aPR 1.17, 95% CI 1.15-1.18), or stroke (aPR 1.08, 95% CI 1.06-1.09). Residents with advancing age (aPR85+ vs. 65-74 years 0.73, 95% CI 0.73-0.74), Alzheimer's disease/dementia (aPR 0.87, 95% CI 0.86-0.88), or cognitive impairment (aPRsevere vs. no impairment 0.62, 95% CI 0.61-0.63) had decreased AED use. Gabapentinoid use was highly associated with pain (aORmoderate/severe vs. no pain 2.07, 95% CI 2.01-2.12) and diabetes (aOR 1.79, 95% CI 1.76-1.82), but not with an epilepsy indication. CONCLUSIONS: AED use was common in nursing homes, with gabapentin most commonly used (presumably for pain). That multiple comorbidities were associated with AED use underscores the need for future studies to investigate the safety and effectiveness of AED use in nursing home residents.