Quality statement 1: Referral

Quality statement

Adults with suspected axial or peripheral spondyloarthritis are referred to a rheumatologist.

Rationale

Both axial and peripheral spondyloarthritis, including psoriatic arthritis, are difficult to diagnose without specialist assessment. Delays in correctly identifying spondyloarthritis can result in significant morbidity and avoidable investigations and treatments. Referring adults with suspected spondyloarthritis to a rheumatologist will reduce delays in diagnosis and starting treatment. This will help improve outcomes, such as reducing joint and tendon damage, loss of function, pain, fatigue and quality of life.

Quality measures

Structure

a) Evidence of local arrangements to raise awareness of signs, symptoms and risk factors of axial and peripheral spondyloarthritis in primary care.

Data source: Local data collection, for example, from education programmes or awareness campaigns.

b) Evidence of local referral criteria and pathways to ensure that adults with suspected axial or peripheral spondyloarthritis are referred to a rheumatologist.

Data source: Local data collection, for example, from referral pathways or referral strategies.

Process

Proportion of adults with suspected axial or peripheral spondyloarthritis referred to a rheumatologist.

Numerator – the number in the denominator referred to a rheumatologist.

Denominator – the number of adults with suspected axial or peripheral spondyloarthritis.

Data source: Local data collection, for example, local audit of patient records.

Outcomes

a) Time from first presentation of symptoms to diagnosis for adults with spondyloarthritis.

Data source: Local data collection, for example, local audit of patient records.

b) Health-related quality-of-life score of adults with spondyloarthritis.

Data source: Local data collection, for example, survey of adults with axial spondyloarthritis using a quality-of-life questionnaire.

c) Functional ability score of adults with axial spondyloarthritis.

Data source: Local data collection, for example, survey of adults with axial spondyloarthritis using a questionnaire to assess functional ability (such as the Bath Ankylosing Spondylitis Functional Index).

d) Joint replacement surgery for adults with peripheral spondyloarthritis.

Data source: Local data collection, for example, local audit of patient records.

What the quality statement means for different audiences

Service providers (such as GP practices and musculoskeletal interface services, physiotherapy, ophthalmology, dermatology and gastroenterology services) ensure that healthcare professionals are aware of the signs, symptoms and risk factors of axial and peripheral spondyloarthritis. They develop referral criteria and pathways with rheumatology services to ensure that people with signs and symptoms of spondyloarthritis are referred to rheumatologists for assessment and diagnosis.

Healthcare professionals (such as GPs, physiotherapists, nurses, dermatologists, gastroenterologists and ophthalmologists) are aware of the signs, symptoms and risk factors of axial and peripheral spondyloarthritis, the groups of people it can affect and local referral pathways. They identify people who have signs and symptoms of spondyloarthritis and refer them to a rheumatologist for investigation and diagnosis.

Commissioners (clinical commissioning groups and NHS England) have service specifications for rheumatology that include referral criteria and referral pathways to ensure that adults presenting with signs, symptoms and risk factors of axial or peripheral spondyloarthritis are referred to a rheumatologist for investigation and diagnosis.

Adults with symptoms that suggest spondyloarthritis (a type of inflammatory arthritis) are referred to a specialist in rheumatology for assessment and tests, which may include an X‑ray or a scan. People who have these assessments and tests will find out sooner whether or not they have spondyloarthritis and can start treatment earlier.

Source guidance

Spondyloarthritis in over 16s: diagnosis and management (2017) NICE guideline NG65, recommendations 1.1.5, 1.1.8, 1.1.9 and 1.1.10

Definitions of terms used in this quality statement

Suspected axial spondyloarthritis

Signs and symptoms of axial spondyloarthritis include a combination of low back pain that started before the age of 45 years and has lasted for longer than 3 months, and:

  • 4 or more of the following additional criteria:

    • low back pain that started before the age of 35 years (this further increases the likelihood that back pain is due to spondyloarthritis, compared with low back pain that started between 35 and 44 years)

    • waking during the second half of the night because of symptoms

    • buttock pain

    • improvement with movement

    • improvement within 48 hours of taking non-steroidal anti-inflammatory drugs

    • a first-degree relative with spondyloarthritis

    • current or past arthritis

    • current or past enthesitis (inflammation of a site at which a tendon or ligament attaches to bone)

    • current or past psoriasis

or

  • 3 of the above additional criteria and a positive result from a HLA‑B27 test.

[NICE's guideline on spondyloarthritis, recommendation 1.1.5 and glossary in the full guideline]

Suspected peripheral spondyloarthritis

Signs, symptoms and risk factors that indicate an adult could have psoriatic arthritis or other peripheral spondyloarthritides are:

  • new-onset inflammatory arthritis, unless rheumatoid arthritis, gout or acute calcium pyrophosphate arthritis ('pseudogout') is suspected

  • dactylitis (inflammation of a finger or toe characteristically resulting in a sausage appearance)

  • enthesitis without apparent mechanical cause if:

    • it is persistent or

    • it is in multiple sites or

    • any of the following are also present:

      • back pain without apparent mechanical cause

      • current or past uveitis

      • current or past psoriasis

      • gastrointestinal or genitourinary infection

      • inflammatory bowel disease (Crohn's disease or ulcerative colitis)

    • a first-degree relative with spondyloarthritis or psoriasis.

[NICE's guideline on spondyloarthritis, recommendations 1.1.8, 1.1.9, 1.1.10 and glossary in the full guideline]

Equality and diversity considerations

There is a common misconception that axial spondyloarthritis mainly affects men. Healthcare professionals should be aware that axial spondyloarthritis affects a similar number of women as men.