The clinical management of patients with ankylosing spondylitis in a real-world cohort
Patel, Akash R.
MetadataShow full item record
BACKGROUND: The Spondyloarthritis Research and Treatment Network (SPARTAN), together with the American College of Rheumatology (ACR) and the Spondylitis Association of America (SAA), published treatment recommendations for ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA) in 2016. The extent to which these recommendations are being followed in clinical practice is unclear. We performed a retrospective chart review focusing on disease activity monitoring, back exercises and DXA scanning in adults with AS. METHODS: We reviewed electronic medical records at a single academic hospital network. The cohort for this study was derived from an existing population of 775 patients identified as having AS or nr-axSpA based on imaging studies, all of whom had 3 or more ICD- 9 or 10 codes for AS (720.x or M45.x). Patients were included if they had at least one rheumatology clinic visit for AS during a three-year study period from July 1, 2016 to June 30, 2019. Data were recorded for the first and last clinic visit within the study period. RESULTS: 358 patients met inclusion criteria. The study population was predominantly male (72.6%) with a mean age of 48.1 years (SD=15.5 years); 84.9% had AS based on review of pelvic or spine radiographs. A total of 661 clinic visits were analyzed. A clinical disease activity measure was recorded at 110/661 (16.6%) visits. RAPID3 was the most frequently used score (57.3%) followed by BASDAI (33.6%) and ASDAS (9.1%). CRP and/or ESR was ordered at 346/661 (52.3%) visits. AS-specific physical therapy (PT) or home exercises for the back were documented in 103/661 (15.6%) visits. A discussion of general exercise unrelated to the back was documented in an additional 153/661 (23.1%) visits. 303/358 patients had two or more visits during the study period. The use of disease activity measures or documentation of AS-specific PT or home exercises did not increase between the first and last visit. 65/358 (18.2%) patients had a DXA scan at any time prior to June 30, 2019. Patients with a DXA were significantly older than those without (58.7 vs. 45.7 years, p<0.001) and more likely to be female (31.6% vs. 13.1%, p<0.0001). 32/358 (8.9%) patients carried a diagnosis of osteoporosis, while 27/358 (7.5%) patients had a history of vertebral fracture. 48.1% of patients with a history of vertebral fracture had a DXA compared to 15.7% of patients without vertebral fracture (p<0.001). CONCLUSION: Monitoring with validated disease activity measures, treatment with AS- specific PT or home exercises, and osteoporosis screening with DXA were performed at low frequencies in our study population. Our data emphasize the need for more education of rheumatologists and the development of implementation strategies along with future updates of the AS/nr-axSpA treatment recommendations.