title: External Validation of a Referral Rule for Axial Spondyloarthritis in Primary Care Patients with Chronic Low Back Pain.
abstract: OBJECTIVE
  To validate and optimize a referral rule to identify primary care patients with chronic low back pain (CLBP) suspected for axial spondyloarthritis (axSpA).
  
  
  METHODS
  Cross-sectional study with data from 19 Dutch primary care practices for development and 38 for validation.
  
  
  METHODS
  Primary care patients aged 18-45 years with CLBP existing more than three months and onset of back pain started before the age of 45 years.
  
  
  RESULTS
  The number of axSpA patients according to the ASAS criteria.
  
  
  METHODS
  The referral rule (CaFaSpA referral rule) was developed using 364 CLBP patients from 19 primary care practices and contains four easy to use variables; inflammatory back pain, good response to nonsteriodal anti-inflammatory drugs, family history of spondyloarthritis and a back pain duration longer than five years. This referral rule is positive when at least two variables are present. Validation of the CaFaSpA rule was accomplished in 579 primary care CLBP patients from 38 practices from other areas. Performance of the referral rule was assessed by c-statistic and calibration plot. To fit the final referral rule the development and validation datasets were pooled leading to a total study population of 943 primary care participants.
  
  
  RESULTS
  The referral rule was validated in 579 patients (41% male, mean age 36 (sd7.0). The percentage of identified axSpA patients was 16% (n=95). External validation resulted in satisfactory calibration and reasonable discriminative ability (c-statistics 0.70 [95% CI, 0.64-0.75]). In the pooled dataset sensitivity and specificity of the referral rule were 75% and 58%.
  
  
  CONCLUSIONS
  The CaFaSpA referral rule for axSpA consists of four easy to use predictors for primary care physicians and has a good predictive value in this validation study. The referral rule has the potential to be a screening tool for primary care by identifying CLBP patients suspected for axSpA.
authors.affiliation: Department of Rheumatology, Erasmus MC, Rotterdam, The Netherlands; Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands.
authors.forename: Lonneke
authors.initials: L
authors.lastname: van Hoeven
authors.affiliation: Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
authors.forename: Yvonne
authors.initials: Y
authors.lastname: Vergouwe
authors.affiliation: Department of Rheumatology, MC Haaglanden, Den Haag, The Netherlands.
authors.forename: P D M
authors.initials: PD
authors.lastname: de Buck
authors.affiliation: Department of Rheumatology, Erasmus MC, Rotterdam, The Netherlands.
authors.forename: Jolanda J
authors.initials: JJ
authors.lastname: Luime
authors.affiliation: Department of Rheumatology, Erasmus MC, Rotterdam, The Netherlands.
authors.forename: Johanna M W
authors.initials: JM
authors.lastname: Hazes
authors.affiliation: Department of Rheumatology, Erasmus MC, Rotterdam, The Netherlands; Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands.
authors.forename: Angelique E A M
authors.initials: AE
authors.lastname: Weel
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D017116:Low Back Pain / Q000209:etiology / Q000473:pathology*; D008297:Male; D009426:Netherlands / Q000453:epidemiology; D058007:Physicians, Primary Care; D012017:Referral and Consultation / Q000592:standards*; D012307:Risk Factors; D025241:Spondylarthritis / Q000175:diagnosis*; D055815:Young Adult