title: Study protocol for a cluster randomized controlled trial to evaluate a referral strategy for axial spondyloarthritis in young primary care patients with chronic low back pain; an impact study.
abstract: Axial spondyloarthritis (axSpA) is a disabling inflammatory joint disease with chronic low back pain (CLBP) as leading symptom. Recognizing axSpA in the large amount of CLBP patients is difficult for general practioners (GP). This evaluation aims to assess the effect of a referral strategy for axSpA in young primary care patients with CLBP by comparing the use of the strategy with usual care. The effect is measured at three different levels; by patient reported outcomes (the clinical effect), process and costs evaluation.
  
  
  
  This study design is a cluster randomized controlled trial with GP as clusters. GPs throughout the Netherlands are invited to participate and randomized to either the intervention or the control group. Patients from participating GPs are invited to participate if they have ever been registered with low back pain, without radiation (ICPC L03) and aged 18-45 years. To be included in the study, patients need to have current low back pain and chronic low back pain (>12 weeks). In the intervention arm a referral strategy for axSpA will be applied in CLBP patients, in the control arm care as usual will be provided for CLBP patients. The referral strategy consists of four easy to use variables. All are questions about the back pain complaints of the patients. Data is prospectively collected in an online database at baseline (T0), 4 months (T1), 12 months (T2) and 24 months (T3). After time point T1 (4 months) patients from the control group will also receive the intervention i.e. the application of a referral strategy for axSpA. The effect of the referral strategy is measured at three different levels, by patient outcomes (e.g. pain scores, quality of life), process measures (e.g. number of axSpA diagnoses by rheumatologists) and by costs (work productivity and health care resources use). Our primary outcome is the Roland Morris Disability Questionnaire after 4 months, secondary outcomes are pain and quality of life. Costs will be assessed before and after the use of the referral strategy, to estimate if the use of the strategy will lead to a reduction in health care costs and improvement in work participation.
  
  
  
  It is anticipated that using the axSpA referral strategy for primary care CLBP patients will increase the quality of life of CLBP patients, will result in more (correct) diagnoses of axSpA by the rheumatologists, and will be cost-effective. Ultimately, the results of this study may contribute to the startup of a national implementation of the axSpA referral strategy to identify timely CLBP patients with axSpA.
  
  
  
  NCT01944163 , date of registration; September 6, 2013 (Clinicaltrials.gov).
authors.affiliation: Erasmus MC, Department of Rheumatology, Wytemaweg 80, 3015, CN, Rotterdam, The Netherlands. l.vanhoeven@erasmusmc.nl.|Maasstad Hospital, Department of Rheumatology, Maasstadweg 21, 3079, DZ, Rotterdam, The Netherlands. l.vanhoeven@erasmusmc.nl.
authors.forename: Lonneke
authors.initials: L
authors.lastname: van Hoeven
authors.affiliation: Erasmus MC, Department of Public Health, Wytemaweg 80, 3015, CN, Rotterdam, The Netherlands.
authors.forename: Yvonne
authors.initials: Y
authors.lastname: Vergouwe
authors.affiliation: Erasmus MC, Department of General Practice, Wytemaweg 80, 3015, CN, Rotterdam, The Netherlands.
authors.forename: Bart W
authors.initials: BW
authors.lastname: Koes
authors.affiliation: Erasmus MC, Department of Rheumatology, Wytemaweg 80, 3015, CN, Rotterdam, The Netherlands.
authors.forename: Johanna M W
authors.initials: JM
authors.lastname: Hazes
authors.affiliation: Erasmus MC, Department of Rheumatology, Wytemaweg 80, 3015, CN, Rotterdam, The Netherlands.|Maasstad Hospital, Department of Rheumatology, Maasstadweg 21, 3079, DZ, Rotterdam, The Netherlands.
authors.forename: Angelique E A M
authors.initials: AE
authors.lastname: Weel
mesh_terms: D000328:Adult; D059350:Chronic Pain / Q000175:diagnosis* / Q000191:economics / Q000209:etiology; D003362:Cost-Benefit Analysis; D058005:General Practitioners; D017048:Health Care Costs; D062489:Health Impact Assessment; D006801:Humans; D017116:Low Back Pain / Q000175:diagnosis* / Q000191:economics / Q000209:etiology; D009426:Netherlands; D010147:Pain Measurement; D000071066:Patient Reported Outcome Measures; D011320:Primary Health Care / Q000191:economics / Q000379:methods*; D011446:Prospective Studies; D011788:Quality of Life; D012017:Referral and Consultation / Q000191:economics*; D025241:Spondylarthritis / Q000150:complications / Q000175:diagnosis* / Q000191:economics; D055815:Young Adult
keywords: Axial Spondyloarthritis; Chronic Low Back Pain; Cluster Randomized Trial; Cost-effectiveness; Primary Care; Referral