Assessing rheumatologists' attitudes and utilization of classification criteria for ankylosing spondylitis and axial spondyloarthritis: a global effort.

OBJECTIVES: This study aims to assess rheumatologists' perceptions, utilization patterns, and attitudes towards the modified New York (mNY) criteria for ankylosing spondylitis (AS) and Assessment of SpondyloArthritis International Society (ASAS) criteria for axial spondyloarthritis (axSpA). METHODS: Members of the national rheumatology societies in five countries (United States of America (USA), Canada, India, Turkey, and Brazil) were invited to participate in a survey containing questions regarding rheumatologists' familiarity, and use of AS and axSpA classification criteria in daily practice, perceived specificity of spondyloarthritis features in making the diagnosis, patterns of imaging tests performed in daily practice, and their opinion about the need for modification of current classification criteria. The responses were analyzed by gender, age, years in practice, as well as by country of practice. Descriptive statistics, t test, and chi-square test were used for comparison of groups. RESULTS: Approximately 6% rheumatologists (478 out of 8021 professional association members) from five countries completed the survey. The country-specific response rates were Brazil 4%, USA 4.3%, India 11%, Canada 14%, and Turkey 29%, though the overall contributions from individual countries were USA 47%, India 14.9%, Brazil 13.8%, Turkey 12.8%, and Canada 8.8%. The mean age of respondents was 50 years (± 11.8), 31% were females and 90% spent majority (> 75%) of their time in clinical practice. The mNY and ASAS criteria were regularly used in clinical practice by 44 and 66% of responders, respectively. Those reporting "always" using ASAS criteria were more likely to be women (p = 0.006), and within 5 years of completing rheumatology training. Vast majority (74%) regarded Inflammatory Back Pain (IBP) as a specific feature for axSpA. Majority (50 and 60%, respectively) regarded uveitis and dactylitis as "very specific" features helping them make the diagnosis of axSpA, whereas heel enthesitis, peripheral inflammatory arthritis, and response to NSAIDs were considered "somewhat specific" by 50% of the responders. Less than half (47%) of the responders used the mNY grading for X-ray of SI joints. In the case of normal X-ray of SI joint, the use of MRI was more frequent than CT scan (83.6 vs. 10.9%) in assessing for sacroiliitis. If sacroiliitis was not seen on X-rays, the likelihood of ordering MRI was significantly higher among rheumatologists completing training within < 15 years versus > 25 years prior (90 vs. 75%, p = 0.007). Overall, 70% thought that ASAS criteria were adequately specific for clinical trials. However, 42% respondents still felt a need to modify ASAS classification criteria for axSpA. Also, 46% respondents felt that mNY criteria should be modified. CONCLUSIONS: In the absence of diagnostic criteria, majority of rheumatologists are using the classification criteria for diagnosis of axSpA. Though axSpA classification criteria are perceived to be specific for clinical trials, 40% rheumatologists feel the need to modify these criteria. Key Points • This study informs how rheumatologists in five countries spread over four different continents diagnose axSpA in clinical practice. • Since majority rheumatologists among survey respondents across the countries use ASAS criteria for diagnosis of axSpA, more specific criteria may be required to avoid overdiagnosis. • MRI is commonly used to rule out sacroiliitis in case of normal X-ray of sacroiliac joints.

Cost burden of second fracture in the US health system.

OBJECTIVES: This retrospective claim-based study assessed 1-year medical costs associated with second fracture(s) for patients over 50 years old with an initial closed hip, clinical vertebral or non-hip non-vertebral (NHNV) fracture using 2002-2008 MarketScan® Commercial and Medicare Supplemental Databases. METHODS: Patients with incident fracture and ≥12-month pre-period and follow-up period from the incident fracture were extracted. Index date was the first subsequent fracture date for patients with subsequent fracture during the 12-month (cases); index dates for patients without subsequent fractures during the 12-month follow-up (controls) were randomly assigned based on the distribution of index dates of cases. Total costs were examined during the 12-month follow-up period using generalized linear models. A decomposition analysis of the incremental costs attributable to the second fracture was conducted to examine what proportion of the difference was due to different patient characteristics and what proportion was due to different model structures between cases and controls. RESULTS: For privately insured patients with hip, vertebral, or NHNV fracture, the 1-year second fracture rate was 8.0%, 5.1%, and 4.0%, and 1-year incremental costs were $47,351, $43,238, and $23,852, respectively; for Medicare patients, the corresponding rates and costs were 8.8%, 9.2%, and 8.2%, and $18,645, $19,702, and $19,697. Nationally projected annual cost of second fracture was $834 (95% confidence interval: $763-$914) million for patients with commercial insurance and $1.13 (95% confidence interval: $1.09-$1.17) billion for Medicare patients. CONCLUSIONS: The average cost of patients with subsequent fracture(s) was substantial. Effective management of first fractures may help reduce the long-term economic and clinical burden.