Centre Characteristics Determine Ambulatory Care and Referrals in Patients With

Centre characteristics determine ambulatory care and referrals in patients with spondyloarthritis

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SectionI. Included variables list

I. Demographic characteristics

Date of birth, gender, civil status, educational level, place for living, distance to the hospital, work activity, sick leave periods.

II. Diseases characteristics

Date of symptoms onset, date of first visit to rheumatology, date of diagnosis, inflammatory markers (ESR, CRP), and disease severity in the previous two years.

SpA specific variables: Type of SpA, fulfilment of classification criteria (Rudwaleit’s inflammatory back pain criteria, the European Spondyloarthropathy Study Group (ESSG) SpA criteria, Amor’s SpA criteria, axial spondylitis Berlin criteria and AS New York criteria), clinical form (axial, peripheral, enthesal, mixed), BASDAI, BASFI, extra-articular manifestations (Uveitis, Psoriasis, inflammatory bowel disease, Lung involvement, Cardiovascular involvement, Neurological involvement, Renal disease, Osteoporosis, Amyloidosis).

III. Comorbidities

Diabetes mellitus, hypertension, coronary heart disease, heart failure, stroke, peptic ulcer, chronic kidney disease, liver disease, serious infections, neoplasm, use of anticoagulation therapy.

IV. Characteristics of the primary contact physician

Age, gender, medical specialty, post, years of practice, typeof practice (public or private).

V. Characteristics of the centre

Location (autonomic region in Spain).

Availability of database about admissions, visits, diagnostic tests and primary care visits.

Attended population, total beds number, type of population (countryside, urban).

VI. Characteristics of the Rheumatology Unit

Patient attending centre (outpatient clinics in hospital and/or outside hospital), number of faculties in staff, registrar training, number of registrars per year, number of assigned beds, total of admissions, total of first and consecutive visits, time to first visit.

Availability of telephone consults line, nurse clinic and monographic clinics (SpA and early SpA). Drug monitoring system.

Taking part in SpA clinical trials.

Section II. List of authors involved in the emAR II group:

C. Escudero, N. Chozas, I. Maries, A. Fernandez, F. Medina, I. Ureña, V. Irigoyen, M. Lopez, P. Espiño, S. Manrique, E. Collantes, P. Font, D. Ruiz, M. Granados, M.J. Pozuelo, I. Moreno, J.M. Pina, R. Roselló, C. Vázquez, J. Beltrán, F.J. Manero-Ruiz, A. Pecondón, E. Giménez, F. Jimenez, J. Marzo, M. Medrano, J. Babío, T. Tinturé, S. González, C. Ordás, M.E. García, L. Espadaler, J. Fernandez, J. Fiter, A. Naranjo, S. Ojeda, J. Tornero, J.A. Piqueras, E. Júdez, C. López, J. Medina, G. Iglesias, M. Alvarez, J. Alegre, M.R. Colazo, J.L. Alonso, B. Alvárez, C. Montilla, S. Gómez, R. López, M.Sánchez, S. Castro, S. Ordóñez, D. Boquet, J. Calvet, D. de la Fuente, V. Rios, J.M. Nolla, A. Martínez-Cristóbal, R. Negueroles, M.L. Muñoz,J. García, F. Gamero, E. del Rincón, E. Pérez-Pampín, L. Fernandez, R. Miguélez, A.M. Ortíz, E. Vicente, S. Pérez Esteban, E. Tomero, A. Casado, M.J. Arias, E. Cuende, C. Bohorquez, J.M. Rodríguez, A. Aragón, J. García, J. Zubieta, A. Gallego, C. Martínez, I. Mateo, A. de Juanes, E. Enríquez, I. Monteagudo, F.J. López-Longo, E. Pagán, M.J. Rubira, P. Mesa, J. Galvez, E. Saiz, C. Tornero, E. Úcar, C. Rodríguez, B. González Álvarez, N. Rivera, F.X. Arasa, S. Bustabad, E. Delgado, J. Maese, and R. Veroz.

Section III. Table S1. List of Spanish hospitals involved in the emAR II study

Hospital / Number of patientsenrolled
12 de Octubre / 26
Arnau de Vilanova / 28
Barbastro / 27
Bellvitge / 27
Cabueñes / 28
Carlos Haya / 30
Central de Asturias / 30
Complejo Cáceres / 28
Complejo León / 19
El Bierzo / 29
General Castellón / 30
Gral Yagüe / 29
Gregorio Marañón / 26
Guadalajara / 28
Htal de Basurto / 25
Htal de la Ribera / 29
Htal Melilla / 14
Joan XXIII / 30
La Paz / 29
La Princesa / 29
Llerena-Zafra / 11
Los Arcos / 27
Miguel Servet / 30
Móstoles / 17
Negrín / 28
NtraSra Candelaria / 25
Palencia / 19
ParcTaulí / 30
Príncipe Asturias / 30
Puerta del Mar / 30
Ramón y Cajal / 28
Reina Sofía / 30
Salamanca / 20
San Jorge / 27
Son Dureta / 30
Univ Albacete / 27
Univ Canarias / 29
Univ Getafe / 30
Univ San Carlos / 20
Univ Santiago / 28
Verge de la Cinta / 30
Virgen de las Nieves / 28
Virgen del Rocío / 30
Virgen Valme / 29
XeralCalde / 14
Total / 1,168

Section IV. TableS2.Patient, unit and centre characteristics. Differences regarding referrals.

Patients’ Demographicdata / No referral / Referral / p-value / Comorbidities / No referral / Referral / p-value
Age (years) / 51.9 (14.3) / 52.0 (13.1) / 0.888 / Hypertension / 87 (22.5) / 64 (22.9) / 0.978
Symptomsonsetage (years) / 33.5 (13.0) / 34.1 (12.7) / 0.573 / Diabetes / 23 (6.0) / 26 (9.3) / 0.137
Female / 133 (34.6) / 99 (36.0) / 0.780 / Coronary heart disease / 21 (5.4) / 12 (4.3) / 0.626
Educational level / Stroke* / 5 (1.3) / 0 (0.0) / 0.078
None / 7 (5.6) / 5 (7.9) / 0.241 / Peptic ulcer / 29 (7.5) / 28 (10.0) / 0.314
Primaryschool / 51 (40.8) / 30 (47.6) / Neoplasm / 18 (4.7) / 12 (4.3) / 0.974
Highschool / 48 (38.4) / 15 (23.8) / Chronickidneydisease / 8 (2.1) / 9 (3.2) / 0.496
University / 19 (15.2) / 13 (20.6) / Liverdisease / 16 (4.1) / 20 (7.2) / 0.127
Distancefromhospital / Infections / 24 (6.2) / 20 (7.2) / 0.742
Same location / 208 (58.4) / 155 (60.5) / 0.229 / Anticoagulation therapy / 16 (4.1) / 4 (1.4) / 0.073
20km / 58 (16.3) / 47 (18.4) / Chronicheartfailure / 12 (3.1) / 4 (1.4) / 0.256
20-50km / 67 (18.8) / 33 (12.9) / Diseasecharacteristics
50km / 23 (6.5) / 21 (8.2) / Spondyloarthritis diagnosis
Off-work >50% time / 34 (14.4) / 30 (20.3) / 0.174 / Ankylosing spondylitis / 173 (47.1) / 154 (56.2) / 0.034
Primary Contact Physiciancharacteristics / Psoriatic arthritis / 95 (25.9) / 56 (20.4)
Female / 139 (37.3) / 83 (34.3) / 0.508 / IBD-associated arthritis / 29 (7.9) / 11 (4.0)
Age (years) / 47.3 (8.2) / 47.6 (8.7) / 0.602 / Reactive arthritis / 4 (1.1) / 7 (2.6)
Experienceyears / 21.0 [10.0-24.0] / 22.0 [10.0-25.0] / 0.517 / Undifferentiated spondyloarthritis / 66 (18.0) / 46 (16.8)
Physiciancategories / Classification criteria fulfilment
Registrar / 2 (0.5) / 1 (0.4) / 0.958 / Rudwaleit’s / 142 (36.8) / 88 (31.5) / 0.186
Consultant / 278 (74.3) / 184 (75.1) / ESSG / 256 (66.3) / 163 (58.4) / 0.045
SectionorDivisionHead / 94 (25.1) / 60 (24.5) / Amor’s / 225 (58.3) / 160 (57.3) / 0.870
Centre and rheumatology unit characteristics / Berlin / 147 (38.1) / 91 (32.6) / 0.171
Attended population, people / 300000 [160000-400029] / 376274 [223355-529588] / <0.001 / New York / 187 (48.4) / 143 (51.3) / 0.525
Urban population / 62.0 (24.1) / 68.9 (25.0) / 0.002 / Patients not fulfilling any SpA criteria / 40 (10.4) / 30 (10.8) / 0.973
Centre beds number / 550 [360-900] / 781 [463-1205] / <0.001 / Number of fulfilled SpA criteria / 2.0 [1.0-4.0] / 2.0 [1.0-4.0] / 0.221
Number of faculties in rheumatology staff / 5.0 [2.0-8.0] / 5.0 [3.0-10.0] / <0.001 / HLA-B27 positivity / 209 (68.8) / 163 (73.1) / 0.325
Unit hospitalization beds number / 3.0 [0.0-4.0] / 4.0 [2.0-7.0] / <0.001 / Familial background of SpA / 54 (31.4) / 38 (27.0) / 0.463
Patients admissions/year / 62.0 [12.7-117.0] / 82.0 [45.0-152.0] / <0.001 / Disease duration (months) / 102.8 [41.6-191.3] / 110.4 [48.8-201.1] / 0.338
First visits/year / 2370 [1335-4207] / 2905 [1450-5463] / 0.005 / Clinical involvement
Time to first visit (months) / 1.0 [1.0-2.0] / 1.0 [1.0-2.0] / 0.743 / Enthesitic / 4 (1.1) / 1 (0.4) / 0.422
Number of registrars/year / 1.0 [1.0-1.0] / 1.0 [1.0-2.0] / 0.038 / Axial / 156 (42.0) / 98 (37.5)
Computerized case notes / 45 (11.7) / 23 (8.2) / 0.192 / Peripheral / 46 (12.4) / 31 (11.9)
Computerized diagnostic techniques / 337 (87.3) / 250 (89.6) / 0.431 / Mixed / 165 (44.5) / 131 (50.2)
Computer-assisted admission orders / 381 (98.7) / 271 (97.1) / 0.246 / Numberofextra-articular manifestations / 1.0 [0.0-2.0] / 1.0 [0.0-2.0] / 0.266
Existence of nurse clinics / 149 (38.6) / 133 (47.7) / 0.024 / Extra-articular complications
Presence of telephone consult line / 132 (34.2) / 106 (38.0) / 0.335 / Uveitis / 81 (21.0) / 66 (23.7) / 0.469
MSK ultrasound in the unit / 252 (65.3) / 195 (69.9) / 0.244 / Psoriasis / 90 (23.3) / 53 (19.0) / 0.214
SpA monographic clinics / 92 (23.8) / 93 (33.3) / 0.009 / IBD / 34 (8.8) / 18 (6.5) / 0.332
Early SpA monographic clinics / 98 (25.4) / 86 (30.8) / 0.145 / Lung involvement / 11 (2.8) / 10 (3.6) / 0.757
SpA clinical trials participation / 174 (45.1) / 159 (57.0) / 0.003 / Cardiovascular involvement / 22 (5.7) / 12 (4.3) / 0.529
Neurological involvement / 4 (1.0) / 7 (2.5) / 0.216
Renal disease / 11 (2.8) / 5 (1.8) / 0.534
Osteoporosis / 23 (6.0) / 18 (6.5) / 0.922
CRP (mg/dl) / 0.8 [0.3-2.0] / 1.1 [0.4-2.8] / 0.212
ESR (mm/h) / 15.0 [7.4-26.1] / 15.5 [7.0-28.0] / 0.654
TNF-alpha blocker therapy / 141 (36.5) / 140 (50.2) / 0.001

OR: odds ratio. CI: confidence interval. For other definitions, see Table 1 footnotes. The variable “amyloidosis” was not included in the analysis as only one case of amyloidosis was reported. BASDAI and BASFI were not included due to significant missing data. * n=5.

Section V. Results of the bivariate analysis.

Table S3. Patient, unit and centre characteristics and their association with the number of visits to rheumatology clinics in a 2-year period.

Patients’ Demographicdata / coefficient (95%CI) / R2 / Comorbidities / coefficient (95%CI) / R2
Age / -0.025 (-0.044, -0.006) / 0.006 / Hypertension / -0.152 (-0.835, 0.530) / 0.001
Symptomsonsetage / -0.018 (-0.005, -0.042) / 0.003 / Diabetes / -0.259 (-1.341, 0.824) / 0.001
Female / 0.440 (-0.115, 0.995) / 0.002 / Coronary heart disease / -1.355 (-2.758, 0.049) / 0.003
Educational level / Stroke / -0.497 (-2.962, 1.969) / 0.001
None / Reference / 0.007 / Peptic ulcer / 0.136 (-0.895, 1.166) / 0.001
Primaryschool / -1.720 (-4.224, 0.785) / Neoplasm / -0.720 (-2.160, 0.719) / 0.001
Highschool / -1.133 (-3.693, 1.427) / Chronickidneydisease / -0.822 (-2.645, 1.001) / 0.001
University / -1.518 (-4.086, 1.051) / Liverdisease / 0.331 (-0.923, 1.586) / 0.001
Distancefromhospital / Infections / 1.418 (0.199, 2.636) / 0.004
Same location / Reference / 0.002 / Anticoagulation therapy / -0.567 (-2.390, 1.257) / 0.001
<20km / 0.444 (-0.331, 1.218) / Chronicheartfailure / -0.673 (-2.832, 1.487) / 0.001
20-50km / -0.105 (-0.829, 0.619) / Diseasecharacteristics
>50km / -0.330 (-1.287, 0.627) / Spondyloarthritis diagnosis
Off-work >50% time / 0.148 (-0.716, 1.011) / 0.001 / Ankylosing spondylitis / Reference / 0.001
Primary Contact Physiciancharacteristics / Psoriatic arthritis / 0.304 (-0.359, 0.967)
Female / 1.192 (0.639, 1.744) / 0.016 / IBD-associated arthritis / 0.007 (-1.301, 1.316)
Age / -0.105 (-0.137, -0.074) / 0.039 / Reactive arthritis / -0.508 (-2.763, 1.747)
Experienceyears / -0.089 (-0.118, -0.059) / 0.033 / Undifferentiated spondyloarthritis / 0.221 (-0.526, 0.967)
Physiciancategories / Classification criteria fulfilment
Trainee / Reference / 0.017 / Rudwaleit’s / 0.282 (-0.270, 0.838) / 0.001
Consultant / -0.651 (-5.709, 4.408) / ESSG / 0.676 (0.146, 1.205) / 0.005
SectionorDivisionHead / -2.013 (-7.090, 3.063) / Amor’s / 0.446 (-0.073, 0.965) / 0.002
Centre and rheumatology unit characteristics / Berlin / 0.332 (-0.224, 0.888) / 0.001
Attended population, people / - / - / New York / 0.231 (-0.286, 0.748) / 0.001
Urban population / -0.006 (-0.018, 0.005) / 0.001 / Patients not fulfilling any SpA criteria / -0.703 (-1.623, 0.216) / 0.002
Centre beds number / 0.001 (0.000, 0.002) / 0.005 / Number of fulfilled SpA criteria / 0.164 (0.010, 0.317) / 0.004
Number of faculties in rheumatology staff / 0.196 (0.124, 0.268) / 0.024 / HLA-B27 positivity / -0.057 (-0.704, 0.589) / 0.001
Unit hospitalization beds number / 0.218 (0.120, 0.315) / 0.018 / Familial background of SpA / 0.734 (0.018, 1.449) / 0.007
Patients admissions/year / 0.008 (0.005, 0.010) / 0.027 / Disease duration / -0.003 (-0.006, 0.001) / 0.005
First visits/year / - / - / Clinical involvement
Time to first visit (months) / 0.189 (-0.075, 0.452) / 0.002 / Enthesitic / Reference / 0.019
Number of trainees/year / 1.192 (0.463, 1.921) / 0.018 / Axial / -2.272 (-5.269, 0.724)
Computerized case notes / -0.012 (-0.884, 0.859) / 0.001 / Peripheral / -1.948 (-5.012, 1.116)
Computerized diagnostic techniques / 0.015 (-0.837, 0.867) / 0.001 / Mixed / -0.982 (-3.976, 2.013)
Computer-assisted admission orders / -0.539 (-2.363, 1.284) / 0.001 / Numberofextra-articular manifestations / 0.088 (-0.169, 0.345) / 0.001
Existence of nurse clinics / 0.838 (0.317, 1.360) / 0.008 / Extra-articular complications
Presence of telephone consult line / 0.003 (-0.531, 0.531) / 0.001 / Uveitis / -0.087 (-0.740, 0.567) / 0.001
MSK ultrasound in the unit / 0.277 (-0.279, 0.833) / 0.001 / Psoriasis / 0.107 (-0.530, 0.744) / 0.001
SpAspecialist clinics / 0.577 (0.012, 1.141) / 0.003 / IBD / 0.007 (-1.083, 1.097) / 0.001
Early SpA specialist clinics / 1.500 (0.939, 2.062) / 0.023 / Lung involvement / -1.470 (-3.078, 0.137) / 0.003
SpA clinical trials participation / 0.857 (0.341, 1.373) / 0.009 / Cardiovascular involvement / -1.005 (-2.348, 0.338) / 0.002
Neurological involvement / 1.700 (-0.595, 3.996) / 0.002
Renal disease / 0.243 (-1.544, 2.031) / 0.001
Osteoporosis / -0.088 (-1.279, 1.103) / 0.001
CRP / 0.051 (0.007, 0.096) / 0.005
ESR / 0.018 (0.001, 0.035) / 0.004
DMARDs / 1.731 (1.374, 2.087) / 0.072
TNFi / 4.209 (3.741, 4.676) / 0.211

CI: confidence interval. For other definitions, see Table 1 footnotes. The variable “amyloidosis” was not included in the analysis as only one case of amyloidosis was reported. BASDAI and BASFI were not included in the bivariate analysis due to significant missing data.

Table S4. Patient, unit and centre characteristics and their association with any referral to other medical specialty from rheumatology.

Patients’ Demographicdata / OR (95% CI) / p-value / Comorbidities / OR (95% CI) / p-value
Age / 1.001 (0.990, 1.012) / 0.890 / Hypertension / 1.023 (0.709, 1.477) / 0.903
Symptomsonsetage / 1.004 (0.990, 1.019) / 0.572 / Diabetes / 1.622 (0.905, 2.907) / 0.104
Female / 1.062 (0.768, 1.467) / 0.718 / Coronary heart disease / 0.781 (0.378, 1.615) / 0.505
Educational level / Stroke* / - / -
None / Reference / Peptic ulcer / 1.373 (0.797, 2.366) / 0.253
Primaryschool / 0.824 (0.240, 2.826) / 0.758 / Neoplasm / 0.919 (0.435, 1.940) / 0.824
Highschool / 0.438 (0.121, 1.583) / 0.208 / Chronickidneydisease / 1.575 (0.600, 4.134) / 0.356
University / 0.958 (0.249, 3.684) / 0.950 / Liverdisease / 1.786 (0.908, 3.512) / 0.093
Distancefromhospital / Infections / 1.165 (0.630, 2.153) / 0.627
Same location / Reference / Anticoagulation therapy / 0.336 (0.111, 1.017) / 0.054
<20km / 1.087 (0.702, 1.684) / 0.707 / Chronicheartfailure / 0.453 (0.145, 1.421) / 0.175
20-50km / 0.661 (0.415, 1.053) / 0.081 / Diseasecharacteristics
>50km / 1.225 (0.654, 2.294) / 0.525 / Spondyloarthritis diagnosis
Off-work >50% time / 1.510 (0.879, 2.594) / 0.135 / Ankylosing spondylitis / Reference
Primary Contact Physiciancharacteristics / Psoriatic arthritis / 0.662 (0.446, 0.983) / 0.041
Female / 0.879 (0.627, 1.233) / 0.454 / IBD-associated arthritis / 0.426 (0.206, 0.882) / 0.021
Age (years) / 1.005 (0.986, 1.025) / 0.601 / Reactive arthritis / 1.966 (0.565, 6.845) / 0.288
Experienceyears / 1.006 (0.988, 1.023) / 0.516 / Undifferentiated spondyloarthritis / 0.783 (0.507, 1.209) / 0.270
Physiciancategories / Classification criteria fulfilment
Trainee / Reference / Rudwaleit’s / 0.792 (0.571, 1.097) / 0.161
Consultant / 1.324 (0.119, 14.704) / 0.819 / ESSG / 0.714 (0.519, 0.981) / 0.038
SectionorDivisionHead / 1.277 (0.113, 14.388) / 0.843 / Amor’s / 0.962 (0.704, 1.314) / 0.808
Centre and rheumatology unit characteristics / Berlin / 0.787 (0.569, 1.088) / 0.147
Attended population, people / 1.000 (1.000, 1.000) / - / New York / 1.119 (0.822, 1.523) / 0.475
Urban population / 1.012 (1.004, 1.019) / 0.002 / Patients not fulfilling any SpA criteria / 1.042 (0.632, 1.719) / 0.872
Centre beds number / 1.001 (1.001, 1.002) / - / Number of fulfilled SpA criteria / 0.946 (0.865, 1.034) / 0.220
Number of faculties in rheumatology staff / 1.114 (1.067, 1.164) / <0.001 / HLA-B27 positivity / 1.235 (0.842, 1.810) / 0.280
Unit hospitalization beds number / 1.206 (1.135, 1.283) / <0.001 / Familial background of SpA / 0.806 (0.493, 1.319) / 0.391
Patients admissions/year / 1.005 (1.003, 1.007) / - / Disease duration (months) / 1.001 (0.999, 1.002) / -
First visits/year / 1.000 (1.000, 1.000) / - / Clinical involvement
Time to first visit / 0.784 (0.658, 0.934) / 0.007 / Enthesitic / Reference
Number of trainees/year / 1.556 (1.018, 2.379) / 0.041 / Axial / 2.513 (0.277, 22.811) / 0.413
Computerized case notes / 0.681 (0.402, 1.154) / 0.153 / Peripheral / 2.696 (0.288, 25.274) / 0.385
Computerized diagnostic techniques / 1.253 (0.770, 2.041) / 0.364 / Mixed / 3.176 (0.351, 28.755) / 0.304
Computer-assisted admission orders / 0.445 (0.144, 1.374) / 0.159 / Numberofextra-articular manifestations / 0.922 (0.796, 1.069) / 0.281
Existence of nurse clinics / 1.449 (1.061, 1.979) / 0.020 / Extra-articular complications
Presence of telephone consult line / 1.179 (0.856, 1.624) / 0.314 / Uveitis / 1.167 (0.807, 1.688) / 0.413
MSK ultrasound in the unit / 1.234 (0.887, 1.718) / 0.212 / Psoriasis / 0.771 (0.527, 1.129) / 0.182
SpAspecialist clinics / 1.598 (1.135, 2.249) / 0.007 / IBD / 0.714 (0.394, 1.292) / 0.266
Early SpA specialist clinics / 1.310 (0.930, 1.844) / 0.122 / Lung involvement / 1.267 (0.531, 3.027) / 0.594
SpA clinical trials participation / 1.614 (1.184, 2.020) / 0.002 / Cardiovascular involvement / 0.744 (0.362, 1.529) / 0.421
Neurological involvement / 2.458 (0.712, 8.478) / 0.155
Renal disease / 0.622 (0.214, 1.811) / 0.384
Osteoporosis / 1.088 (0.576, 2.058) / 0.794
CRP / 1.017 (0.990, 1.044) / 0.218
ESR / 1.002 (0.993, 1.012) / 0.654
DMARDs / 1.277 (1.031, 1.583) / 0.025
TNFi / 1.750 (1.280, 2.393) / <0.001

OR: odds ratio. CI: confidence interval. For other definitions, see Table 1 footnotes. The variable “amyloidosis” was not included in the analysis as only one case of amyloidosis was reported. BASDAI and BASFI were not included in the bivariate analysis due to significant missing data.