Clinical pathway for patients with spondyloarthritis/Vía clínica para pacientes con espondiloartritis

Spondyloarthritis (SpA) affects approximately 1.9% of the general population and represents 13% of the consultations in rheumatology [1]. It particularly affects active people who are around 40 years of age, and in many cases leads to functional disability. In general, it is poorly understood and there is little awareness of the condition, leading to an unacceptable average delay in diagnosis of more than six years from the onset of symptoms, though this is subject to great inequalities and variability. Over the last decade, there have been many advances in this field, with new effective treatments, response and diagnostic criteria, and measurements and, accordingly, it is difficult for non-specialists to provide care according to the best scientific evidence.


Introduction
Spondyloarthritis (SpA) affects approximately 1.9% of the general population and represents 13% of the consultations in rheumatology [1]. It particularly affects active people who are around 40 years of age, and in many cases leads to functional disability. In general, it is poorly understood and there is little awareness of the condition, leading to an unacceptable average delay in diagnosis of more than six years from the onset of symptoms, though this is subject to great inequalities and variability. Over the last decade, there have been many advances in this field, with new effective treatments, response and diagnostic criteria, and measurements and, accordingly, it is difficult for non-specialists to provide care according to the best scientific evidence.
Given all this, the Spanish Society of Rheumatology (SER) set three key objectives: 1) to improve the prognosis (functional status and quality of life of patients with SpA; 2) to facilitate early diagnosis; and 3) to promote research into recent-onset SpA. To this end, a care and research programme, called Esperanza (meaning "hope", in Spanish), was established.

Theory and methods
The general design of the programme arose from analysis of the status quo. The data required to determine the scope of the programme were obtained from the ESPIDEP study [2], a pilot programme of the Early-Onset SpA Unit, focused on training, referral and assessment, carried out in the catchment area of La Paz Hospital in Madrid over a six-month period.
The objectives of the ESPIDEP programme were to estimate the incidence of early-onset SpA and assess the usefulness of the system and criteria for referral. Referred patients had to be under 45 years of age, have inflammatory back pain or asymmetric arthritis of the lower limbs, and have a time since onset of symptoms of 3 to 24 months. The annual incidence was estimated to be 62.5 cases per 100,000 people and the system proved to be effective, there being an agreement between the criteria of the GPs and the rheumatologists in 82.7% of cases. Further, two-thirds of the patients referred had a final diagnosis of SpA.
The data necessary to validate the procedures were based on the SERAP programme of the SER, which was run in 34 health regions, for the detection of arthritis early after onset (referral + diagnosis + treatment) [3]. The programme included instructions and tools for referral, a diagnostic algorithm and flexible, evidencebased treatment recommendations. In SERAP, it was observed that the factors associated with greater efficiency of the units were feedback to primary care (PC), even negative feedback, and short waiting times for general rheumatology were short [4].
For designing the part of the programme that involves PC, data were obtained from a qualitative study involving GPs. This study investigated the beliefs and attitudes of GPs in relation to the application of a clinical pathway for recent-onset SpA in five focus groups [5]. As a result, the groundwork was laid for optimising collaboration with PC. The key elements identified were: simple and practical processes through official channels; as much feedback as possible, allowing rapid consultations and easy access to reports and guidance on treatment, particularly as regards to sick leave; and continuous medical training, preferably certified.
The programme has two components: management and research. The management component involves the establishment of standards, procedures (including the processes of referral and of specialised care, and continuous medical training) and continuous evaluation using quality indicators. The R & D plan establishes calls for proposals for research projects and backs specific projects. Both components are supported by a multidirectional electronic platform that monitors activity in real time.

Results
A total of 25 units in 12 autonomous regions across Spain participated in the study, involving 1844 GPs and 1098 patients. The time elapsing between the visit to PC and the rheumatology appointment decreased from 40±25 to 11±8 days. Table 1 lists the quality indicators with their standards and outcomes to 15th November 2009. The calculations are not described here due to lack of space but are reported in detail in another recent publication concerning the programme [6].

Discussion
Esperanza is the first health care programme on spondyloarthritis with a model for continuous assessment and improvement. By setting it up, we have been able to demonstrate that a programme based on specialised health care in the form of a clinical pathway is viable, and also that it is possible to introduce, assess and monitor the activity of such a programme, using scientific and management indicators. A large number of professionals and patients have benefit from this programme which has exceeded by far the initial objectives set. The standards must be regularly assessed to adapt to current conditions, but we believe that the Esperanza programme, with adjustments as necessary, is a model that could be extrapolated to other hospitals and diseases.
El programa consta de dos planes, el gestor y el de investigación. El Plan gestor define el establecimiento de estándares, procedimientos (incluido el proceso de derivación y de cuidado especializado y la formación médica continua) y la evaluación continua mediante indicadores de calidad. El Plan de I+D, establece las