External Validation of a Referral Rule for Axial Spondyloarthritis in Primary Care Patients with Chronic Low Back Pain

PLoS One. 2015 Jul 22;10(7):e0131963. doi: 10.1371/journal.pone.0131963. eCollection 2015.


Objectives: To validate and optimize a referral rule to identify primary care patients with chronic low back pain (CLBP) suspected for axial spondyloarthritis (axSpA).

Design: Cross-sectional study with data from 19 Dutch primary care practices for development and 38 for validation.

Participants: 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.

Main outcome: 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.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Cross-Sectional Studies
  • Female
  • Humans
  • Low Back Pain / etiology
  • Low Back Pain / pathology*
  • Male
  • Netherlands / epidemiology
  • Physicians, Primary Care
  • Referral and Consultation / standards*
  • Risk Factors
  • Spondylarthritis / diagnosis*
  • Young Adult

Grant support

An unrestricted research grant was provided by AbbVie Netherlands, grantnumber IMM-10-0147 (www.abbvie.nl). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.