Table 5.

Healthcare perspective facilitators of diagnosis

Theme	Sub-themes	Sub-themes	Example quotes
Promoting awareness	Different means of raising awareness to speed up diagnosis times	Promoting awareness in the public	“… presenting three symptoms which in combination might raise concern and then suggesting talking to your doctor… so you see it on the back of buses… I suppose it would certainly trigger a patient’s concern… I’m sure you can place somebody in Coronation Street with it… that often for the short term triggers people to consult about their symptoms, if they’ve seen somebody else with them on telly or in the media…” (H089) “… we do have a patient group [in hospital] we are looking at getting televisions on the walls so we can start using promotional information on there around our service… in waiting areas when people are sitting there…” (H083)
		Promoting awareness in primary care	“… it’s got to fundamentally come down to GP awareness because that’s the patient’s first port of call… so it’s an educational role, I suppose to GPs and to primary care physiotherapists…” (H080) “… I think it’s important to educate the primary care practitioners and they know what questions to ask, if somebody came with back pain, you ask, this question, if that then refer… we want to make their life easier don’t we?” (H091)
		Education delivery	“… it is that training need and not necessarily just a one off training need, but that refresher maybe every couple of years just to keep it fresh in the minds of those in primary care so they don’t forget some of the things that they maybe learned earlier in their career.” (H071) “I think there could be initiatives linking in with primary care clinicians, education and workshops to discuss more and improve knowledge and competence around diagnosing axial SpA…” (H072)
Symptoms and characteristics that could raise suspicion of axSpA	Symptoms and characteristics that could raise clinical suspicion of axSpA		“I would look at lower back pain, inflammatory in nature so we’re talking about waking in the night usually the second part of the night, pain that’s worse in static conditions.” (H071) “Their age and symptoms starting from an early age and with non specific mechanisms of onset of symptoms, so no injury, no trauma. Alternating buttock pain is another one that would make me think…” (H082)
Improving practice in healthcare		The referral process	“… optimising the referral pathways for patients so that we have a streamlined process where patients with axial SpA are seen in a timely fashion, they get scans and diagnostic testing in a timely fashion.” (H072) “… it would be helpful… having fast track pathways where there’s a dedicated clinic for the patients who are not coming to a general pool. And if we can segregate that pool of patients who are waiting to be diagnosed, whether they’ve got axial spondyloarthritis, then direct them into a particular clinic, we can segregate the patients into different categories, for ones who have definitely not got axSpA can be discharged, category B has definitely got the disease…” (H074) “Referral to a specialist centre earlier on to break this revolving door really of GP to physio to GP to physio…” (H083)
		Improvements to first contact	“… first-contact physiotherapists or other, working as an integral part of a primary care team in the same way that midwives and district nurses do, so that referrals from the GP to the physio could happen with reasonable rapidity…” (H078)
		Enhancing consultations	“… you ask a patient, you know under 45, under 35, if they’re waking in the middle of the night feeling painful, stiff symptoms in their back, if they get on and off back pain, if it improves in movement, there’s a few other symptoms you can look for… so in a normal GP consultation for example, I think it could be ascertained quite quickly…” (H076) “… you could, within the search that causes that pop up to trigger, put in things like age and consultation patterns and high NSAID use or associated stiffness, have you considered this as a possibility and consider a referral to a rheumatologist…” (H089)
Patient/HCP interactions	How communication and interaction between HCPs and patients could be improved to speed diagnosis		“I would tend to ask what you were like growing up, were you sporty and they go oh yeah I didn’t have any problems then, what about college, uni, work, that sort of thing… I kind of ask through their phases of life… I don’t think people actually tend to give that kind of information freely…” (H083) “If there really is an antipathy then there’s a communication failure. Occasionally clinicians are unreasonable, occasionally patients are unreasonable but in general if there’s a sense of antipathy, it’s a sign the consultation needs to begin again … I think there would be some patients and clinicians who would be willing to almost literally do that, to start the consultation again. Sometimes it means the patient will go off and see another clinician…” (H078)