Edinburgh case study

Edinburgh case study

How can a MSK GP Advanced Practice Physiotherapist (APP) service improve axial SpA diagnosis?

What was the project?


The MSK GP Advanced Practice Physiotherapist (APP) Service was introduced in 2019 as part of the 2018 General Medical Services Contract (GMS), and Scottish Government Transforming Roles Programme (Scot Gov, 2017, Scot Gov, 2021).

The problem

  • There is limited published research or evaluation of Advanced Practice Physiotherapist Services in Scottish Primary Care.
  • There is a paucity of published data on AxSpA Epidemiology in Scottish Primary Care, as well as the care journeys of individuals, including time to diagnosis.
  • Lack of empirical knowledge of these variables limits understanding of the healthcare system, representing a barrier to service evaluation and development.


  • Empirically evaluate and audit service performance, informing future service improvement activity.
  • To fill current empirical knowledge gaps.
  • Understand the system.

Service evaluation and audit questions

  • What is the incidence and baseline time to diagnosis of Axial Spondyloarthropathy (AxSpA) in the service population?
  • What proportion of APP Rheumatology referrals fulfil the NICE 2017 Guidelines and Spondylarthritis Diagnosis Evaluation (SPADE) Tool criteria (NICE 2017, Habibi, S., Doshi, S., & Sengupta, 2016)?
  • What is the APP Rheumatology referral conversion rate for AxSpA diagnosis and further assessment/investigation?

How was the problem tackled?


  • A quantitative clinical audit and evaluation approach was taken, using a descriptive retrospective case report design over three-years (2019 – 2022)
  • NHSL Caldicott Guardian approval was gained.
  • Project confirmed as service evaluation by NHSL R&D (ACCORD 2023).

Data collection & analysis

  • Identification of relevant clinical cases from the whole-service data-set was conducted using Pivot Tables within Microsoft Excel® (Microsoft Corp)
  • Retrospective electronic record review was conducted of APP Rheumatology referrals and Consultant appointment letters using NHS Lothian TrakCare InterSystems® and SCI Gateway® electronic referral systems.
  • A customised spreadsheet was constructed to record variables of interest.

What were the barriers faced on the project?

  • Free-text entry of data and requirement to transform.
  • Unable to consider unidentified cases, limiting inference that could be drawn on APP effectiveness in identifying AxSpA.
  • Lack of comparator for NICE guidelines or SPADE Tool (primary care), limiting bench marking specific to service population.

Were there any light bulb moments? or big wins?

  • Convenience sample.
  • Data rapidly accessible as routinely collected for service evaluation and audit purposes.
  • Standardised recording of onward referral information allowed relevant cases to be identified easily.
  • Professionalism and diligence of all APP staff in recording data.

What were the results and outcomes?


  • The results of this service evaluation and audit have been published in Musculoskeletal Care, 2023 Sep;21(3):958-967. doi: 10.1002/msc.1769. Epub 2023 Apr 26.


  • Approach of enquiry and study design limited to answering evaluation and audit questions.
  • Not defined as research and limited inference that can be drawn from findings due to small sample size and lack of control comparator.
  • COVID-19.
  • Rheumatology waiting list unknown.

Change ideas

  • Ongoing requirement to empirically validate standardised onward referral strategies.
  • APPs may represent a change lever for improving the early identification of AxSpA and reducing diagnostic delay (Capabilities, Opportunities and Motivation) (Michie, van Stralen, & West, 2021).
  • Accessibility of HLA-B27 testing would facilitate implementation of the SPADE Tool, NICE Guidelines, and published referral strategies for suspected AxSpA in primary care. It is possible that HLA-B27 testing may enhance screening sensitivity and referral diagnostic yield, contributing towards reducing diagnostic delay (Baraliakos et al 2020; Ziade et al 2023).
  • Current discussions with Rheumatology on pathway development.
  • QI Project on-going with planned PDSA as part of cyclical analysis.


The support and advice provided from colleagues below at various stages of study implementation are gratefully acknowledged:

  • Libby Dale, Clinical Lead Physiotherapist, GP Advanced Practice Physiotherapy Service, Edinburgh Health & Social Care Partnership, NHS Lothian.
  • Gavin Frizzell, Clinical Lead Physiotherapist, MSK GP Advanced Practice Physiotherapy Service, Edinburgh Health & Social Care Partnership, NHS Lothian. MSK GP Advanced Practice Physiotherapists, Edinburgh Health & Social Care Partnership, NHS Lothian.
  • Claire Henderson, Musculoskeletal Physiotherapy & Associated Out Patient Service Lead, Edinburgh Health & Social Care Partnership, NHS Lothian. 
  • Professor Stuart H. Ralston, MBChB, MD, FRCP, FFPM (Hon), FMedSci, FRSE. Versus Arthritis Professor of Rheumatology, Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Western General Hospital, Edinburgh, EH4 2XU, UK.
  • Dr Hema G. Bhat, Consultant Rheumatologist, Rheumatic Diseases Unit, Western General Hospital, Edinburgh, EH4 2XU, UK.
  • David New, Primary Care Evaluation and Insight Manager, Edinburgh Health & Social Care Partnership, NHS Lothian.
  • Abdelgawad Amegad, Transformation Manager, Health and Social Care, NHS Lothian.
  • Andy Peters, Research and Development Facilitator, NHS Lothian.


  1. Hay, C. A., Packham, J., Ryanm, S., Mallen, C. D., Chatzixenitidis, A., & Prior, J. A. (2022). Diagnostic delay in axial spondyloarthritis: A systematic review. Clinical Rheumatology, 41(7), 1939–1950. https://doi.org/10.1007/s10067-022-06100-7
  2. Zhao, S. S., Pittam, B., Harrison, N. L., Ahmed, A. E., Goodson, N. J., & Hughes, D. M. (2021). Diagnostic delay in axial spondyloarthritis: A systematic review and meta-analysis. Rheumatology, 60(4), 1620–1628. https://doi.org/10.1093/rheumatology/keaa807. PMID: 33428758
  3. Sykes, M. P., Doll, H., Sengupta, R., & Gaffney, K. (2015). Delay to diagnosis in axial spondyloarthritis: Are we improving in the UK? Rheumatology, 54(12), 2283–2284.
  4. The Scottish Government. (2017). General medical Contract 2018. Available online at: https://www.gov.scot/publications/gms-contract-scotland/
  5. The Scottish Government. (2021). Transforming nursing, Midwifery and health profession (NMaHP) roles: Review of clinical nurse specialist and nurse practitioner roles within Scotland. ’ Available online at: Retrieved from https://www.gov.scot/publications/transforming-nursing-midwifery-health-professionnmahp-roles-review-clinical-nurse-specialist-nurse-practitioner-roles-within-Scotland
  6. NHS Education for Scotland (2023), TURAS Learn – Quality Improvement Zone. Available online at: https://learn.nes.nhs.scot/2274/quality-improvement-zone/qi-tools/pdsa
  7. Academic and Clinical Central Office for Research and Development (ACCORD). Available online at: https://www.accord.scot/
  8. National Institute for Health & Care Excellence Guideline NG65. (2017). Spondyloarthritis in over 16s: Diagnosis and management. Available online at: https://www.nice.org.uk/guidance/ng65/resources
  9. Habibi, S., Doshi, S., & Sengupta, R. (2016). Utility of the spade tool to identify axial spondyloarthritis in patients with chronic back pain. Annals of the Rheumatic Diseases, 10, 1136.
  10. Van den Berg, R., De Hooge, M., Van Gaalen, F., Reijnierse, M., Huizinga T., & Van der Heijde, D. (2013). Percentage of patients with spondyloarthritis in patients referred because of chronic back pain and performance of classification criteria: Experience from the spondyloarthritis caught early (SPACE) cohort. Rheumatology, 52(8), 1492–1499. https://doi.org/10.1093/rheumatology/ket164
  11. Crossfield, S. S. R., Marzo-Ortega, H., Kingsbury, S. R., Pujades-Rodriguez, M., & Conaghan, P. G. (2021). Changes in ankylosing spondylitis incidence, prevalence and time to diagnosis over two decades. RMD Open, 7(3), e001888. https://doi.org/10.1136/rmdopen-2021-001888
  12. Morgan, C. L. I., White, A., Tomlinson, M., Scott, A., & Tian, H. (2020). Incidence, prevalence and associated comorbidity of axSpA within the UK: A retrospective database analysis. Rheumatology, 59(Supplement_2). https://doi.org/10.1093/rheumatology/keaa110.01
  13. Gerdan, V., Akar, S., Solmaz, D., Pehlivan, Y., Onat, A. M., Kisacik, B., Sayarlioglu, M., Erhan, C., Tezcan, M. E., Ozturk, M. A., Onen, F., & Akkoc, N. (2012). Initial diagnosis of lumbar disc herniation is associated with a delay in diagnosis of ankylosing spondylitis. Journal of Rheumatology, 39(10), 1996–1999. https://doi.org/10.3899/jrheum.120106. PMID: 22859360
  14. Sepriano, A., Rubio, R., Ramiro, S., Landewé, R., & van der Heijde, D. (2017). Performance of the ASAS classification criteria for axial and peripheral spondyloarthritis: A systematic literature review and meta-analysis. Annals of the Rheumatic Diseases, 76(5), 886–890. https://doi.org/10.1136/annrheumdis-2016-210747. PMID: 28179264
  15. Michie, S., van Stralen, M. M., & West, R. (2011).The behaviour change wheel: A new method for characterising and designing behaviour change interventionsImplementation Science, 6. 42. https://doi.org/10.1186/1748-5908-6-42. PMID: 21513547
  16. Baraliakos, X., Tsiami, S., Redeker, I., Tsimopoulos, K., Marashi, A., Ruetten, S., Fedorov, K., Avram, A., Morzeck, D., Fruth, M., & Braun, J. (2020). Early recognition of patients with axial spondyloarthritis-evaluation of referral strategies in primary care. Rheumatology, 59(12), 3845–3852. https://doi.org/10.1093/rheumatology/keaa212. PMID: 32472689
  17. Ziade N, Maroof A, Elzorkany B, Abdullateef N, Adnan A, Abogamal A, Saad S, El Kibbi L, Alemadi S, Ansari A, Abi Najm A, Younan T, Kharrat K, Sebaaly A, Rachkidi R, Witte T, Baraliakos X. What is the best referral strategy for axial spondyloarthritis? A prospective multicenter study in patients with suspicious chronic low back pain. Joint Bone Spine. 2023 Sep;90(5):105579. doi: 10.1016/j.jbspin.2023.105579. Epub 2023 Apr 18. PMID: 37080284.

Symptoms starting slowly

Pain in the lower back

Improves with movement

Night time waking

Early onset (under 40)