Data were collected from eMAR II, a study of variability in the treatment of RA and SpA made in 2010 to assess the impact of changes in the management of these diseases since the first eMAR study, 10 years earlier. Study characteristics eMAR II are available through the website of the Spanish Society of Rheumatology.10

The sample consisted of medical records of patients over the age of,16 treated in rheumatology departments of Spanish hospitals with at least one visit to a rheumatologist in the 2 years preceding the date of study onset. Stratified sampling was carried out by autonomous communities and second level hospitals (with probability proportional to size) and patients (random equiprobabilistic selection). The criterion for considering if a patient had a diagnosis was the diagnosis of one of these entities by the rheumatologist in charge of the health care of the patient.

The sample size was calculated according to the hypothesis that the proportion of patients requiring surgery increased from 18% to 26% from eMAR I to eMAR II. Under this premise, and assuming an alpha error of 5%, a power of 80%, 15% of incomplete files and a design effect of 2.5, resulted in a sample size of 1410 patients.

Data from the last 2 years were collected from medical records of patients in the standardized data collection. We collected data from these 2 years, given that the uneven assistance record of patients leads to the existence of a variable number of records for each patient and the records of each patient were pooled to prevent this bias. Nonmodifiable data (sex, education, etc.) were collected only once and dynamic data of disease activity (ESR, VAS, number of swollen joints, etc.), which represent the worst and the best situation along the 2-year study, were collected on each visit.

Information was obtained on: (a) demographic data (age, sex, marital status, education level, occupation, and residence), (b) clinical characteristics (date of disease onset, date of first visit and diagnosis, duration, and type of the form of clinical involvement, compliance with modified New York,11 Amor12 diagnostic criteria for ankylosing spondylitis and the European Group for the Study of Spondyloarthropathies13 for intestinal inflammatory disease14 as well as the Rudwaleit criteria for low back pain [later15 modified, select the cutting point for compliance at 2 of the 4 criteria], and the Berlin criteria for axial16 spondylitis, HLA-B27, family history and extra-articular manifestations), (c) activity data and monitoring methods (ESR, CRP, VAS for pain and activity, morning stiffness, joint assessment, painful enthesis [BASDAI]), (d) employment status and functional ability (BASFI), and (e) comorbidity.

The assessment of disease activity by physician and patient was carried out by subjective and VAS scales. In the first case, we asked for best and worst subjective assessment (doctor and patient) on disease activity in the last 2 years. In this case, it called for the collection of compliant classified data printing (doctor and patient) on the best and worst assessment of activity based on explicit annotations or presence of sufficient data on the clinical history. Below are detailed instructions for filling the form:

– Best and worst subjective assessment of the doctor/patient on disease activity in the last 2 years: classify the impression of doctor/patient on best and worst assessment of disease activity in one of the following categories: if printing is explicitly doctor/patient using this data. If not stated explicitly, and data insufficient to classify in a category, fill according to the following:

• 1.

  No: VAS activity<10mm or patient in complete remission at the discretion of the physician or by one of the commonly used objective criteria, with or without active treatment of disease/or indication by the patient in absence of pain or morning stiffness and swelling in any joint

• 2.

  Mild: VAS activity≥10mm and <40mm or patients with mild activity that does not require treatment modification.

• 3.

  Moderate: VAS activity≥40mm and <60mm or patient with moderate activity in which minor amendments to the treatment have been made (e.g. transient increases in doses of NSAIDs or oral corticosteroids or joint infiltration).

• 4.

  Severe: VAS activity≥60mm or patient with severe activity who has required major modifications of treatment (e.g. increased dose of DMARD, addition or change of DMARD due to treatment failure for lack of disease control).

Descriptive analysis was performed using measures of central tendency (mean or median) and dispersion (standard deviation and 25 and 75 quartile) for continuous variables, as adjusted or not normally distributed, and percentages for qualitative variables. The estimates are adjusted to the sampling design using the svy commands in Stata 9.0 (StataCorp, College Station, USA). The median is a statistic that summarizes the central tendency of the variable non-normal distributions, and the use of which avoids the influence of extreme values or outliers.

68% of patients were male with median age (P25–P75) at the time of review of 49.2 years (39.7–60.5) and 30.4 years (23.2–39.8) at disease onset, and disease duration of 105.1 months (48.4–192.5).

No information on marital status, academic and profession status in 64.2%, 72.5%, and 52.0% of cases were available, although the most common status was: to be married (28.5%), have primary education (11%) and be an unskilled worker (12%). In relation to the place of residence, more than half lived in the same town where the hospital stood (52.1%) and among those residing in a different location, the most common distance to the hospital was between 20 and 50km (41.7%) (Table 1).

The most common diagnosis was that of ankylosing spondylitis (55.2%), followed by psoriatic arthritis (22.2%) and undifferentiated forms (16.1%), 4.4% were related to inflammatory bowel disease and only 1.4% were reactive arthritis. In connection with the classification criteria, more than half of the patients fulfilled ESSG and Amor criteria (61.3% and 55.0%, respectively), 51.2% could be classified as ankylosing spondylitis according to modified New York criteria, and 32.1% and 31.7% as inflammatory back pain or ankylosing according to the Rudwaleit and axial Berlin criteria, respectively. 8.6% did not meet any classification criteria, while 18.2% met all. HLA-B27 was positive in 58.8% of patients. There was a family history of psoriasis, inflammatory bowel disease, oligo- or polyarthritis, uveitis and positive HLA-B27 in 15.3% of cases. The mixed form of clinical involvement was the most frequent (43.0%), followed by the axial (40.1%), and 11.8% with peripheral involvement, with less than 1% entheseal.

Psoriasis was the most common extra-articular manifestation (20.8%), followed by uveitis (19.4%) and enthesitis (16.9%). By contrast, the least common were renal disease (2.1%), neurological (1.3%) and amyloidosis (0.1%); 41.5% of cases did not present any of these manifestations and among those who presented them (34.9%) the usual number was 2 (16.3%) (Table 2).

The ESR values ranged from about minimum and maximum median of 7 and 18, with respective figures of 0.3 and 1.1mg/dl for CRP. The assessment, by pain and activity VAS by the patient showed a minimum of 20 and a maximum of 50, with a VAS activity assessed by the physician of 30. The maximum value of morning stiffness was 30min.

Importantly, a considerable number of reviewed records did not contain information on these parameters. The percentages of files without these data were: ESR 8.0%, CRP 9.4%, VAS pain (patient) 71.5%, VAS activity (patient) 78.1%, VAS activity (physician) 88.0% and morning stiffness 54.2%.

The best subjective assessment of disease activity by the physician rated the majority of patients in the mild category (32.6%) or not of that (23.7%). In the worst subjective evaluation, the most frequent were mild or moderate (23.9% and 21.6%) with absence of this information in 35.0% of the stories. The best and worst assessments of the activity of the patient showed distribution patterns that coincide with those made by their physicians (Table 3).

Most forms were not pure axial joint counts with a minimum of 0 (60.9%) or between 1 and 5 (26.0%) and the maximum was between 1 and 5 joints (44.8%) or not (32.4%). In enthesitic forms, the most common did not affect entheses in the minimum count (58.6%) and 0 (44.8%) or between 1 and 4 (21.4%) in the maximum. SpA activity and functional capacity median values showed a maximum and minimum of 2.9 and 4.5 for the BASDAI and 0.4 and 1.0 for the BASFI (Table 4).

Joint involvement in patients with SpA was not assessed by 68 joints counts or other methods in most of the files (52.6 and 58.9%). Something similar happened with entheseal involvement, as a 13 enthesis count was neither used (58.3%) nor was other equivalent method (74.3%). Similarly, no usual assessment of the overall situation of the patient by VAS (65.6%) or other procedures (65.6%) or nocturnal spinal pain (60.2% and 62.2% for VAS for other procedures) was performed. The duration of morning stiffness was the evaluation method used always in 9.7% of patients, usually in 12.4% and occasionally in 22.2%.

The acute phase reactants were used systematically, both ESR (67.3%) and PCR (66.4%). On the contrary, in general, activity indices such as BASDAI (58.2%), or functional capacity scores such as BASFI (66.7%) were not never calculated. With regard to spinal mobility parameters, the most common situation was the absence of these measures on all visits of the study period, with percentages of the “never” response of 37.7% for Schober, 44.6% for chest expansion, 46.1% for occiput-wall distance and 54.4% for lateral flexion of the trunk. It is worth noting that the data record of clinical activity was very uneven, ranging from the presence of data for ESR in 1076 files and BASFI in 315.

As for work activity, 52.8% of cases (602 patients) had an active job for more than 50% of the study period of 2 years, while some had episodes in which it did not work (ILT) in 8.3% with a median value of ILT episodes (Table 5). These results should be interpreted with caution, since the efficiency in collecting these data was not entirely correct due to various reasons. On the one hand, it is quite common in the medical records to not record this type of information and, secondly, the collection of work disability was not limited exclusively to the disease under study, but might have included other more or less disabling processes (Table 5).

Information was collected on the history of other chronic diseases. The most common conditions were hypertension (17.4%), peptic disease (6.8%) and diabetes mellitus (6.1%). There was no evidence in the medical history of these comorbidities in 65% of patients, which does not mean that they were not present (Table 6).