Diagnostic delay in axial spondyloarthritis: demographic, socioeconomic, and healthcare barriers in the West Bank, Palestine.

introductionDiagnostic delay in axial spondyloarthritis (axSpA) worsens outcomes and increases costs, yet evidence from low-resource settings is scarce. We aimed to quantify diagnostic delay in Palestine and test the hypothesis that referral pathway and socioeconomic factors are independently associated with prolonged delay.

methodWe conducted a cross-sectional study (July-November 2024) across rheumatology clinics in the West Bank. Adults fulfilling ASAS criteria for axSpA were enrolled via structured interviews. Diagnostic delay was defined as years from symptom onset to confirmed diagnosis. Non-parametric tests and Spearman correlations explored univariable associations. Prolonged delay was prespecified as ≥ 6 years and evaluated using multivariable logistic regression. Exploratory patient phenotypes were derived with Partitioning Around Medoids clustering.

resultsSeventy-nine patients were included (73% male; mean age 43.0 ± 12.2 years). Mean diagnostic delay was 6.37 ± 5.8 years (median 5). On univariable analyses, longer delay was associated with older age, lower education, low income, first contact with a general practitioner (GP), HLA-B27 negativity/unknown status, and absence of reduced spinal mobility. In multivariable models, GP first contact independently increased the odds of prolonged delay (OR 3.69, 95% CI 1.04-13.11; p = 0.044), while reduced spinal mobility was associated with shorter diagnostic delay (OR 0.16, 95% CI 0.03-0.70; p = 0.016). Clustering identified three diagnostic phenotypes; the longest delays occurred among patients with low education/income and GP-first referral.

conclusionsPalestinian patients with axSpA experience an average diagnostic delay exceeding six years, comparable to global estimates. Referral pathway is the principal modifiable barrier, whereas overt clinical signs (reduced spinal mobility) may trigger earlier recognition. Targeted GP education, streamlined referral protocols, and improved access to HLA-B27 testing are priorities for reducing delay in low-resource settings. Key Points • General practitioner referral was the strongest independent barrier to timely diagnosis, increasing the odds of prolonged delay more than threefold. • Reduced spinal mobility was associated with shorter delay, suggesting that overt physical findings facilitate earlier recognition and referral. • Socioeconomic disadvantage and HLA-B27 negativity were linked to longer delays in univariable analyses but lost significance after adjustment, indicating that healthcare system factors outweigh individual characteristics. • This first national study from Palestine underscores the need for GP education, accessible rheumatology pathways, and early use of HLA-B27 testing to shorten diagnostic delay in low-resource settings.