Toward a multidimensional Health Assessment Questionnaire (MDHAQ): assessment of advanced activities of daily living and psychological status in the patient-friendly health assessment questionnaire format

Impact of comorbidities on patient-reported outcomes in psoriatic arthritis: a single centre cohort study

BACKGROUND

Comorbidities are frequent in psoriatic arthritis (PsA) and may contribute to worse health-related outcomes. Patient-reported outcomes (PROs) are used to evaluate the burden of the assessed disease. The aim of this study is to evaluate the impact of comorbidities on selected PROs in PsA.

METHODS

Adult patients, diagnosed with PsA, based on CASPAR criteria, were included in this cross-sectional, observational study. Collected data encompassed the comorbidities and PROs (Health Assessment Questionnaire [HAQ], Multi-Dimensional Health Assessment Questionnaire [MDHAQ], 36-Item Short Form Health Survey [SF-36]). Standard statistic methods were performed for data assessment.

RESULTS

There were 267 participants included in the study (54.7% females). The most prevalent comorbidities were cardiovascular diseases (CVD) (29.2 %). Multimorbidity was observed in 50.2% cases and was associated with poorer results of SF-36 questionnaire, regarding bodily pain (34.7 [30.1, 39.3] vs. 47.5 [43.1, 52.0]; p<0.01), physical functioning (52.1 [47.3, 56.9] vs. 63.1 [58.9, 67.4]; p<0.01) and role physical (28.5 [21.2, 35.9] vs. 42.8 [35.2, 50.4]; p<0.01). CVD were associated with poorer MDHAQFn score (β=0.17, p<0.01), while mental disorders negatively influenced mental health (β= -0.35, p<0.01), vitality (β= -0.22, p<0.01), general health (β= -0.19, p<0.01), social functioning (β= -0.15, p=0.04) and role emotional (β= -0.30, p<0.01) dimensions of SF-36.

CONCLUSIONS

Multimorbidity exerts significant impact on physical aspects of quality of life (QoL) in PsA. CVD and mental disorders adversely influence functional capacity as well as mental and social dimensions of QoL, respectively. The impact of comorbidities should be taken into account by clinicians and researchers assessing PROs.

36-40% of Routine Care Patients With Osteoarthritis or Rheumatoid Arthritis Screen Positive for Anxiety, Depression, and/or Fibromyalgia on a Single MDHAQ

OBJECTIVE

Osteoarthritis (OA) and rheumatoid arthritis (RA) are associated with similar patient disease burdens and a high prevalence of comorbid anxiety (ANX), depression (DEP), and fibromyalgia (FM). Nonetheless, these comorbidities are infrequently assessed in routine care, in part because multiple questionnaires are not feasibly completed by patients. We analyzed the prevalence of ANX, DEP, and FM in patients with OA versus patients with RA seen in routine care using indices within a single Multidimensional Health Assessment Questionnaire (MDHAQ) and associations with \ Routine Assessment of Patient Index Data 3 (RAPID3) and its component function, pain, and patient global scores.

METHODS

A retrospective analysis of MDHAQ data in unselected patients with OA or RA receiving routine care at one setting included four indices within an MDHAQ: MDHAQ ANX screen, MDHAQ DEP screen, Fibromyalgia Assessment Screening Tool, and RAPID3. The prevalence of each comorbidity and associations with RAPID3 and components were analyzed in unadjusted and age-adjusted (Mantel-Haenszel) odds ratios (ORs) and 95% confidence intervals.

RESULTS

Overall, 40.4% of 361 patients with OA and 36.3% of 488 patients with RA screened positive for ANX, DEP, and/or FM (8.1% and 7% for all three, respectively). RAPID3 and each component were elevated significantly in patients with any positive screen result for ANX, DEP, and/or FM in both diagnoses (ORs of 2.6-35.8).

CONCLUSION

FM, DEP, and/or ANX rates were 40.4% in patients with OA and 36.3% in patients with RA, associated with significantly poorer patient status measures. Each of these three common comorbidities of patient distress may be feasibly screened for on a single MDHAQ in routine care.

Development of the American College of Rheumatology Patient-Reported Outcome Quality Measures for Systemic Lupus Erythematosus

OBJECTIVE

As part of a Centers for Disease Control and Prevention-funded American College of Rheumatology (ACR) initiative, we sought to develop quality measures related to Patient Reported Outcome Measure (PROM) use for systemic lupus erythematosus (SLE) clinical care.

METHODS

An expert workgroup composed of physician, patient, and researcher representatives convened to identify patient-reported outcome (PRO) domains of greatest importance to people with SLE. A patient advisory panel separately ranked domains. PROMs assessing priority domains were identified through structured literature review, and detailed psychometric reviews were conducted for each PROM. In a Delphi process, the expert workgroup rated PROMs on content validity, psychometric quality, feasibility of implementation, and importance for guiding patient self-management. The patient advisory panel reviewed PROMs in parallel and contributed to the final recommendations.

RESULTS

Among relevant PRO domains, the workgroup and patient partners ranked depression, physical function, pain, cognition, and fatigue as high-priority domains. The workgroup recommended at least once yearly measurement for (1) assessment of depression using the Patient Health Questionnaire or Patient Reported Outcomes Measurement Information System (PROMIS) depression scales; (2) assessment of physical function using PROMIS physical function scales or the Multi-Dimensional Health Assessment Questionnaire; and (3) optional assessments of fatigue and cognition. Pain scales evaluated were not found to be sufficiently superior to what is already assessed in most SLE clinic visits.

CONCLUSION

Expert workgroup members and patient partners recommend that clinicians assess depression and physical function at least once yearly in all people with SLE. Additional PROMs addressing cognition and fatigue can also be assessed. Next steps are to incorporate PROM-based quality measures into the ACR The Rheumatology Informatics System for Effectiveness registry.

PROMIS-29 in rheumatoid arthritis patients who screen positive or negative for fibromyalgia on MDHAQ FAST4 (fibromyalgia assessment screening tool) or 2011 fibromyalgia criteria

BACKGROUND

PROMIS-29 T-scores query health-related quality of life (HRQL) in 7 domains, physical function, pain, fatigue, anxiety, depression, sleep quality, and social participation, to establish population norms. An MDHAQ (multidimensional health assessment questionnaire) scores these 7 domains and includes medical information such as a FAST4 (fibromyalgia assessment screening tool) index. We analyzed PROMIS-29 T-scores in rheumatoid arthritis (RA) patients vs population norms and for positive vs negative fibromyalgia (FM) screens and compared PROMIS-29 T-scores to MDHAQ scores to assess HRQL.

METHODS

A cross-sectional study was performed at one routine visit of 213 RA patients, who completed MDHAQ, PROMIS-29, and reference 2011 FM Criteria. PROMIS-29 T-scores were compared in RA vs population norms and in FM+ vs FM- RA patients, based on MDHAQ/FAST4 and reference criteria. Possible associations between PROMIS-29 T-scores and corresponding MDHAQ scores were analyzed using Spearman correlations and multiple regressions.

RESULTS

Median PROMIS-29 T-scores indicated clinically and statistically significantly poorer status in 26-29% FM+ vs FM- RA patients, with larger differences than in RA patients vs population norms for 6/7 domains. MDHAQ scores were correlated significantly with each of 7 corresponding PROMIS-29 domains (|rho|≥0.62, p<0.001). Linear regressions explained 55-73% of PROMIS-29 T-score variation by MDHAQ scores and 56%-70% of MDHAQ score variation by PROMIS-29 T-scores.

CONCLUSIONS

Scores for 7 PROMIS-29 domains and MDHAQ were highly correlated. The MDHAQ is effective to assess HRQL and offers incremental medical information, including FAST4 screening. The results indicate the importance of assessing comorbidities such as fibromyalgia screening in interpreting PROMIS-29 T-scores.

Intense symptoms of pain are associated with poor sleep, fibromyalgia, depression and sleep apnea in patients with rheumatoid arthritis and psoriatic arthritis. A register-based study

OBJECTIVES

To study whether poor sleep and comorbidities are associated with high symptom levels of patient-reported outcomes (PROs) pain, patient global assessment and fatigue in patients with rheumatoid arthritis (RA) and psoriatic arthritis (PsA), in a nation-wide cross-sectional setting.

METHODS

Clinical data were extracted from The Finnish Rheumatology Quality Register between 1.2021 and 9.2022. Self-reported sleep was categorized as "good" (little/no difficulties) or "poor" (great difficulties/can't) sleep. Data concerning comorbidities were collected from national registers. Descriptive statistics were used. Regression analyses were applied to analyze independent associations of sleep status, comorbidities and disease activity with pain in RA and PsA, adjusting for age and sex.

RESULTS

Among 13,512 patients with RA, 6052 [mean (SD) age 62 (13), 71% female] had sleep status reported; in PsA 1861/3636 [age 55 (13), 48% female]. In RA, 5072 (84%) reported good and 980 (16%) poor sleep; the corresponding numbers in PsA were 1460 (78%) and 401 (22%). Median values for objective disease activity were low and similar in patients with poor sleep and good sleep in both diseases. Among patients with no swollen joints, the median values for PROs were approximately three times higher for patients with poor sleep vs. good sleep in both diagnoses (P<0.001). In regression analyses, "poor" sleep was independently associated with higher symptoms in pain [B (95%CI) 20 (18,22) in RA and 23 (19, 26) in PsA], followed by comorbid fibromyalgia, as well as depression in RA and sleep apnea in PsA.

CONCLUSION

"Poor" sleep quality and comorbidities are independently associated with pain. Patient's sleep status is important to know especially in patients with severe symptoms without objective disease activity.

Design of ANCHOR-RA: a multi-national cross-sectional study on screening for interstitial lung disease in patients with rheumatoid arthritis

BACKGROUND

Patients with rheumatoid arthritis (RA) are at risk of developing interstitial lung disease (ILD), which is associated with high mortality. Screening tools based on risk factors are needed to decide which patients with RA should be screened for ILD using high-resolution computed tomography (HRCT). The ANCHOR-RA study is a multi-national cross-sectional study that will develop a multivariable model for prediction of RA-ILD, which can be used to inform screening for RA-ILD in clinical practice.

METHODS

Investigators will enrol consecutive patients with RA who have ≥ 2 of the following risk factors for RA-ILD: male; current or previous smoker; age ≥ 60 years at RA diagnosis; high-positive rheumatoid factor and/or anti-cyclic citrullinated peptide (titre > 3 x upper limit of normal); presence or history of certain extra-articular manifestations of RA (vasculitis, Felty's syndrome, secondary Sjögren's syndrome, cutaneous rheumatoid nodules, serositis, and/or scleritis/uveitis); high RA disease activity in the prior 12 months. Patients previously identified as having ILD, or who have had a CT scan in the prior 2 years, will not be eligible. Participants will undergo an HRCT scan at their local site, which will be assessed centrally by two expert radiologists. Data will be collected prospectively on demographic and RA-related characteristics, patient-reported outcomes, comorbidities and pulmonary function. The primary outcomes will be the development of a probability score for RA-ILD, based on a multivariable model incorporating potential risk factors commonly assessed in clinical practice, and an estimate of the prevalence of RA-ILD in the study population. It is planned that 1200 participants will be enrolled at approximately 30 sites in the USA, UK, Germany, France, Italy, Spain.

DISCUSSION

Data from the ANCHOR-RA study will add to the body of evidence to support recommendations for screening for RA-ILD to improve detection of this important complication of RA and enable early intervention.

TRIAL REGISTRATION

clinicaltrials.gov NCT05855109 (submission date: 3 May 2023).

Physician estimate of inflammation vs global assessment in explaining variations in swollen joint counts in rheumatoid arthritis patients

Objective

To analyse patients with RA for inflammatory activity by physician estimate of global assessment (DOCGL) vs an estimate of inflammatory activity (DOCINF) to explain variation in the swollen joint count (SJC).

Methods

Patients with RA were studied at routine care visits. Patients completed a multidimensional health assessment questionnaire (MDHAQ) and the physician completed a 28-joint count for swollen (SJC), tender (TJC) and deformed (DJC) joints and a RheuMetric checklist with a 0-10 DOCGL visual numeric scale (VNS) and 0-10 VNS estimates of inflammation (DOCINF), damage (DOCDAM) and patient distress (DOCSTR). The disease activity score in 28 joints with ESR (DAS28-ESR), Clinical Disease Activity Index (CDAI) and Routine Assessment of Patient Index Data 3 (RAPID3) were calculated. Individual scores and RA indices were compared according to Spearman correlation coefficients and regression analyses.

Results

A total of 104 unselected patients were included, with a median age and disease duration of 54.5 and 5 years, respectively. The median DAS28-ESR was 2.9 (Q1-Q3: 2.0-3.7), indicating low activity. DOCINF was correlated significantly with DOCGL (ρ = 0.775). Both DOCGL and DOCINF were correlated significantly with most other measures; correlations with DOCGL were generally higher than with DOCINF other than for SJC. In regression analyses, DOCINF was more explanatory of variation in SJC than DOCGL and other DAS28-ESR components.

Conclusions

Variation in SJC is explained more by a 0-10 DOCINF VNS than the traditional DOCGL or any other measure in RA patients seen in routine care. DOCINF on a RheuMetric checklist can provide informative quantitative scores concerning inflammatory activity in RA patients monitored over long periods.

Motor Dysfunctions in Fibromyalgia Patients: The Importance of Breathing

The classification of fibromyalgia (FM) is not always immediate and simple, with the time from the first diagnosis, compared to the onset of symptoms, of a few years. Currently, we do not have instrumental or biochemical tests considered as gold standards; the clinician will make a diagnosis of FM based on the patient's medical history and subjective assessment. The symptoms can involve physical, cognitive and psychological disorders, with the presence of pain of different origins and classifications: nociplastic, nociceptive and neuropathic pain. Among the symptoms highlighted, postural disorders and neuromotor uncoordination emerge, whose functional dysfunctions can increase the mortality and morbidity rate. An alteration of the diaphragm muscle could generate such functional motor problems. Considering that the current literature underestimates the importance of breathing in FM, the article aims to highlight the relationship between motor and diaphragmatic difficulties in the patient, soliciting new points of view for the clinical and therapeutic framework.

Paradoxical Effects of Depression on Psoriatic Arthritis Outcomes in a Combined Psoriasis-Psoriatic Arthritis Center

Backgroud

Psoriatic arthritis (PsA) is a chronic, inflammatory arthritis that, when left untreated, can lead to erosions, deformities and decrease in quality of life. PsA is known to be associated with multiple comorbidities, including cardiovascular, metabolic and mental health syndromes, all of which can increase its overall morbidity and mortality.

Objective

To characterize a cohort of patients with PsA and understand the impact of depression on PsA outcome measures.

Methods

527 consecutive patients with PsA were enrolled in an observational, longitudinal registry that followed them prospectively at standard of care visits. Demographics, medical history, medication use, and clinical exam were all recorded.

Results

Depression was reported in 22.8% of the population, anxiety in 18%, and attention deficit hyperactivity disorder in 4%. Depression was more common in female participants (P < .001). At baseline, individuals with PsA and concomitant depression had similar tender and swollen joint counts and RAPID3 compared to those without depression, and had lower body surface area affected by psoriasis (P = .04). At year one, all patients had improvement in clinical outcomes. However, patients with depression had a significantly higher tender joint count compared to those without depression (P = .001), despite similar swollen joint count and body surface area.

Conclusion

In patients with depression, there is a discrepancy between improvement in physician assessed measures and patient reported outcomes. These observations underscore the importance of addressing depression and psychological distress as part of PsA treatment outcomes and points towards the need to address residual pain through co-adjuvant approaches.

RheuMetric Quantitative 0 to 10 Physician Estimates of Inflammation, Damage, and Distress in Rheumatoid Arthritis: Validation Against Reference Measures

OBJECTIVE

To analyze a RheuMetric checklist, which includes four feasible physician 0 to 10 scores for DOCGL, inflammation (DOCINF), damage (DOCDAM), and distress (DOCSTR) for criterion and discriminant validity against standard reference measures.

METHODS

A prospective, cross-sectional assessment was performed at one routine care visit at Liverpool Hospital, Sydney, Australia. Rheumatologists recorded DOCGL, DOCINF, DOCDAM, DOCSTR, and 28 joint counts for swelling (SJC), tenderness (TJC), and limited motion/deformity (DJC). Patients completed a multidimensional health assessment questionnaire (MDHAQ), which includes routine assessment of patient index data (RAPID3), fibromyalgia assessment screening tool (FAST4), and MDHAQ depression screen (MDS2). Laboratory tests and radiographic scores were recorded. RheuMetric estimates of inflammation, damage, and distress were compared with reference and other measures using correlations and linear regressions.

RESULTS

In 173 patients with RA, variation in RheuMetric DOCINF was explained significantly by SJC and inversely by disease duration; variation in DOCDAM was explained significantly by DJC, radiographic scores, and physical function; and variation in DOCSTR was explained significantly by fibromyalgia and depression.

CONCLUSION

RheuMetric DOCINF, DOCDAM, and DOCSTR estimates were correlated significantly and specifically with reference measures of inflammation, damage, and distress, documenting criterion and discriminant validity.

Real-World Sarilumab Use and Rule Testing to Predict Treatment Response in Patients with Rheumatoid Arthritis: Findings from the RISE Registry

INTRODUCTION

Clinical trial findings may not be generalizable to routine practice. This study evaluated sarilumab effectiveness in patients with rheumatoid arthritis (RA) and tested the real-world applicability of a response prediction rule, derived from trial data using machine learning (based on C-reactive protein [CRP] > 12.3 mg/l and seropositivity [anticyclic citrullinated peptide antibodies, ACPA +]).

METHODS

Sarilumab initiators from the ACR-RISE Registry, with ≥ 1 prescription on/after its FDA approval (2017-2020), were divided into three cohorts based on progressively restrictive criteria: Cohort A (had active disease), Cohort B (met eligibility criteria of a phase 3 trial in RA patients with inadequate response/intolerance to tumor necrosis factor inhibitors [TNFi]), and Cohort C (characteristics matched to the phase 3 trial baseline). Mean changes in Clinical Disease Activity Index (CDAI) and Routine Assessment of Patient Index Data 3 (RAPID3) were evaluated at 6 and 12 months. In a separate cohort, predictive rule was tested based on CRP levels and seropositive status (ACPA and/or rheumatoid factor); patients were categorized into rule-positive (seropositive with CRP > 12.3 mg/l) and rule-negative groups to compare the odds of achieving CDAI low disease activity (LDA)/remission and minimal clinically important difference (MCID) over 24 weeks.

RESULTS

Among sarilumab initiators (N = 2949), treatment effectiveness was noted across cohorts, with greater improvement noted for Cohort C at 6 and 12 months. Among the predictive rule cohort (N = 205), rule-positive (vs. rule-negative) patients were more likely to reach LDA (odds ratio: 1.5 [0.7, 3.2]) and MCID (1.1 [0.5, 2.4]). Sensitivity analyses (CRP > 5 mg/l) showed better response to sarilumab in rule-positive patients.

CONCLUSIONS

In real-world setting, sarilumab demonstrated treatment effectiveness, with greater improvements in the most selective population, mirroring phase 3 TNFi-refractory and rule-positive RA patients. Seropositivity appeared a stronger driver for treatment response than CRP, although optimization of the rule in routine practice requires further data.

Patient-Physician Communication and Perception of Treatment Goals in Rheumatoid Arthritis: An Online Survey of Patients and Physicians

INTRODUCTION

To evaluate patient-physician communication and patients' understanding of treatment goals in rheumatoid arthritis (RA).

METHODS

A cross-sectional online survey of patients with RA and physicians treating RA was conducted between 16 and 30 June 2021. Participants were asked to rate the importance of 17 goals on a 6-point Likert scale, and mean scores were compared between patients and physicians by the Wilcoxon rank sum test. Patients' satisfaction with physician communication and their understanding of treatment goals were also assessed.

RESULTS

The responses of 502 patients and 216 physicians were analyzed. The most common patient age group was 50-59 years (28.5%), and the mean disease duration was 10.3 years. Physicians had a mean of 19.2 years of treatment experience and were treating a mean of 44.3 patients. Among the 17 goals assessed, patients placed significantly more importance on drug tapering or discontinuation as short-term goals (3-6 months) and on performing basic activities of daily living, being able to engage in daily tasks, achieving and maintaining remission, maintaining better laboratory values, and drug tapering or discontinuation as long-term goals (5-10 years; all adjusted p < 0.05). Patient treatment satisfaction was significantly associated with disease activity, a feeling of treatment effectiveness, satisfaction with physician communication, and agreement with physician goals.

CONCLUSION

Differences exist among patients with RA and physicians treating RA regarding the importance of short- and long-term treatment goals. Good patient-physician communication appears to be important for improving patient satisfaction.

TRIAL REGISTRATION

University Hospital Medical Information Network identifier: UMIN000044463.

Development of a Natural Language Processing System for Extracting Rheumatoid Arthritis Outcomes From Clinical Notes Using the National Rheumatology Informatics System for Effectiveness Registry

OBJECTIVE

To accelerate the use of outcome measures in rheumatology, we developed and evaluated a natural language processing (NLP) pipeline for extracting these measures from free-text outpatient rheumatology notes within the American College of Rheumatology's Rheumatology Informatics System for Effectiveness (RISE) registry.

METHODS

We included all patients in RISE (2015-2018). The NLP pipeline extracted scores corresponding to 8 measures of rheumatoid arthritis (RA) disease activity (DA) and functional status (FS) documented in outpatient rheumatology notes. Score extraction performance was evaluated by chart review, and we assessed agreement with scores documented in structured data. We conducted an external validation of our NLP pipeline using data from rheumatology notes from an academic medical center that is not included in the RISE registry.

RESULTS

We processed over 34 million notes from 854,628 patients, 158 practices, and 24 electronic health record (EHR) systems from RISE. Manual chart review revealed a sensitivity, positive predictive value (PPV), and F1 score of 95%, 87%, and 91%, respectively. Substantial agreement was observed between scores extracted from RISE notes and scores derived from structured data (κ = 0.43-0.68 among DA and 0.86-0.98 among FS measures). In the external validation, we found a sensitivity, PPV, and F1 score of 92%, 69%, and 79%, respectively.

CONCLUSION

We developed an NLP pipeline to extract RA outcome measures from a national registry of notes from multiple EHR systems and found it to have good internal and external validity. This pipeline can facilitate measurement of clinical- and patient-reported outcomes for use in research and quality measurement.

Utility of Opportunistic Infections, Joints' Involvement and Accuracy of Various Screening Tests to Diagnose Rheumatoid Arthritis Patients

Background and Objectives: Rheumatoid Arthritis (RA) is an auto-immune disease in which the body mistakenly considers some parts of its own system as pathogens and attacks them. Prevalence is approximately 0.75% in India. About 40% of the diseased become work disabled within 5 years from the onset of symptoms. The objective of this paper is to assess the sign/symptoms, joints' involvement, difficulties in daily activities and screening accuracy of serology tests of clinically suspected RA patients. Material and Methods: A cross-sectional cohort study design was conducted on two hundred ninety clinically suspected subjects who were referred by different OPDs of hospitals for screening. The profiles of study subjects were carried through a semi-structured, pre-tested schedule method. About 2 mL of blood samples were collected in a plain vial from each patient and tested for diagnostic tests RF, CRP and AntiCCP by using RF-Latex, CRP Latex and ELISA method, respectively, by the laboratory persons. Results: Joint pain shows to be a leading problem in RA as compared to other signs and symptoms. The majority of the study subjects suffer from knee problems (62%). Approximately equal numbers of RA-positive cases were screened by RF and AntiCCP tests. The CRP test screened about one-third of cases. CRP+ AntiCCP, RF+ AntiCCP and RF + CRP all have good sensitivity, and RF+ AntiCCP + CRP has a very high sensitivity for diagnosing RA. Conclusions: This study found that a substantiation of a major proportion of clinically suspected RA patients were suffering from knee pain. Predication of AntiCCP increased the possibility for the diagnosis of RA. However, RF was also moderately related to the diagnosis of RA, and the combination of both tests was more valuable.

Associations between shortened telomeres and rheumatoid arthritis-associated interstitial lung disease among U.S. Veterans

BACKGROUND

Shortened telomeres are associated with several different subtypes of interstitial lung disease (ILD), although studies of telomere length and ILD in rheumatoid arthritis (RA) are lacking.

METHODS

Within the Veterans Affairs Rheumatoid Arthritis (VARA) registry, we performed cross-sectional and case-control studies of prevalent and incident ILD, respectively. We randomly selected a subset of RA patients with ILD and individually matched them to RA patients without ILD according to age, sex, and VARA enrollment date. Telomere length was measured on peripheral blood leukocytes collected at registry enrollment using quantitative PCR (T/S ratio). Short telomeres were defined as a T/S ratio in the lowest 10th percentile of the cohort.

RESULTS

Our cross-sectional study cohort was comprised of 54 RA-ILD patients and 92 RA-non-ILD patients. T/S ratios significantly differed between patients with and without prevalent ILD (1.56 [IQR 1.30, 1.78] vs. 1.96 [IQR 1.65, 2.27], p < 0.001). Similarly, prevalence of ILD was significantly higher in patients with short vs. normal-length telomeres (73.3% vs. 32.8%, p = 0.002). Short telomeres were independently associated with an increased odds of prevalent ILD compared to normal-length telomeres (adjusted OR 6.60, 95% CI 1.78-24.51, p = 0.005). In our case-control analysis, comprised of 22 incident RA-ILD cases and 36 RA-non-ILD controls, short telomeres were not associated with incident RA-ILD (adjusted OR 0.90, 95% CI 0.06-13.4, p = 0.94).

CONCLUSION

Short telomeres were strongly associated with prevalent but not incident ILD among patients with RA. Additional studies are needed to better understand telomere length dynamics among RA patients with and without ILD.

Interleukin 1 receptor antagonist relation to cardiovascular disease risk in patients with rheumatoid arthritis

Interleukin (IL) 1, and its family member, IL-1 receptor antagonist (IL-1ra), are involved in the pathogenesis and inflammation perpetuation of patients with rheumatoid arthritis (RA). Besides, IL-1 has been linked to an increased risk and greater severity of cardiovascular (CV) disease. We aimed to study if IL-1ra is related to the CV manifestations—including lipid pattern and insulin resistance or subclinical atherosclerosis—that accompanies the disease in a large series of patients with RA. Cross-sectional study that encompassed 430 patients with RA. Serum IL-1ra levels were assessed. A multivariable analysis was performed to analyze the relation of IL-1ra to subclinical carotid atherosclerosis, and to traditional CV factors including a complete lipid molecules profile and insulin resistance or beta cell function indices. Body mass index, abdominal circumference, and the presence of obesity were significantly and positively associated with circulating IL-1ra. Similarly, erythrocyte sedimentation rate, and disease activity scores were significantly related to higher IL-1ra serum levels after adjustment for confounders. Neither carotid intima-media thickness nor the presence of carotid plaque were associated with serum levels of IL-1ra. However, after multivariable analysis circulating IL-1ra was independently and positively associated with higher serum levels of total cholesterol, triglycerides, and apolipoproteins B and C-III. Similarly, IL-1ra was related to higher levels of beta-cell function in the univariable analysis, although, in this case, significance was lost after adjustment. Among patients with RA, IL-1ra is associated with both disease activity and several traditional CV risk factors such as obesity and the presence of higher lipid levels. Our findings suggest that IL-1ra can represent a link between the inflammation and the CV disease risk that are present in patients with RA.

Diagnostic value of salivary gland ultrasonography for secondary Sjögren syndrome in patients with systemic lupus erythematosus

BACKGROUND

Salivary gland ultrasound (SGUS) is a reliable technique for assessing the salivary glands in patients with primary Sjögren's syndrome (SS); however, the role of SGUS for diagnosis of secondary SS (sSS) in patients with systemic lupus erythematosus (SLE) was not examined.

OBJECTIVE

To assess the diagnostic value of SGUS for sSS in patients with SLE, and to investigate the relationship between SGUS findings with clinical and laboratory characteristics of patients with SLE.

PATIENTS AND METHODS

This cross-sectional study included 49 patients with SLE. The diagnosis of sSS was confirmed according to the 2016 ACR/EULAR criteria. Salivary gland US was performed for all patients and graded using a validated Hočevar scoring system. A complete clinical and laboratory workup for SLE was assessed. Schirmer's test and the ocular staining were performed.

RESULTS

Of the 49 patients with a mean age of 30.2 ± 9.6 years, 98% were female. 19 (38.8%) had sSS. SGUS changes consistent with sSS (≥17) were found in 29 (59.2%) of the patients. Patients with higher SGUS score had more sicca findings as well as positive anti-Ro, anti-La antibodies, and poorer psychological stress (p < 0.05). The SGUS (≥17) showed a sensitivity of 84.2% and a specificity of 56.7% for sSS diagnosis, with an area under the curve of 0.77 (95% CI: 0.63, 0.91).

CONCLUSION

We propose salivary gland ultrasound as a non-invasive method in the diagnostic workup for sSS in patients with SLE. Further studies to confirm the diagnostic value of SGUS in a larger sample of patients with sSS will be necessary.

The angiopoietin-like protein 4, apolipoprotein C3, and lipoprotein lipase axis is disrupted in patients with rheumatoid arthritis

Background

Modulators of triglyceride metabolism include lipoprotein lipase (LPL), angiopoietin-like protein 4 (ANGPTL4), and apolipoprotein C-3 (ApoC3). There is evidence on the influence of this triangle of molecules on an increased risk of atherosclerotic cardiovascular disease (CV) in the general population. Patients with rheumatoid arthritis (RA) present changes in lipid profiles and accelerated CV disease. In the present study, we set out to study whether the ANGPTL4, ApoC3, and LPL axis differs in subjects with RA compared to controls. In a further step, we investigated the relationship of this axis with subclinical atherosclerosis in patients with RA.

Methods

Cross-sectional study that included 569 individuals, 323 patients with RA and 246 age-matched controls. ANGPTL4, ApoC3 and LPL, and standard lipid profiles were analyzed in patients and controls. Carotid intima-media thickness (cIMT) and carotid plaques were assessed in RA patients. A multivariable analysis was performed to assess whether the ANGPTL4, ApoC3, and LPL axis was altered in RA and to study its relationship with RA dyslipidemia and subclinical carotid atherosclerosis.

Results

Most lipid profile molecules did not differ between patients and controls. Despite this, and after fully multivariable analysis including CV risk factors, use of statins, and changes in the lipid profile caused by the disease itself, patients with RA showed higher serum levels of ANGPTL4 (beta coef. 295 [95% CI 213–376] ng/ml, p<0.001) and ApoC3 (beta coef. 2.9 [95% CI 1.7–4.0] mg/dl, p<0.001), but lower circulating LPL (beta coef. −174 [95% CI −213 to −135] ng/ml, p<0.001). ANGPTL4 serum levels were positively and independently associated with a higher cIMT in patients with RA after fully multivariable adjustment.

Conclusion

The axis consisting in ANGPTL4, ApoC3, and LPL is disrupted in patients with RA. ANGPTL4 serum levels are positively and independently associated with a higher cIMT in RA patients.

The Effects of Hyperbaric Oxygen on Rheumatoid Arthritis: A Pilot Study

BACKGROUND/OBJECTIVE

This case series pilot study assessed the effects of hyperbaric oxygen therapy (HBO2) for treating rheumatoid arthritis (RA).

METHODS

Ten RA subjects received 30 HBO2 treatments over 6 to 10 weeks. Serial rheumatologic evaluations (ie, the Disease Activity Scale [DAS28], the Routine Assessment of Patient Index Data 3, and the Pain and Sleep Quality Questionnaire) were completed at baseline, throughout the course of the study, and at the 6-month follow-up.

RESULTS

There was a statistically significant effect of HBO2 therapy over time on the DAS28-Global Health (p = 0.01), the DAS28-C-reactive protein (p = 0.002), and the DAS28-erythrocyte sedimentation rate (p = 0.008) measures; these analyses excluded 2 patients who were in clinical remission at baseline. Selected post hoc comparisons showed significantly lower DAS28-Global Health, DAS28-C-reactive protein, and DAS28-erythrocyte sedimentation rate scores at 3 and 6 months relative to baseline. In addition, statistically significant decreases in pain as measured by the Routine Assessment of Patient Index Data 3 and Pain and Sleep Quality Questionnaire were observed at the end of HBO2 relative to baseline.

CONCLUSIONS

Hyperbaric oxygen therapy is effective for joint pain in patients with RA based on data from multiple, validated clinical measures. Further research with more subjects and the use of a control group is necessary.

Association of Serum and Crevicular Fluid Dickkopf-1 Levels with Disease Activity and Periodontitis in Patients with Early Rheumatoid Arthritis

BACKGROUND

The aim of this study was to assess DKK-1 levels, in Gingival Crevicular Fluid (GCF) and serum, as a biomarker for bone loss and disease activity in periodontitis and early RA (eRA).

METHODS

In this cross-sectional study, we obtained serum and GCF from 10 interproximal sites (Distal Buccal I/S, Mesio Buccal I/S, Distal Palatal/Lingual, Mesio Palatal/Lingual) according to the highest degree of inflammation by a patient for 240 sites from eRA patients. Patients received a periodontal assessment, a radiographic evaluation, tomography of interproximal sites, and DKK1 levels were determined by ELISA. Comparisons were performed by the Mann-Whitney U test and analysis by Chi2 test, and a logistic regression model was applied.

RESULTS

The mean age was 46.33 ± 12.0 years, the Disease Activity Score (DAS-28-ESR) was 4.08 ± 1.4. Periodontitis was present in 65.2% of the patients, and 59.6% of these patients had bone loss in interproximal sites. Higher GCF-DKK1 levels were associated with serum-DKK1 (OR:2.41 IC95% 1.14-5.09, p=0.021) and were related with DAS28-ESR (p=0.001), Routine Assessment of Patient Index Data 3 (RAPID 3) (p=0.001), and tender joints (p=0.040). Foot bone erosion and juxta-articular osteopenia were associated with high levels of serum-DKK1 (p=0.009 and 0.001, respectively). Serum-DKK1 were associated with SDAI (OR: 2.38 IC95% 1.03-5.52, p=0.043), RAPID 3 (p=0.001), and rheumatoid factor (p=0.018). The GCF-DKK1 levels were associated with periodontal bone loss (p=0.011), periodontitis (p=0.070) and its severity (OR: 2.58 IC95% 2.28-7.28, p=0.001). Bone loss was more frequent in buccal sites (73.5%) and was associated with increased levels of DKK1 (p=0.033).

CONCLUSION

In the early stages of the eRA disease, serum and GCF-DKK1 could be a biomarker for clinical disease activity and periodontal and articular bone erosion.

Risk factors associated with osteoporosis and fracture in psoriatic arthritis

BACKGROUND

Although there are few studies mentioned there may be some relationship between psoriatic arthritis (PsA) and osteoporosis, clinical data in real world still need to be clarified in China. The aim of this study was to assess the areal and volumetric bone mineral density (BMD), frequency of fracture, and risk factors in patients with PsA.

METHODS

A total of one hundred PsA patients who visited Peking University First Hospital and one hundred age- and sex-matched healthy controls with DXA data were enrolled in the study. Patients with clinical fractures confirmed by X-ray during follow-up were also recorded. Clinical characteristics of the patients were recorded and compared between the abnormal BMD group and the normal BMD group, as well as between the fracture and non-fracture groups. Risk factors for fracture and low BMD were analyzed.

RESULTS

Mean BMD at the total hip and femoral neck was significantly lower in PsA patients than that in healthy controls (0.809 ± 0.193 vs. 0.901 ± 0.152 g/cm2, P  = 0.041; 0.780 ± 0.146 vs. 0.865 ± 0.166 g/cm2, P  = 0.037, respectively). Moreover, lumbar spine BMD was negatively correlated with psoriasis duration, swollen joint count and DAS28-CRP (r = -0.503, -0.580, -0.438; P < 0.05). Total hip BMD and femoral neck BMD were negatively correlated with HAQ (r = -0.521, -0.335; P < 0.05). Fractures occurred in 29 patients during the follow-up period. Logistic regression analysis showed that older age (OR 1.132 [95%CI: 1.026-1.248), P < 0.05], higher HAQ score (OR 1.493, 95%CI: 1.214-1.836, P < 0.01), higher disease activity index for psoriatic arthritis (OR 1.033, 95% CI: 1.002-1.679, P < 0.05) and hip joint involvement (OR 6.401, 95% CI: 4.012-44.180, P < 0.05) were risk factors for fracture in the multivariate model.

CONCLUSIONS

Increased risks of osteoporosis and fracture were found in PsA patients compared to healthy controls. Besides age, high disease activity and hip joint involvement were risk factors for decreased BMD and fracture.

Factors affecting quality of life in patients with rheumatoid arthritis in South Korea: a cross-sectional study

INTRODUCTION

Rheumatoid arthritis (RA) is a chronic inflammatory disease that significantly reduces the quality of life (QOL) of affected patients. Many studies have emphasized the deterioration of QOL during the treatment of patients with RA, but factors that affect this phenomenon in Koreans with RA remain unclear.

METHODS

In this cross-sectional study, 166 Korean patients with RA were enrolled, and their general characteristics, disease-related characteristics, fatigue, feelings of depression, self-efficacy, social support, and QOL were assessed.

RESULTS

The overall mean score for RA-specific QOL was 5.8 out of 10. Fatigue, depression, self-efficacy, and social support were found to be significantly associated with the QOL of patients with RA. Notably, self-efficacy was found to be the most significant predictor of QOL.

CONCLUSIONS

Compared to patients with RA in Western countries, Korean patients with RA, even those with better physical function, seem to have a lower QOL. Identification of the relevant physical, psychological, and social factors affecting QOL in Koreans with RA is beneficial for clinical practice. Incorporation of strategies to address these factors, such as cognitive behavioral therapy, should be considered for the holistic management of RA. Key Points • Korean patients with RA report lower levels of QOL. • Factors associated with the QOL of patients with RA were fatigue, depression, self-efficacy, and social support. • Self-efficacy was the strongest factor affecting QOL in this population; thus, it would be beneficial for clinical practitioners to incorporate cognitive-behavioral approaches into patient education to enhance self-management. • Our findings suggest that QOL and psychological factors should also be regularly evaluated for the holistic management of patients with RA.

Autoantibody Seropositivity and Risk for Interstitial Lung Disease in a Prospective Male-Predominant Rheumatoid Arthritis Cohort of U.S. Veterans

Rationale: Prior studies investigating associations of rheumatoid factor (RF) and anti-citrullinated protein antibody (ACPA) seropositivity with risk for rheumatoid arthritis (RA)-associated interstitial lung disease (ILD) have mostly used cross-sectional or case-control designs.Objectives: To determine whether combined autoantibody seropositivity and higher individual autoantibody concentrations were associated with increased risk for RA-ILD in a prospective RA cohort.Methods: Within the Veterans Affairs Rheumatoid Arthritis prospective registry, we performed a cross-sectional study of prevalent ILD and a retrospective cohort study of incident ILD (diagnosed after at least 12 mo of longitudinal follow-up). We used logistic and Cox regression methods to determine whether combined RF/ACPA seropositivity and higher autoantibody concentrations were independently associated with greater risk for prevalent and incident ILD, respectively.Results: Among 2,328 participants (median age 64 yr, 89.3% male), 100 (4.3%) subjects had prevalent ILD at enrollment. During 14,281 patient-years of follow-up, 83 (3.7%) of the remaining 2,228 were subsequently diagnosed with incident ILD (5.8 cases per 1,000 person-years). Patients with combined RF/ACPA seropositivity had a higher probability of prevalent ILD compared with seronegative subjects (odds ratio [OR], 2.90; 95% confidence interval [CI], 1.24-6.78). RF titers demonstrated a monotonic association with prevalent ILD (OR, 2.69; 95% CI, 1.11-6.51 for low-positive [15-45 IU/ml] titers; OR, 3.40; 95% CI, 1.61-7.18 for high-positive [>45 IU/ml] titers; P for trend 0.01). Patients with high-positive (>15 U/ml) ACPA titers were also at higher risk for prevalent ILD (OR, 1.91; 95% CI, 1.04-3.49) compared with ACPA-negative subjects. Combined RF/ACPA seropositivity was not associated with increased risk for incident ILD, nor were high- or low-positive RF or ACPA titers. In a piecewise linear spline model, however, RF titers greater than 90 IU/ml independently correlated with increased risk for incident ILD (hazard ratio, 1.68, 95% CI, 1.02-2.77).Conclusions: Combined RF/ACPA seropositivity and individual autoantibody concentrations were strongly associated with prevalent but not incident RA-ILD. Only patients with RF concentrations >90 IU/ml were observed to be at higher risk of incident RA-ILD.

Socioeconomic Disparities in Functional Status in a National Sample of Patients With Rheumatoid Arthritis

IMPORTANCE

Little is known about the association of poverty with functional status (FS) in patients with rheumatoid arthritis (RA) who use rheumatology care.

OBJECTIVES

To examine the association between socioeconomic status (SES) and FS among patients with RA and to evaluate the association between SES and functional declines over time in patients who received at least some rheumatology care.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the American College of Rheumatology's Rheumatology Informatics System for Effectiveness (RISE) registry between January 1, 2016, and December 31, 2018. Analyses included all adult patients with a confirmed RA diagnosis (ie, had ≥2 encounters associated with RA International Classification of Diseases codes ≥30 days apart) and at least 1 FS score documented between 2016 and 2018 seen at participating rheumatology practices. Data analysis was conducted from April to December 2020.

EXPOSURES

The Area Deprivation Index (ADI), a zip code-based indicator of neighborhood poverty, was used as a proxy for SES. ADI scores were categorized into quintiles.

MAIN OUTCOMES AND MEASURES

FS measures included Multidimensional Health Assessment Questionnaire (MDHAQ), Health Assessment Questionnaire Disability index, and Health Assessment Questionnaire-II. Cross-sectionally, mean FS scores were compared across ADI quintiles. Longitudinally, among patients with at least 2 FS scores, multilevel multivariate regression computed the probability of functional decline, defined as a change greater than the minimum clinically important difference, across ADI quintiles. In a subgroup analysis, whether disease activity mediated the association between SES and functional decline was examined.

RESULTS

Of the 83 965 patients included in the study, 66 649 (77%) were women, and 60 037 (72%) were non-Hispanic White. Mean (SD) age was 63.4 (13.7) years. MDHAQ was the most reported FS measure (56 928 patients [67.8%]). For all measures, mean (SD) FS score was worse at lower SES levels (eg, for MDHAQ quintile 1: 1.79 [1.87]; quintile 5: 2.43 [2.17]). In longitudinal analyses, the probability of functional decline was 14.1% (95% CI, 12.5%-15.7%) in the highest SES quintile and 18.9% (95% CI, 17.1%-20.7%) in the lowest SES quintile. The association between SES and functional decline was partially mediated (7%; 95% CI, 4%-22%) by disease activity.

CONCLUSIONS AND RELEVANCE

In this cohort study of patients with RA, worse FS and faster declines in functioning over time were observed in patients with lower SES. These findings provide a framework for monitoring disparities in RA and for generating evidence to spur action toward achieving health equity.

A Self-Report Multidimensional Health Assessment Questionnaire (MDHAQ) for Face-To-Face or Telemedicine Encounters to Assess Clinical Severity (RAPID3) and Screen for Fibromyalgia (FAST) and Depression (DEP)

Purpose of Review

To update the clinical value of a patient self-report multidimensional health assessment questionnaire (MDHAQ).

Recent Findings

The MDHAQ includes 10 individual quantitative scores for physical function, pain, patient global assessment, fatigue, sleep, anxiety, depression, morning stiffness, change in status, and exercise status, and 5 indices, RAPID3 (routine assessment of patient index data) to assess clinical status in all diseases studied, FAST3 (fibromyalgia assessment screening tool) and MDHAQ-Dep (depression) to screen for fibromyalgia and/or depression, RADAI self-report of specific painful joints and joint count, and a symptom checklist for review of systems, and recognition of flares and medication adverse events. The MDHAQ also uniquely queries traditional “medical” information concerning comorbidities, falls, trauma, new symptoms, illnesses, surgeries, hospitalizations, emergencies, medication changes, and medication side effects. Three MDHAQ versions include long for new patients, short for new and return patients, and telemedicine. An electronic MDHAQ (eMDHAQ) has been developed with software that can interface with any electronic medical record (EMR) through the HL7 FHIR standard. However, EMR collaboration and implementation have proven difficult.

Summary

An MDHAQ provides a quantitative overview of patient status with far more information and documentation than an interview, involving minimal extra work for the physician.

Phase 1 double-blind randomized safety trial of the Janus kinase inhibitor tofacitinib in systemic lupus erythematosus

Increased risk of premature cardiovascular disease (CVD) is well recognized in systemic lupus erythematosus (SLE). Aberrant type I-Interferon (IFN)-neutrophil interactions contribute to this enhanced CVD risk. In lupus animal models, the Janus kinase (JAK) inhibitor tofacitinib improves clinical features, immune dysregulation and vascular dysfunction. We conducted a randomized, double-blind, placebo-controlled clinical trial of tofacitinib in SLE subjects (ClinicalTrials.gov NCT02535689). In this study, 30 subjects are randomized to tofacitinib (5 mg twice daily) or placebo in 2:1 block. The primary outcome of this study is safety and tolerability of tofacitinib. The secondary outcomes include clinical response and mechanistic studies. The tofacitinib is found to be safe in SLE meeting study's primary endpoint. We also show that tofacitinib improves cardiometabolic and immunologic parameters associated with the premature atherosclerosis in SLE. Tofacitinib improves high-density lipoprotein cholesterol levels (p = 0.0006, CI 95%: 4.12, 13.32) and particle number (p = 0.0008, CI 95%: 1.58, 5.33); lecithin: cholesterol acyltransferase concentration (p = 0.024, CI 95%: 1.1, -26.5), cholesterol efflux capacity (p = 0.08, CI 95%: -0.01, 0.24), improvements in arterial stiffness and endothelium-dependent vasorelaxation and decrease in type I IFN gene signature, low-density granulocytes and circulating NETs. Some of these improvements are more robust in subjects with STAT4 risk allele.

Disease activity influences the reclassification of rheumatoid arthritis into very high cardiovascular risk

BACKGROUND

Previous studies have shown that risk chart algorithms, such as the Systematic Coronary Risk Assessment (SCORE), often underestimate the actual cardiovascular (CV) risk of patients with rheumatoid arthritis (RA). In contrast, carotid ultrasound was found to be useful to identify RA patients at high CV. In the present study, we aimed to determine if specific disease features influence the CV risk reclassification of RA patients assessed by SCORE risk charts and carotid ultrasound.

METHODS

1279 RA patients without previous CV events, diabetes, or chronic kidney disease were studied. Disease characteristics including disease activity scores, CV comorbidity, SCORE calculation, and the presence of carotid plaque by carotid ultrasound were assessed. A multivariable regression analysis was performed to evaluate if the reclassification into very high CV risk category was independently associated with specific features of the disease including disease activity. Additionally, a prediction model for reclassification was constructed in RA patients.

RESULTS

After carotid ultrasound assessments, 54% of the patients had carotid plaque and consequently fulfilled definition for very high CV risk. Disease activity was statistically significantly associated with reclassification after fully multivariable analysis. A predictive model containing the presence of dyslipidemia and hypertension, an age exceeding 54 years, and a DAS28-ESR score equal or higher than 2.6 yielded the highest discrimination for reclassification.

CONCLUSION

Reclassification into very high CV risk after carotid ultrasound assessment occurs in more than the half of patients with RA. This reclassification can be independently explained by the activity of the disease.

Measuring Physical Function in Psoriatic Arthritis: Comparing the Multidimensional Health Assessment Questionnaire to the Health Assessment Questionnaire-Disability Index

OBJECTIVE

To compare physical function scales of the Multidimensional Health Assessment Questionnaire (MDHAQ) with that of the Health Assessment Questionnaire-Disability Index (HAQ-DI) in patients with psoriatic arthritis (PsA), and to examine whether either questionnaire is less prone to "floor effects."

METHODS

Data were collected prospectively from 2018 to 2019 across 3 UK hospitals. All patients completed physical function scales within the MDHAQ and HAQ-DI in a single clinic visit. Agreement was assessed using medians and the Bland-Altman method. Intraclass correlation coefficients (ICCs) were used to assess test-retest reliability.

RESULTS

Two hundred ten patients completed the clinic visit; 1 withdrew consent. Thus, 209 were analyzed. Sixty percent were male, with mean age of 51.7 years and median disease duration of 7 years. In clinic, median MDHAQ and HAQ-DI including/excluding aids scores were 0.30, 0.50, and 0.50 respectively. Although the median score for HAQ-DI was higher than for MDHAQ, the difference between the 2 scores was mostly within 1.96 SDs from the mean, suggesting good agreement. The ICCs demonstrated excellent test-retest reliability for both the MDHAQ and HAQ-DI. Similar numbers of patients scored 0 on the MDHAQ and HAQ-DI including/excluding aids (48, 47, and 49, respectively). Using a score of ≤ 0.5 as a cutoff for minor functional impairment, 23 patients had a MDHAQ ≤ 0.5 when their HAQ-DI including aids was > 0.5. Conversely, 4 patients had a MDHAQ > 0.5 when the HAQ-DI including aids was ≤ 0.5.

CONCLUSION

Both the MDHAQ and HAQ-DI appear to be similar in detecting floor effects in patients with PsA.

A comparison of physical function instruments in psoriatic arthritis: HAQ-DI vs MDHAQ vs PROMIS10 global physical health

OBJECTIVES

Physical function is a core outcome in PsA. We examined the construct validity and responsiveness of three commonly used instruments to assess physical function in PsA: HAQ disability index (HAQ-DI), MultiDimensional HAQ (MDHAQ) and the Patient-Reported Outcomes Measurement Information System (PROMIS®) Global-10.

METHODS

Between 2016 and 2019, patients with PsA were enrolled in the Psoriatic Arthritis Research Consortium longitudinal cohort study in the USA. Correlations were calculated at baseline and among change scores using Spearman's correlation coefficient. Standardized response means were calculated. Agreement with the 20% improvement cut-off was used to determine the potential effect of using MDHAQ or the PROMIS Global-10 physical health (GPH) subscore in place of HAQ-DI when assessing the ACR20.

RESULTS

A total of 274 patients were included in the analysis. The mean age of patients was 49 years and 51% were male. At baseline, the mean HAQ-DI was 0.6 (s.d. 0.6; range 0-3), the mean MDHAQ was 1.8 (s.d. 1.6; range 0-10) and the mean GPH T-score was 43.4 (s.d. 9.3; range 0-100). All three instruments were strongly correlated at baseline (rho 0.75-0.85). Change scores were moderately correlated (rho 0.42-0.71). Among therapy initiators, the mean change between two visits in HAQ-DI, MDHAQ and GPH was -0.1 (s.d. 0.4), -0.2 (s.d. 1.2) and 2.5 (s.d. 6.1), respectively. The standardized response means were 0.18, 0.16 and 0.41, respectively.

CONCLUSION

The three instruments tested are not directly interchangeable but have overall similar levels of responsiveness.

Associations of serum cytokines and chemokines with the risk of incident cancer in a prospective rheumatoid arthritis cohort

OBJECTIVES

We aimed to assess whether serum cytokine/chemokine concentrations predict incident cancer in RA patients.

METHODS

Data from cancer-free enrollees in the Veterans Affairs Rheumatoid Arthritis (VARA) Registry were linked to a national VA oncology database and the National Death Index (NDI) to identify incident cancers. Seventeen serum cytokines/chemokines were measured from enrollment serum and an overall weighted cytokine/chemokine score (CK score) was calculated. Associations of cytokines/chemokines with all-site, lung, and lymphoproliferative cancers were assessed in Cox regression models accounting for relevant covariates including age, sex, RA disease activity, and smoking.

RESULTS

In 1216 patients, 146 incident cancers (42 lung and 23 lymphoproliferative cancers) occurred over 10,072 patient-years of follow-up with a median time of 4.6 years from enrollment (cytokine/chemokine measurement) to cancer incidence. In fully adjusted models, CK score was associated with a higher risk of all-site (aHR 1.32, 95% CI 1.01-1.71, p < 0.001), lung (aHR 1.81, 1.40-2.34, p = 0.001), and lung/lymphoproliferative (aHR 1.54 [1.35-1.75], p < 0.001) cancer. The highest quartile of CK score was associated with a higher risk of all-site (aHR 1.91, 0.96-3.81, p = 0.07; p-trend = 0.005), lung (aHR 8.18, 1.63-41.23, p = 0.01; p-trend < 0.001), and lung/lymphoproliferative (aHR 4.56 [1.84-11.31], p = 0.001; p-trend < 0.001) cancer. Thirteen of 17 individual analytes were associated with incident cancer risk.

CONCLUSION

Elevated cytokine/chemokine concentrations are predictive of future cancer in RA patients, particularly lung and lymphoproliferative cancers. These results suggest that the measurement of circulating cytokines/chemokines could be informative in cancer risk stratification and could provide insight into future cancer prevention strategies in RA, and possibly individuals without RA.

Validation of the HAQ-UP-A (Health Assessment Questionnaire-Upper Limbs-Argentine Version) in Patients With Rheumatoid Arthritis

HAQ is considered the gold standard for the evaluation of functional capacity in patients with rheumatoid arthritis (RA), even though it does not focus on any particular anatomical region. With the objective of assessing functional disability of the hand in elderly patients with osteoarthritis, Baron et al. used a modified version of the HAQ which was calculated as the mean value for the categories mostly involving the upper extremities and named it 'HAQ-UP'. This instrument has not been validated in patients with RA.

OBJECTIVE

To validate HAQ-UP-Argentine version in patients with RA.

METHODS

Cross-sectional study. Consecutive patients ≥18years with diagnosis of RA (ACR/EULAR 2010) were included. Socio-demographic data and RA characteristics were recorded. Questionnaires were administered: HAQ-A, HAQ-UP-A, FIHOA, Quick-DASH. The reproducibility of the questionnaire was assessed.

RESULTS

A total of 100 patients were included, 83% women, mean age 57.9years (SD 11.6). Cronbach's alpha test was 0.94. The intra-item correlation did not show redundant questions. HAQ-UP-A showed excellent correlation with HAQ-A (r=.93); FIHOA (r=.89) and Quick-DASH (r=.91). It also showed good correlation with DAS28-ESR (r=.68) and other composite disease activity indices as well as with other parameters of the disease. There was no correlation between HAQ-UP-A and disease duration. The reproducibility of the questionnaire was 0.82. Multiple linear regression adjusted for age and sex showed patient global VAS as the main determinant of HAQ-UP-A, followed by the presence of morning stiffness.

CONCLUSION

HAQ-UP-A was found to be reliable, valid and reproducible in patients with RA, representing a useful tool for the evaluation of the functional capacity of the upper limbs in these patients.

Relationship Between Depression and Disease Activity in United States Veterans With Early Rheumatoid Arthritis Receiving Methotrexate

OBJECTIVE

Depression is common in patients with rheumatoid arthritis (RA), exacerbates disease activity, and may decrease response to first-line disease-modifying antirheumatic drugs. This study aimed to determine if depression affects disease activity among veterans with early RA prescribed methotrexate (MTX).

METHODS

Participants included veterans enrolled in the Veterans Affairs Rheumatoid Arthritis (VARA) registry with early RA (onset < 2 yrs) prescribed MTX. Depression was assessed at enrollment using the International Classification of Diseases, 9th revision codes (296.2-296.39, 300.4, 311). Disease activity was measured using the Disease Activity Score in 28 joints (DAS28) and other core measures of RA disease activity. Propensity score weights were used to adjust depressed (n = 48) and nondepressed (n = 220) patients on baseline confounders within imputed datasets. Weighted estimating equations were used to assess standardized mean differences in disease activity between depressed and nondepressed patients at 6-month, 1-year, and 2-year follow-ups.

RESULTS

The analytic sample was composed of 268 veterans with early RA prescribed MTX who were predominantly male (n = 239, 89.2%) and older (62.7 yrs, SD 10.6) than patients with RA in the general population. Adjusted estimates indicated that depression was associated with significantly higher DAS28 at 6 months (β 0.35, 95% CI 0.01-0.68) but not at the 1- or 2-year follow-up. Also, depression was associated with significantly worse pain at 6 months (β 0.39, 95% CI 0.04-0.73) and 1 year (β 0.40, 95% CI 0.04-0.75).

CONCLUSION

In early RA, depression is associated with greater short-term disease activity during MTX treatment, as well as more persistent and severe pain.

Scale-Banking for Patient Reported Outcome Measures (PROMs) Measuring Functioning in Rheumatoid Arthritis: A Daily Activities Metric

OBJECTIVE

Functioning is an important outcome for rheumatoid arthritis (RA) management. Heterogeneity of respective patient-reported outcome measures (PROMs) challenges direct comparisons between their results. This study aimed to standardize reporting of such PROMs measuring functioning in RA to facilitate comparability.

METHODS

Common Item Non-Equivalent Groups Design (NEAT) with the Health Assessment Questionnaire (HAQ) as a common scale across data sets from various countries (incl. UK, Turkey and Germany) to establish a common metric. Other PROMs included are the Physical Function items of the Multidimensional Health Assessment Questionnaire (MDHAQ), Disabilities of Arm, Shoulder and Hand (DASH), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), World Health Organization Disability Assessment Schedule Version 2.0 (WHODAS 2.0), and four short forms (20, 10, 6, and 4 physical function items) from the Patient-Reported Outcomes Measurement Information System (PROMIS). As the HAQ includes mobility, self-care and domestic life items, this study focuses on these three domains. PROMs were described using Standard Error of Measurement (SEM) and Smallest Detectable Difference (SDD). Rasch Measurement model was used to create the common metric.

RESULTS

Range of SEM is 0.2 (MDHAQ) to 7.4 (SF36-PF). SDD revealed a range from 9.7 % (WOMAC-RAT) to 33.5 % (WHODAS-PF). PROMs co-calibration revealed fit to the Rasch measurement model. A transformation table was developed to allow exchange between PROMs scores.

DISCUSSION

Scores between the Daily Activity PROMs commonly used in RA can now be compared. Factors such as SEM and SDD help determine choice of PROM in clinical practice and research.

The Patient Experienced Symptom State (PESS): a patient-reported global outcome measure that may better reflect disease remission status

OBJECTIVES

In RA, Patient Acceptable Symptom State assesses disease from the patient's perspective, which does not correspond either to disease remission or to full control of disease impact. This study aims to explore the properties of a novel multilevel Patient Experienced Symptom State (PESS).

METHODS

This was a cross-sectional analysis of two datasets of patients with RA. PESS was assessed through the question: 'Consider how your RA has affected you. If you remain in the coming months as you have been the last week, how would you rate your condition?', with five levels (from 'very bad' to 'very good'). Construct validity of PESS was assessed against validated disease activity [DAS28, Simplified Disease Activity Index (SDAI) and Clinical Disease Activity Index (CDAI)] and impact measures [RA Impact of Disease (RAID) and modified HAQ]. Multiple pairwise comparisons between groups and receiver-operating characteristic curves with Youden Index were performed.

RESULTS

A total of 1407 patients [74% female, mean (S.d.) age 53.5 (13.4) years, mean disease duration 14.3 (12.0) years and mean DAS28 3.0 (1.5)] were analysed. Overall, 16.3% considered themselves as being in 'very good', 21.6% in 'good' and 31.9% in 'acceptable' state. Disease activity and impact measures differed significantly across the five levels (P < 0.01). Cut-off values corresponding to 'good' and 'very good' PESS states were in the range of low disease activity/remission (for 'good' and 'very good': DAS28-ESR-4v ≤2.6/≤2.3; CDAI ≤5.0/≤3.1; SDAI ≤5.1/≤3.8, respectively) and very low disease impact (RAID domains all ≤1).

CONCLUSION

PESS 'very good' status corresponds to currently recommended targets for RA management and reflects full control of disease impact. PESS appears to be an easy-to-use and relevant measure in the evaluation of patients with RA.

Higher Checkpoint Inhibitor Arthritis Disease Activity may be Associated With Cancer Progression: Results From an Observational Registry

Objective

To describe clinical features associated with cancer outcomes of patients with immune checkpoint inhibitor (ICI)‐associated arthritis.

Methods

Observational study of patients with ICI‐arthritis enrolled in a single‐center registry. Arthritis phenotype and activity, medications, and cancer status were recorded at every visit. We used descriptive statistic, and Kaplan‐Meier curves using two‐sided log‐rank test and Cox regression analysis were used to identify factors associated with cancer progression‐free survival (PFS).

Results

Forty‐two patients with ICI‐arthritis were followed for a median (interquartile range [IQR]) of 7.4 (1.7, 14.7) months. Fifty‐seven percent were female, 33% had melanoma, and 69% received anti–programmed death ligand 1 monotherapy. Median time from ICI initiation to arthritis onset was 2.8 (0.8, 11.2) months. Sixty‐two percent had a rheumatoid arthritis (RA)‐like small‐joint presentation; 27% of all patients were rheumatoid factor and/or cyclic citrullinated peptide positive. Median (IQR) Clinical Disease Activity Index (CDAI) on presentation was 15 (8, 24); 62% required systemic glucocorticoids, 55% required disease‐modifying antirheumatic drugs (DMARDs), and 69% had ongoing arthritis at 6 months. Arthritis led to ICI discontinuation in five patients. In univariate analysis, baseline CDAI, DMARD use, earlier arthritis onset, and longer duration of follow‐up were associated with shorter PFS. In multivariable Cox regression analysis controlling for DMARD use and time to arthritis onset, CDAI was a significant predictor of cancer progression (hazard ratio 1.09, 95% confidence interval [CI] 1.00‐1.19, P = 0.05)

Conclusion

ICI‐arthritis most commonly presents with an RA‐like phenotype. High disease activity, as measured by CDAI, may portend cancer progression.

Measuring Outcomes in Psoriatic Arthritis: Comparing Routine Assessment of Patient Index Data and Psoriatic Arthritis Impact of Disease

OBJECTIVE

To examine the construct validity of Routine Assessment of Patient Index Data 3 (RAPID3) and Psoriatic Arthritis Impact of Disease (PsAID) in patients with psoriatic arthritis (PsA). In examining construct validity, we also addressed scores among subgroups with severe psoriasis, poly articular disease, enthesitis, and dactylitis, and evaluated influences of sociodemographic factors and comorbidities (contextual factors) on these patient-reported outcomes (PRO).

METHODS

Patients with PsA were enrolled in the Psoriatic Arthritis Research Consortium (PARC) between 2014 and 2016. PARC is a longitudinal observational cohort study conducted at 4 US institutions. In this cross-sectional study, construct validity was assessed by examining Spearman correlation coefficients for RAPID3 and PsAID with physician-reported disease activity measures and other PRO [e.g., Medical Outcomes Study Short Form-12 physical component summary/mental component summary (SF-12 PCS/MCS), Functional Assessment of Chronic Illness Therapy-Fatigue scale (FACIT-F)]. Contextual factors and disease subgroups were assessed in multivariable linear regression models with RAPID3 or PsAID12 as outcomes of interest and the hypothesized contextual factors as covariates.

RESULTS

Among 401 patients enrolled in PARC, 347 completed RAPID3 or PsAID12. Of these, most were white females with a mean age of 51.7 years (SD 14.02). RAPID3 and PsAID were highly correlated (r = 0.90). These measures were also correlated with the SF-12 PCS (r = -0.67) and FACIT-F (r = -0.77). Important contextual factors and disease subgroups included enthesitis, joint counts, education, insurance type, and depression.

CONCLUSION

RAPID3 and PsAID12 have excellent construct validity in PsA and are strongly correlated despite differing items. Contextual factors (i.e., the presence of depression and obesity) should be considered when interpreting raw scores of the RAPID3 and PsAID12.

Multidimensional Health Assessment Questionnaire as an Effective Tool to Screen for Depression in Routine Rheumatology Care

OBJECTIVE

To analyze the use of the Multidimensional Health Assessment Questionnaire (MDHAQ) to screen for depression, as compared to 2 reference standards, the Patient Health Questionnaire 9 (PHQ-9) and the Hospital Anxiety and Depression Scale depression domain (HADS-D).

METHODS

Patients from Barcelona with a primary diagnosis of rheumatoid arthritis (RA) or spondyloarthritis (SpA) completed the MDHAQ, the PHQ-9 (depression ≥10), and the HADS-D (depression ≥8) measures. The MDHAQ includes 2 depression items, 1 in the patient-friendly HAQ, scored in a 4-point format from 0 to 3.3, and a yes/no item on a 60-symptom checklist. Percentage agreement and kappa statistics quantified the agreement between 6 screening criteria: yes on the 60-symptom checklist, a score of ≥1.1, a score of ≥2.2 on a 4-point scale, and either a response of yes on the 60-symptom checklist or scores of ≥2.2, PHQ-9 ≥10, and HADS-D ≥8.

RESULTS

Depression screening was positive according to 6 criteria in 19.6-32.4% of 102 patients with RA, and 27.9-44.8% of 68 with SpA (total = 170). All MDHAQ scores, including depression items, were higher in patients with SpA compared to patients with RA, and within each diagnostic group in patients who met PHQ-9 ≥10 and HADS-D ≥8 depression screening criteria. The highest percentage agreement between an MDHAQ screening criterion versus PHQ-9 ≥10 was 83.3% for either an answer of yes on the 60-symptom checklist or a score of ≥2.2 on a 4-point scale, which we have termed MDHAQ-Dep. The agreement of MDHAQ-Dep versus HADS-D ≥8 was 81.7%, similar to the agreement of PHQ-9 ≥10 versus HADS-D ≥8, which was 82.2%. Kappa measures of agreement were 0.63 for MDHAQ-Dep versus PHQ-9 ≥10, 0.60 for MDHAQ-Dep versus HADS-D ≥8, and 0.62 for PHQ-9 ≥10 versus HADS-D ≥8.

CONCLUSION

A positive MDHAQ-Dep response (either an answer of yes on a 60-symptom checklist or a score of ≥2.2 on a 4-point scale) yielded similar results to PHQ-9 ≥10 or HADS-D ≥8 to screen for depression in these RA and SpA patients.

An Internet-Based Intervention Augmented With a Diet and Physical Activity Consultation to Decrease the Risk of Dementia in At-Risk Adults in a Primary Care Setting: Pragmatic Randomized Controlled Trial

BACKGROUND

There is a need to develop interventions to reduce the risk of dementia in the community by addressing lifestyle factors and chronic diseases over the adult life course.

OBJECTIVE

This study aims to evaluate a multidomain dementia risk reduction intervention, Body Brain Life in General Practice (BBL-GP), targeting at-risk adults in primary care.

METHODS

A pragmatic, parallel, three-arm randomized trial involving 125 adults aged 18 years or older (86/125, 68.8% female) with a BMI of ≥25 kg/m² or a chronic health condition recruited from general practices was conducted. The arms included (1) BBL-GP, a web-based intervention augmented with an in-person diet and physical activity consultation; (2) a single clinician-led group, Lifestyle Modification Program (LMP); and (3) a web-based control. The primary outcome was the Australian National University Alzheimer Disease Risk Index Short Form (ANU-ADRI-SF).

RESULTS

Baseline assessments were conducted on 128 participants. A total of 125 participants were randomized to 3 groups (BBL-GP=42, LMP=41, and control=42). At immediate, week 18, week 36, and week 62 follow-ups, the completion rates were 43% (18/42), 57% (24/42), 48% (20/42), and 48% (20/42), respectively, for the BBL-GP group; 71% (29/41), 68% (28/41), 68% (28/41), and 51% (21/41), respectively, for the LMP group; and 62% (26/42), 69% (29/42), 60% (25/42), and 60% (25/42), respectively, for the control group. The primary outcome of the ANU-ADRI-SF score was lower for the BBL-GP group than the control group at all follow-ups. These comparisons were all significant at the 5% level for estimates adjusted for baseline differences (immediate: difference in means -3.86, 95% CI -6.81 to -0.90, P=.01; week 18: difference in means -4.05, 95% CI -6.81 to -1.28, P<.001; week 36: difference in means -4.99, 95% CI -8.04 to -1.94, P<.001; and week 62: difference in means -4.62, 95% CI -7.62 to -1.62, P<.001).

CONCLUSIONS

A web-based multidomain dementia risk reduction program augmented with allied health consultations administered within the general practice context can reduce dementia risk exposure for at least 15 months. This study was limited by a small sample size, and replication on a larger sample with longer follow-up will strengthen the results.

TRIAL REGISTRATION

Australian clinical trials registration number (ACTRN): 12616000868482; https://anzctr.org.au/ACTRN12616000868482.aspx.

Cross-cultural adaptation and psychometric testing of the Dutch and German versions of the Evaluation of Daily Activity Questionnaire in people with rheumatoid arthritis

The Evaluation of Daily Activity Questionnaire (EDAQ) is a detailed patient-reported outcome measure of activity ability. The objective of this research was to assess the linguistic and cross-cultural validity and psychometric properties of the EDAQ in rheumatoid arthritis for Dutch and German speakers. The EDAQ was translated into Dutch and German using standard methods. A total of 415 participants (Dutch n = 252; German n = 163) completed two questionnaires about four weeks apart. The first included the EDAQ, Health Assessment Questionnaire (HAQ) and 36-item Short-Form v2 (SF-36v2) and the second, the EDAQ only. We examined construct validity using Rasch analysis for the two components (Self-Care and Mobility) of the Dutch and German EDAQ. Language invariance was also tested from the English version. We examined internal consistency, concurrent and discriminant validity and test–retest reliability in the 14 EDAQ domains. The Self-Care and Mobility components satisfied Rasch model requirements for fit, unidimensionality and invariance by language. Internal consistency for all 14 domains was mostly good to excellent (Cronbach’s alpha ≥ 0.80). Concurrent validity was mostly strong: HAQ r_s = 0.65–0.87; SF36v2 r_s = − 0.61 to − 0.87. Test–retest reliability was excellent [ICC (2,1) = 0.77–0.97]. The EDAQ has good reliability and validity in both languages. The Dutch and German versions of the EDAQ can be used as a measure of daily activity in practice and research in the Netherlands and German- speaking countries.

Cervus and cucumis peptides combined umbilical cord mesenchymal stem cells therapy for rheumatoid arthritis

Cervus and cucumis peptides (Lugua polypeptides, LG) are traditional Chinese medicine, which are active components of polypeptide extracted from Sika deer bone and melon seed, and they contain bone induced polypeptide biological factors. Umbilical cord mesenchymal stem cell, (UC-MSC) have tissue repair multiple effects, anti-inflammatory, and immune regulation function, which become a very promising start in rheumatoid arthritis (RA) treatment. Hence, LG combined UC-MSC can significantly enhance the UC-MSC treatment of rheumatoid arthritis (RA).To explore the clinical curative effect and therapeutic mechanism of LG combined UC-MSC for treating RA.119 patients were divided into control and treatment groups, and both groups were treated with methotrexate tablets, leflunomide, and UC-MSC. But, LG were added to the treatment group. In vitro, the effects of LG on UC-MSC cell secretion of anti-inflammatory factors were also performed.The Health Assessment Questionnaire; the 28 joint disease activity score; C reactive protein; the erythrocyte sedimentation rate; rheumatoid factor; and anti-cyclic citrullinated peptide antibody were significantly reduced in treatment group 1 year after treatment (P < .05). In vitro, compared with the control group, the number of hepatocyte growth factor (HGF), the secretion of prostaglandin E2 (PGE2) and tumor necrosis factor-inducible gene 6 protein (TSG6) increased significantly (P < .05).LG combined UC-MSCs can significantly improve the curative effect of RA patients, while LG may reduce inflammatory cytokines, regulate immunity, improve microcirculation, and are conducive to UC-MSCs migration and the repair of damaged tissue.

"How are you?" Estimation of anxiety, sleep quality, and mood using computational voice analysis

We developed a method of estimating impactors of cognitive function (ICF) - such as anxiety, sleep quality, and mood - using computational voice analysis. Clinically validated questionnaires (VQs) were used to score anxiety, sleep and mood while salient voice features were extracted to train regression models with deep neural networks. Experiments with 203 subjects showed promising results with significant concordance correlation coefficients (CCC) between actual VQ scores and the predicted scores (0.46 = anxiety, 0.50 = sleep quality, 0.45 = mood).

Higher Prevalence and Degree of Insulin Resistance in Patients With Rheumatoid Arthritis Than in Patients With Systemic Lupus Erythematosus

OBJECTIVE

Since insulin resistance (IR) is highly prevalent in patients with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), we aimed to determine whether differences in IR exist between the two conditions.

METHODS

We conducted a cross-sectional study comprising 413 subjects without diabetes (186 with SLE and 227 with RA). Glucose, insulin, and C-peptide serum levels, as well as IR by the homeostatic model assessment (HOMA2) were studied. A multivariable regression analysis was performed to evaluate the differences in IR indexes between patients with SLE and RA, as well as to determine if IR risk factors or disease-related characteristics are differentially associated with IR in both populations.

RESULTS

The insulin:C-peptide molar ratio was upregulated in patients with RA compared to patients with SLE (β 0.009, 95% CI 0.005-0.014, P < 0.001) after multivariable analysis. HOMA2 indexes related to insulin sensitivity (HOMA2-%S) were found to be lower (β -27, 95% CI -46 to -9, P = 0.004) and β cell function (HOMA2-%B) showed higher IR indexes (β 38, 95% CI 23-52, P < 0.001) in RA than in SLE patients after multivariable analysis. Patients with RA more often fulfilled the definition of IR than those with SLE (OR 2.15, 95% CI 1.25-3.69, P = 0.005). The size effect of IR factors on IR indexes was found to be equal in both diseases.

CONCLUSION

IR sensitivity is lower and β cell function is higher in RA than in SLE patients. The fact that traditional IR factors have an equal effect on IR in both SLE and RA supports the contention that these differences are related to the diseases themselves.

Reliability, Feasibility, and Patient Acceptance of an Electronic Version of a Multidimensional Health Assessment Questionnaire for Routine Rheumatology Care: Validation and Patient Preference Study

BACKGROUND

A multidimensional health assessment questionnaire (MDHAQ) that was developed primarily for routine rheumatology care has advanced clinical research concerning disease burden, disability, and mortality in rheumatic diseases. Routine Assessment of Patient Index Data 3 (RAPID3), an index within the MDHAQ, is the most widely used index to assess rheumatoid arthritis (RA) in clinical care in the United States, and it recognizes clinical status changes in all studied rheumatic diseases. MDHAQ physical function scores are far more significant in the prognosis of premature RA mortality than laboratory or imaging data. However, electronic medical records (EMRs) generally do not include patient questionnaires. An electronic MDHAQ (eMDHAQ), linked by fast healthcare interoperability resources (FIHR) to an EMR, can facilitate clinical and research advances.

OBJECTIVE

This study analyzed the reliability, feasibility, and patient acceptance of an eMDHAQ.

METHODS

Since 2006, all Rush University Medical Center rheumatology patients with all diagnoses have been asked to complete a paper MDHAQ at each routine care encounter. In April 2019, patients were invited to complete an eMDHAQ at the conclusion of the encounter. Analyses were conducted to determine the reliability of eMDHAQ versus paper MDHAQ scores, arithmetically and by intraclass correlation coefficient (ICC). The feasibility of the eMDHAQ was analyzed based on the time for patient completion. The patient preference for the electronic or paper version was analyzed through a patient paper questionnaire.

RESULTS

The 98 study patients were a typical routine rheumatology patient group. Seven paper versus eMDHAQ scores were within 2%, differences neither clinically nor statistically significant. ICCs of 0.86-0.98 also indicated good to excellent reliability. Mean eMDHAQ completion time was a feasible 8.2 minutes. The eMDHAQ was preferred by 72% of patients; preferences were similar according to age and educational level.

CONCLUSIONS

The results on a paper MDHAQ versus eMDHAQ were similar. Most patients preferred an eMDHAQ.

Systematic Review and Appraisal of the Cross-Cultural Validity of Functional Status Assessment Measures in Rheumatoid Arthritis

Objective

We conducted a systematic review and appraisal of the cross‐cultural adaptation and cross‐cultural validity of the Health Assessment Questionnaire (HAQ) and its derivatives, and of the more recent Patient‐Reported Outcomes Measurement Information System (PROMIS) functional status assessment measures (FSAMs) in rheumatoid arthritis.

Methods

Four electronic medical databases were searched from inception until April 4, 2018 according to the Consensus‐Based Standards for the Selection of Health Measurement Instruments (COSMIN) group search strategy. Included studies were evaluated using the COSMIN tool for cross‐cultural validity and were scored as excellent, good, fair, or poor.

Results

Of 58 articles identified by our search strategy and 3 by manual search, 39 were included: 29 described the translation, cultural adaptation, or cross‐cultural validity of the HAQ disability index, 8 other HAQ derivatives, and 2 PROMIS measures, representing 22 languages. Of the 39 articles reviewed, 3 examined the cross‐cultural validity of translated versions. These studies were rated as follows: 2 as excellent, 3 good, 13 fair, and 21 poor. Two studies examining cross‐cultural validity noted differential item functioning (DIF) between Dutch and US populations for the HAQ‐II and PROMIS measures, and a third study found DIF between Turkish and UK populations on the HAQ, indicating cultural differences in questionnaire response.

Conclusion

This review highlights a paucity of data on the cross‐cultural validity of FSAMs and the mostly poor‐ or fair‐quality methods by which they were translated and adapted, which needs to be considered when using these measures for multinational clinical trials and for day‐to‐day use in clinical practice.

Racial disparities in pre-operative pain, function and disease activity for patients with rheumatoid arthritis undergoing Total knee or Total hip Arthroplasty: a New York based study

Background

Black and Hispanic patients with osteoarthritis have more pain and worse function than Whites at the time of arthroplasty. Whether this is true for patients with rheumatoid arthritis (RA) is unknown.

Methods

This cross-sectional study used data on RA patients acquired between October 2013 and November 2018 prior to elective total knee (TKA) or hip arthroplasty (THA). Pain, function, and disease activity were assessed using the visual analogue scale (VAS), the Multidimensional Health Assessment Questionnaire (MDHAQ), and the Disease Activity Score (DAS28-ESR). We linked the cases to census tracts using geocoding to determine the community poverty level. Race, education, income, insurance and medications were collected via self-report. Using multivariable linear and logistic models we examined whether minority status predicted pain, function and RA disease activity at the time of arthroplasty.

Results

Thirty seven (23%) of the 164 patients were Black or Hispanic (minorities). The MDHAQ and DAS28-ESR were not significantly worse while VAS pain score was significantly worse in minority patients (p = 0.03). There was no significant difference in education between the groups. Insurance varied significantly; 29% of minority patients had Medicaid vs. 0% of Whites (p < 0.0001). In the multivariable analyses minority status was not significantly associated with DAS28-ESR [p = 0.66], MDHAQ [p = 0.26], or VAS pain [p = 0.18].

Conclusions

For Black and/or Hispanic patients with RA undergoing THA or TKA at a high-volume specialty hospital, unlike Black or Hispanic patients with osteoarthritis (OA), there was no association with worse pain, function, or RA disease activity at the time of elective arthroplasty.

Appraisal of Candidate Instruments for Assessment of the Physical Function Domain in Patients with Psoriatic Arthritis

Objective.

Numerous patient-reported outcome measures (PROM) exist for the measurement of physical function for psoriatic arthritis (PsA), but only a few are validated comprehensively. The objective of this project was to prioritize PROM for measuring physical function for potential incorporation into a standardized outcome measurement set for PsA.

Methods.

A working group of 13 members including 2 patient research partners was formed. PROM measuring physical function in PsA were identified through a systematic literature review and recommendations by the working group. The rationale for inclusion and exclusion from the original list of existing PROM was thoroughly discussed and 2 rounds of Delphi exercises were conducted to achieve consensus.

Results.

Twelve PROM were reviewed and discussed. Six PROM were prioritized: Health Assessment Questionnaire (HAQ) and 4 modifications (HAQ-Disability Index, HAQ-Spondyloarthritis, modified HAQ, multidimensional HAQ), Medical Outcomes Study 36-item Short Form survey physical functioning domain, and the Patient-Reported Outcomes Measurement Information System (PROMIS) physical functioning module.

Conclusion.

Through discussion and Delphi exercises, we achieved consensus to prioritize 6 physical function PROM for PsA. These 6 PROM will undergo further appraisal using the Outcome Measures in Rheumatology (OMERACT) Filter 2.1.