Effectiveness of a clinical practice intervention in early rheumatoid arthritis

Early arthritis clinic is effective for rheumatoid and psoriatic arthritides

INTRODUCTION

Early arthritis clinics (EACs) have been well established since 1980s. Most of the data for their effectiveness comes from rheumatoid arthritis (RA) management and is largely limited to process outcomes. There is little evidence that such clinics improve clinical outcomes particularly for psoriatic arthritis (PsA). We examined whether EACs provide better outcomes irrespective of final arthritis diagnosis.

METHODS

A 52-week prospective observational study of all inflammatory arthritis patients presenting to early arthritis service at our secondary care hospital in 2016 was undertaken. A protocolised approach to the early initiation of therapy (within 3 weeks) and 6-weekly review of treatment outcomes was embedded irrespective of the arthritis diagnosis. Statistical analysis was undertaken using Mann-Whitney U test for disease activity scores to ascertain the significance of outcomes.

RESULTS

Of 1884 patients referred, 482 (25.5%) were triaged into EACs based on set criteria. 159 (64.3%) had RA, 55 (22%) with PsA and 33 had other inflammatory arthritides. Mean DAS28 for RA at first visit was 4.65 (0.6-8.0). Treating to target achieved DAS28 remission for 84 (53.5%) and low disease activity (LDA) for a further 44 (34%). Median time to achieve remission or LDA was 20 weeks (0-52 weeks). Mean tender (TJ) and swollen joint (SJ) counts for PsA at first visit were 8.2 (1-35) and 3.5 (0-14), respectively [n = 55]. The patient (PtGA) and physician (PhGA) global assessments mean were 3.0 and 2.9 (1-5). Target [TJ and SJ ≤ 2] was achieved for 38 patients (69%) and good PsARC response for a further four (7%). Median time to achieve the target or good response was 22 weeks (0-48 weeks). Final TJ and SJ mean was significantly better at 1.2 (0-4) and 0.3 (0-2) [p < 0.0001] with similar improvement in PtGA [mean 1.8 (1-4)] and PhGA [mean 1.6 (1-3)].

CONCLUSION

Dedicated EACs help achieve good clinical outcomes in majority of patients with RA and PsA. Nearly 80% of our cohort attained the target or good disease response in less than 6 months. This was despite a significant delay in patients presenting to their GPs and moderately high disease activity.

Severity indices in rheumatoid arthritis: A systematic review

OBJECTIVE

To identify tools designed to evaluate the severity of patients with rheumatoid arthritis (RA) in order to use them in the investigation of prognostic markers in early arthritis.

METHODS

We conducted a systematic review of studies that developed/validated an index for RA disease severity. They were analyzed using the COSMIN checklist to assess their methodological quality. In addition, all the variables included were evaluated for their clarity of definition, feasibility and probability of being present in each outcome during the first 2 years of the disease course. To estimate redundancy, variables were grouped by domains.

RESULTS

After reviewing 3,519 articles, 3 studies were included. The first study, the PAS, assessed whether current and lifetime treatment with disease-modifying antirheumatic drugs and/or biologics accurately predicted RA severity, as measured by the patient-reported PAS. Treatment variables did not fully distinguish patients in the highest and lowest quartiles of PAS scores. Another severity index, the Claims-Based Index for RA Severity (CIRAS), included the variables age, sex, Felty's syndrome, number of rehabilitation and rheumatology visits, test for inflammatory markers, number of chemistry panels/platelet counts ordered and rheumatoid factor test. The correlation was low (r=0.56) with an index previously validated by the same research group, the RA medical records-based index of severity (RARBIS), with Disease Activity Score-C-reactive protein (DAS28-PCR) (r=0.07) and Multidimensional Health Assessment Questionnaire (MD-HAQ) (r=0.008). Finally, the RARBIS, used to validate the CIRAS, was devised as an RA severity index based on medical records. It includes as domains surgery, radiology, extra-articular manifestations, clinical and laboratory variables, previously chosen by an expert panel. RARBIS had a weak correlation with treatment intensity (r=0.35) and with DAS28 (r=0.41).

CONCLUSION

There is no index to assess the severity of RA based on the course of the first 2 years of follow-up that is adapted to the current strategy of therapeutic management of this disease. Therefore, we believe it is reasonable to develop a new ad hoc severity index for patients with early arthritis.

Impact of early diagnosis on functional disability in rheumatoid arthritis

BACKGROUND/AIMS

To determine whether early diagnosis is beneficial for functional status of various disease durations in rheumatoid arthritis (RA) patients.

METHODS

A total of 4,540 RA patients were enrolled as part of the Korean Observational Study Network for Arthritis (KORONA). We defined early diagnosis as a lag time between symptom onset and RA diagnosis of ≤ 12 months, whereas patients with a longer lag time comprised the delayed diagnosis group. Demographic characteristics and outcomes were compared between early and delayed diagnosis groups. Logistic regression analyses were performed to identify the impact of early diagnosis on the development of functional disability in RA patients.

RESULTS

A total of 2,597 patients (57.2%) were included in the early diagnosis group. The average Health Assessment Questionnaire-Disability Index (HAQ-DI) score was higher in the delayed diagnosis group (0.64 ± 0.63 vs. 0.70 ± 0.66, p < 0.01), and the proportion of patients with no functional disability (HAQ = 0) was higher in the early diagnosis group (22.9% vs. 20.0%, p = 0.02). In multivariable analyses, early diagnosis was independently associated with no functional disability (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.01 to 1.40). In a subgroup analysis according to disease duration, early diagnosis was associated with no functional disability in patients with disease duration < 5 years (OR, 1.37; 95% CI, 1.09 to 1.72) but not in patients with longer disease duration (for 5 to 10 years: OR, 1.07; 95% CI, 0.75 to 1.52; for ≥ 10 years: OR, 0.92; 95% CI, 0.65 to 1.28).

CONCLUSIONS

Early diagnosis is associated with no functional disability, especially in patients with shorter disease duration.

Clinical and Radiographic Outcomes in Patients Diagnosed with Early Rheumatoid Arthritis in the First Years of the Biologic Treatment Era: A 10-year Prospective Observational Study

OBJECTIVE

To study short-term and longterm clinical and radiographic outcomes in patients with early rheumatoid arthritis (RA) in the first decade of the biologic treatment era.

METHODS

Patients with early RA diagnosed at a rheumatology outpatient clinic were consecutively enrolled between 1999 and 2001. Data were collected on demographic characteristics, disease activity, patient-reported outcomes, and treatments. Radiographs of hands and feet were performed at baseline and after 2, 5, and 10 years and scored according to the Sharp/van der Heijde method, yielding a modified total Sharp score (mTSS).

RESULTS

Mean baseline age for the 94 included patients (36 men and 58 women) was 50.4 years and symptom duration 12.3 months; 67.8% were rheumatoid factor-positive. The proportion of patients in remission and in low, moderate, and high disease activity status was at baseline 4.3%, 1.1%, 35.1%, and 59.6% and at 10 years 52.1%, 20.5%, 27.4%, and 0.0%, respectively. For the period 0-2 years, 62.8% had used prednisolone, 91.5% synthetic disease-modifying antirheumatic drug (DMARD), and 18.1% biologic DMARD, and for the period 2-10 years the numbers were 50.6%, 89.3%, and 62.7%, respectively. At baseline, 70% of the patients had erosions on radiographs. Mean annual change in mTSS was for 0-2 years 3.4, 2-5 years 1.7, and 5-10 years 1.2.

CONCLUSION

A large proportion of our patients with RA diagnosed and treated in the new biologic treatment era achieved a status of clinical remission or low disease activity and had only a minor increase in radiographic joint damage after the first years of followup.

Biomarkers predicting a need for intensive treatment in patients with early arthritis

The heterogeneous nature of rheumatoid arthritis (RA) complicates early recognition and treatment. In recent years, a growing body of evidence has demonstrated that intervention during the window of opportunity can improve the response to treatment and slow—or even stop—irreversible structural changes. Advances in therapy, such as biologic agents, and changing approaches to the disease, such as the treat to target and tight control strategies, have led to better outcomes resulting from personalized treatment to patients with different prognostic markers. The various biomarkers identified either facilitate early diagnosis or make it possible to adjust management to disease activity or poor outcomes. However, no single biomarker can bridge the gap between disease onset and prescription of the first DMARD, and traditional biomarkers do not identify all patients requiring early aggressive treatment. Furthermore, the outcomes of early arthritis cohorts are largely biased by the treatment prescribed to patients; therefore, new challenges arise in the search for prognostic biomarkers. Herein, we discuss the value of traditional and new biomarkers and suggest the need for intensive treatment as a new surrogate marker of poor prognosis that can guide therapeutic decisions in the early stages of RA.

Consensus statement on a framework for the management of comorbidity and extra-articular manifestations in rheumatoid arthritis

The objective of the study was to develop evidence-based and practical recommendations for the detection and management of comorbidity in patients with rheumatoid arthritis (RA) in daily practice. We used a modified RAND/UCLA methodology and systematic review (SR). The process map and specific recommendations, based on the SR, were established in discussion groups. A two round Delphi survey permitted (1) to prioritize the recommendations, (2) to refine them, and (3) to evaluate their agreement by a large group of users. The recommendations cover: (1) which comorbidities should be investigated in clinical practice at the first and following visits (including treatments, risk factors and patient's features that might interfere with RA management); (2) how and when should comorbidities and risk factors be investigated; (3) how to manage specific comorbidities, related or non-related to RA, including major adverse events of RA treatment, and to promote health (general and musculoskeletal health); and (4) specific recommendations to assure an integral care approach for RA patients with any comorbidity, such as health care models for chronic inflammatory patients, early arthritis units, relationships with primary care, specialized nursing care, and self-management. These recommendations are intended to guide rheumatologists, patients, and other stakeholders, on the early diagnosis and management of comorbidity in RA, in order to improve disease outcomes.

Spanish Rheumatology Society and Hospital Pharmacy Society Consensus on recommendations for biologics optimization in patients with rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis

OBJECTIVE

The aim of this study was to establish guidelines for the optimization of biologic therapies for health professionals involved in the management of patients with RA, AS and PsA.

METHODS

Recommendations were established via consensus by a panel of experts in rheumatology and hospital pharmacy, based on analysis of available scientific evidence obtained from four systematic reviews and on the clinical experience of panellists. The Delphi method was used to evaluate these recommendations, both between panellists and among a wider group of rheumatologists.

RESULTS

Previous concepts concerning better management of RA, AS and PsA were reviewed and, more specifically, guidelines for the optimization of biologic therapies used to treat these diseases were formulated. Recommendations were made with the aim of establishing a plan for when and how to taper biologic treatment in patients with these diseases.

CONCLUSION

The recommendations established herein aim not only to provide advice on how to improve the risk:benefit ratio and efficiency of such treatments, but also to reduce variability in daily clinical practice in the use of biologic therapies for rheumatic diseases.

Development and validation of a new disease activity index as a numerical sum of four variables in patients with early arthritis

OBJECTIVE

To describe the development and validation of a disease activity index in early arthritis that can be easily applied in daily practice and clinical research.

METHODS

The Hospital Universitario La Princesa Index (HUPI) was developed after analysis of data from an early arthritis cohort (202 patients with 756 visits). It is the sum of 4 variables (graded 0-3): tender joint count, swollen joint count, patient global assessment, and acute-phase reactants (erythrocyte sedimentation rate [ESR] and/or C-reactive protein [CRP] level, depending on availability at the moment of evaluation). The score for each variable was based on its quartile distribution in the cohort. The HUPI was validated using the following properties: feasibility, internal consistency (Cronbach's alpha), convergent validity (Pearson's r coefficients with other activity measures), criterion validity (area under the receiver operating characteristic curve [AUC ROC] to detect minimal disease activity [MDA]), and sensitivity to change (AUC ROC) to detect change with the physician's and patient's assessment of disease activity.

RESULTS

Internal consistency is reasonable (α = 0.63). The HUPI correlates well with activity measures such as the Disease Activity Score in 28 joints (DAS28; r = 0.89) and the Simplified Disease Activity Index (SDAI; r = 0.70), and correlates slightly worse with the functional index of the Health Assessment Questionnaire (r = 0.69). It discriminates MDA correctly (AUC 0.95), and its sensitivity to change is slightly superior (AUC 0.902) to that of the DAS28-ESR (AUC 0.864), the DAS28-CRP (AUC 0.889), and the SDAI (AUC 0.791).

CONCLUSION

The HUPI has face validity, is easy to calculate, is sensitive, and is a valid composite index for the assessment of disease activity in patients with early arthritis, both in clinical research and in routine care.

Quality-of-care standards for early arthritis clinics

The diagnosis and treatment of early arthritis is associated with improved patient outcomes. One way to achieve this is by organising early arthritis clinics (EACs). The objective of this project was to develop standards of quality for EACs. The standards were developed using the two-round Delphi method. The questionnaire, developed using the best-available scientific evidence, includes potentially relevant items describing the dimensions of quality of care in the EAC. The questionnaire was completed by 26 experts (physicians responsible for the EACs in Spain and chiefs of the rheumatology service in Spanish hospitals). Two hundred and forty-four items (standards) describing the quality of the EAC were developed, grouped by the following dimensions: (1) patient referral to the EAC; (2) standards of structure for an EAC; (3) standards of process; (4) relation between primary care physicians and the EAC; (5) diagnosis and assessment of early arthritis; (6) patient treatment and follow-up in the EAC; (7) research and training in an EAC; and (8) quality of care perceived by the patient. An operational definition of early arthritis was also developed based on eight criteria. The standards developed can be used to measure/establish the requirements, resources, and processes that EACs have or should have to carry out their treatment, research, and educational activities. These standards may be useful to health professionals, patient associations, and health authorities.