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Duarte C, Ferreira RJO, Welsing PMJ, Jacobs JWG, Gossec L, Machado PM, van der Heijde D, da Silva JAP. Remission definitions guiding immunosuppressive therapy in rheumatoid arthritis: which is best fitted for the purpose? RMD Open 2024; 10:e003972. [PMID: 38443090 PMCID: PMC11146381 DOI: 10.1136/rmdopen-2023-003972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 02/16/2024] [Indexed: 03/07/2024] Open
Abstract
OBJECTIVE To assess which definition of remission best predicts good radiographic outcome (GRO) and good functional outcome (GFO) in rheumatoid arthritis, focusing the updated American College of Rheumatology/European Alliance of Associations for Rheumatology criteria. MATERIAL AND METHODS Meta-analyses of individual patient data (IPD) from randomised controlled trials (RCTs). Six definitions of remission were considered: (1) Boolean with Patient Global Assessment (PGA)≤1 (Boolean); (2) Simplified Disease Activity Index (SDAI)≤3.3; (3) Clinical Disease Activity Index (CDAI)≤2.8; (4) Boolean with PGA≤2 (Updated-Boolean); (5) Boolean with Physician Global Assessment (PhGA≤1) replacing PGA (Boolean-PhGA) and (6) Boolean excluding PGA (3VBoolean). GRO was defined as a worsening ≤0.5 units in radiographic score and GFO as a no worsening in Health Assessment Questionnaire (HAQ), that is, ∆HAQ-DI≤0.0 units. Relationships between each remission definition at 6 and/or 12 months and GRO and GFO during the second year were analysed. Pooled probabilities for each outcome for each definition and their predictive accuracy were estimated. RESULTS IPD from eight RCTs (n=4423) were analysed. Boolean, SDAI, CDAI, Updated-Boolean, Boolean-PhGA and 3VBoolean were achieved by 24%, 27%, 28%, 32%, 33% and 43% of all patients, respectively. GRO among patients achieving remission ranged from 82.4% (3VBoolean) to 83.9% (SDAI). 3VBoolean showed the highest predictive accuracy for GRO: 51.1% versus 38.8% (Boolean) and 44.1% (Updated-Boolean). The relative risk of GFO ranged from 1.16 (Boolean) to 1.05 (3VBoolean). However, the proportion of GFO correctly predicted was highest for the 3VBoolean (50.3%) and lowest for the Boolean (43.8%). CONCLUSION 3VBoolean definition provided the most accurate prediction of GRO and GFO, avoiding the risk of overtreatment in a substantial proportion of patients without increment in radiographic damage progression, supporting the proposal that 3VBoolean remission is preferable to guide immunosuppressive treatment. The patient's perspective, which must remain central, is best served by an additional patient-oriented target: a dual-target approach.
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Affiliation(s)
- Catia Duarte
- Department of Rheumatology, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
- Institute for Clinical and Biomedical Research, University of Coimbra, Coimbra, Portugal
| | - Ricardo J O Ferreira
- Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), Higher School of Nursing of Lisbon, Lisboa, Portugal
- Health Sciences Research Unit: Nursing (UICiSA:E), Higher School of Nursing of Coimbra, Coimbra, Portugal
| | - Paco M J Welsing
- Department of Rheumatology and Clinical Immunology, Utrecht University, Utrecht, The Netherlands
| | - Johannes W G Jacobs
- Department of Rheumatology and Clinical Immunology, Utrecht University, Utrecht, The Netherlands
| | - Laure Gossec
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Sorbonne Universite, Paris, France
- Department of Rheumatology, APHP, Hopital Universitaire Pitie Salpetriere, Paris, France
| | - Pedro M Machado
- Department of Neuromuscular Diseases, MRC Centre for Neuromuscular Diseases, University College London, London, UK
- Department of Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK
| | | | - Jose Antonio Pereira da Silva
- Department of Rheumatology, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
- Institute for Clinical and Biomedical Research, University of Coimbra, Coimbra, Portugal
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Duarte C, Kvien TK, Sexton J, Santos E, de Wit M, Gossec L, da Silva JAP. Patient Experienced Symptom State in rheumatoid arthritis: sensitivity to change in disease activity and impact. Rheumatology (Oxford) 2022; 62:98-107. [PMID: 35482485 DOI: 10.1093/rheumatology/keac257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 04/19/2022] [Accepted: 04/19/2022] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES The Patient Experienced Symptom State (PESS) is a single-question, patient-reported outcome that is validated to assess global disease impact in RA. This study addresses its sensitivity to change, and reliability. METHODS Disease activity, disease impact in the seven domains of RA Impact of Disease (RAID) and PESS were assessed in patients with RA from the NOR-DMARD registry, at two visits, 6 months apart. The PESS over the last week was scored at five levels, from 'very bad' to 'very good'. Disease impact and disease activity were compared between patients who improved, maintained or worsened PESS over time, through one-way analysis of variance, with post hoc Bonferroni correction. Correlations between changes in these parameters were assessed through Spearman's correlation coefficient. Sensitivity to change was assessed by standardized response mean (SRM) between the two visits. Reliability was analysed through intraclass correlation coefficient (ICC) between the two visits in patients with stable disease activity and impact. RESULTS In 353 patients [76.8% females, mean (s.d.) 9.9 (9.6) years disease duration], improvement in PESS level was associated with substantial improvements in mean impact in all domains as well as disease activity (P <0.02). PESS change was moderately to strongly correlated with RAID domains and disease activity (rho: 0.4-0.7). PESS was responsive to change (SRM: 0.65, 95% CI: 0.54, 0.76), particularly among RAID responders (SRM: 1.79, 95% CI: 1.54, 1.99). PESS was moderately reliable in patients with stable condition (ICC: 0.72, 95% CI: 0.52, 0.83). CONCLUSION PESS is valid, feasible, reliable and responsive, representing an opportunity to improve the assessment of disease impact with minimal questionnaire burden.
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Affiliation(s)
- Catiá Duarte
- Department of Rheumatology, Centro Hospitalar e Universitário de Coimbra.,Coimbra Institute for Clinical and Biomedical Research, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Joe Sexton
- Department of Rheumatology, Diakonhjemmet Hospital
| | - Eduardo Santos
- Viseu Higher School of Health, Viseu.,Health Sciences Research Unit: Nursing, Nursing School of Coimbra, Coimbra, Portugal
| | | | - Laure Gossec
- Institut Pierre Louis d'Epidémiologie et de Santé Publique, Sorbonne Université, INSERM.,Rheumatology Department, Pitié Salpêtrière Hospital, AP-HP, Paris, France
| | - Jose A P da Silva
- Department of Rheumatology, Centro Hospitalar e Universitário de Coimbra.,Coimbra Institute for Clinical and Biomedical Research, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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Duarte C, Ferreira RJO, Santos EJF, da Silva JAP. Treating-to-target in rheumatology: Theory and practice. Best Pract Res Clin Rheumatol 2021; 36:101735. [PMID: 34980566 DOI: 10.1016/j.berh.2021.101735] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Despite its inclusion in current treatment recommendations, adherence to the treat-to-target strategy (T2T) is still poor. Among the issues are the definition(s) of target, especially the caveats of the patient global assessment (PGA), included in all recommended definitions of remission. The PGA is poorly related to inflammation, especially at low levels of disease activity, rather being a measure of the disease impact. Up to 60% of all patients otherwise in remission still score PGA at >1 and as high as 10. These patients (PGA-near-remission) are exposed to overtreatment if current recommendations are strictly followed and will continue to endure significant impact, unless adjuvant measures are implemented. A proposed method to overcome both these risks is to systematically pursue two targets: one focused on the disease process (the biological target) and another focused on the symptoms and impact (the impact target), the dual-target strategy. Candidate instruments to define each of these targets are discussed.
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Affiliation(s)
- Cátia Duarte
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research, Faculty of Medicine, University of Coimbra, Portugal
| | - Ricardo J O Ferreira
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Health Sciences Research Unit: Nursing (UICSA:E), Nursing School of Coimbra (ESEnfC), Coimbra, Portugal
| | - Eduardo J F Santos
- Health Sciences Research Unit: Nursing (UICSA:E), Nursing School of Coimbra (ESEnfC), Coimbra, Portugal; Viseu Higher School of Health, Viseu, Portugal
| | - José A P da Silva
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research, Faculty of Medicine, University of Coimbra, Portugal.
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De Cock D, Buckinx E, Pazmino S, Bertrand D, Stouten V, Westhovens R, Verschueren P. Belgian rheumatologists' preferences regarding measures of disease activity in patients with rheumatoid arthritis: results from a mixed-methods study. Rheumatol Int 2021; 42:815-823. [PMID: 34687348 DOI: 10.1007/s00296-021-05020-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/02/2021] [Indexed: 12/01/2022]
Abstract
The reliability and clinical usefulness of the different composite disease activity scores and their individual components in Rheumatoid Arthritis (RA) are still debated. This study investigated which measures of disease activity were preferred by rheumatologists. A mixed-method study was performed. First, ten Belgian rheumatologists were invited for individual interviews on their current practice and preferences for measurement of RA disease activity. Results of this qualitative study and evidence from literature served as input for developing a survey. This survey asked rheumatologists to rate preferred standard disease activity score(s), their individual components, ultrasound and related patient-reported outcomes (PROs), by maximum difference scaling. The relative importance score (RIS) for each indicator was calculated using hierarchical Bayes modeling. The qualitative study included 6/10 invited rheumatologists. Composite scores and components were perceived as useful, while PROs were found subjective. Interestingly, ultrasound was used to mediate discrepancies between physician and patient. The survey based on this was sent to 244 Belgian rheumatologists, 83/244 (34%) responded, including 66/83 (80%) complete and 17/83 (20%) incomplete surveys (two missing essential information). Most rheumatologists (75/81, 93%) used a disease activity score and 68/81 (84%) preferred the DAS28-CRP. Swollen joint count obtained the highest mean ± SD RIS (22.54 ± 2.64), followed by DAS28 ESR/CRP (20.61 ± 4.06), ultrasound (16.47 ± 7.97), CRP (13.34 ± 6.11) and physician's global assessment (12.59 ± 7.83). PROs including fatigue, pain, and patient's global assessment, and Health Assessment Questionnaire, obtained the lowest mean RIS (0.34-2.54). Rheumatologists place more faith in self-assessed disease activity components or in laboratory tests. Trust in PROs to evaluate disease activity is low in clinical practice.
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Affiliation(s)
- D De Cock
- Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium.
| | - E Buckinx
- Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium
| | - S Pazmino
- Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium
| | - D Bertrand
- Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium
| | - V Stouten
- Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium
| | - R Westhovens
- Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium.,Department of Rheumatology, University Hospitals of Leuven, 3000, Leuven, Belgium
| | - P Verschueren
- Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium.,Department of Rheumatology, University Hospitals of Leuven, 3000, Leuven, Belgium
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Gnanasakthy A, Barrett A, Norcross L, D'Alessio D, Romano CD. Use of Patient and Investigator Global Impression Scales: A Review of Food and Drug Administration-Approved Labeling, 2009 to 2019. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:1016-1023. [PMID: 34243825 DOI: 10.1016/j.jval.2021.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 01/25/2021] [Accepted: 01/31/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Identify disease categories in which single-item global impression (GI) scales were included in product labeling of new drugs approved by the US Food and Drug Administration (FDA) in January 2009-December 2019 and review the characteristics of GIs included in product labeling of new FDA-approved drugs (January 2017-December 2019). METHODS FDA Clinical Outcome Assessment (COA) Compendium was reviewed for drug labels that included GIs for drugs approved in 2009-2016. The indication, year of approval, ICD-10 code, and GI respondent were noted. A manual review of labels of FDA-approved drugs (2017-2019) was undertaken to identify GIs included in the labels. Corresponding drug approval packages were reviewed to identify details of any regulatory reviewer comments related to GIs. GI characteristics were noted from the drug label or the review documents, including the respondent, type of measure (static or dynamic), item wording, concept assessed, and response options. RESULTS Product labeling containing GIs was most common in diseases related to the skin, nervous system, behavioral disorders, and the musculoskeletal system. GIs were included in 30/77 (39.0%) drug labels in the four disease categories. CONCLUSION In the past 10 years, GIs have been included as endpoint measures in confirmatory clinical trials and have generated evidence of treatment benefit in diseases related to the skin, nervous system, behavioral disorders, and the musculoskeletal system. GIs frequently provide important insights into the patient experience. Before GIs are included in clinical trials to assess treatment benefit, it is important to ensure that they are valid, reliable, and responsive.
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Affiliation(s)
| | - Amy Barrett
- RTI Health Solutions, Research Triangle Park, NC, USA
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Blaney C, Hitchon CA, Marrie RA, Mackenzie C, Holens P, El-Gabalawy R. Support for a non-therapist assisted, Internet-based cognitive-behavioral therapy (iCBT) intervention for mental health in rheumatoid arthritis patients. Internet Interv 2021; 24:100385. [PMID: 33912401 PMCID: PMC8056225 DOI: 10.1016/j.invent.2021.100385] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 03/12/2021] [Accepted: 03/18/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Anxiety is common in patients with rheumatoid arthritis (RA) and associated with worse RA outcomes. This study assessed the feasibility and preliminary health impacts (mental and physical) of a non-therapist assisted, online mental health intervention targeting anxiety in this population. METHODS Participants with confirmed RA and elevated anxiety symptoms were enrolled into the Worry and Sadness program, an Internet-based cognitive-behavioral therapy (iCBT) intervention for anxiety and depression shown to be effective in the general population. Validated self-report measures of anxiety, depression, pain interference, fatigue, physical health-related quality of life, functional status, and patient-reported disease severity were collected at baseline, post-intervention, and at three-month follow-up. Emotional distress scores were tracked between lessons. Participants provided qualitative feedback in writing post-intervention. RESULTS We analyzed the responses of 34 participants; the majority was female (86%) and the mean age was 57 (SD = 13). Of these, 80% (n = 28) completed the study in its entirety. Among these completers, 94.1% described the program as worthwhile. We found statistically significant improvements in anxiety, depression and fatigue from baseline to three-month follow-up, with small to large effect sizes (d = 0.39-0.81). Post-hoc analyses revealed that statistically significant change occurred between baseline and post-intervention for anxiety and depression and was maintained at three-month follow-up, whereas statistically significant change occurred between baseline and three-month follow-up for fatigue. Statistically significant reductions in emotional distress occurred across the program, with a large effect size (d = 1.16) between the first and last lesson. CONCLUSION The Worry and Sadness program shows promise as a feasible resource for improving mental health in RA.
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Affiliation(s)
- Caitlin Blaney
- Department of Psychology, University of Manitoba, 190 Dysart Road, Winnipeg, Manitoba R3T 2N2, Canada
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, 671 William Avenue, Winnipeg, Manitoba R3E 0Z2, Canada
| | - Carol A. Hitchon
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ruth Ann Marrie
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Corey Mackenzie
- Department of Psychology, University of Manitoba, 190 Dysart Road, Winnipeg, Manitoba R3T 2N2, Canada
| | - Pamela Holens
- Department of Psychology, University of Manitoba, 190 Dysart Road, Winnipeg, Manitoba R3T 2N2, Canada
- Department of Clinical Health Psychology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Renée El-Gabalawy
- Department of Psychology, University of Manitoba, 190 Dysart Road, Winnipeg, Manitoba R3T 2N2, Canada
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, 671 William Avenue, Winnipeg, Manitoba R3E 0Z2, Canada
- Department of Clinical Health Psychology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Psychiatry, University of Manitoba, 771 Bannatyne Avenue, Winnipeg, Manitoba R3T 2N2, Canada
- Corresponding author at: AE-2, Harry Medovy House, 671 William Avenue, Winnipeg, Manitoba R3E 0Z2, Canada.
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Pope JE, Rampakakis E, Movahedi M, Cesta A, Sampalis JS, Bombardier C. Time to remission in swollen joints is far faster than patient reported outcomes in rheumatoid arthritis: results from the Ontario Best Practices Research Initiative (OBRI). Rheumatology (Oxford) 2021; 60:717-727. [PMID: 32789456 DOI: 10.1093/rheumatology/keaa343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/08/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES RA patients are often not in remission due to patient global assessment of disease activity (PtGA) included in disease activity indices. The aim was to assess the lag of patient-reported outcomes (PROs) after remission measured by clinical disease activity index (CDAI) or swollen joint count (SJC28). METHODS RA patients enrolled in the Ontario Best Practices Research Initiative registry not in low disease state at baseline with at ≥6 months of follow-up, were included. Low disease state was defined as CDAI ≤ 10, SJC28 ≤ 2, PtGA ≤ 2cm, pain score ≤ 2cm, or fatigue ≤ 2cm. Remission included CDAI ≤ 2.8, SJC28 ≤ 1, PtGA ≤ 1cm, pain score ≤ 1cm, or fatigue ≤ 1cm. Time to first low disease state/remission based on each definition was calculated overall and stratified by early vs established RA. RESULTS A total of 986 patients were included (age 57.4 (12.9), disease duration 8.3 (9.9) years, 80% women). The median (95% CI) time in months to CDAI ≤ 10 was 12.4 (11.4, 13.6), SJC28 ≤ 2 was 9 (8.2, 10), PtGA ≤ 2cm was 18.9 (16.1, 22), pain ≤ 2cm was 24.5 (19.4, 30.5), and fatigue ≤ 2cm was 30.4 (24.8, 31.7). For remission, the median (95% CI) time in months to CDAI ≤ 2.8 was 46.5 (42, 54.1), SJC28 ≤ 1 was 12.5 (11.4, 13.4), PtGA ≤ 1cm was 39.6 (34.6, 44.8), pain ≤ 1cm was 54.7 (43.6, 57.5) and fatigue ≤ 1cm was 42.6 (36.8, 48). Time to achieving low disease state and remission was generally significantly shorter in early RA compared with established RA with the exception of fatigue. CONCLUSION Time to achieving low disease state or remission based on PROs was considerably longer compared with swollen joint count. Treating to a composite target in RA could lead to inappropriate changes in DMARDs.
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Affiliation(s)
- Janet E Pope
- Divisions of Rheumatology, Epidemiology, and Biostatistics, Department of Medicine, Western University, London, ON, Canada
| | | | - Mohammad Movahedi
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada
| | - Angela Cesta
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - John S Sampalis
- Medical Affairs, JSS Medical Research, Montreal, QC, Canada.,Department of Surgery, McGill University, Montreal, QC, Canada
| | - Claire Bombardier
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.,Division of Rheumatology, Mount Sinai Hospital, Toronto, ON, Canada.,Department of Medicine, (DOM) and Institute of Health Policy, Management, and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada
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Ferreira RJO, de Wit M, Duarte C, da Silva JAP, Ndosi M. Comment on: 'It can't be zero!' difficulties in completing patient global assessment in rheumatoid arthritis: a mixed methods study: reply. Rheumatology (Oxford) 2021; 60:e30-e31. [PMID: 33020820 DOI: 10.1093/rheumatology/keaa488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ricardo J O Ferreira
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra.,Health Sciences Research Unit: Nursing (UICiSA:E), Nursing School of Coimbra (ESEnfC), Coimbra, Portugal
| | - Maarten de Wit
- Patient Research Partner, EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Cátia Duarte
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra.,Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - José A P da Silva
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra.,Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Mwidimi Ndosi
- Department of Nursing and Midwifery, University of the West of England, Bristol, UK
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9
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Ferreira RJO, de Wit M, Henriques M, Pinto AF, Duarte C, Mateus E, Mendes G, da Silva JAP, Ndosi M. 'It can't be zero!' Difficulties in completing patient global assessment in rheumatoid arthritis: a mixed methods study. Rheumatology (Oxford) 2020; 59:1137-1147. [PMID: 31600398 DOI: 10.1093/rheumatology/kez467] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/20/2019] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Patient global assessment (PGA) is purported to add the patient's perspective in the composite measures of RA. However, PGA is not standardized and it is not known whether patients' interpretation of the measure is consistent with its intended purpose. This study aimed to explore difficulties experienced by patients with RA in completing PGA, and to assess the impact of a structured explanation in improving its validity and reliability. METHODS This was a mixed methods study, using interviews, focus groups and PGA data. During interviews, patients (convenience sample, n = 33) completed three often-used PGA formulations. Then a nurse provided structured explanation about what PGA is and why it is used. After further discussion, patients completed one PGA version again. Interviews were recorded, transcribed and analysed using inductive thematic analysis. We compared PGA scores pre- and post-explanation (Wilcoxon signed-ranks) and the proportion of patients achieving RA remission with PGA ⩽1 (McNemar's tests). RESULTS Three themes emerged: understanding the meaning of PGA, the purpose of PGA and measurement difficulties. The difficulties caused systematic errors in PGA completion such as marking higher when feeling well, marking near the centre or away from zero. The structured explanation was helpful. Following the explanation, the median PGA score decreased from 3.0 to 2.1 cm, and the proportion of non-remission solely due to PGA >1 from 52% to 41%; none of these changes was statistically significant. CONCLUSION Many patients have difficulties in completing PGA. Standardization of PGA and a structured explanation may improve its clarity, validity and reliability.
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Affiliation(s)
- Ricardo J O Ferreira
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra.,Health Sciences Research Unit: Nursing (UICiSA: E), Nursing School of Coimbra (ESEnfC), Coimbra, Portugal
| | - Maarten de Wit
- Department of Medical Humanities, Amsterdam University Medical Centre, Amsterdam, The Netherlands.,Patient Research Partner, EULAR standing committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | | | - Ana F Pinto
- Faculty of Medicine, University of Coimbra, Coimbra
| | - Cátia Duarte
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra.,Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine -University of Coimbra, Coimbra
| | - Elsa Mateus
- Patient Research Partner, EULAR standing committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland.,Portuguese League Against Rheumatic Diseases (LPCDR), Lisbon
| | - Gabriel Mendes
- Department of National Team, Portuguese Cycling Federation, Lisbon
| | - José A P da Silva
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine -University of Coimbra, Coimbra.,Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Mwidimi Ndosi
- Department of Nursing and Midwifery, University of the West of England, Bristol, UK
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10
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Ferreira RJO, Carvalho PD, Ndosi M, Duarte C, Chopra A, Murphy E, van der Heijde D, Machado PM, da Silva JAP. Impact of Patient's Global Assessment on Achieving Remission in Patients With Rheumatoid Arthritis: A Multinational Study Using the METEOR Database. Arthritis Care Res (Hoboken) 2020; 71:1317-1325. [PMID: 30821895 DOI: 10.1002/acr.23866] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 02/26/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE There is an ongoing debate about excluding patient's global assessment (PtGA) from composite and Boolean-based definitions of rheumatoid arthritis (RA) remission. This study aimed at determining the influence of PtGA on RA disease states, exploring differences across countries, and understanding the association between PtGA, measures of disease impact (symptoms), and markers of disease activity (inflammation). METHODS Cross-sectional data from the Measurement of Efficacy of Treatment in the Era of Outcome in Rheumatology international database were used. We calculated the proportion of patients failing American College of Rheumatology/European League Against Rheumatism Boolean-based remission (4-variable remission) solely due to PtGA (PtGA-near-remission) in the overall sample and in the most representative countries (i.e., those with >3,000 patients in the database). Multivariable linear regression models were used to identify the main determinants of PtGA, grouped in predominantly inflammatory impact factors (28 tender joint counts, 28 swollen joint counts, and C-reactive protein level) and disease impact factors (pain and function). RESULTS This study included 27,768 patients. Excluding PtGA from the Boolean-based definition (3-variable remission) increased the remission rate from 5.8% to 15.8%. The rate of PtGA-near-remission varied considerably between countries, from 1.7% in India to 17.9% in Portugal. One-third of the patients in PtGA-near-remission group scored PtGA >4 of 10. Pain and function were the main correlates of PtGA, with inflammation-related variables contributing less to the model (R2 = 0.57). CONCLUSION PtGA is moderately related to joint inflammation overall, but only weakly so in low levels of disease activity. A considerable proportion of patients otherwise in biologic remission still perceive high PtGA, putting them at risk of excessive immunosuppressive treatment.
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Affiliation(s)
- Ricardo J O Ferreira
- Centro Hospitalar e Universitário de Coimbra, and Nursing School of Coimbra, Coimbra, Portugal
| | | | - Mwidimi Ndosi
- University of the West of England and University Hospitals Bristol, Bristol, UK
| | - Cátia Duarte
- Centro Hospitalar e Universitário de Coimbra, Coimbra Institute for Clinical and Biomedical Research, and University of Coimbra, Coimbra, Portugal
| | | | | | | | - Pedro M Machado
- University College London, Northwick Park Hospital, and London North West University Healthcare NHS Trust, London, UK
| | - José A P da Silva
- Centro Hospitalar e Universitário de Coimbra, Coimbra Institute for Clinical and Biomedical Research, and University of Coimbra, Coimbra, Portugal
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Ferreira RJO, Santos EJF, de Wit M, Marques A, Barbieri-Figueiredo MDC, Marques A, Ventura F, da Silva JAP, Ndosi M. Shared decision-making in people with chronic disease: Integrating the biological, social and lived experiences is a key responsibility of nurses. Musculoskeletal Care 2020; 18:84-91. [PMID: 31837252 DOI: 10.1002/msc.1443] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 06/10/2023]
Affiliation(s)
- Ricardo J O Ferreira
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Coimbra, Portugal
| | - Eduardo J F Santos
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Coimbra, Portugal
- Abel Salazar Institute of Biomedical Sciences, University of Porto, Porto, Portugal
| | - Maarten de Wit
- Patient research partner, EULAR Standing Committee of People with Arthritis/Rheumatism in Europe, Zurich, Switzerland
- Department of Medical Humanities, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Andréa Marques
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Coimbra, Portugal
- Nursing School of Coimbra, Coimbra, Portugal
| | - Maria do Céu Barbieri-Figueiredo
- Abel Salazar Institute of Biomedical Sciences, University of Porto, Porto, Portugal
- Nursing School of Porto, Porto, Portugal
- CINTESIS - Center for Health Technology and Services Research, University of Porto, Porto, Portugal
| | - António Marques
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Coimbra, Portugal
- AGI médica I, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
| | - Filipa Ventura
- Health Sciences Research Unit: Nursing (UICISA: E), Nursing School of Coimbra (ESEnfC), Coimbra, Portugal
| | - José A P da Silva
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (iCBR) - Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Mwidimi Ndosi
- Department of Nursing and Midwifery, University of the West of England, Bristol, UK
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Hirsh J, Wood P, Keniston A, Peng M, Ramaswami S, Caplan L, Davis L. Limited Health Literacy and Patient Confusion About Rheumatoid Arthritis Patient Global Assessments and Model Disease States. Arthritis Care Res (Hoboken) 2019; 71:611-619. [PMID: 29953748 DOI: 10.1002/acr.23692] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 06/26/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Patient global assessment visual analog scales (PGA-VAS) are widely used in rheumatoid arthritis (RA) practice and research, and low PGA-VAS scores are required for remission. Vulnerable patients with RA may have difficulty completing the PGA-VAS. There is limited information about both patients' perceptions of PGA-VAS and how patients score VAS model disease states. The objective of this study was to understand the perspectives of vulnerable patients regarding PGA-VAS and model disease states. METHODS We enrolled patients with RA at Denver Health (n = 300). Subjects completed the PGA-VAS in the Disease Activity Score in 28 joints and the Multidimensional Health Assessment Questionnaire and completed a questionnaire regarding these PGA-VAS. Subjects also scored remission, mild, moderate, and severe model disease states by VAS. We performed analyses by linear and logistic regression and by using summary statistics. Outcomes included whether subjects found the PGA-VAS confusing, whether subjects' responses to the model disease states followed a natural progression (remission <mild <moderate <severe), and whether responses to the remission model would meet Boolean and Simplified Disease Activity Index-based remission criteria. RESULTS Approximately 40% of subjects found the PGA-VAS confusing; lower health literacy and depressive symptoms were associated with finding them confusing. Less than 25% of subjects ranked the model disease states with natural progression and ranked the remission model at the threshold for remission; higher health literacy and income were associated with accomplishing these objectives. CONCLUSION Vulnerable patients perceive difficulty with PGA-VAS and do not reliably rate a model disease state VAS. These patients are potentially at risk for disease activity misclassification because of literacy and other barriers in completing VAS.
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Affiliation(s)
- Joel Hirsh
- Denver Health and Hospital Authority Denver, Colorado and University of Colorado Medical School, Denver, Colorado
| | - Patrick Wood
- Denver Veterans Affairs and Medical Center, and University of Colorado Medical School, Denver, Colorado
| | - Angela Keniston
- Denver Health and Hospital Authority Denver, Colorado and University of Colorado Medical School, Denver, Colorado
| | - Mandy Peng
- University of Colorado Medical School, Denver
| | - Sai Ramaswami
- Denver Health and Hospital Authority, Denver, Colorado
| | - Liron Caplan
- Denver Veterans Affairs and Medical Center, and University of Colorado Medical School, Denver, Colorado
| | - Lisa Davis
- Denver Health and Hospital Authority Denver, Colorado and University of Colorado Medical School, Denver, Colorado
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Dual target strategy: a proposal to mitigate the risk of overtreatment
and enhance patient satisfaction in rheumatoid arthritis. Ann Rheum Dis 2018; 78:e109. [DOI: 10.1136/annrheumdis-2018-214199] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 07/31/2018] [Indexed: 11/03/2022]
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