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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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2
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Balay-Dustrude E, Shenoi S. Current Validated Clinical and Patient Reported Disease Outcome Measures in Juvenile Idiopathic Arthritis. Open Access Rheumatol 2023; 15:189-206. [PMID: 37841510 PMCID: PMC10574249 DOI: 10.2147/oarrr.s261773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/29/2023] [Indexed: 10/17/2023] Open
Abstract
Juvenile idiopathic arthritis (JIA) is a common chronic illness in childhood and comprises seven categories based on the International League of Associations for Rheumatology (ILAR) criteria. Accurate assessment and measurement of the clinical, functional, and quality of life outcomes of patients with JIA are paramount for understanding the disease course and formulating effective treatment strategies. Interest in the development and use of outcome measurements specifically focused on rheumatologic conditions has greatly expanded over the last two decades, adding to and improving upon the established disease measures. Furthermore, many of these measures have been validated using the widely accepted Outcome Measures in Rheumatology (OMERACT) core principles of instrument validation, allowing researchers and clinicians to gain confidence in these tools. This review summarizes the current validated disease outcome measures in JIA, including clinical, imaging, patient-reported, and functional outcome measurement tools, and highlights ongoing work that continues to refine and improve upon the available tools. The clinical disease outcome measures discussed in this review include physician global assessment (PhGA), American College of Rheumatology (ACR, Wallace) criteria for clinical inactive disease and clinical remission, juvenile arthritis disease activity scores (JADAS), juvenile spondyloarthritis disease activity index (JSPaDA), juvenile arthritis damage index (JADAI), and the ACR pediatric response scores. The imaging outcome measures discussed include the Dijkstra composite scores, childhood arthritis radiographic score of the hip (CARSH), and Poznanski Score. The patient-reported disease outcome measures discussed include patient global assessment (PtGA), patient-reported outcome measurement information system for JIA (PROMIS), juvenile arthritis parent/child centered disease assessment index (JAPAI, JACAI), juvenile arthritis multidimensional assessment report (JAMAR), and the Pediatric quality of life inventory rheumatology module (PedsQL). The functional outcome tools discussed include the Childhood Health Assessment Questionnaire (CHAQ), juvenile arthritis functionality scale and index (JAFS and JASI), and Juvenile Arthritis Functional Assessment Report and Scale (JAFAS and JAFAR).
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Affiliation(s)
- Erin Balay-Dustrude
- Department of Pediatrics, Division of Rheumatology, University of Washington, Seattle, WA, USA
- Department of Pediatric Rheumatology, Seattle Children’s Hospital and Research Center, Seattle, WA, USA
| | - Susan Shenoi
- Department of Pediatrics, Division of Rheumatology, University of Washington, Seattle, WA, USA
- Department of Pediatric Rheumatology, Seattle Children’s Hospital and Research Center, Seattle, WA, USA
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3
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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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4
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Ross L, Nikpour M, D'Aoust J, Khanna D, Merkel PA, Pauling JD, Baron M. Patient and Physician Global Assessments of Disease Status in Systemic Sclerosis. Arthritis Care Res (Hoboken) 2022. [PMID: 36342397 DOI: 10.1002/acr.25056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/11/2022] [Accepted: 11/03/2022] [Indexed: 11/09/2022]
Abstract
Global assessments of disease by both patients and physicians are widely used in clinical studies of systemic sclerosis (SSc). They are commonly secondary end points in randomized controlled trials (RCTs) and are considered important items in composite measures of treatment response. A comprehensive literature review was conducted of the formats, wording, and clinimetric properties of the patient global assessment of disease status (PtGA) and physician global assessment of disease status (PhGA) used in RCTs of SSc. Marked heterogeneity was found in the wording and measurement scales of the global assessments applied in RCTs. These instruments were not developed using rigorous methodology and have not been fully validated. There is a pressing need for standardization and validation of patient and physician global assessment tools in SSc to enable universal application of these measures across RCTs in SSc.
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Affiliation(s)
- Laura Ross
- The University of Melbourne at St Vincent's Hospital and St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Mandana Nikpour
- The University of Melbourne at St Vincent's Hospital and St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Julie D'Aoust
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | | | | | | | - Murray Baron
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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Ibrahim F, Ma M, Scott DL, Scott IC. Defining the relationship between pain intensity and disease activity in patients with rheumatoid arthritis: a secondary analysis of six studies. Arthritis Res Ther 2022; 24:218. [PMID: 36088424 PMCID: PMC9463789 DOI: 10.1186/s13075-022-02903-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 08/09/2022] [Indexed: 12/03/2022] Open
Abstract
Background Pain is the main concern of patients with rheumatoid arthritis (RA) while reducing disease activity dominates specialist management. Disease activity assessments like the disease activity score for 28 joints with the erythrocyte sedimentation rate (DAS28-ESR) omit pain creating an apparent paradox between patients’ concerns and specialists’ treatment goals. We evaluated the relationship of pain intensity and disease activity in RA with three aims: defining associations between pain intensity and disease activity and its components, evaluating discordance between pain intensity and disease activity, and assessing temporal changes in pain intensity and disease activity. Methods We undertook secondary analyses of five trials and one observational study of RA patients followed for 12 months. The patients had early and established active disease or sustained low disease activity or remission. Pain was measured using 100-mm visual analogue scales. Individual patient data was pooled across all studies and by types of patients (early active, established active and established remission). Associations of pain intensity and disease activity were evaluated by correlations (Spearman’s), linear regression methods and Bland-Altman plots. Discordance was assessed by Kappa statistics (for patients grouped into high and low pain intensity and disease activity). Temporal changes were assessed 6 monthly in different patient groups. Results A total of 1132 patients were studied: 490 had early active RA, 469 had established active RA and 173 were in remission/low disease activity. Our analyses showed, firstly, that pain intensity is associated with disease activity in general, and particularly with patient global assessments, across all patient groups. Patient global assessments were a reasonable proxy for pain intensity. Secondly, there was some discordance between pain intensity and disease activity across all disease activity levels, reflecting similar discrepancies in patient global assessments. Thirdly, there were strong temporal relationships between changes in disease activity and pain intensity. When mean disease activity fell, mean pain intensity scores also fell; when mean disease activity increased, there were comparable increases in pain intensity. Conclusions These findings show pain intensity is an integral part of disease activity, though it is not measured directly in DAS28-ESR. Reducing disease activity is crucial for reducing pain intensity in RA.
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Rose E, Ferrada MA, Quinn KA, Arnaud L, Goodspeed W, Kim J, Allen C, Sirajuddin A, Chen M, Grayson PC. Discordance in patient and physician global assessment in relapsing polychondritis. Rheumatology (Oxford) 2022; 61:2025-2033. [PMID: 34559216 PMCID: PMC9071565 DOI: 10.1093/rheumatology/keab587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 07/01/2021] [Accepted: 07/16/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Relapsing polychondritis (RP) is a rare, heterogeneous, systemic inflammatory disease that targets cartilage. Patient-reported outcome measures may differ from physician assessment. This study compared patient global assessment (PtGA) and physician global assessment (PhGA) scores in a prospective cohort of patients with RP. METHODS Adult patients with RP underwent a standardized comprehensive evaluation at ∼6 month intervals. At each visit, three physicians scored PhGA by consensus. The patient independently completed four patient-reported outcomes: PtGA, 36-item Short Form Health Survey (SF-36), Brief Illness Perception Questionnaire (BIPQ) and Multidimensional Fatigue Inventory (MFI). Patient-physician discordance was defined as a difference between PtGA and PhGA of ≥3 on a 0-10 scale. RESULTS A total of 76 patients were evaluated over 154 visits. The median PhGA was 3 [interquartile range (IQR) 2-3] and the median PtGA was 5 (IQR 4-7). PtGA and PhGA were concordant in 66 visits (42.9%) and patients scored disease severity ≥3 points higher than physicians scored disease activity (positive discordance) in 84 visits (54.5%). Compared with visits with concordance, visits with positive discordance were associated with significantly worse scores on the MFI, BIPQ, SF-36 physical component score and SF-36 mental component score. CONCLUSION Patients with RP typically self-report high PtGA that does not align with PhGA. Discordance is likely driven by the high physical and psychological burden of illness experienced by patients. Multifaceted treatment approaches that address the burden of disease in RP from the patient perspective are needed.
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Affiliation(s)
- Emily Rose
- Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Marcela A Ferrada
- Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Kaitlin A Quinn
- Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Laurent Arnaud
- Department of Rheumatology, National Reference Center for Autoimmune Diseases, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Wendy Goodspeed
- Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | - Clint Allen
- Otolaryngology, National Institute on Deafness and Other Communication Disorders
| | - Arlene Sirajuddin
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Marcus Chen
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Peter C Grayson
- Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
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7
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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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8
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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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Brites L, Rovisco J, Costa F, Freitas JPDD, Jesus D, Eugénio G, Serra S, Duarte C, Ferreira RJO, da Silva JAPD. High patient global assessment scores in patients with rheumatoid arthritis otherwise in remission do not reflect subclinical inflammation. Joint Bone Spine 2021; 88:105242. [PMID: 34166795 DOI: 10.1016/j.jbspin.2021.105242] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 06/01/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To assess whether high patient global assessment (PGA) scores by patients with rheumatoid arthritis (RA) otherwise in remission reflect subclinical inflammation. METHODS Cross-sectional, single-center study, including consecutive RA patients. Remission states were defined based on the ACR/EULAR Boolean definition: 4V-remission (tender and swollen 28-joint counts (TJC28/SJC28), C-reactive protein (CRP), and PGA all≤1), PGA-near-remission (the same, except PGA>1), and non-remission (any of TJC28, SJC28, CRP>1). A blinded expert musculoskeletal ultrasonographer scanned 44 joints, 38 tendon sheaths, 4 bursae on the same day of the clinical evaluation. Each structure was assessed for the presence of Grey Scale synovial hypertrophy (GS) and Power Doppler (PD), both scored using a semi-quantitative scale (0-3 points). The Global OMERACT-EULAR Synovitis Score (GLOESS, 0-132, primary outcome), and a global tenosynovitis/bursitis score (GTBS) were compared between remission states, using non-parametric tests. Different sensitivity analyses comparing GS and PD subscores were performed. RESULTS In total, 130 patients (mean age 63 years, 86% female, average disease duration 14 years) were included 40 being in 4V-remission, 40 in PGA-near-remission, 50 in non-remission. 4v-remission and PGA-near-remission presented similar median (IQR) GLOESS, [6 (5-11) and 4 (1-7), P>0.05, respectively] and GTBS [0 (0-1) and 0 (0-2), P>0.05, respectively]. The same was observed in GS, PD scores, and in global synovitis score considering only the 16 joints not included in 28-joint counts. These observations were confirmed in patients with≤5 years disease duration. CONCLUSIONS Subclinical inflammation is not present among persons with elevated PGA who are otherwise in remission. PGA-near-remission patients would be exposed to the risk of overtreatment if current treatment recommendations were strictly followed. This study supports the need to reconsider the role of PGA in definitions used to target immunosuppressive therapy and to provide a separate and enhanced focus to the patient's experience of the disease.
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Affiliation(s)
- Luisa Brites
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - João Rovisco
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Flávio Costa
- Rheumatology Department, Centro Hospitalar Vila, Nova de Gaia, Portugal
| | | | - Diogo Jesus
- Rheumatology Department, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Gisela Eugénio
- Rheumatology Department, Centro Hospitalar do Baixo-Vouga, Aveiro, Portugal
| | - Sara Serra
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Cátia Duarte
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculty of Medicine, Coimbra Institute for Clinical and Biomedical Research (i.CIBR), University of Coimbra, Coimbra, Portugal
| | - Ricardo J O Ferreira
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Health Sciences Research Unit: Nursing, Nursing School of Coimbra, Coimbra, Portugal
| | - José António Pereira da da Silva
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculty of Medicine, Coimbra Institute for Clinical and Biomedical Research (i.CIBR), University of Coimbra, Coimbra, Portugal.
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Bugatti S, De Stefano L, Manzo A, Sakellariou G, Xoxi B, Montecucco C. Limiting factors to Boolean remission differ between autoantibody-positive and -negative patients in early rheumatoid arthritis. Ther Adv Musculoskelet Dis 2021; 13:1759720X211011826. [PMID: 34093745 PMCID: PMC8141996 DOI: 10.1177/1759720x211011826] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 03/31/2021] [Indexed: 12/14/2022] Open
Abstract
Background: The patient global assessment of disease activity (PGA) is the major limiting factor to Boolean remission in patients with established rheumatoid arthritis (RA). Here, we investigated the limiting variables to disease remission in patients with early RA treated with conventional synthetic disease modifying anti-rheumatic drugs, also in relation to autoantibody status. Methods: Data were retrieved from 535 early RA patients (<12 months of symptoms) with an observation period of 6–12 months upon initiation of therapy with methotrexate aimed at the achievement of low disease activity based on the 28-joints disease activity score. Near-remission was defined as any of the four core items of Boolean remission >1 with the remaining three all ⩽1. Reasons for missing Boolean remission and predictors of near-remission subcategories were analyzed in relation to baseline disease variables. Results: After 6 and 12 months, near-remission was two-times more frequent than Boolean remission (25.6% and 26.9% at the two time-points). A 28-swollen joint count (SJC28) >1 was responsible for the majority of near-remission (56.2% and 57.6% at 6 and 12 months, respectively), and PGA > 1 accounted for approximatively 35% of the cases. Autoantibody-positivity independently predicted the risk of missing remission because of SJC28 > 1 [adjusted odds ratio (OR) 95% confidence interval (CI) 2.81 (1.59–4.9) at 6 months and 1.73 (1.01–3.01) at 12 months], whilst autoantibody-negativity was an independent predictor of PGA near-remission [adjusted OR (95% CI) 2.45 (1.25–4.80) at 6 months and 5.71 (2.47–13.2) at 12 months]. Conclusion: In early RA, Boolean remission is more frequently missed because of persistent swollen joints. However, barriers to full-remission vary in relation to the autoantibody status. Autoantibody-positive patients more commonly experience residual swollen joints, whilst PGA more frequently impairs remission in autoantibody-negative patients. Efforts to target full-remission in early RA may thus require different strategies according to autoantibody profile.
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Affiliation(s)
- Serena Bugatti
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation University Hospital, Viale Golgi 19, Pavia, 27100, Italy
| | - Ludovico De Stefano
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Antonio Manzo
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | | | - Blerina Xoxi
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
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11
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Pincus T, Gibson KA, Yazici Y, Bergman M, Schmukler J, Block JA. Comment on: 'It can't be zero!' Difficulties in completing patient global assessment in rheumatoid arthritis: a mixed methods study. Rheumatology (Oxford) 2021; 60:e28-e29. [PMID: 33020808 DOI: 10.1093/rheumatology/keaa489] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 07/09/2020] [Indexed: 02/01/2023] Open
Affiliation(s)
- Theodore Pincus
- Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Kathryn A Gibson
- Department of Rheumatology, Liverpool Hospital and University of New South Wales, Sydney, NSW, Australia
| | - Yusuf Yazici
- Department of Medicine, New York University School of Medicine, New York, NY
| | - Martin Bergman
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA
| | - Juan Schmukler
- Department of Medicine, Mount Sinai Hospital, Chicago, IL, USA
| | - Joel A Block
- Department of Medicine, Rush University Medical Center, Chicago, IL, USA
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12
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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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13
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Grainger R, Townsley HR, Stebbings S, Harrison AA, Taylor WJ, Stamp LK. Codevelopment of Patient Self-Examination Methods and Joint Count Reporting for Rheumatoid Arthritis. ACR Open Rheumatol 2020; 2:705-709. [PMID: 33200883 PMCID: PMC7738803 DOI: 10.1002/acr2.11197] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 10/09/2020] [Indexed: 12/15/2022] Open
Abstract
Objective To determine whether training increases accuracy of self‐reported joint counts in people with rheumatoid arthritis (RA) and describe the knowledge and techniques for self‐examination of joints for reporting of RA disease activity. Methods This mixed‐methods study included 10 patients with RA and four rheumatologists. A rheumatologist presented about joint inflammation and disease monitoring in RA. Patients then self‐examined and reported 28‐tender joint count (28‐TJC) and 28‐swollen joint count (28‐SJC). Next, two paired rheumatologists examined patients and reported 28‐TJC and 28‐SJC. After watching a joint examination video for training physicians, patients discussed their training needs for self‐examination, with discussion analyzed using thematic analysis. Self‐examination techniques were determined by consensus. Finally, patients self‐examined and reported 28‐TJC and 28‐SJC. Reliability between the first and second patient‐reported 28‐TJCs and 28‐SJCs and rheumatologist pair‐reported 28‐TJC and 28‐SJC was determined with the intraclass coefficient. Results The reliability for patient self‐reported joint counts was higher for the 28‐TJC than for the 28‐SJC. Reliability improved following rheumatologist examination and training. Patients identified a preference for practical information rather than detailed information on joint anatomy and pathophysiology. Clear definitions of “swollen” and “tender” were important; patients found the concept of “tenderness” difficult. Techniques for self‐examination and reporting of joint counts were agreed on and demonstrated in an instructional video. Conclusion Training increased reliability of patient‐reported joint counts. Patients with RA identified important aspects of training for self‐examination and reporting of joint counts. An 8‐minute instructional video was codeveloped; the next step is the evaluation of the video’s impact on patient‐reported joint counts.
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Affiliation(s)
- Rebecca Grainger
- University of Otago, Wellington, New Zealand.,Hutt Hospital, Hutt Valley District Health Board, Lower Hutt, New Zealand
| | | | - Simon Stebbings
- University of Otago, Dunedin School of Medicine, New Zealand.,Dunedin Hospital, Dunedin, New Zealand
| | - Andrew A Harrison
- University of Otago, Wellington, New Zealand.,Hutt Hospital, Hutt Valley District Health Board, Lower Hutt, New Zealand
| | - William J Taylor
- University of Otago, Wellington, New Zealand.,Hutt Hospital, Hutt Valley District Health Board, Lower Hutt, New Zealand
| | - Lisa K Stamp
- University of Otago, Christchurch, New Zealand.,Christchurch Hospital, Christchurch, New Zealand
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14
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Duarte C, Santos E, da Silva JAP, Kristianslund EK, Kvien TK, Dougados M, de Wit M, Gossec L, Heiberg T. The Patient Experienced Symptom State (PESS): a patient-reported global outcome measure that may better reflect disease remission status. Rheumatology (Oxford) 2020; 59:3458-3467. [PMID: 32375173 DOI: 10.1093/rheumatology/keaa149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/28/2020] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Cátia Duarte
- Department of Rheumatology, Centro Hospitalar e Universitário de Coimbra, Coimbra.,Coimbra Institute for Clinical and Biomedical Research - Faculty of Medicine, University of Coimbra, Coimbra
| | - Eduardo Santos
- Department of Rheumatology, Centro Hospitalar e Universitário de Coimbra, Coimbra.,Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto.,Health Sciences Research Unit: Nursing, Nursing School of Coimbra, Coimbra, Portugal
| | - José A P da Silva
- Department of Rheumatology, Centro Hospitalar e Universitário de Coimbra, Coimbra.,Coimbra Institute for Clinical and Biomedical Research - Faculty of Medicine, University of Coimbra, Coimbra
| | | | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Maxime Dougados
- Université de Paris, Paris.,Department of Rheumatology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris.,INSERM (U1153): Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France
| | | | - Laure Gossec
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Sorbonne Université, Paris.,Rheumatology Department, Pitié Salpêtrière Hospital, Sorbone Univeristé-AP-HP, Paris, France
| | - Turid Heiberg
- Faculty of Health and Welfare, Østfold University College, Halden.,Regional Research Support, Oslo University Hospital, Oslo, Norway
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15
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Carvajal Bedoya G, Davis LA, Hirsh JM. Patient-Reported Outcomes in Rheumatology Patients With Limited English Proficiency and Limited Health Literacy. Arthritis Care Res (Hoboken) 2020; 72 Suppl 10:738-749. [PMID: 33091257 DOI: 10.1002/acr.24243] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/28/2020] [Indexed: 12/13/2022]
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16
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Ferreira RJ, Santos E, Gossec L, da Silva JA. The patient global assessment in RA precludes the majority of patients otherwise in remission to reach this status in clinical practice. Should we continue to ignore this? Semin Arthritis Rheum 2020; 50:583-585. [DOI: 10.1016/j.semarthrit.2020.03.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 03/20/2020] [Indexed: 02/07/2023]
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17
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Cock DD, Hirsh J. The rheumatoid arthritis patient global assessment: improve it or lose it! Rheumatology (Oxford) 2020; 59:923-924. [PMID: 31747022 DOI: 10.1093/rheumatology/kez566] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/18/2019] [Indexed: 01/22/2023] Open
Affiliation(s)
- Diederik De Cock
- KU Leuven Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, Leuven, Belgium
| | - Joel Hirsh
- Denver Health and Hospital Authority Denver, Colorado and University of Colorado Medical School, Denver, CO, USA
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