Improving accuracy of self-reported diagnoses of rheumatoid arthritis in the French prospective E3N-EPIC cohort: a validation study

A novel method to monitor rheumatoid arthritis prevalence using hospital and medication databases

BACKGROUND

Most estimates of rheumatoid arthritis (RA) prevalence, including all official figures in Australia and many other countries, are based on self-report. Self-report has been shown to overestimate RA, but the 'gold standard' of reviewing individual medical records is costly, time-consuming and impractical for large-scale research and population monitoring. This study provides an algorithm to estimate RA cases using administrative data that can be adjusted for use in multiple contexts to provide the first approximate RA cohort in Australia that does not rely on self-report.

METHODS

Survey data on self-reported RA and medications from 25 467 respondents of the Australian Longitudinal Study on Women's Health (ALSWH) were linked with data from the national medication reimbursement database, hospital and emergency department (ED) episodes, and Medicare Benefits codes. RA prevalence was calculated for self-reported RA, self-reported RA medications, dispensed RA medications, and hospital/ED RA presentations. Linked data were used to exclude individuals with confounding autoimmune conditions.

RESULTS

Of 25 467 survey respondents, 1367 (5·4%) women self-reported disease. Of the 26 840 women with hospital or ED presentations, 292 (1·1%) received ICD-10 codes for RA. There were 1038 (2·8%) cases by the medication database definition, and 294 cases (1·5%) by the self-reported medication definition. After excluding individuals with other rheumatic conditions, prevalence was 3·9% for self-reported RA, 1·9% based on the medication database definition and 0·5% by self-reported medication definition. This confirms the overestimation of RA based on self-reporting.

CONCLUSIONS

We provide an algorithm for identifying individuals with RA, which could be used for population studies and monitoring RA in Australia and, with adjustments, internationally. Its balance of accuracy and practicality will be useful for health service planning using relatively easily accessible input data.

Accuracy of self-reported diagnoses of polymyalgia rheumatica and giant cell arteritis in the French prospective E3N- EPIC cohort: A validation study

OBJECTIVES

To assess the accuracy of self-reported giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) diagnoses in a large French population-based prospective cohort, and to devise algorithms to improve their accuracy.

METHODS

The E3N-EPIC cohort study (Etude Epidémiologique auprès des femmes de la Mutuelle Générale de l'Education Nationale) includes 98,995 French women born between 1925 and 1950, recruited in 1990 to study risk factors of cancer and chronic diseases. They completed biennially mailed questionnaires to update their health-related information and lifestyle characteristics. In three questionnaires, women could self-report a diagnosis of GCA/PMR. Those women were additionally sent a specific questionnaire, designed to ascertain self-reported diagnoses of GCA/PMR. Four algorithms were then devised to improve their identification. Accuracies of self-reported diagnoses and of each algorithm were calculated by comparing the diagnoses with a blinded medical chart review.

RESULTS

Among 98,995 participants, 1,392 women self-reported GCA/PMR. 830 women sent back the specific questionnaire, and 202 women provided medical charts. After independent review of the 202 medical charts, 87.6 % of the self-reported diagnoses of GCA/PMR were accurate. Using additional data from a specific questionnaire (diagnosis confirmation by a physician, and self-report of >3-month of glucocorticoids), and from a reimbursement database (at least two deliveries of glucocorticoids in less than 3 consecutive months) improved their accuracy (91.8 % to 92.8 %).

CONCLUSION

The accuracy of self-reported diagnosis of GCA/PMR was high in the E3N-cohort but using additional data as a specific GCA/PMR questionnaire and/or corticosteroid reimbursement database further improved this accuracy. With nearly 600 detected cases of GCA/PMR, we will be able to investigate risk factors for GCA/PMR in women.

Prevalence of rheumatoid arthritis in Greece: results from the national health examination survey EMENO

Rheumatoid arthritis (RA) is considered the most common form of autoimmune arthritis. The disease's prevalence is around 0.5-1% worldwide, but it seems to vary among different populations. The aim of this study was to estimate the prevalence of self-reported diagnosed RA in the general adult population in Greece. The data were derived from the Greek Health Examination Survey EMENO, a population-based survey performed between 2013 and 2016. Of the 6006 participants (response rate 72%), 5884 were eligible for this study. Prevalence estimates were calculated according to the study design. Prevalence of self-reported RA was estimated to be overall 0.5% (95% CI 0.4-0.7) being approximately three times higher in women than in men (0.7% vs 0.2%, p value = 0.004). A decrease in the prevalence of RA was observed in urban areas of the country. In contrast, higher disease rates were reported in individuals with lower socioeconomic status. Multivariable regression analysis showed that gender, age, and income were related to the occurrence of the disease. Osteoporosis and thyroid disease were the two comorbidities observed at statistically significant higher rates in individuals with self-reported RA. The prevalence of self-reported RA in Greece is similar to that reported in other European countries. Gender, age, and income are the main factors related to the disease's prevalence in Greece.

Leveraging Patient Preference Information in Medical Device Clinical Trial Design

Use of robust, quantitative tools to measure patient perspectives within product development and regulatory review processes offers the opportunity for medical device researchers, regulators, and other stakeholders to evaluate what matters most to patients and support the development of products that can best meet patient needs. The medical device innovation consortium (MDIC) undertook a series of projects, including multiple case studies and expert consultations, to identify approaches for utilizing patient preference information (PPI) to inform clinical trial design in the US regulatory context. Based on these activities, this paper offers a cogent review of considerations and opportunities for researchers seeking to leverage PPI within their clinical trial development programs and highlights future directions to enhance this field. This paper also discusses various approaches for maximizing stakeholder engagement in the process of incorporating PPI into the study design, including identifying novel endpoints and statistical considerations, crosswalking between attributes and endpoints, and applying findings to the population under study. These strategies can help researchers ensure that clinical trials are designed to generate evidence that is useful to decision makers and captures what matters most to patients.

A Roadmap for Investigating Preclinical Autoimmunity Using Patient-Oriented and Epidemiologic Study Designs: Example of Rheumatoid Arthritis

Background & Aims

Rheumatoid arthritis (RA) is a prototypic autoimmune disease causing inflammatory polyarthritis that affects nearly 1% of the population. RA can lead to joint destruction and disability along with increased morbidity and mortality. Similar to other autoimmune diseases, RA has distinct preclinical phases corresponding to genetic risk, lifestyle risk factors, autoantibody development, and non-specific symptoms prior to clinical diagnosis. This narrative review will detail observational studies for RA risk and clinical trials for RA prevention as a roadmap to investigating preclinical autoimmunity that could be applied to other diseases.

Methods

In this narrative review, we summarized previous and ongoing research studies investigating RA risk and prevention, categorizing them related to their design and preclinical phases.

Results

We detailed the following types of studies investigating RA risk and prevention: retrospective population-based and administrative datasets; prospective studies (case-control and cohort; some enrolling based on genetics, first-degree relative status, elevated biomarkers, or early symptoms/arthritis); and randomized clinical trials. These correspond to all preclinical RA phases (genetic, lifestyle, autoimmunity, early signs/symptoms). Previous and ongoing randomized controlled trials have enrolled individuals at very elevated risk for RA based on biomarkers, symptoms, imaging abnormalities, or early signs/symptoms.

Conclusion

We detailed the rich variety of study designs that is necessary to investigate distinct preclinical phases of an autoimmune disease such as RA. However, further progress is needed to fully elucidate the pathogenesis of RA that may ultimately lead to prevention or delay of disease onset.

Passive smoking in childhood and adulthood and risk of rheumatoid arthritis in women: results from the French E3N cohort study

Objective

The association between passive smoking exposure in childhood or in adulthood, and the risk of rheumatoid arthritis (RA) has been incompletely investigated. We aimed to assess the relationship between exposure to passive smoking and the risk of incident RA in a French prospective cohort of healthy women.

Methods

The E3N Study (Etude Epidémiologique auprès des femmes de la Mutuelle générale de l’Education Nationale) is a French prospective cohort of women included in 1990. Exposures to passive smoking were assessed using self-reported questionnaires. RA cases were self-reported and subsequently validated. Cox proportional hazards regression models adjusted for age and for potential confounders were used to estimate HRs and 95% CIs for incident RA.

Results

Among 79 806 women, 698 incident cases of RA were identified; 10 810 (13.5%) women were exposed to passive smoking in childhood, and 42 807 (53.6%) in adulthood. Median age at inclusion was 47.8 years. Passive smoking in childhood and in adulthood was associated with RA risk in all models (HRs (95% CIs) 1.24 (1.01 to 1.51) and 1.19 (1.02 to 1.40), respectively). The absolute risk of RA among never smokers with exposure to passive smoking in childhood and/or adulthood (47.6/100 000 person-years) was close to the risk of ever smokers with no passive smoking exposure (47.2/100 000 person-years), while it was highest in ever smokers also exposed to passive smoking (53.7/100 000 person-years).

Conclusion

Exposure to passive smoking in childhood and/or adulthood increases the risk of RA by the same order than active smoking. Such exposure should be suppressed, especially in individuals at risk of RA.

Anthropometric Measures and Risk of Rheumatoid Arthritis in the French E3N Cohort Study

We aimed to assess the relationships between anthropometric measures and risk of rheumatoid arthritis (RA). The E3N cohort included 98,995 women (aged 40−65 years at the recruitment) who completed mailed questionnaires on reproductive factors, lifestyle, and health-related information, including anthropometric measures, every 2−3 years. Cox proportional hazards regression models with age as the time scale and adjusted on known RA risk factors were used to estimate hazard ratios (HRs) and 95% confidence intervals for the risk of incident RA in the overall population (n = 78,452) and after stratification on smoking exposure. Incident RA diagnosis was validated in 698 women. Abdominal obesity (waist circumference >88 cm) was associated with RA (HR = 1.2 (1.0−1.5)), independent of BMI; whereas obesity, defined as BMI ≥ 30 kg/m2, was marginally associated with RA (HR = 1.26 (0.9−1.5), ptrend = 0.0559). Taking lean body shape (BS) as reference, medium BS at puberty (HR = 1.3 (1.0−1.7)) and medium-large BS at perimenopausal period (HR = 1.5 (1.1−1.9)) were associated with the risk of RA among never-smoker women, independent of BMI. Regarding BS trajectory, taking constantly lean BS as reference, constantly large BS from puberty to perimenopause was associated with RA among non-smokers (HR = 2.10 (1.2−3.6)), independent of BMI.

Fish Consumption and Risk of Rheumatoid Arthritis: Findings from the E3N Cohort Study

Fish consumption has been thought to reduce the risk of rheumatoid arthritis (RA), but the reported data are conflicting. We aimed to assess the association between fish consumption (overall, lean fish, and oily fish) and the risk of RA. The E3N Study is a French prospective cohort study including 98,995 women since 1990. Dietary data were collected via a validated food frequency questionnaire in 1993. Cox proportional hazards models were used to calculate HRs and 95% CIs for incident RA. Models were adjusted for age and for the main potential confounders including cigarette smoking. Among 62,629 women, 480 incident cases of RA were identified. In the overall population, we did not find a linear association between overall fish consumption and RA risk (p for trend 0.65), but a moderate consumption of fish was associated with a decreased risk of RA (HR 0.74; 95% CI 0.59–0.94 for tertile 2 compared with tertile 1), especially among current or former smokers (HR 0.61; 95% CI 0.44–0.85). Although not statistically significant, a trend towards an inverse association was only found with oily fish consumption (HR 0.81; 95% CI 0.65–1.02), but not with lean fish. Our results suggest that moderate fish consumption could reduce the risk or RA and potentially counterbalance the increased risk of RA induced by smoking. This inverse association might be explained by the omega-3 fatty acid content of oily fish.

Validation of Self-Reported Rheumatoid Arthritis Using Medicare Claims: A Nationally Representative Longitudinal Study of Older Adults

Objective

To determine the validity of self‐reported physician diagnosis of rheumatoid arthritis (RA) using multiple gold‐standard measures based on Medicare claims in a nationally representative sample of older adults and to verify whether additional questions about taking medication and having seen a physician in the past two years for arthritis can improve the positive predictive value (PPV) and other measures of the validity of self‐reported RA.

Methods

A total of 3768 Medicare‐eligible respondents with and without incident self‐reported RA were identified from the 2004, 2008, and 2012 waves of the United States Health and Retirement Study. Self‐reported RA was validated using the following three claims‐based algorithms: 1) a single International Classification of Diseases, ninth edition, Clinical Modification claim for RA, 2) two or more claims no greater than 2 years apart, and 3) two or more claims with at least one diagnosis by a rheumatologist. Additional self‐report questions of medication use and having seen a doctor for arthritis in the past two years were validated against the same criteria.

Results

A total of 345 respondents self‐reported a physician diagnosis of RA. Across all three RA algorithms, the PPV of self‐report ranged from 0.05 to 0.16., the sensitivity ranged from 0.23 to 0.55., and the κ statistic ranged from 0.07 to 0.15. Additional self‐report data regarding arthritis care improved the PPV and other validity measures of self‐report; however, the values remained low.

Conclusion

Most older adults who self‐report RA do not have a Medicare claims history consistent with that diagnosis. Revisions to current self‐reported RA questions may yield more valid identification of RA in national health surveys.

Female hormonal exposures and risk of rheumatoid arthritis in the French E3N-EPIC cohort study

OBJECTIVE

To assess the relationships between female hormonal exposures and risk of RA in a prospective cohort of French women.

METHODS

E3N (Etude Epidémiologique auprès des femmes de la Mutuelle générale de l'Education Nationale) is an on-going French prospective cohort that included 98 995 women aged 40-65 years in 1990. Every 2-3 years, women completed mailed questionnaires on their lifestyles, reproductive factors and health conditions. Cox proportional hazards regression models were used to determine factors associated with risk of incident RA, with age as the time scale, adjusted for known risk factors of RA, and considering endogenous and exogenous hormonal factors. Hazard ratios (HRs) and 95% CIs were estimated. Effect modification by smoking history was investigated.

RESULTS

A total of 698 incident cases of RA were ascertained among 78 452 women. In multivariable-adjusted Cox regression models, risk of RA was increased with early age at first pregnancy (<22 vs ≥27 years; HR = 1.34; 95% CI 1.0, 1.7) and menopause (≤45 vs ≥53 years; HR = 1.40; 95% CI 1.0, 1.9). For early menopause, the association was of similar magnitude in ever and never smokers, although the association was statistically significant only in ever smokers (HR = 1.54; 95% CI 1.0, 2.3). We found a decreased risk in nulliparous women never exposed to smoking (HR = 0.44; 95% CI 0.2, 0.8). Risk of RA was inversely associated with exposure to progestogen only in perimenopause (>24 vs 0 months; multi-adjusted HR = 0.77; 95% CI 0.6, 0.9).

CONCLUSIONS

These results suggest an effect of both endogenous and exogenous hormonal exposures on RA risk and phenotype that deserves further investigation.

Mediterranean Diet and Risk of Rheumatoid Arthritis: Findings From the French E3N-EPIC Cohort Study

OBJECTIVE

The Mediterranean diet has been reported to be associated with a significant reduction in risk of noncommunicable diseases. We undertook this study to assess the relationship between adherence to the Mediterranean diet and the risk of rheumatoid arthritis (RA), especially in high-risk individuals.

METHODS

The E3N study (Etude Epidémiologique Auprès des Femmes de la Mutuelle Générale de l'Education Nationale) is a French prospective cohort study that has included 98,995 women since 1990. Dietary data were collected via a validated food frequency questionnaire in 1993. Adherence to the Mediterranean diet was assessed using a 9-unit dietary score evaluating consumption of vegetables, legumes, cereal products, fish, meat, dairy products, olive oil, and alcohol. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) for incident RA were estimated using Cox proportional hazards regression models adjusted for age and the main potential confounders, including smoking.

RESULTS

Among 62,629 women, we identified 480 incident cases of RA. In the entire study population, the Mediterranean diet adherence score was not associated with RA risk (HR 0.86 [95% CI 0.67-1.09] for high score versus low score; P for trend = 0.09); however, among ever-smokers, a higher score was associated with a decreased risk of RA (HR 0.91 [95% CI 0.84-0.99] for 1-point increase in score; P = 0.03). In ever-smokers, the absolute risks of RA in those with high scores and those with low scores were 38.3 and 51.5 per 100,000 person-years, respectively, compared to 35.8 per 100,000 person-years in never-smokers with high Mediterranean diet scores.

CONCLUSION

Our results suggest that adherence to the Mediterranean diet could reduce the high risk of RA among ever-smoking women. Our results must be confirmed in future research.

Chronic diarrhoea and risk of rheumatoid arthritis: findings from the French E3N-EPIC Cohort Study

Objectives

To assess the relationship between gastrointestinal disorders and the risk of further development of RA.

Methods

The Etude Epidémiologique auprès des femmes de la Mutuelle générale de l’Education Nationale-European Prospective Investigation into Cancer and Nutrition Study is a French prospective cohort including 98 995 healthy women since 1990. Participants completed mailed questionnaires on their lifestyles and health-related information. Gastrointestinal disorders were assessed in the third questionnaire (sent in 1993). Hazard ratios and 95% CIs for incident RA were estimated using Cox proportional hazards regression models with age as the time scale. Models were age adjusted, and then additionally adjusted for known risk factors of RA such as smoking, and for potential cofounders.

Results

Among 65 424 women, 530 validated incident RA cases were diagnosed after a mean (s.d.) of 11.7 (5.9) years after study baseline. In comparison with no gastrointestinal disorder, chronic diarrhoea was associated with an increased risk of developing RA during follow-up (hazard ratio = 1.70, 95% CI 1.13, 2.58), independently of dysthyroidism or dietary habits. The association was stronger among ever-smokers (hazard ratio = 2.21, 95% CI 1.32, 3.70). There was no association between RA risk and constipation or alternating diarrhoea/constipation.

Conclusion

Chronic diarrhoea was associated with an increased risk of subsequent RA development, particularly among ever-smokers. These data fit with the mucosal origin hypothesis of RA, where interaction between intestinal dysbiosis and smoking could occur at an early stage to promote emergence of autoimmunity, followed years later by clinical disease.