Systematic review and metaanalysis of patient self-report versus trained assessor joint counts in rheumatoid arthritis

Patient-reported swelling in arthralgia patients at risk for rheumatoid arthritis: is it of value?

OBJECTIVE

Patients with Clinically Suspect Arthralgia (CSA) are at risk for developing Rheumatoid Arthritis (RA). These patients often report joint swelling while this is not objectified by physical examination. To explore the value of patient-reported swelling in CSA, we aimed to determine its association with subclinical joint-inflammation on imaging and RA-development.

METHODS

In two independent, similarly designed CSA-cohorts from the Netherlands, symptomatic patients at risk for RA were studied. At baseline, patients indicated whether they had experienced swelling in hand joints. Subclinical joint-inflammation was assessed with MRI or ultrasound (US). Patients were followed for inflammatory arthritis development.

RESULTS

In total, 534 CSA-patients from two independent cohorts were studied, patient-reported swelling was present in 57% in cohort 1, and in 43% in cohort 2. In both cohorts patient-reported swelling was associated with subclinical joint-inflammation. Using MRI, it associated specifically with tenosynovitis (OR 3.7 (95%CI 2.0-6.9)) and when using US with synovitis (OR 2.3 (95%CI 1.04-5.3)). CSA-patients with self-reported swelling at baseline developed arthritis more often, with hazard ratios of 3.7 (95%CI 2.0-6.9) and 3.4 (95%CI 1.4-8.4) in cohort 1 and 2, respectively. This was independent of clinical predictors (e.g. morning stiffness), autoantibody-positivity and US-detected subclinical joint-inflammation. However, when corrected for MRI-detected subclinical joint-inflammation, self-reported swelling was no longer an independent predictor.

CONCLUSION

Patient-reported joint swelling in CSA relates to subclinical joint-inflammation and is an independent risk factor for RA-development, but it is less predictive than the presence of MRI-detected subclinical joint-inflammation.

Singing Voice Concern in Tertiary Laryngology Practice

OBJECTIVES

To determine the prevalence and characteristics of patients who identify singing voice as a primary concern when presenting with general voice complaints to a voice clinic.

METHODS

Data were collected from medical records on demographics, medical history, laryngoscopy exam, diagnosis, and subsequent treatments; and from self-report questionnaires including the Voice Handicap Index-10 (VHI-10) and clinical voice questionnaire.

RESULTS

A total of 17% of patients presenting to a voice clinic with general voice problems who completed a VHI-10 identified singing voice as a primary concern. Compared to the reference cohort, patients concerned about singing voice report greater handicap on several questions of the VHI-10, particularly in personal and social life impact, loss of income, unpredictability of vocal clarity, subjective upset, and subjective handicap. Those concerned with singing voice were also more concerned about their vocal problem, and both more likely to be recommended voice therapy and participate in voice therapy despite no statistical differences in categorical diagnoses.

CONCLUSIONS

When considering both professional and recreational singers, voice concerns occurred in 17% of the cohort under study. Patients with singing voice concerns are accounted for largely by recreational singers, who remain poorly characterized in the literature. We underscore the importance of sensitivity and responsivity to the needs of this group of patients.

Best Practices for Virtual Care, a Consensus Statement from the Canadian Rheumatology Association

Objective

To develop best practice statements for the provision of virtual care in adult and pediatric rheumatology for the Canadian Rheumatology Association's (CRA) Telehealth Working Group (TWG).

Methods

Four members of the TWG representing adult, pediatric, university-based and community rheumatology practices defined the scope of the project. A rapid literature review was conducted between April-May 2021 of existing systematic reviews, policy documents and published literature and abstracts on the topic. The review informed a candidate set of 7 statements and a supporting document. The statements were submitted to a 3-round (R) modified Delphi process with 22 panelists recruited through the CRA and patient advocacy organizations. Panelists rated the importance and feasibility of the statements on a Likert scale of 1-9. Statements with final median ratings between 7-9 with no disagreement were retained in the final set.

Results

21 (95%) panelists participated in R1, 15 (71%) in R2 and 18 (82%) in R3. All but one statement met inclusion criteria during R1. Revisions were made to 5/7 statements following R2 and an additional statement was added. All statements met inclusion criteria following R3. The statements addressed the following themes in the provision of virtual care: adherence to existing standards and regulations, appropriateness, consent, physical examination, patient-reported outcomes, use in addition to in-person visits, and complex co-management of disease.

Conclusion

The best practice statements represent a starting point for advancing virtual care in rheumatology. Future educational efforts to help implement these best practices and research to address identified knowledge gaps are planned.

Effect of Training on Patient Self-Assessment of Joint Counts in Rheumatoid Arthritis: A Systematic Review

Objective

Patient self‐assessed joint counts, if accurate and reliable, could potentially serve as a useful clinical assessment tool in rheumatoid arthritis (RA). This systematic review examines the effect of patient training on the inter‐rater reliability of joint counts between patients and clinicians.

Methods

The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. A search was performed in PubMed, Embase, Cochrane Library, and CINAHL for articles that incorporated patient training and measured the reliability of patient self‐assessed joint counts in RA. Articles were included if they reported on the inter‐rater reliability between patient and clinician joint counts in both trained and untrained patients with RA. Data were extracted on characteristics of patients, structure and components of the training interventions, joint count reliability of patients with and without training, and patient feedback on training interventions. The relevant data were summarized and described.

Results

Multiple training methods have been studied (n = 5), including in‐person sessions run by rheumatologists and instructional videos on the joint examination. Overall, training improved the reliability of patient self–joint counts, with more marked improvement in reliability of swollen joint counts than tender joint counts. Patients had positive feedback when surveyed on their experiences with training.

Conclusion

Various training modalities (in‐person and video‐based) may be effective at improving reliability of patient self–joint counts. More research is needed on this topic, with potential areas for future research including 1) comparison between the efficacy of different modalities of training, and 2) impact of patient factors (education level and disease severity) on the efficacy of training.

The Reproducibility of Patient Self-reported Joint Counts in Rheumatoid Arthritis: A Closer Look at the Results of a Review

In the management of rheumatoid arthritis (RA), the systematic evaluation of disease activity is of paramount importance. It is the cornerstone of the "treat-to-target" approach, aiming at disease remission and optimization of quality of life.¹ In times of increasing delivery of remote care, accelerated due to the coronavirus disease 2019 (COVID-19) pandemic, the role of patients in the monitoring of disease activity becomes more topical.

Exploring the Pain in Patellofemoral Pain: A Systematic Review and Meta-Analysis Examining Signs of Central Sensitization

BACKGROUND

Patellofemoral pain (PFP) has high recurrence rates and minimal long-term treatment success. Central sensitization refers to dysfunctional pain modulation that occurs when nociceptive neurons become hyperresponsive. Researchers in this area of PFP have been increasingly productive in the past decade.

OBJECTIVE

To determine whether evidence supports manifestations of central sensitization in individuals with PFP.

DATA SOURCES

We searched MeSH terms for quantitative sensory testing (QST) pressure pain thresholds (PPTs), conditioned pain modulation (CPM), temporal summation, sensitization, hyperalgesia, and anterior knee pain or PFP in PubMed, SPORTDiscus, CINAHL, Academic Search Complete, and EBSCOhost.

STUDY SELECTION

Peer-reviewed studies that were written in English and published between 2005 and 2020 and investigated QST or pain mapping in a sample with PFP were included in this review.

DATA EXTRACTION

The initial search yielded 140 articles. After duplicates were removed, 78 abstracts were reviewed. The full text of 21 studies was examined, and we included 15 studies in our evaluation: 6 in the meta-analysis, 4 in the systematic review, and 5 in both the meta-analysis and systematic review.

DATA SYNTHESIS

A random-effects meta-analysis was conducted for 4 QST variables (local PPTs, remote PPTs, CPM, temporal summation). Strong evidence supported lower local and remote PPTs, impaired CPM, and facilitated temporal summation in individuals with PFP compared with pain-free individuals. Evidence for heat and cold pain thresholds was conflicting. Pain mapping demonstrated expanding pain patterns associated with long duration of PFP symptoms.

CONCLUSIONS

Signs of central sensitization were present in individuals with PFP, indicating altered pain modulation. The etiologic and treatment models of PFP should reflect the current body of evidence regarding central sensitization. Signs of central sensitization should be monitored clinically, and treatments with central effects should be considered as part of a multimodal plan of care.

Systematic Review and Metaanalysis of the Reproducibility of Patient Self-reported Joint Counts in Rheumatoid Arthritis

OBJECTIVE

To assess the reproducibility of patient-reported tender (TJCs) and swollen joint counts (SJCs) of patients with rheumatoid arthritis (RA) compared to trained clinicians.

METHODS

We conducted a systematic literature review and metaanalysis of studies comparing patient-reported TJCs and/or SJCs to clinician counts in patients with RA. We calculated pooled summary estimates for correlation. Agreement was compared using a Bland-Altman approach.

RESULTS

Fourteen studies were included in the metaanalysis. There were strong correlations between clinician and patient TJCs (0.78, 95% CI 0.76-0.80), and clinician and patient SJCs (0.59, 95% CI 0.54-0.63). TJCs had good reliability, ranging from 0.51 to 0.85. SJCs had moderate reliability, ranging from 0.28 to 0.77. Agreement for TJCs reduced for higher TJC values, suggesting a positive bias for self-reported TJCs, which was not observed for SJCs.

CONCLUSION

Our metaanalysis has identified a strong correlation between patient- and clinician-reported TJCs, and a moderate correlation for SJCs. Patient-reported joint counts may be suitable for use in annual review for patients in remission and in monitoring treatment response for patients with RA. However, they are likely not appropriate for decisions on commencement of biologics. Further research is needed to identify patient groups in which patient-reported joint counts are unsuitable.

Systematic Review of Outcomes and Patient Experience with Virtual Care in Rheumatoid Arthritis

OBJECTIVE

To conduct a systematic review on patient outcomes of virtual care compared to conventional care in rheumatoid arthritis (RA) including disease activity and patient experience.

METHODS

A systematic search of MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials was performed from database inception to 03/19/2020. Observational and randomized controlled trials (RCTs) describing the use of RA virtual care supplanting conventional visits and reporting on disease activity and/or patient experience were included. A narrative synthesis of results was conducted as a meta-analysis was not possible due to heterogeneity of study designs and outcome reporting.

RESULTS

352 studies were identified, and 6 were selected for final inclusion: 3 were RCTs and 3 were observational studies. Disease activity and patient experience were comparable between virtual and conventional care models. In addition, one RCT found no difference in observed outcomes between virtual care delivered by a rheumatologist and by a rheumatology nurse. Virtual care was found to have additional benefits for improved treatment adherence, maintenance of functional status, and quality of life. The overall risk of bias was low in 2/3 RCTs, but high in the observational studies. Study quality was limited by incomplete data reporting, lack of sample size justification and sufficient timeframe to assess objectives.

CONCLUSIONS

There is limited evidence that virtual RA care is an acceptable alternative to conventional care, maintaining comparable patient outcomes and experience of care. Additional research into effective implementation strategies and long-term health system and patient outcomes of virtual care are needed.

SIGNIFICANCE AND INNOVATIONS

There is a paucity of research in the use of virtual care for rheumatology, especially describing the ability of virtual care modalities to supplant in person visits. Virtual care for rheumatoid arthritis (RA) management appears in the short term to provide equivalent control of disease activity and good patient experience compared to conventional follow-up strategies. Future studies should evaluate the long-term impacts of virtual care on RA outcomes and health service utilization.

Telemedicine for patients with rheumatic and musculoskeletal diseases during the COVID-19 pandemic; a positive experience in the Netherlands

To describe the delivery of care for patients with rheumatic and musculoskeletal diseases (RMDs) from the perspective of rheumatologists in the Netherlands during the first months of the COVID-19 pandemic. A mixed methods design was used with quantitative and qualitative data from a cross-sectional survey sent to all members of the Dutch Rheumatology Society in May 2020. The survey contained questions on demographics, the current way of care delivery, and also on usage, acceptance, facilitators and barriers of telemedicine. Quantitative data were analyzed descriptively. The answers to the open questions were categorized into themes. Seventy-five respondents completed the survey. During the COVID-19 pandemic, continuity of care was guaranteed through telephone and video consultations by 99% and 9% of the respondents, respectively. More than 80% of the total number of outpatient visits were performed exclusively via telephone with in-person visits only on indication. One-quarter of the respondents used patient reported outcomes to guide telephone consultations. The top three facilitators for telemedicine were less travel time for patients, ease of use of the system and shorter waiting period for patients. The top three barriers were impossibility to perform physical examination, difficulty estimating how the patient is doing and difficulty in reaching patients. During the COVID-19 epidemic, care for patients with RMDs in the Netherlands continued uninterrupted by the aid of telemedicine. On average, respondents were content with current solutions, although some felt insecure mainly because of the inability to perform physical examination and missing nonverbal communication with their patients.

COVID-19: What Do Rheumatologists Need to Know?

PURPOSE OF REVIEW

Severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) emerged in December 2019, rapidly reaching global pandemic proportions. Coronavirus disease 2019 (COVID-19) has presented unique challenges to the rheumatology community. It is known that many individuals with rheumatic disease are at increased risk of severe disease from other infections, sparking a similar fear for COVID-19. In addition, medications routinely used in rheumatology practice are being trialled as treatments, with the potential for drug shortages for rheumatology patients.

RECENT FINDINGS

Underlying comorbidities and active disease are associated with worse COVID-19 outcomes in patients with rheumatic disease. Tocilizumab and hydroxychloroquine have not proven to be effective treatments in the management of COVID-19. Telehealth has become an essential tool for the rheumatology community to monitor patients during the pandemic. In this article, we summarise the available COVID-19 evidence that is of relevance to the rheumatology community. We discuss the risk of contracting COVID-19 in individuals with rheumatic disease, along with presenting features and clinical outcomes. We provide an overview of the treatments for COVID-19 which have significance for rheumatology. We highlight published recommendations which can guide our management of rheumatic disease populations during this pandemic. Finally, we discuss the challenges in delivering effective care virtually and present methods and tools which could be adapted for use.

Are telephone consultations here to stay in rheumatology?

Objectives

During the COVID-19 pandemic, face-to-face rheumatology follow-up appointments were mostly replaced with telephone or virtual consultations in order to protect vulnerable patients. We aimed to investigate the perspectives of rheumatology patients on the use of telephone consultations compared with the traditional face-to-face consultation.

Methods

We carried out a retrospective survey of all rheumatology follow-up patients at the Royal Wolverhampton Trust who had received a telephone consultation from a rheumatology consultant during a 4-week period via an online survey tool.

Results

Surveys were distributed to 1213 patients, of whom 336 (27.7%) responded, and 306 (91.1%) patients completed all components of the survey. Overall, an equal number of patients would prefer telephone clinics or face-to-face consultations for their next routine appointment. When divided by age group, the majority who preferred the telephone clinics were <50 years old [χ² (d.f. = 3) = 10.075, P = 0.018]. Prevalence of a smartphone was higher among younger patients (<50 years old: 46 of 47, 97.9%) than among older patients (≥50 years old: 209 of 259, 80.7%) [χ² (d.f. = 3) = 20.919, P < 0.001]. More patients reported that they would prefer a telephone call for urgent advice (168, 54.9%).

Conclusion

Most patients interviewed were happy with their routine face-to-face appointment being switched to a telephone consultation. Of those interviewed, patients >50 years old were less likely than their younger counterparts to want telephone consultations in place of face-to-face appointments. Most patients in our study would prefer a telephone consultation for urgent advice. We must ensure that older patients and those in vulnerable groups who value in-person contact are not excluded. Telephone clinics in some form are here to stay in rheumatology for the foreseeable future.

Codevelopment of Patient Self-Examination Methods and Joint Count Reporting for Rheumatoid Arthritis

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.

Immune checkpoint inhibitor-induced inflammatory arthritis: identification and management

INTRODUCTION

Immune checkpoint inhibitors (ICIs) have proved to be groundbreaking in the field of oncology. However, immune system overactivation from ICIs has introduced a novel medical entity known as immune-related adverse events (irAEs), that can affect any organ or tissue. ICI-induced inflammatory arthritis (ICI-IIA) is the most common musculoskeletal irAE and can lead to significant morbidity and limitation in anti-cancer therapy.

AREAS COVERED

In this review, the authors focus on ICI-IIA. Relevant articles were identified through PubMed searches, spanning 2010 to the present. The authors detail the current understanding of its pathogenesis, diagnostic evaluation, and management strategies.

EXPERT OPINION

ICI-IIA is a complex irAE that we are just beginning to understand mechanistically and pathologically. It often presents later in the disease course than other irAEs and, due to various reasons, is under-recognized. In some patients, ICI-IIA may become a chronic disease, which distinguishes it from most irAEs that resolve after ICI discontinuation. Multiple important questions still demand further research including which patients may develop ICI-IIA? What are possible diagnostic and prognostic markers? Do anti-arthritis therapies interfere with the anti-tumor response? and when should steroid-sparing agents be initiated? Close collaboration and shared decision-making between oncologists, rheumatologists, and the patient are essential when managing this particular irAE.

Brief Report: Adaptation of American College of Rheumatology Rheumatoid Arthritis Disease Activity and Functional Status Measures for Telehealth Visits

Objective

To provide guidance on the implementation of recommended American College of Rheumatology (ACR) rheumatoid arthritis (RA) disease activity and functional status assessment measures in telehealth settings.

Methods

An expert panel was assembled from the recently convened ACR RA disease activity and functional status measures working groups to summarize strategies for implementation of ACR‐recommended RA disease activity (the Clinical Disease Activity Index [CDAI], Disease Activity Score in 28 joints using the erythrocyte sedimentation rate or the C‐reactive protein level [DAS28‐ESR/CRP], Patient Activity Scale II [PAS‐II], Simplified Disease Activity Index [SDAI], and Routine Assessment of Patient Index Data 3 [RAPID3]) and functional status (the Health Assessment Questionnaire II [HAQ‐II], Multidimensional Health Assessment Questionnaire [MDHAQ], and PROMIS physical function 10‐item short form [PROMIS PF‐10]) measures in telehealth settings.

Results

Measures composed of patient‐reported items (disease activity: PAS‐II, RAPID3; functional status: HAQ‐II, MDHAQ, PROMIS PF‐10) require minimal modification for use in telehealth settings. Measures requiring formal joint counts (the CDAI, DAS28‐ESR/CRP, and SDAI) can be calculated using patient‐reported swollen and tender joint counts. When the feasibility of laboratory testing is limited, the CDAI can be used in place of the SDAI, and scoring modifications of the DAS28‐ESR/CRP without the acute‐phase reactant are available. Assessment of the validity of these modifications is limited. Implementation of these measures can be facilitated by electronic health record collection, mobile applications, and provider/staff administration during telehealth visits.

Conclusion

The ACR‐recommended RA disease activity and functional status measures can be adapted for use in telehealth settings to support high‐quality clinical care. Research is needed to better understand how telehealth settings may impact the validity of these measures.

Patient-physician discrepancy in the perception of immune-mediated inflammatory diseases: rheumatoid arthritis, psoriatic arthritis and psoriasis. A qualitative systematic review of the literature

Introduction

Recommendations on chronic diseases management emphasise the need to consider patient perspectives and shared decision-making. Discrepancies between patients and physicians’ perspectives on treatment objectives, disease activity, preferences and treatment have been described for immune-mediate inflammatory diseases. These differences could result on patient dissatisfaction and negatively affect outcomes.

Objective

To describe the degree of patient-physician discrepancy in three chronic immune-mediated inflammatory diseases (rheumatoid arthritis [RA], psoriatic arthritis [PsA] and psoriasis [Ps]), identifying the main areas of discrepancy and possible predictor factors.

Methods

Qualitative systematic review of the available literature on patient and physician discrepancies in the management of RA, PsA and Ps. The search was performed in international (Medline/PubMed, Cochrane Library, ISI-WOK) and Spanish electronic databases (MEDES, IBECS), including papers published from April 1, 2008 to April 1, 2018, in English or Spanish, and conducted in European or North American populations. Study quality was assessed by the Oxford Centre for Evidence-Based Medicine criteria.

Results

A total of 21 studies were included (13 RA; 3 PsA; 4 Ps; 1 RA, Ps, and Axial Spondyloarthritis). A significant and heterogeneous degree of discrepancy between patients and physicians was found, regarding disease activity, treatment, clinical expectations, remission concept, and patient-physician relationship. In RA and PsA, studies were mainly focused on the evaluation of disease activity, which is perceived as higher from the patient’s than the physician’s perspective, with the discrepancy determined by factors such as patient’s perception of pain and fatigue. In Ps, studies were focused on treatment satisfaction and patient-physician relationship, showing a lower degree of discrepancy in the satisfaction regarding these aspects.

Conclusions

There is a significant degree of patient-physician discrepancy regarding the management of RA, PA, and Ps, what can have a major impact on shared decision-making. Future research may help to show whether interventions considering discrepancy improve shared decision-making.

Flares in rheumatoid arthritis: do patient-reported swollen and tender joints match clinical and ultrasonography findings?

OBJECTIVES

To investigate how patient-reported flares in RA are related to clinical joint examination and inflammation detected by US.

METHODS

Eighty RA patients with DAS28-CRP <3.2 and no swollen joints at baseline were followed for 1 year. In case of patient-reported hand flare with swollen and tender joints (SJ and TJ, respectively), patients underwent clinical examination for SJ/TJ and US of bilateral wrists, MCP and PIP 1st-5th, six extensor tendon compartments and wrist flexor tendons for synovitis/tenosynovitis. Percentage agreement and kappa were calculated between patient-reported SJ and TJ, clinical examination for SJ/TJ and US findings indicative of inflammation. With US as reference, sensitivity, specificity, positive/negative predictive value and accuracy of patient-reported and clinically examined joints were determined.

RESULTS

Hand flare was reported by 36% (29/80) of patients. At time of flare, all clinical and ultrasonographic measures of disease activity deteriorated compared with baseline. Agreement between patient-reported SJ/TJ, clinically examined SJ/TJ and US was slight (kappa = 0.02-0.20). Patients and clinicians agreed in 79-93% of joints, more frequently on SJ than TJ. With US as reference, specificities were 86-100% and 88-100%, and sensitivities 12-34% and 4-32% for patient-reported SJ/TJ and clinically examined SJ/TJ, respectively.

CONCLUSION

Over 12 months of follow-up, hand flare was reported by every third RA patient. Self-reported flares were associated with increased disease activity as determined by clinical examination and US. Patient-reported joint assessment may aid in capturing flares between routine clinical visits.

Patients with Rheumatoid Arthritis Acquire Sustainable Skills for Home Monitoring: A Prospective Dual-country Cohort Study (ELECTOR Clinical Trial I)

OBJECTIVE

In an eHealth setting, to investigate intra- and interrater reliability and agreement of joint assessments and Disease Activity Score using C-reactive protein (DAS28-CRP) in patients with rheumatoid arthritis (RA) and test the effect of repeated joint assessment training.

METHODS

Patients with DAS28-CRP ≤ 5.1 were included in a prospective cohort study (clinicaltrials.gov: NCT02317939). Intrarater reliability and agreement of patient-performed joint counts were assessed through completion of 5 joint assessments over a 2-month period. All patients received training on joint assessment at baseline; only half of the patients received repeated training. A subset of patients was included in an appraisal of interrater reliability and agreement comparing joint assessments completed by patients, healthcare professionals (HCP), and ultrasonography. Cohen's κ coefficients and intraclass correlation coefficients (ICC) were used for quantifying of reliability of joint assessments and DAS28-CRP. Agreement was assessed using Bland-Altman plots.

RESULTS

Intrarater reliability was excellent with ICC of 0.87 (95% CI 0.83-0.90) and minimal detectable change of 1.13. ICC for interrater reliability ranged between 0.69 and 0.90 (good to excellent). Patients tended to rate DAS28-CRP slightly higher than HCP. In patients receiving repeated training, a mean difference in DAS28-CRP of -0.08 was observed (limits of agreements of -1.06 and 0.90). After 2 months, reliability between patients and HCP was similar between groups receiving single or repeated training.

CONCLUSION

Patient-performed assessments of joints and DAS28-CRP in an eHealth home-monitoring solution were reliable and comparable with HCP. Patients can acquire the necessary skills to conduct a correct joint assessment after initial and thorough training. [clinicaltrials.gov (NCT02317939)].

Swollen, but not tender joints, are independently associated with ultrasound synovitis: results from a longitudinal observational study of patients with established rheumatoid arthritis

Objectives

Joint swelling and tenderness are considered a proxy for inflammation in patients with rheumatoid arthritis (RA). With ultrasound-detected inflammation as reference, our objectives were to explore on patient and joint level the associations between ultrasound synovitis and joint swelling, tenderness and patient-reported joint pain (PRJP).

Methods

209 patients with established RA were examined six times during 12 months with assessment of 32 joints in upper/lower extremities for joint swelling/tenderness and Grey scale (GS)/power Doppler (PD) synovitis. PRJP was assessed on a manikin. Correlations between different sum scores were at each examination calculated using Spearman’s rho (r), agreement at joint level was examined by Cohen’s kappa and logistic regression models were used to explore the associations between joint assessment and GS/PD scores.

Results

At patient level, swollen joints were strongly correlated with GS/PD sum scores (r=0.64–0.88), while tender joints were primarily associated with PRJP (r=0.54–0.68). At joint level, GS/PD pathology had higher agreement with swelling (kappa 0.54–0.57) than tenderness (kappa 0.20–0.21) or PRJP (0.23–0.25). Higher percentages of joints were swollen according to increasing GS/PD scores, independently of joint tenderness. However, joints being tender, but not swollen, were not associated with GS/PD scores. Receiver operating curves showed swollen but not tender joints to be associated with GS/PD scores.

Conclusions

Swollen joints were strongly associated with ultrasound detected synovitis at both patient and joint level, while this association was not found for tender joints. These results may question if tender joints reflect ongoing inflammation in established RA.

Comorbidities in Patients with Rheumatoid Arthritis and Their Association with Patient-reported Outcomes: Results of Claims Data Linked to Questionnaire Survey

OBJECTIVE

To investigate the prevalence of comorbidities in a population-based cohort of persons with rheumatoid arthritis (RA) compared to matched controls and to examine their association with patient-reported outcomes in a survey sample.

METHODS

Data of 96,921 persons with RA [International Classification of Diseases, 10th ed (ICD-10) M05/M06] and 484,605 age- and sex-matched controls without RA of a German statutory health fund were studied regarding 26 selected comorbidities (ICD-10). A self-reported questionnaire, comprising joint counts [(tender joint count (TJC), swollen joint count (SJC)], functional status (Hannover Functional Ability Questionnaire), effect of the disease (Rheumatoid Arthritis Impact of Disease), and well-being (World Health Organization 5-item Well-Being Index; WHO-5) was sent to a random sample of 6193 persons with RA, of whom 3184 responded. For respondents who confirmed their RA (n = 2535), associations between comorbidities and patient-reported outcomes were analyzed by multivariable linear regression.

RESULTS

Compared to controls, all investigated comorbidities were more frequent in persons with RA (mean age 63 yrs, 80% female). In addition to cardiovascular risk factors, the most common were osteoarthritis (44% vs 21%), depression (32% vs 20%), and osteoporosis (26% vs 9%). Among the survey respondents, 87% of those with 0-1 comorbidity but only 77% of those with ≥ 8 comorbidities were treated by rheumatologists. Increasing numbers of comorbidities were associated with poorer values for TJC, SJC, function, and WHO-5.

CONCLUSION

Compared to a matched population, persons with RA present with increased prevalence of numerous comorbidities. Patients with RA and multimorbidity are at risk of insufficient rheumatological care and poorer patient-reported outcomes.

Prevalence and correlates of hepatitis C virus-associated inflammatory arthritis in a population-based cohort

OBJECTIVES

The objectives of this study were to determine the prevalence of hepatitis C virus-associated inflammatory arthritis, to describe its clinical and immunologic correlates, and to identify features that are characteristic of arthritis in chronic hepatitis C.

METHODS

Participants with chronic hepatitis C infection enrolled in a population-based cohort study in Alaska and who had not received anti-viral treatment for hepatitis C were recruited. In a cross-sectional study, we assessed joint symptoms and signs, performed autoantibody and cytokine testing, and abstracted medical records for features of hepatitis C and arthritis.

RESULTS

Of the 117 enrolled participants, 8 (6.8%) had hepatitis C-associated arthritis. The participants with arthritis were younger than those without (median age: 45 vs. 52, p = 0.02). Rheumatoid factor was commonly present among patients with hepatitis C-associated arthritis. The only studied autoantibody found more commonly in patients with HCV arthritis than those without arthritis was anti-nuclear antibody (63% vs. 23%, p = 0.026). The only joint symptom significantly more common in hepatitis C arthritis was self-reported joint swelling (75% vs. 26%, p = 0.007). Features of fibromyalgia were more common and functional status was worse in those with arthritis than those without. No cytokines differed in patients with and without arthritis. There were no associations of arthritis or autoantibodies with liver-related outcomes.

CONCLUSIONS

In this study of a cohort of individuals with chronic HCV infection, HCV-associated arthritis was present in less than 10%. Few serologic features distinguished participants with or without arthritis, but self-reported joint swelling was more common in those with arthritis.

The Association of Low Income with Functional Status and Disease Burden in German Patients with Rheumatoid Arthritis: Results of a Cross-sectional Questionnaire Survey Based on Claims Data

OBJECTIVE

To assess the influence of income on self-reported disease and work productivity outcomes.

METHODS

Persons with rheumatoid arthritis (RA) diagnosis (International Classification of Diseases, 10th ed. codes M05/M06) on health insurance claims data in at least 2 quarters of 2013 were randomly selected. They were mailed questionnaires covering RA diagnosis, household income, functional capacity [Hannover functional status questionnaire (FFbH), 0-100], RA Impact of Disease questionnaire (RAID; 0-10), self-reported swollen joint count (SJC; 0-48), tender joint count (TJC; 0-50), and effect of RA on work productivity (change of work, fewer working hours, sick leave, application for disability pension, and others). Weighted multivariable linear regression models were used to assess the association between income and disease outcomes.

RESULTS

A total of 1492 persons of working age who confirmed RA diagnosis were available for analysis. The mean age was 55 years, 82% were women, and 74% were under rheumatologic care. A total of 27%, 52%, and 21% had a low (< €1500), medium (€1500-3200), and high monthly income (> €3200), respectively. Respondents with low income had the worst mean FFbH, RAID, SJC, and TJC values. This was confirmed in the regression model: mean FFbH low versus high income -8.65 (95% CI -9.72 to -7.58), RAID 0.73 (0.59-0.86), and SJC 3.47 (2.86-4.08). Sick leave (8.7%/3.5%/1.8%) and disability pension (18.1%/9.6%/6.9%) were more frequent in patients with low versus medium versus high income (p < 0.05).

CONCLUSION

The association of low income with a higher disease burden, more functional disability, and higher rates of work loss emphasizes the need to focus on these outcomes when choosing treatment strategies for patients in the lower income groups.

Misalignment between physicians and patient satisfaction with psoriatic arthritis disease control

The main objective of the present study is to evaluate the misalignment between psoriatic arthritis (PsA) patient- and physician-reported satisfaction with PsA control. Data came from the Adelphi Rheumatology Disease Specific Programme, a retrospective, cross-sectional survey of US-based rheumatologists and patients. Physicians provided satisfaction and clinical characteristics on tender joint count, swollen joint count, and percent body surface area (BSA) affected by psoriasis. Patients provided data on satisfaction, the Work Productivity Activity Impairment and Health Assessment Questionnaire-Disability Index (HAQ-DI) questionnaires. Based on their satisfaction response, patient-physician pairs were classified into aligned (both satisfied or dissatisfied) or misaligned (rated satisfaction differently) groups. Multivariate analysis evaluated association of characteristics with misalignment. Among 305 paired patient-physician records analyzed, 23.6% were misaligned and 76.4% were aligned. The misaligned group had shorter disease duration (mean years, 5.2 vs. 6.4), used fewer biologic disease-modifying antirheumatic drugs (49.3 vs. 62.9%), had more swollen (mean, 3.7 vs. 1.9, P = 0.0002) and tender joints (mean, 5.6 vs. 2.9, P < 0.0001), greater proportion of patients with comorbidities (72.2 vs. 63.1%), and >3% BSA affected by psoriatic skin lesions (64.2 vs. 55.1%). Misaligned patients reported greater work impairment (mean, 38.7 vs. 21.4, P = 0.0004), daily activities (mean, 38.7 vs. 22.3, P < 0.0001), and higher disease burden (mean HAQ-DI; 0.56 vs. 0.37, P = 0.0001). Multivariate analysis found the number of swollen joints (P = 0.02) and HAQ-DI score (P = 0.03) was significantly associated with misalignment among all patients; however, not in the subgroup of employed patients. Patient-physician misalignment is associated with increased disease activity and disability among patients with PsA.

Discordance between patient and physician assessments of global disease activity in rheumatoid arthritis and association with work productivity

BACKGROUND

Discordance between patient and physician ratings of rheumatoid arthritis (RA) severity occurs in clinical practice and correlates with pain scores and measurements of joint disease. However, information is lacking on whether discordance impacts patients' ability to work. We evaluated the discordance between patient and physician ratings of RA disease activity before and after treatment with etanercept and investigated the associations between discordance, clinical outcomes, and work productivity.

METHODS

In the PRESERVE clinical trial, patients with moderate RA received open-label etanercept 50 mg once weekly plus methotrexate for 36 weeks. Baseline and week-36 disease characteristics and clinical and work productivity outcomes were categorized according to week-36 concordance category, defined as positive discordance (patient global assessment - physician global assessment ≥2), negative discordance (patient global assessment - physician global assessment ≤ -2), and concordance (absolute difference between the two disease activity assessments = 0 or 1). Correlations between discordance, clinical outcomes, and predictors of discordance were determined.

RESULTS

At baseline, 520/762 (68.2 %) patient and physician global assessment scores were concordant, 194 (25.5 %) were positively discordant, and 48 (6.3 %) were negatively discordant. After 36 weeks of therapy, 556/763 (72.9 %) scores were concordant, 189 (24.8 %) were positively discordant, and 18 (2.4 %) were negatively discordant. Patients with week-36 concordance had the best 36-week clinical and patient-reported outcomes, and overall, the greatest improvement between baseline and week 36. Baseline pain, swollen joint count, duration of morning stiffness, fatigue, and patient general health significantly correlated with week-36 discordance, p < 0.0001 to p < 0.05. Additionally, baseline pain, patient general health, and C-reactive protein were predictors of week-36 discordance (odds ratios 1.22, 1.02, and 0.98, respectively). For the employed patients, percent impairment while working and percent overall work impairment were highest (greatest impairment) at baseline and 36 weeks in the group with positive discordance.

CONCLUSIONS

The percentage of patients with concordance increased after 36 weeks of treatment with etanercept, with concordant patients demonstrating the greatest improvement in clinical and patient-reported outcomes. Discordance correlated with several measures of disease activity and was associated with decreased work productivity.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00565409 . Registered 28/11/2007.

Validity and reliability of the Patient-Reported Arthralgia Inventory: validation of a newly-developed survey instrument to measure arthralgia

Background

There is a need for a survey instrument to measure arthralgia (joint pain) that has been psychometrically validated in the context of existing reference instruments. We developed the 16-item Patient-Reported Arthralgia Inventory (PRAI) to measure arthralgia severity in 16 joints, in the context of a longitudinal cohort study to assess aromatase inhibitor-associated arthralgia in breast cancer survivors and arthralgia in postmenopausal women without breast cancer. We sought to evaluate the reliability and validity of the PRAI instrument in these populations, as well as to examine the relationship of patient-reported morning stiffness and arthralgia.

Methods

We administered the PRAI on paper in 294 women (94 initiating aromatase inhibitor therapy and 200 postmenopausal women without breast cancer) at weeks 0, 2, 4, 6, 8, 12, 16, and 52, as well as once in 36 women who had taken but were no longer taking aromatase inhibitor therapy.

Results

Cronbach’s alpha was 0.9 for internal consistency of the PRAI. Intraclass correlation coefficients of test-retest reliability were in the range of 0.87–0.96 over repeated PRAI administrations; arthralgia severity was higher in the non-cancer group at baseline than at subsequent assessments. Women with joint comorbidities tended to have higher PRAI scores than those without (estimated difference in mean scores: −0.3, 95% confidence interval [CI] −0.5, −0.2; P<0.001). The PRAI was highly correlated with the Functional Assessment of Cancer Therapy-Endocrine Subscale item “I have pain in my joints” (reference instrument; Spearman r range: 0.76–0.82). Greater arthralgia severity on the PRAI was also related to decreased physical function (r=−0.47, 95% CI −0.55, −0.37; P<0.001), higher pain interference (r=0.65, 95% CI 0.57–0.72; P<0.001), less active performance status (estimated difference in location (−0.6, 95% CI −0.9, −0.4; P<0.001), and increased morning stiffness duration (r=0.62, 95% CI 0.54–0.69; P<0.0001).

Conclusion

We conclude that the psychometric properties of the PRAI are satisfactory for measuring arthralgia severity.

Impact of patient programs on adherence and persistence in inflammatory and immunologic diseases: a meta-analysis

OBJECTIVES

Patient adherence and persistence is important to improve outcomes in chronic conditions, including inflammatory and immunologic (I&I) diseases. Patient programs that aim at improving medication adherence or persistence play an essential role in optimizing care. This meta-analysis assessed the effectiveness of patient programs in the therapeutic area of I&I diseases.

METHODS

A global systematic literature review was conducted with inclusion criteria of: patient programs in I&I diseases; published in English language between January 2008 and September 2013; and reporting measures of adherence or persistence, including medication possession ratio >80% and persistence rate. A meta-analysis was performed using a random effects model. Subgroup analyses based on the type of program was performed whenever feasible.

RESULTS

Of 67 studies reviewed for eligibility, a total of 17 studies qualified for inclusion in the meta-analysis. Overall, patient programs increased adherence (odds ratio [OR]=2.48, 95% confidence interval [CI]=1.68-3.64, P<0.00001) as compared with standard of care. Combination patient programs that used both informational and behavioral strategies were superior in improving adherence (OR=3.68, 95% CI=2.20-6.16, P<0.00001) compared with programs that used only informational (OR=2.16, 95% CI=1.36-3.44, P=0.001) or only behavioral approaches (OR=1.85, 95% CI=1.00-3.45, P=0.05). Additionally, patients were more likely to be persistent (OR=2.26, 95% CI=1.16-4.39, P=0.02) in the intervention group as compared with the control group. Persistence (in days) was significantly (P=0.007) longer, by 42 additional days, in the intervention group than in the control group.

CONCLUSIONS

Patient programs can significantly improve adherence as well as persistence in the therapeutic area of I&I diseases. Programs employing a multimodal approach are more effective in improving adherence than programs with informational or behavioral strategies alone. This in turn may improve patient outcomes.

Patient-reported Joint Count in Juvenile Idiopathic Arthritis: The Reliability of a Manikin Format

Objective.

To evaluate the reliability of a manikin format, patient-reported joint count in juvenile idiopathic arthritis (JIA), and to detect changes in agreement at a second visit.

Methods.

Patients with JIA aged 12–21 were asked to mark joints with active arthritis on a manikin before their regular clinic visit. The physician then performed a joint count without having seen the patient’s assessment. Agreement between scores of physician-reported and patient-reported joint counts was assessed using ICC. Kappa statistics were used to assess reliability of scoring individual joints.

Results.

The study included 75 patients with JIA. In general, patients had a low number of active joints (median 1 joint, indicated by the physician). ICC was moderate (0.61) and κ ranged from 0.3–0.7. At the second visit, κ were similar; the ICC was 0.19. When a patient scored 0 joints, the physician confirmed this 93%–100% of the time. When the patient marked ≥ 1 joints, the physician confirmed arthritis 59%–76% of the time. Sensitivity to change was moderate.

Conclusion.

Agreement between physician and patient on the number of joints with active arthritis was reasonable. Untrained patients tended to overestimate the presence of arthritis when they marked active joints on a manikin-format joint count. When the patient indicated absence of arthritis, the physician usually confirmed this. As the agreement did not improve at followup, future research should focus on the possibility of achieving this through training. For now, the patient-reported joint count cannot replace the physicians’ joint count in clinical practice; it may be used in epidemiological studies with caution.

Comprehensive arthritis referral study -- phase 2: analysis of the comprehensive arthritis referral tool

OBJECTIVE

Rheumatologists triage referrals to assess those patients who may benefit from early intervention. We describe a referral tool and formally evaluate its sensitivity for urgent and early inflammatory arthritis (EIA) referrals.

METHODS

All referrals received on a standardized referral tool were reviewed by a rheumatologist and, based on the information conferred, assigned a triage grade using a previously described triage system. Each referral was also dichotomized as suspected EIA or not. After the initial rheumatologic assessment, the diagnosis was recorded and a consultation grade, blinded to referral grade, was assigned to each case. Agreement between referral and consultation grades was assessed. A regression analysis was performed to determine factors that predicted truly urgent referrals including EIA.

RESULTS

We evaluated 696 referrals. A total of 210 (30.2%) were categorized as urgent at the time of consultation. The referral tool was able to successfully detect 169 of these referrals (sensitivity 80.5%, specificity 79.4%). EIA occurred in 95 (13.6%); of those referrals, 86 were correctly classified as urgent at the time of triage (sensitivity 90.5%, specificity 69.6%). Items that helped correctly discriminate urgent or EIA referrals included patient age < 60, duration of disease, morning stiffness, patient-reported joint swelling, a personal or family history of psoriasis, urgency as rated by referring physician, prior assessment by a rheumatologist, elevated C-reactive protein, and a positive rheumatoid factor.

CONCLUSION

A 1-page referral tool that includes parts completed by the referring physician and patient has good sensitivity to detect urgent referrals including EIA.

Is tightly controlled disease activity possible with online patient-reported outcomes?

OBJECTIVE

To evaluate the performance of patient-reported outcomes (PRO) as primary indices for identification and prediction of a 28-joint Disease Activity Score (DAS28)>3.2 among patients with rheumatoid arthritis (RA).

METHODS

Patients with RA completed monthly online PRO [Health Assessment Questionnaire (HAQ), Rheumatoid Arthritis Disease Activity Index (RADAI), visual analog scale (VAS) fatigue] and were clinically assessed every 3 months using the DAS28. Simple descriptive statistics, logistic regression, and the Bayesian joint modeling approach were used to analyze the data. The Bayesian joint model combines the scores and changes in the scores of 3 PRO to predict a DAS28>3.2 at the subsequent timepoint.

RESULTS

A group of 159 patients with RA participated. Stratified summaries of the PRO by DAS28 categories at baseline provided incremental values of the PRO for more active disease. However, on an individual level, the DAS28 and the PRO fluctuated over time. The prediction of subsequent DAS score by a single instrument at single timepoints resulted in moderate sensitivity and specificity. Using the intercept and slope of the combined PRO of the first 3 measurements to predict the DAS28 state at 3 months resulted in a sensitivity of 0.81 and a specificity of 0.92. After 10-fold cross validation, the model had a sensitivity of 0.61 and specificity of 0.75 to identify patients with a DAS28>3.2.

CONCLUSION

PRO showed fluctuating levels of disease activity over time, while on a group level disease activity stayed the same. Using the changes in RADAI, HAQ, and VAS fatigue over time to predict future DAS28>3.2 resulted in moderate performance after the internal cross-validation of the model (sensitivity 0.61, specificity 0.75).

Assessment of disease activity by patients with juvenile idiopathic arthritis and the parents compared to the assessment by pediatric rheumatologists

BACKGROUND

Self assessment of arthritis is important for recognition of disease activity and early initiation of therapy. Proper interpretation of physical symptoms is necessary for this. The purpose was to investigate the assessment by patients and parents of disease activity in juvenile idiopathic arthritis (JIA) and to compare their assessments to rheumatologists' assessments.

METHODS

Patients and parents assessed 69 joints on a paper homunculus and marked each joint with a different color according to presumed presence of disease: active disease (AD), doubt, and non-active disease (NAD). Their assessments were compared to the rheumatologists' assessments. If patients and/or parents marked an inflamed joint, it counted as AD. Pain, functional impairment, and disease duration were analyzed to differentiate more precise between true and false positive and true and false negative assessments.

RESULTS

We collected assessments of 113 patients and/or parents. AD was assessed 54 times, 33 of which were true positives. NAD was assessed 23 times, 22 of which were true negatives. Doubt was expressed 36 times, 9 of which were assessed by the rheumatologist as AD. Sensitivity and specificity of AD was 0.77 and 0.31. Pain and functional impairment scored highest in AD, intermediate in doubt, and lowest in NAD.

CONCLUSION

Patients and/or parents seldom missed arthritis but frequently overestimated disease activity. Pain, functional impairment, disease duration, gender, and age did not differentiate between true and false positives for. Patients perceived JIA as active if they experienced pain and functional impairment. To reduce overestimation of the presence of AD we need to improve their understanding of disease activity by teaching them to distinguish between primary symptoms of JIA and symptoms like pain and functional impairment.

Reliability of joint count assessment in rheumatoid arthritis: a systematic literature review

BACKGROUND

Joint counts are central to the assessment of rheumatoid arthritis (RA) but reliability is an issue.

OBJECTIVES

To evaluate the reliability and agreement of joint counts (intra-observer and inter-observer) by health care professionals (physicians, nurses, and metrologists) and patients in RA, and the impact of training and standardization on joint count reliability through a systematic literature review.

METHODS

Articles reporting joint count reliability or agreement in RA in PubMed, EMBase, and the Cochrane library between 1960 and 2012 were selected. Data were extracted regarding tender joint counts (TJCs) and swollen joint counts (SJCs) derived by physicians, metrologists, or patients for intra-observer and inter-observer reliability. In addition, methods and effects of training or standardization were extracted. Statistics expressing reliability such as intraclass correlation coefficients (ICCs) were extracted. Data analysis was primarily descriptive due to high heterogeneity.

RESULTS

Twenty-eight studies on health care professionals (HCP) and 20 studies on patients were included. Intra-observer reliability for TJCs and SJCs was good for HCPs and patients (range of ICC: 0.49-0.98). Inter-observer reliability between HCPs for TJCs was higher than for SJCs (range of ICC: 0.64-0.88 vs. 0.29-0.98). Patient inter-observer reliability with HCPs as comparators was better for TJCs (range of ICC: 0.31-0.91) compared to SJCs (0.16-0.64). Nine studies (7 with HCPs and 2 with patients) evaluated consensus or training, with improvement in reliability of TJCs but conflicting evidence for SJCs.

CONCLUSION

Intra- and inter-observer reliability was high for TJCs for HCPs and patients: among all groups, reliability was better for TJCs than SJCs. Inter-observer reliability of SJCs was poorer for patients than HCPs. Data were inconclusive regarding the potential for training to improve SJC reliability. Overall, the results support further evaluation for patient-reported joint counts as an outcome measure.

Chronic widespread pain in patients with rheumatoid arthritis and the relation between pain and disease activity measures over the first 5 years

OBJECTIVE

To study the prevalence of chronic widespread pain (ChWP), chronic regional pain (ChRP), and fibromyalgia in patients with early rheumatoid arthritis (RA) followed for 5 years after inclusion, and to study the effect of pain on measures of disease activity and function.

METHODS

A questionnaire was sent to 1910 patients participating in the Better Anti-Rheumatic Pharmacotherapy study. The responders (73%) were divided into 3 groups according to the reported pain duration and distribution - patients having no chronic pain (NChP), ChWP, and ChRP. Outcome measures were the 28-joint Disease Activity Score (DAS28), the Health Assessment Questionnaire (HAQ), and C-reactive protein (CRP).

RESULTS

Thirty-four percent of respondents reported ChWP, 46% ChRP, and 20% NChP. Patients reporting ChWP were more often women and had more pain and tender joints at inclusion. From 6 months to 5 years of followup, mean DAS28, visual analog scale (VAS) pain, VAS global health, and HAQ were significantly higher in the ChWP group than in the other groups. However, all groups showed a similar pattern in swollen joint count, erythrocyte sedimentation rate (ESR), and CRP. From 12 months the ChWP group was treated with prednisolone to a greater extent than the ChRP group, and it had a rate of treatment with disease-modifying antirheumatic drugs similar to that of the ChRP group.

CONCLUSION

ChWP is a common feature in RA, more associated with high values for variables related to pain such as the DAS28 and HAQ than to indicators of ongoing inflammation such as swollen joint count, ESR, and CRP. Patients with ChWP should be identified so that adequate treatment also of the noninflammatory pain may be instituted.

Test-retest reliability of the disease activity score 28 CRP (DAS28-CRP), the simplified disease activity index (SDAI) and the clinical disease activity index (CDAI) in rheumatoid arthritis when based on patient self-assessment of tender and swollen joints

Composite disease activity scores are frequently used in daily practice as tools for treatment decisions in patients with rheumatoid arthritis (RA). If reliable, patient-reported disease activity may be time saving in the busy clinic. The objective was to examine the test-retest reliability of the Disease Activity Score 28 CRP (DAS28-CRP) with four variables (4v) and three variables (3v), the Simplified Disease Activity Index (SDAI) and the Clinical Disease Activity Index (CDAI) when based on patient self-assessment of tender and swollen joints and to examine the agreement between these scores and physician-derived scores. Thirty out-clinic RA patients with stable disease were included. A joint count was performed two times 1 week apart by the patient and by an experienced physician. Test-retest reliability was expressed as the least significant difference (LSD), as the LSD in percent of the mean score (%LSD) and as intra-individual coefficients of variation (CVi). Mean scores based on physician vs. patient joint counts (visit 1) were: DAS28-CRP(4v) 3.5 ± 1.0 vs. 3.6 ± 1.1 (not significant (NS)), DAS28-CRP(3v) 3.4 ± 0.9 vs. 3.5 ± 0.9 (NS), SDAI 14.2 ± 9.4 vs.14.1 ± 9.4 (NS) and CDAI 13.4 ± 9.3 vs. 13.3 ± 9.4 (NS). The LSDs (%LSD) for duplicate assessments of patient-derived scores (visit 2 vs. 1) were: DAS28-CRP(4v) 0.8 (23.2), DAS28-CRP(3v) 0.9 (25.2), SDAI 8.3 (59.9) and CDAI 8.4 (63.8). Similar LSDs were found for differences between duplicate assessments of physician-derived scores and for differences between physician and patient-derived scores. CVis for SDAI and CDAI were significantly higher than for DAS28-CRP(4v) and DAS28-CRP(3v) (p < 0.005). Patient- and physician-derived scores agreed closely on group level. On the individual level, the LSDs between patient- and physician-derived scores were considerable but corresponded to both patient and physician intra-observer LSDs. Thus, scores based on patient-performed joint counts may be an alternative to traditional physician-derived scores in patients with stable disease.

Swedish version of the multi dimensional health assessment questionnaire -- translation and psychometric evaluation

BACKGROUND

Health assessment measurements for patients with Rheumatoid arthritis (RA) have to be meaningful, valid and relevant. A commonly used questionnaire for patients with RA is the Stanford Health Assessment Questionnaire Disability Index (HAQ), which has been available in Swedish since 1988. The HAQ has been revised and improved several times and the latest version is the Multi Dimensional Health Assessment Questionnaire (MDHAQ). The aim of this study was to translate the MDHAQ to Swedish conditions and to test the validity and reliability of this version for persons with RA.

METHODS

Translation and adaption of the MDHAQ were performed according to guidelines by Guillemin et al. The translated version was tested for face validity and test-retest in a group of 30 patients with RA. Content validity, criterion validity and internal consistency were tested in a larger study group of 83 patients with RA. Reliability was tested with test-retest and Cronbach´s alpha for internal consistency. Two aspects of validity were explored: content and criterion validity. Content validity was tested with a content validity index.Criterion validity was tested with concurrent validity by exploring the correlation between the MDHAQ-S and the AIMS2-SF. Floor and ceiling effects were explored.

RESULTS

Test-retest with intra-class correlation coefficient (ICC) gave a coefficient of 0.85 for physical function and 0.79 for psychological properties. Reliability test with Cronbach´s alpha gave an alpha of 0.65 for the psychological dimension and an alpha of 0.88 for the physical dimension of the MDHAQ-S.The average sum of the content validity index for each item was of the MDHAQ-S was 0.94. The MDHAQ-S had mainly a moderate correlation with the AIMS2-SF, except for the social dimension of the AIMS2-SF, which had a very low correlation with the MDHAQ-S.

CONCLUSIONS

The MDHAQ-S was considered to be reliable and valid, but further research is needed concerning sensitivity to change.

Differences in activity limitation, pain intensity, and global health in patients with rheumatoid arthritis in Sweden and the USA: a 5-year follow-up

OBJECTIVE

In this study we compared activity limitations, pain intensity, and global health in patients with rheumatoid arthritis (RA) in Sweden and the USA and aimed to determine whether nationality is associated with these outcomes.

METHODS

We used longitudinal data from the 'Swedish TIRA project' (n = 149) and the University of California, San Francisco (UCSF) RA panel study (n = 85). Data were collected annually concerning use of medications [disease-modifying anti-rheumatic drugs (DMARDs), biologics, and corticosteroids], morning stiffness, number of swollen joints, and number of painful joints. Three self-reported outcome measures were examined: pain intensity measured on a 0-100 visual analogue scale (VAS), activity limitation according to the Health Assessment Questionnaire (HAQ), and global health. To analyse the data, the Student's t-test, the χ(2)-test, and the generalized estimating equation (GEE) method were used.

RESULTS

Nationality was significantly related to HAQ score and pain intensity, even after adjustment for covariates. The patients in the TIRA cohort reported a lower HAQ score and a higher pain intensity than the patients in the UCSF cohort. Nationality was not related to global health.

CONCLUSION

Patients with RA should be assessed with awareness of the psychosocial and cultural context because disability seems to be affected by nationality. Further knowledge to clarify how a multinational setting affects disability could improve the translation of interventions for patients with RA across nationalities.