Proposed Severity and Response Criteria for Routine Assessment of Patient Index Data (RAPID3): Results for Categories of Disease Activity and Response Criteria in Abatacept Clinical Trials

A snapshot of primary care physiotherapy management of knee osteoarthritis in an Australian setting: does it align with evidence-based guidelines?

BACKGROUND

Systematic implementation of evidence-based, clinical practice guidelines for management of knee osteoarthritis (OA) in primary care physiotherapy in Australia is embryonic. Clinical practice guidelines have been implemented in the public healthcare sector at a State-level for physiotherapists in the form of multidisciplinary programs, but the reach of physiotherapy-led OA management programs is grossly inadequate in the private sector.

OBJECTIVE

To provide a snapshot of the management of people with knee OA in private physiotherapy practice in an Australian setting. Primarily the aim was to determine the alignment between the treatment provided and guideline-based management. Secondary aims included the capture of both patient-reported improvement after 3-months and patient satisfaction with treatment. Whether patient-reported outcome measures (PROMS) were routinely used was also ascertained.

METHODS

A prospective, observational study enrolling adults >=45 years with knee OA across nine primary care physiotherapy practices. Knee injury OA Outcome Score (KOOS) and Routine Assessment Patient Index 3 (RAPID3) were collected (baseline; 3 months) by researchers along with satisfaction with treatment. Treatment details and use of PROMS were obtained from physiotherapy record audit and patient interview. The treatment provided was compared to the minimum core elements of management stipulated in OA management guidelines.

RESULTS

Twenty-six adults (58% female, mean age 60 (9) years, 54% overweight or obese) participated. 100% were prescribed ≥1 appropriate exercise(s); 42% received OA education; 12% received weight management advice. Mean improvement (95%CI) in KOOS Pain was 9.8 (3.4 to 16.1) and RAPID3 was -3.4 (-5.5 to -1.3). Satisfaction with treatment was high (8.3/10). No PROMs were used for assessment or monitoring.

CONCLUSION

Primary care physiotherapy treatment of knee OA did not meet minimum criteria per clinical practice guidelines. However, participant improvement at three months reached minimally important change thresholds for patient-reported measures and satisfaction was high. The data provide useful insights about areas that are deficient, thus, should inform future implementation strategies designed to improve care delivery and the uptake of routine measurement of patient-reported outcomes.

Integrating PROMIS Measures in a Treat-to-Target Approach to Standardize Patient-Centered Treatment of Rheumatoid Arthritis

OBJECTIVE

To evaluate the effect of a patient-centered rheumatoid arthritis (RA) treat-to-target (T2T) disease management approach on patient outcomes and patient satisfaction with care.

METHODS

In this longitudinal, observational pilot study, rheumatologists implemented a modified T2T approach that integrated Patient Reported Outcomes Measurement Information System (PROMIS) measures for depression, fatigue, pain interference, physical function, and social function into RA care. Study participants selected 1 PROMIS domain to target treatment and completed quarterly follow-up assessments. Participants were classified as improved if their Clinical Disease Activity Index (CDAI) changed by > 5 points. Change in PROMIS t scores was examined for the group with improved CDAI, and then compared to those with unchanged or worsened CDAI. Satisfaction with care was assessed using multiple measures, including the Functional Assessment of Chronic Illness Therapy-Treatment Satisfaction-Patient Satisfaction Scale.

RESULTS

The analytical sample (n = 119, median age 57 years, 90.8% female) was split between those with CDAI > 10 (n = 63) and CDAI ≤ 10 (n = 53). At 1 year, there was improvement in CDAI by > 5 points in 66% and 13% of individuals with baseline CDAI > 10 and baseline CDAI ≤ 10, respectively. Across all participants, improvement in CDAI by > 5 points correlated with improvements in the 5 PROMIS domains. Satisfaction with RA treatment also increased.

CONCLUSION

The integration of PROMIS measures into the T2T approach for RA care was associated with improvements in disease activity, and improvement in disease activity was associated with improvements in PROMIS measures.

Patient Reported Outcome Measures for Rheumatoid Arthritis Disease Activity: a systematic review following COSMIN guidelines

BACKGROUND

The current standard of care in rheumatoid arthritis (RA) requires regular assessment of disease activity (DA). All standard RA DA measurement instruments require joint counts to be undertaken by a healthcare professional with/without a blood test. Few healthcare providers have the capacity to assess patients as frequently as stipulated by guidelines. Patient Reported Outcome Measures (PROMs) could be an efficient and informative way to assess RA DA, which is highlighted by the SARS-COV-2 pandemic, as most consultations are remote rather than face-to-face. We aimed to assess all PROMs for RA DA against the internationally recognised COSMIN guidelines to provide evidence-based recommendations to select the most suitable PROMs.

METHODS

Review registered on PROSPERO as CRD42020176176. The search strategy was based on a previous similar systematic review and expanded to include all articles up to January 2019. All identified articles were rated by two independent assessors following the COSMIN guidelines.

RESULTS

668 abstracts were identified, with 10 articles included. A further 21 were identified from a previous review. Ten PROMs were identified. There was insufficient evidence to place any of the identified PROMs into recommendation for use category A due to lack of evidence for content validity, as stipulated by the COSMIN guidelines.

CONCLUSION

Lack of evidence of content validity limits suitable PROM selection, therefore none can be recommended for use. It is acknowledged that all included PROMs were developed before the COSMIN guidelines were published. Future research on PROMs for RA DA must provide evidence of content validity.

A Self-Report Multidimensional Health Assessment Questionnaire (MDHAQ) for Face-To-Face or Telemedicine Encounters to Assess Clinical Severity (RAPID3) and Screen for Fibromyalgia (FAST) and Depression (DEP)

Purpose of Review

To update the clinical value of a patient self-report multidimensional health assessment questionnaire (MDHAQ).

Recent Findings

The MDHAQ includes 10 individual quantitative scores for physical function, pain, patient global assessment, fatigue, sleep, anxiety, depression, morning stiffness, change in status, and exercise status, and 5 indices, RAPID3 (routine assessment of patient index data) to assess clinical status in all diseases studied, FAST3 (fibromyalgia assessment screening tool) and MDHAQ-Dep (depression) to screen for fibromyalgia and/or depression, RADAI self-report of specific painful joints and joint count, and a symptom checklist for review of systems, and recognition of flares and medication adverse events. The MDHAQ also uniquely queries traditional “medical” information concerning comorbidities, falls, trauma, new symptoms, illnesses, surgeries, hospitalizations, emergencies, medication changes, and medication side effects. Three MDHAQ versions include long for new patients, short for new and return patients, and telemedicine. An electronic MDHAQ (eMDHAQ) has been developed with software that can interface with any electronic medical record (EMR) through the HL7 FHIR standard. However, EMR collaboration and implementation have proven difficult.

Summary

An MDHAQ provides a quantitative overview of patient status with far more information and documentation than an interview, involving minimal extra work for the physician.

Patient-Reported Outcomes in Lupus

Patient-reported outcome (PRO) was identified as a core systemic lupus erythematosus (SLE) outcome in 1999. More than 20 years later, however, generic PRO measures evaluating impact in SLE are used mainly for research. Generic and disease-targeted PRO tools have unique advantages. Significant progress in identification of patient disease-relevant PRO concepts and development of new PRO tools for SLE has occurred over the past 20 years. Further research needs to focus on responsiveness and minimally important differences of existing, promising PRO tools to facilitate their use in SLE patient care and research.

Impact of assessing patient-reported outcomes with mobile apps on patient-provider interaction

OBJECTIVE

To explore the effect of apps measuring patient-reported outcomes (PROs) on patient-provider interaction in the rheumatic diseases in an observational setting.

METHODS

Patients in the Swiss Clinical Quality Management in Rheumatic Diseases Registry were offered mobile apps (iDialog and COmPASS) to track disease status between rheumatology visits using validated PROs (Rheumatoid Arthritis Disease Activity Index-5 score, Bath Ankylosing Spondylitis Disease Activity Index score, Routine Assessment of Patient Index Data-3 score and Visual Analogue Scale score for pain, disease activity and skin symptoms). We assessed two aspects of patient-provider interaction: shared decision making (SDM) and physician awareness of disease fluctuations. We used logistic regressions to compare outcomes among patients who (1) used an app and discussed app data with their physician (app+discussion group), (2) used an app without discussing the data (app-only group) or (3) did not use any app (non-app users).

RESULTS

2111 patients were analysed, including 1799 non-app users, 150 app-only users and 162 app+discussion users (43% male; with 902 patients with rheumatoid arthritis, 766 patients with axial spondyloarthritis and 443 patients with psoriatic arthritis). App users were younger than non-app users (mean age of 47 vs 51 years, p<0.001). Compared with non-app users, the app+discussion group rated their rheumatologist more highly in SDM (OR 1.7, 95% CI 1.1 to 2.4) and physician awareness of disease fluctuations (OR 2.0, 95% CI 1.3 to 3.1). This improvement was absent in the app-only group.

CONCLUSION

App users who discussed app data with their rheumatologist reported more favourably on patient-provider interactions than app users who did not and non-app users. Apps measuring PROs may contribute little to patient-provider interactions without integration of app data into care processes.

Rheumatoid Arthritis: Defining Clinical and Ultrasound Deep Remission

The prognosis of patients with rheumatoid arthritis (RA) has improved substantially in the last two decades due to the appearance of biological therapies, but above all, due to the improvement in the strategy and management of the disease. Our goal in RA should be to achieve remission, or in its absence, the lowest inflammatory activity. Achieving remission will prevent from structural and functional damage highly associated with RA itself. Clinical remission is defined as the absence of significant signs and symptoms of inflammatory disease activity, as well as the abrogation of any signs of systemic inflammation. Currently, there are some controversies about remission. Which is the real remission? Which remission criteria should be used and when? Does clinical remission mean ultrasound remission? In the present review, we try to answer and put some light into it, focusing on clinical and ultrasound deep remission.

Multidimensional Health Assessment Questionnaire as an Effective Tool to Screen for Depression in Routine Rheumatology Care

OBJECTIVE

To analyze the use of the Multidimensional Health Assessment Questionnaire (MDHAQ) to screen for depression, as compared to 2 reference standards, the Patient Health Questionnaire 9 (PHQ-9) and the Hospital Anxiety and Depression Scale depression domain (HADS-D).

METHODS

Patients from Barcelona with a primary diagnosis of rheumatoid arthritis (RA) or spondyloarthritis (SpA) completed the MDHAQ, the PHQ-9 (depression ≥10), and the HADS-D (depression ≥8) measures. The MDHAQ includes 2 depression items, 1 in the patient-friendly HAQ, scored in a 4-point format from 0 to 3.3, and a yes/no item on a 60-symptom checklist. Percentage agreement and kappa statistics quantified the agreement between 6 screening criteria: yes on the 60-symptom checklist, a score of ≥1.1, a score of ≥2.2 on a 4-point scale, and either a response of yes on the 60-symptom checklist or scores of ≥2.2, PHQ-9 ≥10, and HADS-D ≥8.

RESULTS

Depression screening was positive according to 6 criteria in 19.6-32.4% of 102 patients with RA, and 27.9-44.8% of 68 with SpA (total = 170). All MDHAQ scores, including depression items, were higher in patients with SpA compared to patients with RA, and within each diagnostic group in patients who met PHQ-9 ≥10 and HADS-D ≥8 depression screening criteria. The highest percentage agreement between an MDHAQ screening criterion versus PHQ-9 ≥10 was 83.3% for either an answer of yes on the 60-symptom checklist or a score of ≥2.2 on a 4-point scale, which we have termed MDHAQ-Dep. The agreement of MDHAQ-Dep versus HADS-D ≥8 was 81.7%, similar to the agreement of PHQ-9 ≥10 versus HADS-D ≥8, which was 82.2%. Kappa measures of agreement were 0.63 for MDHAQ-Dep versus PHQ-9 ≥10, 0.60 for MDHAQ-Dep versus HADS-D ≥8, and 0.62 for PHQ-9 ≥10 versus HADS-D ≥8.

CONCLUSION

A positive MDHAQ-Dep response (either an answer of yes on a 60-symptom checklist or a score of ≥2.2 on a 4-point scale) yielded similar results to PHQ-9 ≥10 or HADS-D ≥8 to screen for depression in these RA and SpA patients.

Changes in Alcohol Use and Associations With Disease Activity, Health Status, and Mortality in Rheumatoid Arthritis

OBJECTIVE

Better disease activity and quality of life have been observed among patients with rheumatoid arthritis (RA) who drink alcohol. This association might be explained by reverse causality. We undertook this study to identify predictors of change in alcohol use and to evaluate independent associations between alcohol use and RA activity and mortality.

METHODS

Participants in Forward, The National Databank for Rheumatic Diseases, were asked about alcohol use (any versus none), and disease activity was collected through the Patient Activity Scale-II (PAS-II) on semiannual surveys. We identified factors associated with changes in alcohol use and determined associations between alcohol use and disease activity and mortality using linear and logistic regression models, Cox proportional hazards models, and marginal structural models.

RESULTS

A total of 121,280 observations were studied among 16,762 unique participants. Discontinuation and initiation of alcohol were common among drinkers and abstainers (8.2% and 9.2% of observations, respectively). Greater discontinuation and less initiation were observed with greater disease activity, older age, female sex, nonwhite race, obesity, greater comorbidity, low quality of life, low educational level, low income, and work disability. While alcohol users had lower PAS-II (β = -0.15 [95% confidence interval (95% CI) -0.18, -0.11], P < 0.001) and a lower mortality (odds ratio 0.87 [95% CI 0.76, 0.98], P = 0.03) in traditional models, associations were not seen in marginal structural models.

CONCLUSION

Higher disease activity, disability, comorbidity, and poor quality of life contribute to reductions in alcohol use. Active use and changes in use were not associated with disease activity or mortality when adjusting for confounding, suggesting no clear benefit of alcohol consumption in RA.

Minimal Clinically Important Improvement of Routine Assessment of Patient Index Data 3 in Rheumatoid Arthritis

OBJECTIVE

To estimate minimal clinically important improvement (MCII) of RAPID-3 (Routine Assessment of Patient Index Data 3) in rheumatoid arthritis (RA).

METHODS

RAPID-3 was computed before and after treatment escalation in a prospective study of adults with active RA. Patient judgment of improvement was used as the standard for a receiver-operating characteristic curve, from which MCII was estimated.

RESULTS

Mean RAPID-3 improved from 16.3 to 11.1 between visits. MCII was -3.8 based on simultaneously optimized sensitivity and specificity, -3.5 using the 0.80 specificity criterion, and -4.1 using the Youden index.

CONCLUSION

RAPID-3 improvement of 3.8/30 units appears clinically meaningful.

A somatization comorbidity phenotype impacts response to therapy in rheumatoid arthritis: post-hoc results from the certolizumab pegol phase 4 PREDICT trial

Background

Comorbidities may contribute to disease activity and treatment response in rheumatoid arthritis (RA) patients. We defined a somatization comorbidity phenotype (SCP) and examined its influence on response to certolizumab pegol (CZP) using data from the PREDICT trial.

Methods

Patients in PREDICT were randomized to the patient-reported Routine Assessment of Patient Index Data 3 (RAPID3) or physician-based Clinical Disease Activity Index (CDAI) for treatment response assessment. Post-hoc analyses identified patients with the SCP, which included diagnosis of depression, fibromyalgia/myalgias, and/or use of medications indicated for treatment of depression, anxiety, or neuropathic pain. The effect of the SCP on RAPID3 or CDAI response at week 12 and low disease activity (LDA; Disease Activity Score in 28 joints based on erythrocyte sedimentation rate ≤ 3.2) at week 52, in week-12 responders, was analyzed using non-parametric analysis of covariance (ANCOVA).

Results

At baseline, 43% (313/733) of patients met the SCP classification. Patients with the SCP were 9% more likely to withdraw from the trial. American College of Rheumatology 20% (ACR20), ACR50, and ACR70 responses were 5–14% lower among those with the SCP, and 11% more patients reported adverse events (AEs). Patients without SCP in the CDAI arm were twice as likely to achieve LDA at week 52 compared with those with SCP (32% versus 16%). No differentiation by SCP was observed in the RAPID3 arm (pooled result 21.5%).

Conclusions

We operationalized a potentially important somatization comorbidity phenotype in a trial setting that was associated with a substantially lower likelihood of treatment response and a higher frequency of AEs. Including large numbers of patients with this phenotype in RA trials may reduce the measured clinical effectiveness of a new molecule.

Trial registration

ClinicalTrials.gov, NCT01255761. Registered on 6 December 2010.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-017-1412-z) contains supplementary material, which is available to authorized users.

Routine Assessment of Patient Index Data 3 and the American College of Rheumatology/European League Against Rheumatism Provisional Remission Definitions as Predictors of Radiographic Outcome in a Rheumatoid Arthritis Clinical Trial With Tocilizumab

OBJECTIVE

The American College of Rheumatology/European League Against Rheumatism established definitions of remission for rheumatoid arthritis (RA) based on composite scores, including tender (TJC) and swollen joint counts (SJC), patient global visual analog scale (VAS) score, laboratory tests, and, in the Simplified Disease Activity Index (SDAI), the physician global score. Time constraints on a physician's schedule demand an easy yet accurate tool to measure disease activity. We assessed the predictive ability of the Routine Assessment of Patient Index Data 3 (RAPID3) with and without a single swollen joint versus the SDAI and/or Boolean remission criteria for functional and radiographic outcomes.

METHODS

Data were from the Tocilizumab Safety and the Prevention of Structural Joint Damage phase III trial in RA patients. We assessed the ability at year 1 of a RAPID3 score of ≤3 + 1 SJC, RAPID3 score of ≤3 (remission) without SJC, SDAI score of ≤3.3 (remission), and/or Boolean remission (SJC, TJC, patient global VAS, and C-reactive protein level [mg/dl] all ≤1) to predict year 2 Health Assessment Questionnaire (HAQ) disability index (DI) score of ≤0.5 (normal), no worsening of HAQ DI score from year 1, and no worsening of Genant-modified Total Sharp Score from year 1.

RESULTS

Among 690 patients, the mean ± SD baseline Disease Activity Score in 28 joints was 6.5 ± 0.96, RAPID3 score was 14.2 ± 5.51, and the SDAI score was 41.7 ± 13.01. Achieving year 1 measures was associated with good functional and radiographic outcomes at year 2. Sensitivity, specificity, positive predictive values, and negative predictive values were 49.1%, 83.2%, 37.4%, and 88.9% (RAPID3 remission); 26.4%, 91.7%, 36.8%, and 87.1% (RAPID3 + 1 SJC); 26.7%, 90.9%, 37.3%, and 85.9% (SDAI remission); and 17.0%, 96.6%, 47.4%, and 86.4% (Boolean remission), respectively.

CONCLUSION

The predictive ability of RAPID3 (with or without joint count) was similar to that of SDAI and Boolean criteria.

Systematic review of patient-reported outcome measures (PROMs) for assessing disease activity in rheumatoid arthritis

Patient assessment of disease activity in rheumatoid arthritis (RA) may be useful in clinical practice, offering a patient-friendly, location independent, and a time-efficient and cost-efficient means of monitoring the disease. The objective of this study was to identify patient-reported outcome measures (PROMs) to assess disease activity in RA and to evaluate the measurement properties of these measures. Systematic literature searches were performed in the PubMed and EMBASE databases to identify articles reporting on clinimetric development or evaluation of PROM-based instruments to monitor disease activity in patients with RA. 2 reviewers independently selected articles for review and assessed their methodological quality based on the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) recommendations. A total of 424 abstracts were retrieved for review. Of these abstracts, 56 were selected for reviewing the full article and 34 articles, presenting 17 different PROMs, were finally included. Identified were: Rheumatoid Arthritis Disease Activity Index (RADAI), RADAI-5, Patient-based Disease Activity Score (PDAS) I & II, Patient-derived Disease Activity Score with 28-joint counts (Pt-DAS28), Patient-derived Simplified Disease Activity Index (Pt-SDAI), Global Arthritis Score (GAS), Patient Activity Score (PAS) I & II, Routine Assessment of Patient Index Data (RAPID) 2–5, Patient Reported Outcome-index (PRO-index) continuous (C) & majority (M), Patient Reported Outcome CLinical ARthritis Activity (PRO-CLARA). The quality of reports varied from poor to good. Typically 5 out of 10 clinimetric domains were covered in the validations of the different instruments. The quality and extent of clinimetric validation varied among PROMs of RA disease activity. The Pt-DAS28, RADAI, RADAI-5 and RAPID 3 had the strongest and most extensive validation. The measurement properties least reported and in need of more evidence were: reliability, measurement error, cross-cultural validity and interpretability of measures.

Reductions in disease activity in the AMPLE trial: clinical response by baseline disease duration

Objectives

To evaluate clinical response by baseline disease duration using 2-year data from the AMPLE trial.

Methods

Patients were randomised to subcutaneous abatacept 125 mg weekly or adalimumab 40 mg bi-weekly, with background methotrexate. As part of a post hoc analysis, the achievement of validated definitions of remission (Clinical Disease Activity Index (CDAI) ≤2.8, Simplified Disease Activity Index (SDAI) ≤3.3, Routine Assessment of Patient Index Data 3 (RAPID3) ≤3.0, Boolean score ≤1), low disease activity (CDAI <10, SDAI <11, RAPID3 ≤6.0), Health Assessment Questionnaire-Disability Index response and American College of Rheumatology responses were evaluated by baseline disease duration (≤6 vs >6 months). Disease Activity Score 28 (C-reactive protein) <2.6 or ≤3.2 and radiographic non-progression in patients achieving remission were also evaluated.

Results

A total of 646 patients were randomised and treated (abatacept, n=318; adalimumab, n=328). In both treatment groups, comparable responses were achieved in patients with early rheumatoid arthritis (≤6 months) and in those with later disease (>6 months) across multiple clinical measures.

Conclusions

Abatacept or adalimumab with background methotrexate were associated with similar onset and sustainability of response over 2 years. Patients treated early or later in the disease course achieved comparable clinical responses.

Trial registration number

NCT00929864, Post-results.

Comparative Effectiveness of Etanercept and Adalimumab in Patient Reported Outcomes and Injection-Related Tolerability

OBJECTIVE

To describe patient preferences in selecting specific biologics and compare clinical response using patient reported outcomes (PROs) among patients with rheumatoid arthritis (RA) started on different anti-tumor necrosis factor (TNF) therapies.

METHODS

Participants were enrollees in Kaiser Permanente Northern California. Patients with RA who had at least two provider visits and started a new anti-TNF therapy from 10/2010-8/2011, were eligible for participation in this longitudinal study. Using a telephone survey, patient preferences in biologic selection and RAPID3, MDHAQ, and SF-12 scores were collected at baseline and at 6 months. Patient scores rating injection/infusion-site burning and stinging (ISBS) were collected at 6 months.

RESULTS

In all, 267 patients with RA responded to the baseline survey, of whom 57% preferred an injectable biologic, 22% preferred an infused biologic, and 21% had no preference. Motivation for injectable biologics was convenience (92%) and for infusion therapy was dislike or lack of self-efficacy for self-injection (16%). After 6 months of treatment with anti-TNF, 70% of the 177 patients who answered the ISBS question reported ISBS with the last dose; on a scale of 1 (none) to 10 (worst), 41% of these reported a score of 2-5; and 29% reported a score of 6-10. Adalimumab users experienced 3.2 times (95% confidence interval 1.2-8.6) the level of ISBS that etanercept users experienced. There were no significant differences in RAPID3, MDHAQ, or SF-12 scores between etanercept or adalimumab initiators.

CONCLUSION

Convenience and fear of self-injection were important considerations to patients selecting a biologic drug. Although more convenient, adalimumab associated with more ISBS than did etanercept, and this rate was higher than reported in clinical trials. At 6 months, PROs did not differ between etanercept and adalimumab users.

Impact of certolizumab pegol on patient-reported outcomes in rheumatoid arthritis and correlation with clinical measures of disease activity

INTRODUCTION

The effect of certolizumab pegol (CZP) on patient-reported outcomes (PROs) was investigated in 1063 patients with rheumatoid arthritis (RA) from the REALISTIC trial (double-blind, placebo-controlled to week 12, open-label to week 28; randomized 4:1 [CZP:placebo]). Correlations between PROs and RA signs and symptoms, and the relative efficacy of these measures, were examined.

METHODS

Adults with RA and an inadequate response to at least one disease-modifying antirheumatic drug were enrolled. PROs assessed included physical function (using the Health Assessment Questionnaire-Disability Index), pain, fatigue, sleep disturbance, Patient Global Assessment of Disease Activity (PtGA), Routine Assessment of Patient Index Data 3 (RAPID3), and Rheumatoid Arthritis Disease Activity Index (RADAI).

RESULTS

Early significant and clinically meaningful improvements in all PROs were observed to week 12 with CZP vs. placebo and were maintained to the end of the trial (week 28). At week 12, up to one-third more CZP patients showed improvements compared with placebo that were greater than or equal to the minimal clinically important difference (MCID) in fatigue, sleep problems, pain, PtGA, RADAI, and RAPID3. The changes in PROs were correlated with clinical measures of disease activity, including the Disease Activity Score in 28 joints using C-reactive protein as well as tender and swollen joint counts.

CONCLUSIONS

Rapid improvements in PROs were seen in patients with RA treated with CZP. The magnitude of improvement exceeded the MCID in multiple domains and demonstrated that CZP improves aspects of health-related quality of life that are meaningful to patients and superior to placebo. PROs provide information complementary to clinical outcomes in assessment of treatment benefits.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00717236 . Registered on 15 July 2008.

Evaluating patient reported outcomes in routine practice of patients with rheumatoid arthritis treated with biological disease modifying anti rheumatic drugs (b-DMARDs)

Objectives

In this study the concordance between the Routine Assessment of Patient Index Data 3 (RAPID3) and the Disease Activity Score 28-joint count (DAS28) was investigated in a clinical routine outpatient setting.

Patients and methods

A sample of 150 adult patients with stable RA treated with biological DMARDs (bDMARDs) was asked to complete the RAPID3 (digital or on paper) just before their outpatient routine visit during which DAS28 assessment took place. The RAPID3 correlation with and the agreement in four DAS28 categories was studied using Spearman’s rank order and Cohen’s observed kappa statistics respectively. The positive (PPV) and negative (NPV) predictive values were calculated to test whether RAPID3 could make distinction in active disease (DAS28 >3.2) or not.

Results

A moderate correlation (ρ 0.576) and a poor kappa value of 0.13 were found in the whole study population. Patients reported a higher disease severity than was measured by DAS28. The PPV of RAPID3 for active disease by DAS28 was 0.59 (95 % CI 0.50–0.68) and the NPV was 0.91 (95 % CI 0.75–0.98) with a sensitivity and specificity of 96 and 40 % respectively.

Discussion

While RAPID3 correlates to some extent with DAS28 at the group level, agreement between RAPID3 and DAS28 at the individual patient level is to poor to rely on RAPID3 results in monitoring patients with RA. RAPID3 tends to over-report disease activity as assessed by DAS28.

Do inpatient multidisciplinary rehabilitation programmes improve health status in people with long-term musculoskeletal conditions? A service evaluation

BACKGROUND

Long-term musculoskeletal (MSK) conditions impair health and function. Guidelines recommend a multidisciplinary team (MDT) approach for the optimum management of people with long-term MSK conditions, but there is limited evidence for MDT care. This service evaluation investigates the short-term effectiveness of an inpatient MDT rehabilitation programme on self-reported function and disease status in people with long-term MSK conditions.

METHODS

A convenience sample of adults with rheumatoid arthritis (RA), osteoarthritis (OA), low back pain (LBP) and chronic widespread pain (CWP) participated in an inpatient MDT rehabilitation programme, consisting of needs assessment, collaborative goal setting and planning, exercise and self-management. The Routine Assessment of Patient Index Data (RAPID3) (primary outcome), the Multi-Dimensional Health Assessment Questionnaire (MDHAQ), Pain Visual Analogue Scale (VAS) and global well-being VAS were assessed at baseline and immediately following MDT rehabilitation.

RESULTS

A total of 183 people [mean age 62 (standard deviation, 14.5) years, 145 females] with RA, OA, LBP or CWP were evaluated before and after inpatient MDT rehabilitation (median duration, ten days). Overall, there was a 28% improvement in RAPID3 (mean difference [95% confidence intervals] in effect size, 5.0 [4.3, 5.8], d=-0.98, p<0.05). Clinically relevant changes were found in people with RA (5.7 [4.4, 6.9], d=-1.08, p<0.05, 32%), OA 6.1 [3.4, 8.7], d=-1.07, p<0.05, 35%), LBP 4.0 [2.8, 5.2], d=-0.91, p<0.05, 22%), CWP 4.6 [2.7, 6.6], d=-0.84, p<0.05, 25%). These changes were reflected in all secondary outcomes.

CONCLUSION

This inpatient MDT rehabilitation programme provides short-term evidence of improved function and disease status in people with long term MSK conditions.

MDHAQ/RAPID3 to recognize improvement over 2 months in usual care of patients with osteoarthritis, systemic lupus erythematosus, spondyloarthropathy, and gout, as well as rheumatoid arthritis

OBJECTIVE

To analyze whether MDHAQ (Multidimensional Health Assessment Questionnaire) scores for physical function (FN), pain, Patient Global Estimate (PATGL), and RAPID3 (Routine Assessment of Patient Index Data, a composite of these 3 measures) document improvement in patients with osteoarthritis, systemic lupus erythematosus, spondyloarthropathy, and gout, similarly to rheumatoid arthritis.

METHODS

In a solo rheumatology practice, every patient completes an MDHAQ/RAPID3 and is assigned a Physician Global Estimate (DOCGL) at every visit. Mean and median FN (0-10 scale), pain (0-10), PATGL (0-10), RAPID3 (0-30), and DOCGL (0-10) were computed at first visit and 2 months later in 141 new patients with 5 diagnoses. Proportions with RAPID3 high (>12), moderate (6.1-12), and low (3.1-6) severity and remission (≤3) were computed. Differences between baseline and 2-month follow-up for each diagnosis were analyzed using paired t tests. Mean changes over 2 months across 5 diagnoses were compared using analysis of variance.

RESULTS

Mean baseline scores for all measures were in narrow ranges for all 5 diagnoses: FN 1.5 to 2.5, pain 4.2 to 5.9, PATGL 4.3 to 5.6, RAPID3 10.1 to 13.7, and DOCGL 2.4 to 4.0. Improvement for FN was 9.4% to 26.8% in all diagnoses but osteoarthritis, for pain 20.2% to 35.3% in all diagnoses, PATGL 11.3% to 30.4%, RAPID3 16.8% to 27.5%, and for DOCGL 23.8% to 36.4%, similar in 5 diagnostic groups.

CONCLUSIONS

MDHAQ, RAPID3, and DOCGL document similar baseline and improvement scores in patients with 5 diagnoses. These quantitative data may supplement traditional narrative, "gestalt" descriptions in usual care of patients with any rheumatic disease.

Should modern imaging be part of remission criteria in rheumatoid arthritis?

With recent improvements in the treatment of rheumatoid arthritis (RA), remission has become an achievable goal for a large proportion of RA patients, and remission is now a defined target in current RA guidelines. However, studies have shown that progression of radiographic joint damage may occur in clinical remission, regardless of the choice of remission definition. Sub-clinical inflammation detected by modern imaging techniques such as ultrasonography and magnetic resonance imaging is present in the majority of patients in clinical remission, and is associated with progressive joint damage and disease activity flare in these patients. This chapter aims to assess the importance of imaging findings in RA patients in clinical remission and to discuss the possible role of modern imaging in future remission criteria.

Can remission in rheumatoid arthritis be assessed without laboratory tests or a formal joint count? possible remission criteria based on a self-report RAPID3 score and careful joint examination in the ESPOIR cohort

OBJECTIVE

To explore 5 possible criteria for remission in rheumatoid arthritis (RA) based on a patient self-report index, the Routine Assessment of Patient Index Data (RAPID3), with a careful joint examination and possible physician global estimate (DOCGL), but without a formal joint count or laboratory test.

METHODS

The ESPOIR early RA cohort of 813 French patients recruited in 2002-2005 was analyzed to identify patients in remission 6 months after enrollment, according to 2 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria: Boolean ≤ 1 for total tender joint count-28, swollen joint count-28, C-reactive protein, and patient global estimate (PATGL), and Simplified Disease Activity Index (SDAI) ≤ 3.3. Agreement with 7 other remission criteria was analyzed - Disease Activity Score-28 (DAS28) ≤ 2.6, Clinical Disease Activity Index (CDAI) ≤ 2.8, and 5 candidate criteria based on RAPID3, joint examination, and DOCGL: "RAPID3R" (RAPID3 ≤ 3.0); "RAPID3R+SJ1" (RAPID3 ≤ 3.0, ≤ 1 swollen joint); "RAPID3R+SJ1+D1" (RAPID3 ≤ 3.0, ≤ 1 swollen joint, DOCGL ≤ 1); "RAPID3R+SJ0" (RAPID3 ≤ 3.0, 0 swollen joints); and "RAPID3R+SJ0+D1" (RAPID3 ≤ 3.0, 0 swollen joints, DOCGL ≤ 1), according to kappa statistics, sensitivity, and specificity. Residual global, articular, and questionnaire abnormalities according to each criteria set were analyzed.

RESULTS

Among 813 ESPOIR patients, 720 had complete data to compare all 9 possible criteria. Substantial agreement with the Boolean criteria was seen for SDAI, CDAI, RAPID3R+SJ1, RAPID3R+SJ1+D1, RAPID3R+SJ0, and RAPID3R+SJ0+D1 (92.2%-94.7%, kappa 0.67-0.79), versus only moderate agreement for DAS28 or RAPID3R (79.9%-85.8%, kappa 0.46-0.55).

CONCLUSION

Remission according to CDAI and RAPID3R+SJ1, but not DAS28 or RAPID3R, is similar to that of the ACR/EULAR criteria. RAPID3 scores require a complementary careful joint examination for clinical decisions, do not preclude formal joint counts or other indices, and may be useful in busy clinical settings.