Construct Validity of the Modified Numeric Rating Scale of Patient Global Assessment in Psoriatic Arthritis

Central Sensitization in Psoriatic Arthritis: Relationship With Composite Measures of Disease Activity, Functional Disability, and Health-Related Quality of Life

OBJECTIVE

To investigate the prevalence of central sensitization (CS) in patients with psoriatic arthritis (PsA) and its association with disease activity and patient-reported outcome measures.

METHODS

This cross-sectional study included adults with PsA without coexisting fibromyalgia (FM). Patients underwent a clinimetric assessment to collect variables regarding disease activity, quality of life (QOL), functional ability, impact of disease, and CS. Spearman ρ was used to examine the relationship between CS Inventory (CSI) scores and other variables. A multivariate analysis was performed to determine the independent contribution of each variable to the 12-item Psoriatic Arthritis Impact of Disease (PsAID-12) score.

RESULTS

One hundred fifty-seven patients were enrolled. Of them, 45.2% scored a CSI ≥ 40, indicating a high probability of CS. Significant correlations were found between CSI and disease activity, as evaluated by Disease Activity in Psoriatic Arthritis score and Psoriatic Arthritis Disease Activity Score (ρ 0.587 and ρ 0.573, respectively), between CSI and the Health Assessment Questionnaire (ρ 0.607), and between CSI and the 36-item Short Form Health Survey physical component summary and mental component summary scores (ρ -0.405 and ρ -0.483, respectively). In multivariate analysis, CSI score was the principal independent variable (P < 0.001) contributing to PsAID-12 score.

CONCLUSION

Patients with PsA with symptoms of CS had higher disease activity, worse functional ability, and worse QOL. The presence of CS is the major contributor in the impact of disease.

From healthcare system to individuals through stroke rehabilitation pathways.Outcomes, information, and satisfaction along 12 months prospective cohort in Portugal

BACKGROUND

The nature and quality of stroke survivor rehabilitation varies throughout Europe, including in Portugal, having not been widely monitored or benchmarked.

OBJECTIVES

This study analyses the stroke care pathway from three perspectives: healthcare system, process, and patient.

METHODS

The study uses data from a one-year single-center prospective cohort of first stroke patients, assessed at baseline, 3, 6, and 12 months. Care pathways and settings were described in terms of organizational model, funding, patient involvement, frequency and intensity and multidisciplinary team. Patient-level information and satisfaction were evaluated using a 10-point numeric rating scale. Kruskal - Wallis and post-hoc tests were used to compare EQ-5D-3 L, National Institute of Health Stroke Scale (NIHSS), Modified Rankin Scale (mRS), Barthel Index, Mini-Mental State Examination scores between pathways and settings.

RESULTS

A total of 391 acute stroke patients, with a mean disability of 3.7 (mRS) and severity of 11.7 (NIHSS) participated. Six pathways and eight settings were described. A lack of compliance between guidelines and care was identified. There were significant differences in the four outcomes between the six pathways (p-values 0.007 to 0.020) suggesting inefficiency and inequalities, with an inadequate level of information and patient satisfaction. After post-hoc analysis, pathways 1 and 2 showed highest outcomes (p-values 0.001 to 0.002). Within settings, short-term units showed high scores, followed by rehabilitation center, outpatient hospital, and community clinic (p-values 0.001 to 0.040).

CONCLUSION

A multilevel characterization of the post-stroke rehabilitation pathway showed a more complete perspective on stroke management which may contribute to future rehabilitation and stroke policies.

Measurement properties of the patient global assessment numerical rating scale in moderate-to-severe psoriasis

BACKGROUND

Patient global assessment (PtGA) has been recommended as one of the core domains in psoriasis clinical trials. Among multiple versions of PtGA, the single-question, 11-point PtGA numeric rating scale (NRS) remains to be validated in patients with plaque psoriasis.

OBJECTIVES

To evaluate the psychometric characteristics of an 11-point PtGA NRS for disease severity in patients with moderate-to-severe plaque psoriasis.

METHODS

Data were analysed from 759 patients with moderate-to-severe psoriasis in the Shanghai Psoriasis Effectiveness Evaluation CoHort (SPEECH), a prospective, multicentre and observational registry assessing the comparative effectiveness and safety of biologics (adalimumab, ustekinumab, secukinumab or ixekizumab), conventional systemic therapies (acitretin or methotrexate) and phototherapy.

RESULTS

The test-retest reliability of the PtGA NRS showed good agreement (intraclass correlation coefficient range 0.79-0.83). No floor or ceiling effects of PtGA NRS were observed. The PtGA NRS was significantly correlated with the Psoriasis Area and Severity Index (PASI), static Physician Global Assessment (sPGA), body surface area, Dermatology Quality of Life Index (DLQI) and Hospital Anxiety and Depression Scale. Relatively large correlations of PtGA NRS with PASI and the DLQI 'symptoms and feelings' domain (all correlations ≥ 0.4 except at baseline) supported convergent validity. The presence of psoriatic arthritis or joint symptoms had no significant association with the PtGA NRS. In multivariate regression analyses, the PtGA NRS at baseline was predicted by age, lesion extent, lesion intensity, patients' symptoms and feelings, and impact on work or school. The PtGA NRS displayed known-groups validity with the PASI, sPGA and DLQI score bands. The PtGA NRS was responsive to change in PASI and DLQI after treatment. Anchor- and distribution-based approaches supported -3 as the minimal important difference for PtGA NRS. An absolute PtGA NRS ≤ 2 during follow-up was concordant with the state of minimal disease activity based on a 90% reduction in PASI (PASI 90) or PASI 90 plus a DLQI of 0/1. Sensitivity analysis using subgroup comparison and multiple imputation model yielded consistent conclusions.

CONCLUSIONS

The PtGA NRS showed good reliability, validity and responsiveness in patients with psoriasis, and was feasible in clinical trials and daily practice.

Comparing the Visual Analog Scale and the Numerical Rating Scale in Patient-reported Outcomes in Psoriatic Arthritis

OBJECTIVE

Patient self-report scales are invaluable in psoriatic arthritis (PsA), as they allow physicians to rapidly assess patient perspectives of disease activity. We aimed to assess the agreement of the visual analog scale (VAS), a 100-mm horizontal line, and the numerical rating scale (NRS), a 21-point scale ranging from 0 to 10 in increments of 0.5, in patients with PsA.

METHODS

Data were collected prospectively across 3 UK hospital trusts from 2018 to 2019. All patients completed the VAS and NRS for pain, arthritis, skin psoriasis (PsO), and global disease activity. A subset completed an identical pack 1 week later. Demographic and clinical data were also collected. Agreement was assessed using medians and the Bland-Altman method. Intraclass correlation coefficients (ICCs) were used to assess test-retest reliability. Spearman rank correlation coefficients were used to assess dependency between scale scores and clinical variables.

RESULTS

Two hundred ten patients completed the study; 1 withdrew consent. Thus, 209 were analyzed. For pain, arthritis, skin PsO, and global disease activity, the difference between the VAS and NRS lay mostly within 1.96 SD of the mean, suggesting reasonable agreement between the 2 scales. Among the patients, 64.1% preferred the NRS. The ICCs demonstrated excellent test-retest reliability for both VAS and NRS. Higher VAS and NRS scores were associated with increased tender/swollen joint count, poorer functional status, and greater life impact.

CONCLUSION

The VAS and NRS show reasonable agreement in key patient-reported outcomes in PsA. Results from both scales are correlated with disease severity and life impact.

Residual Disease Burden in Patients With Axial Spondyloarthritis and Psoriatic Arthritis Despite Low Disease Activity States in a Multiethnic Asian Population

Objectives

To evaluate the burden of residual disease in patients with axial spondyloarthritis (axSpA) or psoriatic arthritis (PsA) who achieved low disease activity (LDA) status.

Methods

We used baseline data from a clinic registry of SpA in a tertiary hospital in Singapore. For axSpA, LDA was defined as Ankylosing Spondylitis (AS) Disease Activity Score based on erythrocyte sedimentation rate (ASDAS-ESR) < 2.1 or Bath AS Disease Activity Index (BASDAI) < 3/10. For PsA, LDA was defined by achieving 5/7 cutoffs in the minimal disease activity (MDA) or Clinical Disease Activity Index for Psoriatic Arthritis (cDAPSA) ≤ 13.

Results

In 262 cases of axSpA (21% women; mean ± standard deviation (SD) age 42 ± 14 yrs), 33% and 43% of patients achieved ASDAS-ESR and BASDAI LDA states, respectively, while in 142 cases of PsA (49% women, mean age 51 ± SD 14 yrs), 35% and 63% achieved MDA and cDAPSA LDA, respectively. Both axSpA and PsA patients with LDA had pain scores ranging from 14.0 to 21.4/100 and fatigue scores ranging from 3.1 to 3.6/10. Substantial burden in physical disability and mental well-being were observed, with low physical and mental component summary scores on the 36-item Short Form Health Survey. AxSpa patients in BASDAI LDA had higher ESR and lower disability than those in ASDAS-ESR LDA. cDAPSA classified nearly twice as many PsA patients into LDA than MDA. Compared to PsA patients in MDA LDA, those in cDAPSA LDA had higher active joint counts, dactylitis, enthesitis, pain scores, and patient global assessment.

Conclusion

Despite being in LDA, patients with axSpA and PsA experienced substantial residual burden in pain, poorer physical function, and mental well-being.

Measurement properties of instruments assessing psoriatic arthritis symptoms for psoriasis clinical trials: a systematic literature review

Introduction: The International Dermatology Outcome Measures (IDEOM) identified 'Psoriatic Arthritis (PsA) Symptoms' as a core domain to be measured in psoriasis clinical trials. This domain includes the measurement of pain, patient global and physical function. Herein, we evaluated the quality (i.e. measurement properties) of five candidate 'PsA Symptoms' measures: Patient Global Assessment (PGA) for Joints, PGA for PsA, the Routine Assessment Patient Index 3 (RAPID3), the PsA Impact of Disease 9 (PsAID9) and PsAID12.Areas covered: We searched MEDLINE and EMBASE (inception-to-March 2018) for studies assessing the measurement properties of candidate instruments. Two reviewers independently assessed the risk of bias of 12 eligible articles using the COSMIN checklist. For each measurement property, we rated the quality of the evidence as 'high,' 'moderate,' 'low,' or 'very low' (GRADE approach) and classified the results as 'sufficient,' 'insufficient,' or 'inconsistent.' Finally, we provided recommendations.Expert opinion: In PsA, RAPID3 had 'very low' quality evidence for 'sufficient' content validity and no evidence of internal structure. Global assessment instruments had 'very low' quality evidence for 'inconsistent' content validity. PsAID9 and PsAID12 had 'low' evidence for 'sufficient' content validity and were recommended to measure 'PsA Symptoms.' Further validation studies will improve the level of evidence of this recommendation.

Endorsement of the 66/68 Joint Count for the Measurement of Musculoskeletal Disease Activity: OMERACT 2018 Psoriatic Arthritis Workshop Report

OBJECTIVE

The Psoriatic Arthritis (PsA) Core Domain Set for randomized controlled trials and longitudinal observational studies has recently been updated. The joint counts are central to the measurement of the peripheral arthritis component of the musculoskeletal (MSK) disease activity domain. We report the Outcome Measures in Rheumatology (OMERACT) 2018 meeting's approaches to seek endorsement of the 66/68 swollen and tender joint count (SJC66/TJC68) for inclusion in the PsA Core Outcome Measurement Set (COS).

METHODS

Using the OMERACT Filter 2.1 Instrument Selection Process, the SJC66/TJC68 was assessed for (1) domain match, (2) feasibility, (3) numerical sense (construct validity), and (4) discrimination (test retest reliability, longitudinal construct validity, sensitivity in clinical trials, and thresholds of meaning). A protocol was designed to assess the measurement properties of the SJC66/TJC68 joint count. The results were summarized in a Summary of Measurement Properties table developed by OMERACT. OMERACT members discussed and voted on whether the strength of the evidence supported that the SJC66/TJC68 had passed the OMERACT Filter as an outcome measurement instrument for the PsA COS.

RESULTS

OMERACT delegates endorsed the use of the SJC66/TJC68 for the measurement of the peripheral arthritis component of the MSK disease activity domain. Among patient research partners, 100% voted for a "green" endorsement, whereas among the group of other stakeholders, 88% voted for a "green" endorsement.

CONCLUSION

The SJC66/TJC68 is the first fully endorsed outcome measurement instrument using the OMERACT Filter 2.1 and the first instrument fully endorsed within the PsA COS.

Factors associated with patient-physician discordance in a prospective cohort of patients with psoriatic arthritis: An Asian perspective

Objectives

To evaluate factors associated with patient‐physician discordance in a multiethnic Asian cohort of psoriatic arthritis (PsA) patients.

Methods

We used data from a prospective cohort of consecutive patients with PsA fulfilling the Classification Criteria for Psoriatic Arthritis, recruited from a single center in Singapore. Sociodemographic, clinical data and patient‐reported outcomes were collected using a standardized protocol at baseline, 4 months, 8 months, 1 year, 2 years and 5 years. patient‐physician discordance was defined as patient global assessment minus physician global assessment (PGA‐PhGA). We evaluated variables associated with patient‐physician discordance using generalized linear regression to control for within‐subject effect.

Results

One hundred and fortytwo patients (51.4% male, 66.2% Chinese, mean [SD] age and duration of illness 51.1 [13.8] years and 27.5 [98.3] months) were recruited at baseline. Paired results for PGA and PhGA were available for 291 visits with median (interquartile range) follow‐up time of 11.6 (17) months. In univariable analysis, duration of illness, fatigue, pain, tender and swollen joint count, dactylitis count, and health‐related quality of life (Short Form‐36) domains were significantly correlated with patient‐physician discordance. In multivariable analysis, age, fatigue level, pain score were positively associated with patient‐physician discordance, while swollen joint count and mental health were negatively associated with patient physician discordance.

Conclusions

Increased age, higher fatigue levels, higher pain score  and poorer mental health may explain underestimation of disease activity by physicians. Physicians’ overestimation of disease activity may be explained by higher swollen joint counts.

Effect of ethnicity on disease activity and physical function in psoriatic arthritis in a multiethnic Asian population

Geographic differences in manifestation of psoriatic arthritis (PsA) could be related to differences in genetic or environmental factors. We aimed to compare the disease activity and functional status using validated outcome measures among patients with PsA of different ethnicities living in the same environment. We performed a cross-sectional study on consecutive patients with PsA classified by the Classification Criteria for Psoriatic Arthritis (CASPAR) criteria from a single center. Sociodemographic data, clinical variables, and patient-reported outcomes were collected using a standardized protocol. Disease activities were assessed by validated composite scores: clinical Disease Activity Index for Psoriatic Arthritis (cDAPSA), Composite Psoriatic Disease Activity Index (CPDAI), and minimal disease activity (MDA). Physical function was assessed with Health Assessment Questionnaire (HAQ) and the Medical Outcome Study Short-Form 36 (SF36) physical function subscales. Linear regression analyses were performed to identify variables associated with disease activities and physical function. Ninety-eight patients (51.5%, men) with mean (±SD) age and duration of PsA of 51.5 ± 13.8 and 5.5 ± 8.4 years were recruited. Indian was overrepresented compared with the national distribution of ethnicities. Compared to Chinese, Indian patients were more likely to be using biological therapies, have higher tender joint count, and worse enthesitis. Higher proportion of Indians had higher disease activity categories measured by cDAPSA, CPDAI, and MDA and had poorer physical function. In the multivariable analysis, ethnicity was significantly associated with HAQ and SF36-PF. Compared to Chinese, Indians with PsA living in the same environment had worse disease activity and physical function measured by validated outcomes.

Patient's Global Assessment as an Outcome Measure for Psoriatic Arthritis in Clinical Practice: A Surrogate for Measuring Low Disease Activity?

OBJECTIVE

To assess the low disease activity (LDA) in a group of patients with psoriatic arthritis (PsA) receiving antitumor necrosis factor-α (TNF-α) by using the patient's global assessment (PtGA) in clinical practice, and to compare PtGA with minimal disease activity (MDA) and other outcome measures.

METHODS

Patients with PsA classified by the ClASsification for Psoriatic ARthritis (CASPAR) criteria and consecutively admitted to an outpatient clinic dedicated to biologic therapy were assessed during their routine followup. The primary outcome measure was the proportion of patients achieving a PtGA ≤ 20 at 4-, 8-, and 12-month followups. Secondary outcome measures included the proportion of patients achieving MDA and other outcome measures. Correlation of PtGA with MDA and other process and outcome measures were also performed.

RESULTS

During the period of observation, 124 patients were evaluated. PtGA ≤ 20 was achieved in 25.7% at 4 months, 48.9% at 8 months, and 65.3% at 12 months of followup. The percentage of PtGA ≤ 20 statistically improved throughout the 3 timepoint assessments and it was statistically correlated to MDA. A significant correlation with the Disease Activity index for PSoriatic Arthritis (DAPSA), Bath Ankylosing Spondylitis Disease Activity Index, and Health Assessment Questionnaire was also observed. MDA, DAPSA, and Disease Activity Score at 28 joints with C-reactive protein remission were achieved at 12 months in 64%, 36%, and 71% of patients, respectively.

CONCLUSION

PtGA can estimate the LDA status and could be considered as a surrogate of outcome measures for the assessment of global disease activity in patients with PsA receiving anti-TNF therapy during routine clinical practice. These data suggest that PtGA might be used in outpatient settings, being a simple, reliable, and not time-consuming instrument.

Patient involvement in outcome measures for psoriatic arthritis

Psoriatic arthritis (PsA) is a heterogeneous inflammatory arthritis with a varied clinical phenotype. There has been considerable international collaboration over recent years to develop and prioritise appropriate disease domains and outcome measures to capture all aspects of this complex disease. It has been recognised that patient-reported measures and physician assessments are complementary and, when used together, allow an improved reflection of disease burden. Taking this concept one step further, the experience in rheumatoid arthritis has demonstrated benefits of incorporating the patient perspective in the development of outcome measures. We report a systematic review demonstrating (1) that there has been little incorporation of the patient perspective in the development of outcome measures and domains in PsA, (2) the proceedings from the preliminary patient involvement in outcome measures for PsA (PIOMPSA) meetings, and (3) a proposed roadmap for improving patient involvement.

Comparison of EuroQol-5D and short form-6D utility scores in multiethnic Asian patients with psoriatic arthritis: a cross-sectional study

OBJECTIVE

To compare EuroQol-5D (EQ-5D) and Short Form-6D (SF-6D) utility scores in multiethnic Asian patients with psoriatic arthritis (PsA).

METHODS

Consecutive patients fulfilling the Classification Criteria for Psoriatic Arthritis attending a rheumatology outpatient clinic were recruited and completed the EQ-5D and SF-6D questionnaires. Comparisons were performed by score distribution, mean, median, and the Outcome Measures in Rheumatology filter: i.e., truth, discrimination, and feasibility.

RESULTS

Eighty-six patients were enrolled (69 English-speaking and 17 Chinese-speaking; male:female ratio 0.91). The score distribution of SF-6D was normal, while that of EQ-5D was bimodal. A ceiling effect was observed in 20% of patients for EQ-5D and none for SF-6D. There were moderate correlations (Spearman's rho = 0.59, p < 0.0001) between the 2 scores, but poor agreements on scatterplot, intraclass correlation (ICC 0.43 and standardized ICC 0.21), and Bland-Altman plots. EQ-5D generated lower utility scores than SF-6D in the poorer health subgroup. SF-6D had stronger correlation with the general health status and other external measures of health; and it distinguished better between good and poor general health status, with better effect size and relative efficiency statistics. EQ-5D demonstrated higher patient acceptability.

CONCLUSION

EQ-5D and SF-6D instruments generated different utility scores in PsA. SF-6D may be superior because of normal scaling distribution and the absence of ceiling and floor effects. SF-6D also had better construct validity and better discrimination of poor health status. More studies are required for cost-utility analysis in PsA.