Validation of the rheumatic disease comorbidity index

Circulating Adipokines and Associations With Incident Cardiovascular Disease in Rheumatoid Arthritis

OBJECTIVE

To assess whether circulating levels of adiponectin, leptin, and fibroblast growth factor 21 (FGF-21) are associated with incident cardiovascular disease (CVD) in rheumatoid arthritis (RA).

METHODS

Adipokines were measured using banked enrollment serum from patients with RA and dichotomized above/below the median value. Incident CVD events (coronary artery disease [CAD], stroke, heart failure [HF] hospitalization, venous thromboembolism, CVD-related deaths) were identified using administrative data and the National Death Index. Covariates were derived from medical record, biorepository, and registry databases. Multivariable Cox models were generated to quantify associations between adipokine concentrations and CVD incidence. Five-year incidence rates were predicted.

RESULTS

Among 2,598 participants, 639 (25%) had at least 1 CVD event over 19,585 patient-years of follow-up. High adiponectin levels were independently associated with HF hospitalization (hazard ratio [HR] 1.39 [95% confidence interval (95% CI) 1.07-1.79], P = 0.01) and CVD-related death (HR 1.49 [95% CI 1.16-1.92], P = 0.002) but not with other CVD events. High leptin was independently associated with CVD-related death (HR 1.44 [95% CI 1.05-1.97], P = 0.02). High FGF-21 levels were independently associated with lower rates of CAD (HR 0.75 [95% CI 0.58-0.97], P = 0.03). In subgroup analyses, associations between high adiponectin and leptin levels with CVD-related death were driven by strong associations in nonobese patients.

CONCLUSION

Adipokines are associated with HF hospitalization and CVD-related death in patients with RA, with stronger associations in nonobese participants. These findings suggest that adipokines effectively predict clinically important outcomes in RA perhaps through an association with body composition and metabolic health. Further study is needed to determine whether adipokine measures might augment existing tools to identify RA patients at increased risk of CVD.

Inflammaging and Frailty in Immune-Mediated Rheumatic Diseases: How to Address and Score the Issue

Frailty is a new concept in rheumatology that can help identify people more likely to have less favorable outcomes. Sarcopenia and inflammaging can be regarded as the biological foundations of physical frailty. Frailty is becoming more widely accepted as an indicator of ageing and is linked to an increased risk of negative outcomes such as falls, injuries, and mortality. Frailty identifies a group of older adults that seem poorer and more fragile than their age-matched counterparts, despite sharing similar comorbidities, demography, sex, and age. Several studies suggest that inflammation affects immune-mediated pathways, multimorbidity, and frailty by inhibiting growth factors, increasing catabolism, and by disrupting homeostatic signaling. Frailty is more common in the community-dwelling population as people get older, ranging from 7 to 10% in those over 65 years up to 40% in those who are octogenarians. Different parameters have been validated to identify frailty. These primarily relate to two conceptual models: Fried's physical frailty phenotype and Rockwood's cumulative deficit method. Immune-mediated rheumatic diseases (IMRDs), such as rheumatoid arthritis, spondyloarthritis, systemic lupus erythematosus, systemic sclerosis, and vasculitis, are leading causes of frailty in developing countries. The aim of this review was to quantitatively synthesize published literature on the prevalence of frailty in IMRDs and to summarize current evidence on the relevance and applicability of the most widely used frailty screening tools.

Healthcare resource utilization and costs in stable patients with rheumatoid arthritis: Comparing nurse-led and rheumatologist-led models of care delivery

OBJECTIVES

Having previously shown similar clinical outcomes, this study compared the healthcare resource utilization and direct costs in stable patients with RA followed in the nurse-led care (NLC) and rheumatologist-led care (RLC) models.

METHODS

Previously collected clinical data were linked to data on practitioner claims, ambulatory care, and hospital discharges. Assessed resources included physician visits; emergency department (ED) visits; hospital admissions, and disease-modifying anti-rheumatic drugs (DMARDs). The mean per-patient resource utilization and cost (2020 Canadian dollars) over 1 year were compared between the groups using Wilcoxon rank-sum test. The mean per-patient cost of health services and total cost were also estimated using Generalized Linear Models (GLMs) accounting for the baseline differences between the groups.

RESULTS

Overall, 244 patients were included. No differences in the number of visits to the ED or to general practice and internal medicine physicians and orthopedic surgeons were found. The NLC group had fewer hospitalizations than the RLC group (p-value=0.03). The mean cost of health services was not statistically different in NLC and RLC groups ($2275 vs. $3772, p-value=0.30). The RLC group included more patients on biologic DMARDs, contributing to a higher mean total cost than the NLC group ($9191 vs. $3056, p-value<0.01). The mean cost estimates with GLMs were consistent with the observed costs.

CONCLUSIONS

A nurse-led model of care delivery for stable patients with RA was not associated with increases in healthcare resource utilization or cost as compared to RLC. NLC is one approach to meeting patient needs and better managing scarce healthcare resources.

Risk of Prostate Cancer in US Veterans With Rheumatoid Arthritis

OBJECTIVE

Patients with rheumatoid arthritis (RA) have an increased risk of select cancers, including lymphoma and lung cancer. Whether RA influences prostate cancer risk is uncertain. We aimed to determine the risk of prostate cancer in patients with RA compared to patients without RA in the Veterans Health Administration (VA).

METHODS

We performed a matched (up to 1:5) cohort study of male patients with and without RA in the VA from 2000 to 2018. RA status, as well as covariates, were obtained from national VA databases. Prostate cancer was identified through linked VA cancer databases and the National Death Index. Multivariable Cox models compared prostate cancer risk between patients with RA and patients without RA, including models that accounted for retention in the VA system.

RESULTS

We included 56,514 veterans with RA and 227,284 veterans without RA. During 2,337,104 patient-years of follow-up, 6,550 prostate cancers occurred. Prostate cancer incidence (per 1,000 patient-years) was 3.50 (95% confidence interval [95% CI] 3.32-3.69) in patients with RA and 2.66 (95% CI 2.58-2.73) in patients without RA. After accounting for confounders and censoring for attrition of VA health care, RA was modestly associated with a higher prostate cancer risk (adjusted HR [HRadj ] 1.12 [95% CI 1.04-1.20]). There was no association between RA and prostate cancer mortality (HRadj 0.92 [95% CI 0.73-1.16]).

CONCLUSION

RA was associated with a modestly increased risk of prostate cancer, but not prostate cancer mortality, after accounting for relevant confounders and several potential sources of bias. However, even minimal unmeasured confounding could explain these findings.

Cause-Specific Mortality in Patients With Gout in the US Veterans Health Administration: A Matched Cohort Study

OBJECTIVE

To compare all-cause and cause-specific mortality risk between patients with gout and patients without gout in the Veteran's Health Administration (VHA).

METHODS

We performed a matched cohort study, identifying patients with gout in the VHA from January 1999 to September 2015 based on the presence of ≥2 International Classification of Diseases, Ninth Revision codes for gout (274.X). Gout patients were matched up to 1:10 on birth year, sex, and year of VHA enrollment with patients without gout and followed until death or end of study (December 2017). Cause of death was obtained from the National Death Index. Associations of gout with all-cause and cause-specific mortality were examined using multivariable Cox regression.

RESULTS

Gout (n = 559,243) and matched non-gout controls (n = 5,428,760) had a mean age of 67 years and were 99% male. There were 246,291 deaths over 4,250,371 patient-years in gout patients and 2,000,000 deaths over 40,441,353 patient-years of follow-up in controls. After matching, gout patients had an increased risk of death (hazard ratio [HR] 1.09 [95% confidence interval (95% CI) 1.08-1.09]), which was no longer present after adjusting for comorbidities (HR 0.98 [95% CI 0.97-0.98]). The strongest association of gout with cause-specific mortality was observed with genitourinary conditions (HR 1.50 [95% CI 1.47-1.54]). Gout patients were at lower risk of death related to neurologic (e.g., Alzheimer's disease and Parkinson's disease) (HR 0.63 [95% CI 0.62-0.65]) and mental health (HR 0.66 [95% CI 0.65-0.68]) conditions.

CONCLUSION

A higher risk of death among gout patients in the VHA was related to comorbidity burden. While deaths attributable to neurologic and mental health conditions were less frequent among gout patients, genitourinary conditions were the most overrepresented causes of death.

Lower Frequency of Comorbidities Prior to Onset of Giant Cell Arteritis: A Population-Based Study

OBJECTIVE

To assess the frequency of comorbidities and metabolic risk factors at and prior to giant cell arteritis (GCA) diagnosis.

METHODS

This is a retrospective case control study of patients with incident GCA between January 1, 2000, and December 31, 2019, in Olmsted County, Minnesota. Two age- and sex-matched controls were identified, and each assigned an index date corresponding to an incidence date of GCA. Medical records were manually abstracted for comorbidities and laboratory data at incidence date, 5 years, and 10 years prior to incidence date. Twenty-five chronic conditions using International Classification of Diseases, 9th revision, diagnosis codes were also studied at incidence date and 5 years prior to incidence date.

RESULTS

One hundred and twenty-nine patients with GCA (74% female) and 253 controls were identified. At incidence date, the prevalence of diabetes mellitus (DM) was lower among patients with GCA (5% vs 17%; P = 0.001). At 5 years prior to incidence date, patients were less likely to have DM (2% vs 13%; P < 0.001) and hypertension (27% vs 45%; P = 0.002) and had a lower mean number (SD) of comorbidities (0.7 [1.0] vs 1.3 [1.4]; P < 0.001) compared to controls. Moreover, patients had significantly lower median fasting blood glucose (FBG; 96 mg/dL vs 104 mg/dL; P < 0.001) and BMI (25.8 vs 27.7; P = 0.02) compared to controls. Multivariable logistic regression analysis revealed negative associations for FBG with GCA at 5 and 10 years prior to diagnosis/index date.

CONCLUSION

DM prevalence and median FBG and BMI were lower in patients with GCA up to 5 years prior to diagnosis, suggesting that metabolic factors influence the risk of GCA.

Reduction of Cardiovascular Disease and Mortality Versus Risk of New-Onset Diabetes Mellitus With Statin Use in Patients With Rheumatoid Arthritis

OBJECTIVE

To assess the effect of statin use on the risk of cardiovascular disease (CVD), all-cause mortality, and type 2 diabetes mellitus (DM) in patients with rheumatoid arthritis (RA).

METHODS

We identified a cohort of patients with RA between 1989 and 2018, within the UK Clinical Practice Research Datalink. We employed a prevalent new-user cohort design by which patients initiating statins were each matched to 2 concurrent nonusers by the time-conditional propensity score (TCPS). Patients were followed until the occurrence of the composite end point of myocardial infarction, stroke, hospitalized heart failure or CVD mortality, all-cause mortality, and incident type 2 DM. The Cox proportional hazards model was used to estimate the hazard ratio (HR) of each outcome associated with as-treated statin use, with adjustment for TCPS deciles and imbalanced covariables.

RESULTS

Among 1,768 statin initiators and 3,528 nonusers, 63 versus 340 CVD (3.0 per 100 person-years versus 2.7 per 100 person-years) and 62 versus 525 deaths (2.8 per 100 person-years versus 4.1 per 100 person-years) occurred. Incident type 2 DM was noted in 128 of 3,608 statin initiators (3.0 per 100 person-years) and 518 of 7,208 nonusers (2.0 per 100 person-years). Statin initiation was associated with 32% (HR 0.68 [95% confidence interval (95% CI) 0.51-0.90]) reduction in CVD, 54% (HR 0.46 [95% CI 0.35-0.60]) reduction in all-cause mortality, and 33% increase in type 2 DM (HR 1.33 [95% CI 1.09-1.63]). The number needed to treat/number needed to harm to prevent a CVD or all-cause mortality or to cause type 2 DM in 1 year was 102, 42, and 127, respectively.

CONCLUSION

Statins are associated with important reductions in CVD and mortality that outweigh the modest increase in type 2 DM risk in RA patients.

High burden of polypharmacy and comorbidity in persons with psoriatic arthritis: an analysis of claims data, stratified by age and sex

OBJECTIVE

To assess polypharmacy in women and men with psoriatic arthritis (PsA).

METHODS

From the German BARMER health insurance database, 11 984 persons with PsA and disease-modifying antirheumatic drug therapy in 2021 were included and compared with sex-matched and age-matched controls without inflammatory arthritis. Medications were analysed by Anatomical Therapeutic Chemical (ATC) groups. Polypharmacy (≥5 concomitant drugs) was compared by sex, age and comorbidity using the Rheumatic Disease Comorbidity Index (RDCI) and the Elixhauser Score. The mean difference in the number of medications between persons with PsA and controls was estimated using a linear regression model.

RESULTS

Compared with controls, all ATC drug classes were significantly more frequent in persons with PsA, most commonly musculoskeletal (81% vs 30%), immunomodulatory (56% vs 2.6%), cardiovascular (62% vs 48%), alimentary tract/metabolic (57% vs 31%) and nervous system (50% vs 31%) drugs. Polypharmacy was significantly higher in PsA (49%) compared with controls (17%), more frequent in women (52%) compared with men (45%) and strongly increased with age and comorbidity. For each unit increase of the RDCI, the age-adjusted number of medications increased by 0.98 (95% CI 0.95 to 1.01) units in men and 0.93 (95% CI 0.90 to 0.96) units in women. Compared with controls, the number of medications in PsA (mean 4.9 (SD 2.8)) was 2.4 (95%CI 2.34; 2.43) units higher in women and 2.3 (95% CI 2.21 to 2.35) units higher in men.

CONCLUSIONS

Polypharmacy is common in PsA and is composed of PsA-specific medication as well as frequent medications for comorbidities, equally affecting women and men.

Multimorbidity status and annual healthcare expenditures of rheumatoid arthritis patients: a Dutch hospital-centered versus population-based comparison

The prevalence of multimorbidity among rheumatoid arthritis (RA) patients is increasing and associated with worse outcomes. Therefore, management of multimorbid patients requires a multidisciplinary approach. However, healthcare systems consist of mono-disciplinary subsystems, which limits collaboration across subsystems. To study the importance of a multidisciplinary, integrated approach, associations between expenditures and multimorbidity are assessed in real-life data. Retrospective data on RA patients from a Dutch single-hospital are analyzed and compared to the Dutch RA population data. The Elixhauser index is used to measure the multimorbidity prevalence. Regression analyses were conducted to derive the relationship between multimorbidity, healthcare costs and self-reported quality of life (e.g. EQ-5D). When analyzing the impact of multimorbidity within RA patients in context of a single-hospital context, multimorbidity is only partially captured: 13% prevalence versus 24% of the Dutch population. Multimorbidity is associated with higher care expenditures. Depending on the type of multimorbidity, expenditures are €43-€5821 higher in a single-hospital and from €2259-€9648 in population data. Finally, medication use associated with chronic diseases and self-reported aspects of well-being are associated with similar increases in healthcare expenditures as multimorbidity based on hospital care. Within RA, a single-hospital approach underestimates the association between multimorbidity and healthcare expenditures as 43% of healthcare utilization and expenditures are missed. To overcome a single-provider perspective in healthcare and efficiently coordinate multimorbid patients, besides providing holistic care, professionals also need to use data providing comprehensive pictures of patients.

Identification of Multimorbidity Patterns in Rheumatoid Arthritis Through Machine Learning

OBJECTIVE

Recognizing that the interrelationships between chronic conditions that complicate rheumatoid arthritis (RA) are poorly understood, we aimed to identify patterns of multimorbidity and to define their prevalence in RA through machine learning.

METHODS

We constructed RA and age- and sex-matched (1:1) non-RA cohorts within a large commercial insurance database (MarketScan) and the Veterans Health Administration (VHA). Chronic conditions (n = 44) were identified from diagnosis codes from outpatient and inpatient encounters. Exploratory factor analysis was performed separately in both databases, stratified by RA diagnosis and sex, to identify multimorbidity patterns. The association of RA with different multimorbidity patterns was determined using conditional logistic regression.

RESULTS

We studied 226,850 patients in MarketScan (76% female) and 120,780 patients in the VHA (89% male). The primary multimorbidity patterns identified were characterized by the presence of cardiopulmonary, cardiometabolic, and mental health and chronic pain disorders. Multimorbidity patterns were similar between RA and non-RA patients, female and male patients, and patients in MarketScan and the VHA. RA patients had higher odds of each multimorbidity pattern (odds ratios [ORs] 1.17-2.96), with mental health and chronic pain disorders being the multimorbidity pattern most strongly associated with RA (ORs 2.07-2.96).

CONCLUSION

Cardiopulmonary, cardiometabolic, and mental health and chronic pain disorders represent predominant multimorbidity patterns, each of which is overrepresented in RA. The identification of multimorbidity patterns occurring more frequently in RA is an important first step in progressing toward a holistic approach to RA management and warrants assessment of their clinical and predictive utility.

Comorbidities and treatment patterns in early rheumatoid arthritis: a nationwide Swedish study

OBJECTIVE

To examine how comorbidities in patients with early rheumatoid arthritis (RA) associate with use of different disease-modifying antirheumatic drugs (DMARDs).

METHODS

We used Swedish nationwide clinical and quality registers to collect comorbidity data for patients diagnosed with RA during 2006-2019 (n=13 505). We compared the use of DMARDs at diagnosis and after 1 year, in relation to comorbidity categories 5 years prior to RA diagnosis and overall comorbidity burden. For each comorbidity category, we also calculated adjusted ORs of being on treatment with other (or no) DMARDs compared with methotrexate (MTX) monotherapy 1 year after RA diagnosis.

RESULTS

At RA diagnosis, 68% (n=9178) of all patients were treated with MTX monotherapy, with the lowest proportion in patients with chronic kidney (CKD, 48%, n=50) and respiratory diseases (57%, n=413). At 1 year, most patients still received MTX monotherapy (<11% decrease, across all comorbidity categories). At 1 year, 13% received biological/targeted synthetic DMARDs, with the lowest proportion among patients with malignant diseases (OR=0.69, 95% CI=0.51 to 0.95). Being without DMARD at 1 year was more common among patients with CKD (OR=3.25, 95% CI=2.20 to 4.81), respiratory diseases (OR=1.83, 95% CI=1.32 to 2.53) or a history of hospitalisation due to infection (OR=1.47, 95% CI=1.23 to 1.75), and among patients with higher comorbidity burden and older age.

CONCLUSION

In a nationwide setting with universal healthcare, most comorbid conditions do not limit the initiation or continuation of MTX or other DMARDs in early RA, although patients with certain comorbid conditions, higher comorbidity burden and higher age were somewhat less intensively treated.

Association between Rheumatic Disease Comorbidity Index and factors of poor prognosis in a cohort of 280 patients with rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) is commonly associated with higher rates of comorbidities. Recent recommendations highlight screening comorbidities during the disease course because of their impact on patients' ability to function, on disease outcome, but also on treatment choices. Hence the interest of our study that aimed to quantify the impact of comorbidities among RA patients using a validated tool the Rheumatic Disease Comorbidity Index (RDCI) and to explore the association between comorbidities and disease characteristics.

METHODS

We conducted a cross-sectional study over 12 months period, including patients followed for an established RA according to the ACR/EULAR 2010 criteria and hospitalized in our rheumatology department. Patients' characteristics and disease features were collected for each patient. Comorbidities were quantified using the RDCI. We looked for the association between RDCI and patients characteristics and RA parameters. Univariable and multivariable analysis were made.

RESULTS

They were 280 patients: 233 female (83.2%) and 47 male (16.8%) with a mean age of 58.07 (SD 11.12) years. The mean follow-up period was 14.74 (SD 1.63) years. Comorbidities were noted in 133 patients (47.5%). The mean comorbidity score measured by the RDCI was 1.05 (SD 1.23). RDCI was positively correlated with age (p < 0.001, r = 0.359). RA patients whose age of disease onset exceeds 40 years have significantly higher RDCI (1.8 (SD 1.3) [CI 95%: 1.36-1.88] vs. 1.5 (SD 1.2), p = 0.007). Moreover, RDCI was significantly associated with the presence pulmonary involvement (p < 0.001) and ocular involvement (p = 0.002). RDCI was also associated with erosive RA (p = 0.006), the presence of atlanto-axial dislocation (p = 0.014), and coxitis (p = 0.029). Regarding therapy regimen, RDCI was statistically increased in patients receiving bDMARDs compared to patients under csDMARDs (2.8 (SD 1.6) vs. 1.0 (SD 1.0), p = 0.021).

CONCLUSION

In this study, comorbidity index was associated with signs of poor prognosis such as erosions, coxitis, and atlanto-axial dislocation. This confirmed the hypothesis that comorbidity can be a threat to the improvement in the long-term prognosis in RA patients.

The association between lower socioeconomic position and functional limitations is partially mediated by obesity in older adults with symptomatic knee osteoarthritis: Findings from the English Longitudinal Study of Ageing

Objective

To assess the longitudinal associations of socioeconomic position (SEP) with functional limitations and knee joint replacement surgery (JRS) in people with symptomatic knee osteoarthritis (OA), and whether body mass index (BMI) mediated these relationships.

Methods

Data came from the English Longitudinal Study of Ageing, a national longitudinal panel study of adults aged ≥50 years. A total of 1,499 participants (62.3% female; mean age 66.5 (standard deviation (SD) 9.4) years; 47.4% obese) self-reporting an OA diagnosis and knee pain, with at least one BMI measurement were included. Mixed effect models estimated longitudinal associations of each SEP variable (education, occupation, income, wealth and deprivation index) and obesity (BMI ≥30.0 kg/m²) with repeated measures of functional limitations. Cox regression analyses estimated associations between SEP indicators and obesity at baseline and risk of knee JRS at follow-up. Structural equation modeling estimated any mediating effects of BMI on these relationships.

Results

Lower SEP and obesity at baseline were associated with increased odds of functional limitations in people with knee OA [e.g., difficulty walking 100 yards: no qualification vs. degree adjOR 4.33 (95% CI 2.20, 8.55) and obesity vs. no obesity adjOR 3.06 (95% CI 2.14, 4.37); similar associations were found for the other SEP indicators]. A small proportion of the association between lower SEP and functional limitations could be explained by BMI (6.2-12.5%). Those with lower income, lower wealth and higher deprivation were less likely to have knee JRS [e.g., adjHR most vs. least deprived 0.37 (95% CI 0.19, 0.73)]; however, no clear association was found for education and occupation. Obesity was associated with increased hazards of having knee JRS [adjHR 1.87 (95% CI 1.32, 2.66)]. As the direction of the associations for SEP and obesity with knee JRS were in opposite directions, no mediation analyses were performed.

Conclusions

Lower SEP was associated with increased odds of functional limitations but lower hazards of knee JRS among people with knee OA, potentially indicating underutilization of JRS in those with lower SEP. Obesity partially mediated the relationship between lower SEP and increased odds of functional limitations, suggesting adiposity as a potential interventional target.

Factors Associated With Quality Care Among Adults With Rheumatoid Arthritis

IMPORTANCE

Although quality care markers exist for patients with rheumatoid arthritis (RA), the predictors of meeting these markers are unclear.

OBJECTIVE

To explore factors associated with quality care among patients with RA.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study using insurance claims from 2009 to 2017 was conducted, and 6 sequential logistic regression models were built to evaluate quality care markers. Quality care markers were measured at 1 year post-RA diagnosis for each patient. The MarketScan Research Database, which contains commercial and Medicare Advantage administrative claims data from more than 100 million individuals in the US, was used to identify patients aged 18 to 64 years with a diagnosis claim for RA. Patients with conditions presenting similar to RA and missing demographic characteristics were excluded. Data analysis occurred between February 18 and May 5, 2022.

EXPOSURES

Success or failure to meet selected RA quality care markers within 1 year after RA diagnosis.

MAIN OUTCOMES AND MEASURES

Prevalence of meeting successive quality care markers for RA.

RESULTS

Among 581 770 patients, 430 843 (74.1%) were women and the mean (SD) age was 48.9 (11.3) years. Most patients (236 285 [40.6%]) resided in the South and had an income less than or equal to $45 200 (490 366 [84.3%]). Of the total study population, 399 862 individuals (68.7%) met at least 1 quality care marker and 181 908 (31.3%) met 0 markers. Most commonly, patients met annual laboratory testing (299 323 [51.5%]) and referral to a rheumatologist (256 765 [44.1%]) markers. The least met marker was receiving hepatitis B screening prior to initiation of disease-modifying antirheumatic drug (DMARD) therapy (18 548 [3.2%]). Women were most likely to meet all quality care markers except receiving DMARDs with hepatitis B screening (odds ratio, 1.14; 95% CI, 1.12-1.16). Individuals with lower median household income had lower odds of receiving a rheumatologist referral, an annual physical examination, or annual laboratory testing, but greater odds of receiving the other quality care markers. Patients with Medicare and those with comorbidities were generally less likely to meet quality care markers.

CONCLUSIONS AND RELEVANCE

In this cohort study of patients with RA, findings indicated downstream associations with rheumatologist referral and receiving DMARDs and varied associations between meeting quality care markers and patient characteristics. These findings suggest that prioritizing early care, especially for vulnerable patients, will ensure that quality care continues.

Factors associated to COVID-19 vaccine acceptance in Mexican patients with rheumatic diseases: A cross-sectional and multicenter study

COVID-19 vaccination is recommended in patients with rheumatic diseases (RDs) to prevent hospitalized COVID-19 and worse outcomes. However, patients' willingness to receive a SARS-CoV-2 vaccine and the associated factors vary across populations, vaccines, and time. The objective was to identify factors associated with COVID-19 vaccine acceptance (VA) in Mexican outpatients with RDs. This multicenter study was performed between March 1 and September 30, 2021, and four national centers contributed with patients. Participants filled out a questionnaire, which included 32 items related to patients' perception of the patient-doctor relationship, the COVID-19 vaccine component, the pandemic severity, the RD-related disability, comorbid conditions control, immunosuppressive treatment impact on the immune system, and moral/civil position of COVID-19 vaccine. Sociodemographic, disease-related, and treatment-related variables and previous influenza record vaccination were also obtained. Multiple logistic regression analyses identified factors associated with VA, which was defined based on a questionnaire validated in our population. There were 1439 patients whose data were analyzed, and the most frequent diagnoses were Rheumatoid Arthritis in 577 patients (40.1%) and Systemic Lupus Erythematosus in 427 (29.7%). Patients were primarily middle-aged women (1235 [85.8%]), with (mean±SD) 12.1 (±4.4) years of formal education. Years of education, corticosteroid use, patient perceptions about the vaccine and the pandemic severity, patient civil/moral position regarding COVID-19 vaccine, and previous influenza vaccination were associated with VA. In Mexican patients with RDs, COVID-19 VA is associated with individual social-demographic and disease-related factors, patient´s perceptions, and previous record vaccination. This information is crucial for tailoring effective vaccine messaging in Mexican patients with RDs.

Difficult-to-Treat Rheumatoid Arthritis in Older Adults: Implications of Ageing for Managing Patients

Difficult-to-treat rheumatoid arthritis is a heterogeneous term in which patients may present with difficulties in their management for different reasons. This can ultimately lead to patients being exposed to multiple treatments because of inefficacy (resulting from mechanisms intrinsic to rheumatoid arthritis or from non-inflammatory causes such as chronic pain syndrome or structural damage, among others), toxicity or adverse effects that may be linked to comorbidities. One particular group in which such characteristics may be more patent is older patients. Increasing life expectancy, an ageing population and the late onset of rheumatoid arthritis have led to an increased interest in the particularities of treating older patients. This may pose a challenge for physicians, as ageing has implications for optimal patient treatment owing to the potential presence of comorbidities, the risk of adverse events and perceptions of disease status by both physicians and patients. All of these factors may have implications for classifying and managing patients aged > 65 years as difficult-to-treat rheumatoid arthritis, as these patients could be misclassified. This can occur when a significant proportion may still exhibit signs of active disease but not necessarily be difficult to treat because the treatment criterion has not been fulfilled. Alternatively, patients may be exposed to multiple biologic/targeted disease-modifying antirheumatic drugs because of contraindications and/or comorbid conditions. Treatment-to-target strategies and an adequate assessment of inflammatory rheumatoid arthritis activity in older patients should be undertaken, taking special care with associated comorbidities, polypharmacy and risk profiles. Such an approach can help to ensure appropriate treatment for older adults and avoid the misclassification of difficult-to-treat patients.

Side Effects of Methotrexate and Tumor Necrosis Factor Inhibitors: Differences in Tolerability Among Patients With Psoriatic Arthritis and Rheumatoid Arthritis

Objective

To examine the prevalence of side effects with methotrexate (MTX) and tumor necrosis factor inhibitors (TNFi) among patients with psoriatic arthritis (PsA) and rheumatoid arthritis (RA).

Methods

This retrospective analysis, conducted between January 2000 and January 2019, used data from the FORWARD databank. Adult patients enrolled in the registry with self‐reported and physician‐confirmed diagnosis of PsA or RA were included if they had completed at least one questionnaire before initiating and within 12 months following initiation of MTX or a TNFi. The primary outcome was to examine the prevalence of side effects with MTX and TNFi within the year following treatment initiation. Multivariate logistic regression analysis was performed to examine the association between PsA and RA and the reporting of their side effects.

Results

Overall, 116 patients with PsA and 4247 patients with RA newly initiated MTX, and 124 patients with PsA and 4361 patients with RA newly initiated a TNFi. Patients with PsA were more likely to report MTX‐related side effects than those with RA (44.8% vs. 29.4%), whereas similar proportions of patients with PsA and RA reported TNFi‐related side effects within the first year (24.2% and 22.8%, respectively). Additionally, patients with PsA initiating MTX were more likely to report nausea, vomiting, abdominal pain, depression, and tinnitus than patients with RA initiating MTX or those with PsA or RA initiating a TNFi.

Conclusion

Patients with PsA reported more side effects than patients with RA, and this difference was more pronounced in those receiving MTX versus TNFi.

What Factors Influence Treatment Effectiveness in Rheumatoid Arthritis: An Evidence-Based Approach to Multidimensional Measurement of Treatment Effectiveness

Purpose: The aim of the study was to examine the effects of socio-demographic characteristics, disease-related characteristics and health care use related-characteristics on the treatment effectiveness of rheumatoid arthritis patients, both separately and together. Methods: The sample of the study consisted of 440 rheumatoid arthritis patients for 99% confidence level, and this sample was reached based on the convenience sampling method. Patients who received at least one anti-TNF therapy were included in the study. Treatment effectiveness levels of rheumatoid arthritis patients were measured with a questionnaire. In the analysis of the study, four different regression models were established. In the first model, socio-demographic characteristics; in the second model, disease characteristics; in the third model, health care use characteristics: in the fourth model, the effect of all these variables on treatment effectiveness was examined. Results: In the study, smoking status, age (socio-demographic characteristics), drug regimen complexity, comorbidity status, education about the disease, disease duration (disease characteristics), and a number of admissions (health care use characteristics), were found to have a significant effect on treatment effectiveness. Conclusion: In the study, the factors affecting the treatment effectiveness were determined. Therefore, it is important to consider these factors revealed in this study in order to increase the treatment effectiveness in patients with rheumatoid arthritis.

Dr. Gunderson et al reply

We thank Drs. Liao, Liao, and Liaw for their interest in our article on multimorbidity burden in patients with rheumatoid arthritis (RA).1 We agree that not all morbidities were included in the assessment of multimorbidity in our article, and further research is warranted to more comprehensively assess multimorbidity in patients with RA.

The impact of disease severity measures on survival in U.S. veterans with rheumatoid arthritis-associated interstitial lung disease

OBJECTIVES

To determine whether RA and interstitial lung disease (ILD) severity measures are associated with survival in patients with RA-ILD.

METHODS

We studied US veterans with RA-ILD participating in a multicentre, prospective RA cohort study. RA disease activity (28-joint DAS [DAS28-ESR]) and functional status (multidimensional HAQ [MDHAQ]) were collected longitudinally while pulmonary function tests (forced vital capacity [FVC], diffusing capacity for carbon monoxide) were obtained from medical records. Vital status and cause of death were determined from the National Death Index and administrative data. Predictors of death were assessed using multivariable Cox regression models adjusting for age, sex, smoking status, ILD duration, comorbidity burden and medications.

RESULTS

We followed 227 RA-ILD participants (93% male and mean age of 69 years) over 1073 person-years. Median survival after RA-ILD diagnosis was 8.5 years. Respiratory diseases (28%) were the leading cause of death, with ILD accounting for 58% of respiratory deaths. Time-varying DAS28-ESR (adjusted hazard ratio [aHR] 1.21; 95% CI: 1.03, 1.41) and MDHAQ (aHR 1.85; 95% CI: 1.29, 2.65) were separately associated with mortality independent of FVC and other confounders. Modelled together, the presence of either uncontrolled disease activity (moderate/high DAS28-ESR) or FVC impairment (<80% predicted) was significantly associated with mortality risk. Those with a combination of moderate/high disease activity and FVC <80% predicted had the highest risk of death (aHR 4.43; 95% CI: 1.70, 11.55).

CONCLUSION

Both RA and ILD disease severity measures are independent predictors of survival in RA-ILD. These findings demonstrate the prognostic value of monitoring the systemic features of RA-ILD.

Elevations in adipocytokines and mortality in rheumatoid arthritis

OBJECTIVES

This study assessed whether circulating levels of adiponectin and leptin are associated with higher mortality in patients with RA.

METHODS

Participants were adults from the Veterans Affairs RA Registry. Adipokines and inflammatory cytokines were measured as part of a multi-analyte panel on banked serum at enrolment. Dates and causes of death were derived from the Corporate Data Warehouse and the National Death Index. Covariates were derived from medical record, biorepository and registry databases. Multivariable Cox proportional hazard models evaluated associations between biomarkers and all-cause and cause-specific mortality.

RESULTS

A total of 2583 participants were included. Higher adiponectin levels were associated with older age, male sex, white race, lower BMI, autoantibody seropositivity, radiographic damage, longer disease duration, prednisone use and osteoporosis. Higher adiponectin concentrations were also associated with higher levels of inflammatory cytokines but not higher disease activity at enrolment. Leptin was primarily associated with greater BMI and comorbidity. The highest quartile of adiponectin (vs lowest quartile) was associated with higher all-cause mortality [hazard ratio (HR): 1.46 (95% CI: 1.11, 1.93), P = 0.009] and higher cardiovascular mortality [HR: 1.85 (95% CI: 1.24, 2.75), P = 0.003], after accounting for covariates. Higher leptin levels were also associated with greater all-cause and cancer mortality.

CONCLUSIONS

Elevations in adipokines are associated with age, BMI, comorbidity and severe disease features in RA and independently predict early death. Associations between adiponectin and inflammatory cytokines support the hypothesis that chronic subclinical inflammation promotes metabolic changes that drive elevations in adipokines and yield adverse health outcomes.

Exploring the disparity between inflammation and disability in the 10-year outcomes of people with rheumatoid arthritis

OBJECTIVES

To identify groups of people with RA with different disability trajectories over 10 years, despite comparable levels of inflammation.

METHODS

Data for this analysis came from three European prospective cohort studies of people with RA [Norfolk Arthritis Register (NOAR), Early RA Network (ERAN), Étude et Suivi des Polyarthrites Indifférenciées Récentes (ESPOIR)]. Participants were assessed regularly over 8 (ERAN) to 10 (NOAR/ESPOIR) years. Inclusion criteria were: recruited after 1 January 2000, <24 months baseline symptom duration, and disability (HAQ) and inflammation [two-component DAS28 (DAS28-2C)] recorded at baseline and at one other follow-up. People in each cohort also completed patient-reported outcome measures at each assessment (pain, fatigue, depressive symptoms). Group-based trajectory models were used to identify distinct groups of people with similar HAQ and DAS28-2C trajectories over follow-up.

RESULTS

This analysis included 2500 people with RA (NOAR: 1000, ESPOIR: 766, ERAN: 734). ESPOIR included more women and the participants were younger [mean (standard deviation) age: NOAR: 57.1 (14.6), ESPOIR: 47.6 (12.5), ERAN: 56.8 (13.8); women: NOAR: 63.9%, ESPOIR: 76.9%, ERAN: 69.1%). Within each cohort, two pairs of trajectories following the hypothesized pattern (comparable DAS28-2Cs but different HAQs) were identified. Higher pain, fatigue and depressive symptoms were associated with increased odds of being in the high HAQ trajectories.

CONCLUSION

Excess disability is persistent in RA. Controlling inflammation may not be sufficient to alleviate disability in all people with RA, and effective pain, fatigue and mood management may be needed in some groups to improve long-term function.

Charlson Comorbidity Index: A Critical Review of Clinimetric Properties

The present critical review was conducted to evaluate the clinimetric properties of the Charlson Comorbidity Index (CCI), an assessment tool designed specifically to predict long-term mortality, with regard to its reliability, concurrent validity, sensitivity, incremental and predictive validity. The original version of the CCI has been adapted for use with different sources of data, ICD-9 and ICD-10 codes. The inter-rater reliability of the CCI was found to be excellent, with extremely high agreement between self-report and medical charts. The CCI has also been shown either to have concurrent validity with a number of other prognostic scales or to result in concordant predictions. Importantly, the clinimetric sensitivity of the CCI has been demonstrated in a variety of medical conditions, with stepwise increases in the CCI associated with stepwise increases in mortality. The CCI is also characterized by the clinimetric property of incremental validity, whereby adding the CCI to other measures increases the overall predictive accuracy. It has been shown to predict long-term mortality in different clinical populations, including medical, surgical, intensive care unit (ICU), trauma, and cancer patients. It may also predict in-hospital mortality, although in some instances, such as ICU or trauma patients, the CCI did not perform as well as other instruments designed specifically for that purpose. The CCI thus appears to be clinically useful not only to provide a valid assessment of the patient's unique clinical situation, but also to demarcate major diagnostic and prognostic differences among subgroups of patients sharing the same medical diagnosis.

Quality of life of patients with rheumatic diseases during the COVID-19 pandemic: The biopsychosocial path

BACKGROUND

Previous models that assess quality-of-Life (QoL) in patients with rheumatic diseases have a strong biomedical focus. We evaluated the impact of COVID-19 related-health care interruption (HCI) on the physical, psychological, social relationships and environment QoL-dimensions, and explored factors associated with QoL when patients were reincorporated to the outpatient clinic, and after six-month follow-up.

PATIENTS AND METHODS

Study phase-1 consisted of a COVID-19 survey administered from June 24th-October 31st 2020, to outpatients with rheumatic diseases who had face-to-face consultation at outpatient clinic reopening. Study phase-2 consisted of 3 consecutive assessments of patient´s QoL (WHOQOL-BREF), disease activity/severity (RAPID-3), and psychological comorbidity/trauma (DASS-21 and IES-R) to patients from phase-1 randomly selected. Sociodemographic, disease and treatment-related information, and comorbidities were obtained. Multiple linear regression analysis identified factors associated with the score assigned to each WHOQOL-BREF dimension.

RESULTS

Patients included (670 for phase-1 and 276 for phase-2), had primarily SLE and RA (44.2% and 34.1%, respectively), and all the dimensions of their WHOQOL-BREF were affected. There were 145 patients (52.5%) who referred HCI, and they had significantly lower dimensions scores (but the environment dimension score). Psycho-emotional factors (primarily feeling confused, depression and anxiety), sociodemographic factors (age, COVID-19 negative economic impact, years of scholarship, HCI and having a job), and biomedical factors (RAPID-3 score and corticosteroid use) were associated with baseline QoL dimensions scores. Psycho-emotional factors showed the strongest magnitude on dimensions scores. Most consistent predictor of six-month follow-up QoL dimensions scores was each corresponding baseline dimension score, while social determinants (years of scholarship and having a job), emotional factors (feeling bored), and biomedical aspects (RAPID 3) had an additional impact.

CONCLUSIONS

HCI impacted the majority of patient´s QoL dimensions. Psycho-emotional, sociodemographic and biomedical factors were consistently associated with QoL dimensions scores, and these consistently predicted the QoL trajectory.

Prevalence of Frailty in Ankylosing Spondylitis, Psoriatic Arthritis, and Rheumatoid Arthritis: Data from a National Claims Dataset

OBJECTIVE

Frailty is associated with disability and mortality independent of age. Although studies have evaluated frailty in rheumatoid arthritis (RA), information on the prevalence of frailty in ankylosing spondylitis (AS) and psoriatic arthritis (PsA) is limited. We aimed to determine the prevalence of frailty in AS and PsA and to evaluate whether characteristics known to be associated with frailty, including anxiety, differ among these three types of inflammatory arthritis.

METHODS

We performed a cross sectional study of Centers for Medicare & Medicaid Services (CMS) beneficiaries aged 65 years or older with AS, PsA, or RA enrolled in 2014. We operationalized frailty using a validated claims-based frailty index. We also explored the prevalence of frailty among CMS beneficiaries younger than age 65 years with work disability, a younger population that also may be at risk of frailty.

RESULTS

The prevalence of frailty in beneficiaries aged 65 years or older with AS and PsA was 45.2% and 46.7%, respectively, significantly lower than in RA (65.9%, P < 0.05). The prevalence of frailty in beneficiaries less than 65 years old was much lower overall, though still highest in RA; 11.7%, 4.4%, and 7.0% in RA, AS, and PsA, respectively (P < 0.05). Anxiety was significantly associated with frailty in subjects of all ages, particularly among those less than 65 years old (P < 0.05).

CONCLUSION

Almost half of beneficiaries with AS or PsA aged 65 years old or older were frail, higher than in younger disabled beneficiaries. Further studies are needed to understand the risks of developing frailty in these diseases. Frailty was associated with anxiety, particularly in the younger age groups.

Cumulative comorbidity burden does not worsen outcomes in management of chronic rhinosinusitis

BACKGROUND

The impact of multiple coexisting medical comorbidities on treatment outcomes in chronic rhinosinusitis (CRS) is unknown. In this study we sought to evaluate the effect of comorbidities on sinonasal quality of life (QOL) and general health utility values by utilizing the Functional Comorbidity Index (FCI) in CRS patients.

METHODS

Patients with CRS were prospectively enrolled in a cross-sectional study of medical and surgical therapies. The 22-item Sino-Nasal Outcome Test (SNOT-22) and Medical Outcomes Study Short-Form 6D (SF-6D) scores were recorded at enrollment and 6-month follow-up; Lund-Kennedy endoscopy and Lund-Mackay computed tomography scores were recorded at enrollment. The FCI was calculated using the electronic medical record. The impact of cumulative comorbidity burden on baseline and posttreatment outcomes was assessed using univariate and bivariate correlations.

RESULTS

A total of 428 participants with CRS were included. The average (mean standard ± deviation) FCI score was 3.03 ± 2.28 (range, 0-12). Significant linear correlations were identified between increasing FCI score and baseline SNOT-22 and SF-6D scores (R = 0.166, p = 0.001 and R = -0.245, p < 0.001, respectively). There was no correlation between FCI and change in SNOT-22 or SF-6D scores after CRS treatment (R = 0.066, p = 0.17 and R = -0.087, p = 0.074, respectively). Achievement of a minimally clinically important difference was also independent of FCI.

CONCLUSION

Although cumulative comorbidity burden, as measured by FCI, is associated with worse baseline SNOT-22 and SF-6D scores, it does not appear to limit posttreatment improvement in either outcome measure. On average, patients with high comorbidity burden report substantial improvement in both QOL and health utility after CRS treatment, similar to those with fewer comorbidities.

OUP accepted manuscript

OBJECTIVES

Control of disease activity in RA is a crucial part of its management to prevent long-term joint damage and disability. This study aimed to identify early predictors of poor disease activity at 5 and 10 years, focusing on comorbidities and clinical/sociodemographic factors at first presentation.

METHODS

Patients from two UK-based RA cohorts were classified into two groups; low (&lt;3.2) and moderate/high (≥3.2) DAS using 28 joint counts (DAS28) at 5/10 years. Clinical variables (e.g. rheumatoid nodules, erosions), sociodemographic factors (e.g. ethnicity, deprivation) and comorbidities were recorded at baseline and yearly thereafter. The Rheumatic Diseases Comorbidity Index quantified patient comorbidity burden. Binary logistic regression models (outcome low vs moderate/high DAS28) were fitted using multiple imputation.

RESULTS

A total of 2701 patients living with RA were recruited (mean age 56.1 years, 66.9% female); 5-year data were available for 1718 (63.4%) patients and 10-year data for 820 (30.4%). Baseline Rheumatic Diseases Comorbidity Index was not associated with DAS28 at 5 [odds ratio (OR) 1.05, 95% CI 0.91, 1.22] or 10 years (OR 0.99, 95% CI 0.75, 1.31) in multivariable analyses. Sociodemographic factors (female gender, worse deprivation) and poorer baseline HAQ-Disability Index were associated with DAS28 ≥3.2 at both timepoints. Being seropositive was associated with 5-year DAS28 ≥3.2.

CONCLUSION

This study demonstrates an association between sociodemographic and clinical factors and long-term RA disease activity, in models adjusting for comorbidity burden. The findings call for more holistic and targeted patient management in patients with RA and provide insights for more individualized management plans even on first presentation to rheumatology.

Central sensitization has major impact on quality of life in patients with axial spondyloarthritis

INTRODUCTION

Persistent pain has large potential impact on quality of life (QoL). During the course of the disease, many patients with axial spondyloarthritis (axSpA) report persistent pain. Central sensitization (CS) may explain part of this chronic pain. However, the role of CS in relation to QoL has been sparsely studied in axSpA. Therefore, our aim was to explore the relationship between CS and QoL in patients with axSpA.

METHODS

Consecutive outpatients from the Groningen Leeuwarden axSpA (GLAS) cohort completed the Central Sensitization Inventory (CSI; range 0-100) and the AS Quality of Life (ASQoL; range 0-18). Multivariable linear regression analysis was used to explore the relationship between CSI and ASQoL scores correcting for potential confounders.

RESULTS

Of the 178 included axSpA patients, mean CSI score was 38.0 ± 14.1 and 45% scored ≥40, which indicates a high probability of CS. Mean ASQoL score was 6.0 ± 5.3 and mean ASDAS_CRP 2.1 ± 1.0. A CSI score ≥40 was significantly associated with higher ASQoL score (mean 9.7 vs. 3.3), higher ASDAS_CRP (mean 2.6 vs. 1.7), female gender (60% vs. 29%) and more often entheseal involvement (61% vs. 26%). In univariable analysis, CSI score explained a large proportion of the variation in ASQoL (B = 0.06, 95%CI: 0.05-0.07; R²=0.46). This association remained significant after correction for ASDAS_CRP, gender, entheseal involvement, comorbidities, symptom duration, smoking status, BMI class and educational level (B = 0.04, 95%CI: 0.03-0.05).

CONCLUSION

CS is strongly related to patient-reported QoL in patients with axSpA independently from other patient- and disease-related aspects.

Fatigue in Early Rheumatoid Arthritis: Data from the Early Rheumatoid Arthritis Network

OBJECTIVES

Fatigue is a disabling symptom in people with Rheumatoid Arthritis (RA). This study aims to describe the prevalence, risk factors and the longitudinal course of fatigue in early RA.

METHODS

Demographic, clinical, quality of life (QoL), comorbidities and laboratory data were from the Early Rheumatoid Arthritis Network (ERAN), a UK multicentre inception cohort of people with RA.Fatigue was measured using the Vitality subscale of SF36 where higher values represented better QoL. Baseline prevalences of fatigue classifications were age and sex standardised. Linear regression, hierarchical growth curve modelling and group-based trajectory modelling (GBTM) were utilized.

RESULTS

At baseline (n = 1236, 67% female, mean age 57), mean Vitality was 41 (SD ± 11), disease duration 11 months (IQR : 7-18). Age and sex standardized prevalence rates of fatigue and severe fatigue were 44% (CI: 39-50) and 19% (CI: 15-23) respectively.Fatigue changed little over 3 years and 5 measurement occasions, ß=-0.13 (-0.23 to -0.02). GBTM identified 2 sub-groups, which we named 'Fatigue' (53%) and 'No-fatigue' (47%) groups. Female sex, worse pain, mental health, and functional ability were associated with greater fatigue and predicted 'Fatigue' group membership (AUROC = 0.81). Objective measures of inflammation-swollen joint count (SJC) and erythrocyte sedimentation rate (ESR) were not significantly associated with fatigue.

CONCLUSIONS

Fatigue is prevalent and persistent in early RA. Diverse characteristics indicative of central mechanisms are associated with persistent fatigue. Management of fatigue might require interventions targeted at central mechanisms in addition to inflammatory disease modification. People who require such interventions might be identified at presentation with early RA.

Everyday Lives of Middle-Aged Persons with Multimorbidity: A Mixed Methods Systematic Review

The healthcare burden of patients with multimorbidity may negatively affect their family lives, leisure time and professional activities. This mixed methods systematic review synthesizes studies to assess how multimorbidity affects the everyday lives of middle-aged persons, and identifies skills and resources that may help them overcome that burden. Two independent reviewers screened title/abstracts/full texts in seven databases, extracted data and used the Mixed Methods Appraisal Tool (MMAT) to assess risk of bias (RoB). We synthesized findings from 44 studies (49,519 patients) narratively and, where possible, quantitatively. Over half the studies provided insufficient information to assess representativeness or response bias. Two studies assessed global functioning, 15 examined physical functioning, 18 psychosocial functioning and 28 work functioning. Nineteen studies explored skills and resources that help people cope with multimorbidity. Middle-aged persons with multimorbidity have greater impairment in global, physical and psychosocial functioning, as well as lower employment rates and work productivity, than those without. Certain skills and resources help them cope with their everyday lives. To provide holistic and dynamic health care plans that meet the needs of middle-aged persons, health professionals need greater understanding of the experience of coping with multimorbidity and the associated healthcare burden.

COVID-19 vaccine hesitancy among Mexican outpatients with rheumatic diseases

Vaccine hesitancy (VH) has emerged as a recognized threaten to contain the COVID-19 pandemic. Historically, low vaccine acceptance rates had been described among patients with rheumatic diseases (RMDs). The study objective was to determine COVID-19 VH among Mexican outpatients with RMDs and validate the COVID-19 VH questionnaire. This cross-sectional study was developed in three steps. Step 1 consisted of translation/cultural adaptation of the Oxford-COVID-19-VH questionnaire. Step 2 consisted of pilot testing and questionnaire feasibility, content, construct and criterion validity, reliability (internal consistency and temporal stability) and questionnaire sensitivity to change. Step 3 consisted of VH phenomenon quantification in patients from two metropolitan tertiary-care-level centers. Step 1 followed ISPOR-task-force recommendations. Patients who participated in step 2 (n = 50 for pilot testing/feasibility and n = 208 for questionnaire validation [91 in test-retest and 70 in questionnaire-sensitivity to change]) and step 3 (n = 600) were representative outpatients with RMDs. The seven-item COVID-19 VH questionnaire was found feasible, valid (experts' agreement ≥80%; a 1-factor structure accounted for 60.73% of the total variance; rho = 0.156, p = .025 between COVID-19 VH questionnaire and score from the Spanish version of the Vaccine Hesitancy Scale; and lower questionnaire scores in patients who reported 5 years-previous influenza vaccination), reliable (Cronbach's ɑ = 0.889, intra-class correlation coefficient = 0.933 and 95% confidence interval = 0.898-0.956) and sensitive to change (effect size = 1.17 and 0.86, respectively, in patients who decreased [n = 34] and increased [n = 31] questionnaire-score after intervention). VH phenomenon was 35.5%. VH phenomenon was present in a substantial number of Mexican patients with RMDs. The COVID-19 VH questionnaire showed good psychometric properties to assess COVID-19 VH in our population.

Subjective Cognitive Dysfunction in Patients With and Without Fibromyalgia: Prevalence, Predictors, Correlates, and Consequences

BACKGROUND

Subjective cognitive dysfunction (SCD) is common in fibromyalgia (FM), where it has been called 'fibrofog.' But its predictors and correlates are not well understood, including the extent to which SCD is present in fibromyalgia and non-fibromyalgia clinical populations. In addition, there are no studies available concerning SCD and fibromyalgia in the general population. We investigated these issues in a longitudinal rheumatic disease research databank and two cross-sectional general population studies.

METHODS

11,150 unselected patients with rheumatoid arthritis completed an assessment of FM and cognitive severity (CS) status using the full 0-3 fibromyalgia 2016 criteria assessment. In addition, CS was dummy coded as present/absent (CS+). Assessments of SCD and fibromyalgia prevalence were available in two German general population studies.

RESULTS

Fibromyalgia was present (FM+) in 2,493 (21.7%) of clinical subjects and absent (FM-) in 9,017 (78.3%) by FM 2016 criteria. Cognitive severity was present in 1,304 (52.3%) of those with fibromyalgia and 1,009 (11.2%) of non-fibromyalgia subjects (FM-). In two general population studies, 42.0% to 52.3% of those with fibromyalgia were CS+ as were 1.4% to 5.5% of FM- subjects. Patients with CS+ had more abnormal scores for every measure of rheumatoid arthritis (RA) severity, fibromyalgia severity, and general health. The presence of CS+ was strongly related to somatic and non-somatic symptoms scores and less strongly to pain variables. The best predictor of CS+ in the clinic and the general population was the symptom severity scale (SSS), a criterion of fibromyalgia.

CONCLUSIONS

Persons with SCD have high counts of somatic and psychological symptoms. Subjective cognitive dysfunction is best predicted by a simple symptoms score, and not by pain extent scores. Although SCD is called fibrofog in patients with FM, 43.6% of CS+ cases occurred in FM- subjects. Fibromyalgia and CS are correlated but appear to be different parts of a symptom severity continuum. 'Fibrofog' as a phenomenon linked only to fibromyalgia is a misnomer because it can be identified in many non-fibromyalgia patients as well.

Determinants of Diagnostic Delay in Complex Regional Pain Syndrome Type 1: An Observational Study of 180 Consecutive New Cases

BACKGROUND/OBJECTIVE

Complex regional pain syndrome type 1 (CRPS-1) is a disabling painful disease, with variable outcomes in terms of chronic pain and disability. A long time between onset and diagnosis seems predictive for late recovery and progression toward a chronic disease. This study aims to investigate demographic and clinical variables associated with delayed CRPS-1 diagnosis.

METHODS

From March 2013 to January 2018, consecutive patients newly diagnosed according to International Association for the Study of Pain diagnostic criteria for CRPS-1 were recruited. Demographic and clinical variables were collected at diagnosis. Student t test and Mann-Whitney U test were used for comparisons; Cox proportional hazards model was applied to evaluate the variables associated with delayed CRPS-1 diagnosis.

RESULTS

One hundred eighty patients entered the study. At diagnosis, women were older, and foot was more often involved than hand. The triggering event was more commonly a trauma without fracture for foot disease and a fracture for hand localization. No differences between hand and foot disease were found by the International Association for the Study of Pain diagnostic categories (clinical vs research) or pain measures. Variables significantly associated with a longer time between disease onset and diagnosis were foot localization, general practitioner referral, higher number of visits before CRPS diagnosis, and prior physiotherapy prescribed for symptoms later diagnosed as CRPS. An overt clinical manifestation (research CRPS-1) predicted a shorter delay.

CONCLUSIONS

Foot localization, prior physiotherapy prescribed for symptoms later diagnosed as CRPS, and a disease without overt clinical manifestations were independent predictive factors for a delayed diagnosis. Clinicians should pay attention to these issues to ensure a timely diagnosis and possibly avoid progression toward a chronic disease.

Comparison of Indexes to Measure Comorbidity Burden and Predict All-Cause Mortality in Rheumatoid Arthritis

Objectives: To examine the comorbidity burden in patients with rheumatoid arthritis (RA) patients using a nationwide population-based cohort by assessing the Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index (ECI), Multimorbidity Index (MMI), and Rheumatic Disease Comorbidity Index (RDCI) scores and to investigate their predictive ability for all-cause mortality. Methods: We identified 24,767 RA patients diagnosed from 1998 to 2008 in Taiwan and followed up until 31 December 2013. The incidence of comorbidities was estimated in three periods (before, during, and after the diagnostic period). The incidence rate ratios were calculated by comparing during vs. before and after vs. before the diagnostic period. One- and 5-year mortality rates were calculated and discriminated by low and high-score groups and modified models for each index. Results: The mean score at diagnosis was 0.8 in CCI, 2.8 in ECI, 0.7 in MMI, and 1.3 in RDCI, and annual percentage changes are 11.0%, 11.3%, 9.7%, and 6.8%, respectively. The incidence of any increase in the comorbidity index was significantly higher in the periods of “during” and “after” the RA diagnosis (incidence rate ratios for different indexes: 1.33–2.77). The mortality rate significantly differed between the high and low-score groups measured by each index (adjusted hazard ratios: 2.5–4.3 for different indexes). CCI was slightly better in the prediction of 1- and 5-year mortality rates. Conclusions: Comorbidities are common before and after RA diagnosis, and the rate of accumulation accelerates after RA diagnosis. All four comorbidity indexes are useful to measure the temporal changes and to predict mortality.

Characteristics of patients with difficult-to-treat rheumatoid arthritis in clinical practice

OBJECTIVES

The aim of this study was to investigate the clinical characteristics of patients with difficult-to-treat RA (D2T RA) and the usefulness of switching to drugs with different modes of action in real-world.

METHODS

We reviewed all consecutive patients with RA treated at Keio University Hospital between 2016 and 2017 with a definition of D2T RA. We analysed clinical characteristics and evaluated the usefulness of changing drugs according to mode of action.

RESULTS

Among 1709 patients with RA, 173 (10.1%) were D2T RA. The reason for the D2T RA was multi-drug resistance in 59 patients (34.1%), comorbidity in 17 (9.8%), and socio-economic reasons in 97 (56.1%). The multi-drug-resistance group had significantly higher tender joint count and evaluator global assessment than the other groups, despite receiving the most intensive treatment. The comorbidity group showed a significantly older age and higher rheumatic disease comorbidity index. Although changing the drug to another with a different mode of action was useful, the proportion of patients who achieved remission or low disease activity decreased as the number of switches increased.

CONCLUSION

Of the patients with RA, 10.1% were still difficult to treat in clinical practice, despite intensive treatment. Their characteristics were distinct by the reasons of D2T RA, which suggests the need for a personalized approach to D2T RA.

Multimorbidity Burden in Rheumatoid Arthritis: A Population-based Cohort Study

OBJECTIVE

To estimate the prevalence and incidence of multimorbidity (MM) in a population-based cohort of patients with rheumatoid arthritis (RA) compared to subjects without RA.

METHODS

Between 1999-2013, residents of Olmsted County, Minnesota with incident RA who met the 1987 American College of Rheumatology criteria were compared to age- and sex-matched non-RA subjects from the same population. Twenty-five chronic comorbidities from a combination of the Charlson, Elixhauser, and Rheumatic Disease Comorbidity Indices were included, excluding rheumatic comorbidities. The Aalen-Johansen method was used to estimate the cumulative incidence of MM (MM2+; ≥ 2 chronic comorbidities) or substantial MM (MM5+; ≥ 5), adjusting for the competing risk of death.

RESULTS

The study included 597 patients with RA and 594 non-RA subjects (70% female, 90% White, mean age 55.5 yrs). At incidence/index date, the prevalence of MM2+ was higher in RA than non-RA subjects (38% RA vs 32% non-RA, P = 0.02), whereas prevalence of MM5+ was similar (5% RA vs. 4% non-RA, P = 0.68). During follow-up (median 11.6 yrs RA, 11.3 yrs non-RA), more patients with RA developed MM2+ (214 RA vs 188 non-RA; adjusted HR 1.39, 95% CI 1.14-1.69). By 10 years after RA incidence/index, the cumulative incidence of MM2+ was 56.5% among the patients with RA (95% CI 56.5-62.3%) compared with 47.9% among the non-RA (95% CI 42.8-53.7%). Patients with RA showed no evidence of increase in incidence of MM5+ (adjusted HR 1.17, 95% CI 0.93-1.47).

CONCLUSION

Patients with RA have both a higher prevalence of MM at the time of RA incidence as well as increased incidence thereafter.

Investigating changes in disease activity as a mediator of cardiovascular risk reduction with methotrexate use in rheumatoid arthritis

OBJECTIVE

Examine the association of methotrexate (MTX) use with cardiovascular disease (CVD) in rheumatoid arthritis (RA) using marginal structural models (MSM) and determine if CVD risk is mediated through modification of disease activity.

METHODS

We identified incident CVD events (coronary artery disease (CAD), stroke, heart failure (HF) hospitalisation, CVD death) within a multicentre, prospective cohort of US Veterans with RA. A 28-joint Disease Activity Score with C-reactive protein (DAS28-CRP) was collected at regular visits and medication exposures were determined by linking to pharmacy dispensing data. MSMs were used to estimate the treatment effect of MTX on risk of incident CVD, accounting for time-varying confounders between receiving MTX and CVD events. A mediation analysis was performed to estimate the indirect effects of methotrexate on CVD risk through modification of RA disease activity.

RESULTS

Among 2044 RA patients (90% male, mean age 63.9 years, baseline DAS28-CRP 3.6), there were 378 incident CVD events. Using MSM, MTX use was associated with a 24% reduced risk of composite CVD events (HR 0.76, 95% CI 0.58 to 0.99) including a 57% reduction in HF hospitalisations (HR 0.43, 95% CI 0.24 to 0.77). Individual associations with CAD, stroke and CVD death were not statistically significant. In mediation analyses, there was no evidence of indirect effects of MTX on CVD risk through disease activity modification (HR 1.03, 95% CI 0.80 to 1.32).

CONCLUSIONS

MTX use in RA was associated with a reduced risk of CVD events, particularly HF-related hospitalisations. These associations were not mediated through reductions in RA disease activity, suggesting alternative MTX-related mechanisms may modify CVD risk in this population.

Improvement of osteoporosis Care Organized by Nurses: ICON study - Protocol of a quasi-experimental study to assess the (cost)-effectiveness of combining a decision aid with motivational interviewing for improving medication persistence in patients with a recent fracture being treated at the fracture liaison service

Background

Given the health and economic burden of fractures related to osteoporosis, suboptimal adherence to medication and the increasing importance of shared-decision making, the Improvement of osteoporosis Care Organized by Nurses (ICON) study was designed to evaluate the effectiveness, cost-effectiveness and feasibility of a multi-component adherence intervention (MCAI) for patients with an indication for treatment with anti–osteoporosis medication, following assessment at the Fracture Liaison Service after a recent fracture. The MCAI involves two consultations at the FLS. During the first consultation, a decision aid is will be used to involve patients in the decision of whether to start anti-osteoporosis medication. During the follow-up visit, the nurse inquires about, and stimulates, medication adherence using motivational interviewing techniques.

Methods

A quasi-experimental trial to evaluate the (cost-) effectiveness and feasibility of an MCAI, consisting of a decision aid (DA) at the first visit, combined with nurse-led adherence support using motivational interviewing during the follow-up visit, in comparison with care as usual, in improving adherence to oral anti-osteoporosis medication for patients with a recent fracture two Dutch FLS. Medication persistence, defined as the proportion of patients who are persistent at one year assuming a refill gap < 30 days, is the primary outcome. Medication adherence, decision quality, subsequent fractures and mortality are the secondary outcomes. A lifetime cost-effectiveness analysis using a model-based economic evaluation and a process evaluation will also be conducted. A sample size of 248 patients is required to show an improvement in the primary outcome with 20%. Study follow-up is at 12 months, with measurements at baseline, after four months, and at 12 months.

Discussion

We expect that the ICON-study will show that the MCAI is a (cost-)effective intervention for improving persistence with anti-osteoporosis medication and that it is feasible for implementation at the FLS.

Trial registration

This trial has been registered in the Netherlands Trial Registry, part of the Dutch Cochrane Centre (Trial NL7236 (NTR7435)).

Version 1.0; 26-11-2020.

Treatment response and several patient-reported outcomes are early determinants of future self-efficacy in rheumatoid arthritis

BACKGROUND

Self-efficacy, or patients' confidence in their ability to control disease and its consequences, was recently prioritised in EULAR recommendations for inflammatory arthritis self-management strategies. However, it remains unclear which factors influence self-efficacy in early rheumatoid arthritis (RA).

METHODS

Data were analysed from the 2-year RCT Care in early RA (CareRA), which studied remission-induction treatment regimens for early RA. Participants completed the Arthritis Self-Efficacy Scale (ASES), Short-Form 36 (SF-36), Revised Illness Perception Questionnaire (IPQ-R), Utrecht Coping List (UCL), RAQoL and Health Assessment Questionnaire (HAQ). Depending on time to first remission (DAS28-CRP < 2.6) and persistence of remission, treatment response was defined as persistent response, secondary failure, delayed response, late response or non-response. The association between ASES scores and clinical/psychosocial factors was explored with Spearman correlation and multivariate linear mixed models. Baseline predictors of week 104 ASES were identified with exploratory linear regression followed by multiple regression of significant predictors adjusted for DAS28-CRP, HAQ, treatment arm, treatment response, cumulative CRP/SJC28 and demographic/serologic confounders.

RESULTS

All 379 patients had a recent diagnosis of RA and were DMARD-naïve at study initiation. Most patients were women (69%) and RF/ACPA-positive (66%), and the mean (SD) age was 52 (13) years. For all tested outcome measures, better perceived health correlated with higher self-efficacy. While patient-reported factors (HAQ, SF-36, RAQoL, IPQ-R, pain, fatigue and patient's global assessment) showed moderate/strong correlations with ASES scores, correlations with physician-reported factors (physician's global assessment, SJC28), TJC28 and DAS28-CRP were weak. Only more favourable outcomes on patient-reported factors and DAS28-CRP were associated with higher ASES scores at each time point. An earlier, persistent treatment response predicted higher ASES scores at both weeks 52 and 104. Significant baseline predictors of week 104 ASES included HAQ; SF-36 mental component score, vitality, mental health and role emotional; IPQ-R illness coherence, treatment control, emotional representations and consequences; UCL Passive reacting; and the RAQoL.

CONCLUSIONS

Patient-reported outcomes and treatment response were early determinants of long-term self-efficacy in an early RA trial. These results provide further relevance for the window of opportunity in an early treat-to-target strategy and could help to timely identify patients who might benefit from self-management interventions.

TRIAL REGISTRATION

EudraCT 2008-007225-39.

Disease activity and its predictors in early inflammatory arthritis: findings from a national cohort

OBJECTIVES

We set out to characterize patient factors that predict disease activity during the first year of treatment for early inflammatory arthritis (EIA).

METHODS

We used an observational cohort study design, extracting data from a national clinical audit. All NHS organizations providing secondary rheumatology care in England and Wales were eligible to take part, with recruitment from 215/218 (99%) clinical commissioning groups (CCGs)/Health Boards. Participants were >16 years old and newly diagnosed with RA pattern EIA between May 2018 and May 2019. Demographic details collected at baseline included age, gender, ethnicity, work status and postcode, which was converted to an area level measure of socioeconomic position (SEP). Disease activity scores (DAS28) were collected at baseline, three and 12 months follow-up.

RESULTS

A total of 7455 participants were included in analyses. Significant levels of CCG/Health board variation could not be robustly identified from mixed effects modelling. Gender and SEP were predictors of low disease activity at baseline, three and 12 months follow-up. Mapping of margins identified a gradient for SEP, whereby those with higher degrees of deprivation had higher disease activity. Black, Asian and Minority Ethnic patients had lower odds of remission at three months follow-up.

CONCLUSION

Patient factors (gender, SEP, ethnicity) predict disease activity. The rheumatology community should galvanise to improve access to services for all members of society. More data are required to characterize area level variation in disease activity.

Cluster analysis identifies unmet healthcare needs among patients with rheumatoid arthritis

Objective: To identify the patterns of healthcare resource utilization and unmet needs of persistent disease activity, pain, and physical disability in rheumatoid arthritis (RA) by cluster analysis.Method: Patients attending the Jyväskylä Central Hospital rheumatology unit, Finland, were, from 2007, prospectively enrolled in a clinical database. We identified all RA patients in 2010-2014 and combined their individual-level data with well-recorded administrative data on all public healthcare contacts in fiscal year 2014. We ran agglomerative hierarchical clustering (Ward's method), with 28-joint Disease Activity Score with three variables, Health Assessment Questionnaire index, pain (visual analogue scale 0-100), and total annual health service-related direct costs (€) as clustering variables.Results: Complete-case analysis of 939 patients derived four clusters. Cluster C1 (remission and low costs, 550 patients) comprised relatively young patients with low costs, low disease activity, and minimal disability. C2 (chronic pain, disability, and fatigue, 269 patients) included those with the highest pain and fatigue levels, and disability was fairly common. C3 (inflammation, 97 patients) had rather high mean costs and the highest average disease activity, but lower average levels of pain and less disability than C2, highlighting the impact of effective treatment. C4 (comorbidities and high costs, 23 patients) was characterized by exceptionally high costs incurred by comorbidities.Conclusions: The majority of RA patients had favourable outcomes and low costs. However, a large group of patients was distinguished by chronic pain, disability, and fatigue not unambiguously linked to disease activity. The highest healthcare costs were linked to high disease activity or comorbidities.

Treat-to-target in axial spondyloarthritis - what about physical function and activity?

In patients with axial spondyloarthritis (axSpA), pain, functional and structural impairments, reduced mobility and potential deformity of the axial skeleton are the most prominent health concerns. Limitations in physical function and spinal mobility are caused by both inflammation and structural damage, and therefore restrictions to physical function must be monitored throughout a patient's life. Consequently, the assessment of physical function is recommended as a key domain in the Assessment of Spondyloarthritis International Society-OMERACT Core Outcome Set. However, in comparison with disease activity, physical function seems to be a relatively neglected target of intervention in patients with axSpA, even though physical function is a major contributor to costs and disability in this disease. This Review aims to reacquaint rheumatologists with the targets for physical function, physical activity and performance by giving guidance on determinants of physical function and how physical function can be examined in patients with axSpA.

Incidence, Prevalence, and Burden of Gout in the Veterans Health Administration

OBJECTIVE

To determine the prevalence, incidence, and burden of gout in the Veterans Health Administration (VHA) from 2005 to 2014.

METHODS

We used national VHA data from January 1999 to December 2014 to determine the annual incidence and prevalence of gout in the VHA. Gout burden to the VHA was determined by the proportion of patients with an encounter related to gout. Rates of urate-lowering therapy (ULT) and opiate use were determined annually. Characteristics of those with and without gout were compared using 2014 data.

RESULTS

From 2005 to 2014, gout prevalence in the VHA increased from 4.2% to 5.8%, while disease incidence ranged from 5.8 to 7.4 cases per 1,000 patient-years. Gout prevalence was highest among men, older patients, and non-Hispanic black patients. During 2014, 4.0% of all inpatient or outpatient encounters and 1.3% of hospitalizations were gout related. Administration of ULT remained stable over the 10-year period, with 46% of gout patients receiving ULT in 2014. In contrast, 16.4% of prevalent gout patients were receiving a weak opioid in 2014, nearly doubling the prescription rate of weak opioids in 2005, while the use of stronger opioids did not change significantly over this period. Patients with gout had greater comorbidity and health care utilization than patients without gout.

CONCLUSION

The burden posed by gout in the VHA is considerable and increased between 2005 and 2014. While the use of ULT has remained stable, the use of opioid therapy has increased among patients with gout.

Obesity and the Risk of Incident Chronic Opioid Use in Rheumatoid Arthritis

OBJECTIVE

The present study was undertaken to evaluate whether the rate of incident chronic opioid use is higher in obese patients with rheumatoid arthritis (RA).

METHODS

Participants with RA in the FORWARD databank were asked about their use of weak and strong opioid medications on semiannual surveys. Incident chronic opioid use was defined as new reported use extending over 2 contiguous surveys (~7-12 months). Cox proportional hazards models were used to evaluate associations between body mass index (BMI) at enrollment and incident chronic opioid use (overall use and strong opioid use). Models adjusted for demographics, smoking, disease duration, RA treatments, household income, and education level. The predicted 5-year cumulative incidence was calculated from Cox models.

RESULTS

Among 19,794 participants, 2,802 experienced an incident episode of chronic opioid use over 93,254 person-years of follow-up. Higher BMI was associated with higher risk of chronic opioid use. Severe obesity (BMI >35 kg/m² ) was associated with a higher risk of overall use (adjusted hazard ratio [HR_adj ] 1.74 [95% confidence interval (95% CI) 1.72-2.04], P < 0.0001) and strong opioid use (HR_adj 2.11 [95% CI 1.64-2.71], P < 0.001) compared to normal BMI. This association was partially explained by greater comorbidity, pain, and disability in obese groups. The attributable risk for obesity was 15% of overall opioid use and 24% of strong opioid use.

CONCLUSION

Obesity is associated with a substantially higher risk of incident chronic opioid use. Approximately 1 in 4 cases of incident use of strong opioids may be attributable to obesity, suggesting a major public health impact. Interventions to prevent or reduce obesity could have an important impact on the use of opioids.

Comorbidity burden in the first three years after diagnosis in patients with rheumatoid arthritis, psoriatic arthritis or spondyloarthritis: a general practice registry-based study

OBJECTIVES

Rheumatoid arthritis (RA), psoriatic arthritis (PsA) and spondyloarthritis (SpA) are chronic inflammatory rheumatic conditions with high levels of comorbidity requiring additional therapeutic attention. We aimed to compare the 3-year comorbidity incidence and pain medication prescription in patients diagnosed with RA, PsA or SpA versus controls.

METHODS

Data between 1999 and 2012 were obtained from Intego, a general practitioner (GP) morbidity registry in Flanders, Belgium. Cases were identified by International Classification of Primary Care (ICPC-2) codes representing 'rheumatoid/seropositive arthritis (L88)' or 'musculoskeletal disease other (L99)'. The registered keywords mapped to these ICPC-2 codes were further verified and mapped to a RA/SpA/PsA diagnosis. Controls were matched on age, gender, GP practice and diagnosis date. We analysed the 3-year comorbidity burden in cases and controls, measured by the Rheumatic Diseases Comorbidity Index (RDCI). All electronically GP-prescribed drugs were registered.

RESULTS

In total, 738, 229 and 167 patients were included with a diagnosis of RA, SpA or PsA, respectively. Patients with RA or PsA had comparable median RDCI scores at baseline, but higher scores at year 3 compared with controls (RA: p=0.010; PsA: p=0.008). At baseline, depression was more prevalent in PsA patients vs controls (p<0.003). RA patients had a higher 3-year incidence of cardiovascular disease including myocardial infarction than controls (p<0.035). All disease population were given more prescriptions than controls for any pain medication type, even opioids excluding tramadol.

CONCLUSIONS

This study highlights the increasing comorbidity burden of patients with chronic inflammatory rheumatic conditions, especially for individuals with RA or PsA. The high opioid use in all populations was remarkable.

Large joints are progressively involved in rheumatoid arthritis irrespective of rheumatoid factor status-results from the early rheumatoid arthritis study

This study aimed to examine the progression of large joint involvement from early to established RA in terms of range of movement (ROM) and time to joint surgery, according to the presence of rheumatoid factor (RF). We used a historical longitudinal cohort of early RA patients. Patients were deemed RF negative if all repeated assessments were negative. The rate of progression from normal to any loss of range of movement (ROM) from years 3 to 14 were modelled using generalized estimating equations, for elbows, wrists, hips, knees and ankle, adjusting for confounders. Time to joint surgery was analysed using multivariable Cox models. A total of 1458 patients were included (66% female, mean age 55 years) and 74% were RF-positive. The prevalence of any loss of ROM, from year 3 through to 14 was highest in the wrist followed by ankle, knee, elbow and hip. Odds of loss of ROM increased over time in all joint regions assessed, at around 7–13% per year from year 3 to 14. Time to surgery was similar according to RF-status for the wrist and ankle, but RF-positive cases had a lower hazard of surgery at the elbow (HR 0.37, 0.15–0.90), hip (HR 0.69, 0.48–0.99) and after 10 years at the knee (HR 0.41, 0.25–0.68). Large joints become progressively involved in RA, most frequently affecting the wrist followed by ankle, which is overlooked in composite disease activity indices. RF-negative and positive cases progressed similarly. Treat-to-target approaches should be followed irrespective of RF status.

Heterogeneity in patient characteristics and differences in treatment across four Canadian rheumatoid arthritis cohorts

OBJECTIVE

To compare clinical characteristics and treatment of patients with rheumatoid arthritis (RA) across 4 Canadian cohorts.

METHODS

The four longitudinal cohorts included: The Canadian Early Arthritis Cohort (CATCH) (n=2878); Ontario Best Practices Research Initiative (OBRI) (n=3734); RHUMADATA® (Quebec, n=2890), and the Rheum4U Precision Health Registry (Calgary, n=709). Data were from cohort inception (range 1998-2016) to 2020. Clinical characteristics and drug treatments were summarized descriptively.

RESULTS

10,211 patients with RA were included. The percentage of patients who entered the cohort with early RA ( ≤ 2 years of disease at enrolment) ranged from 29% (Rheum4U) to 100% (CATCH). Mean age (55 years), sex (74% female) and seropositivity (69%) were similar between cohorts. At the time of initial disease modifying anti-rheumatic drug (DMARD) use, median disease activity scores (DAS-28) varied, ranging from 2.99 (Rheum4U) to 5.19 (CATCH), but were more similar at the time of the first DMARD switch (range:3.57-5.03), first biologic or targeted synthetic DMARD (bDAMRD, tsDMARD) use (range:4.01-4.67) and second bDAMRD or tsDMARD (range:3.71-4.39). The initial DMARD was most commonly methotrexate, either in monotherapy (32%, range:18%-40%) or dual therapy (34%, range:29%- 42%). The first DMARD switch was to another DMARD monotherapy in 20% (range:10%- 32%), dual therapy in 49% (range:39%-56%), and bDMARD or tsDMARD in 24% (range:15%- 28%). The first bDMARD was an anti-TNF in 79% (range:78%-85%).

CONCLUSION

Canadian RA cohorts demonstrate some heterogeneity in treatment which could reflect differences in inclusion criteria, calendar year, or regional differences. This project is a first step towards conducting harmonized analyses across Canadian RA cohorts.

Predictors of poor function in RA based on two prospective UK inception cohorts. Do comorbidities matter?

Objectives

Evidence suggests that factors beyond disease activity associate with functional disability in RA. The primary study objective was to explore associations between comorbidities, sociodemographic factors and functional outcomes at five and 10 years.

Methods

RA patients from two UK prospective cohorts were grouped into low (<1.5) and high (≥1.5) five- and 10-year health assessment questionnaire (HAQ) score. Clinical variables (e.g. disease activity, rheumatoid nodules, erosions) and sociodemographic factors (e.g. ethnicity, deprivation) were recorded at baseline and yearly thereafter. Comorbidity was measured using the Rheumatic Diseases Comorbidity Index (RDCI). Binary logistic regression models were fitted using multiple imputation.

Results

In total, 2701 RA patients were recruited (mean age 56.1 years, 66.9% female). A total of 1718 (63.4%) had five-year and 820 (30.4%) 10-year follow-up data. In multivariable analysis, no association was found between RDCI and HAQ ≥ 1.5 at five or 10 years. Sociodemographic factors (increased age at disease onset, female gender, minority ethnicity) were associated with higher odds of HAQ ≥ 1.5 at five and 10 years, with worse deprivation additionally associated with HAQ ≥ 1.5 at 10 years (OR 0.79, 95% CI: 0.69, 0.90).

Conclusion

Comorbidities at baseline have not been found to be associated with worse RA functional outcome in the long-term. On the other hand, sociodemographic factors, independently of disease measures, are associated with worse functional outcome in RA at five and 10 years, in models adjusting for comorbidity burden. Tailoring management interventions according to not only clinical disease parameters but also patient sociodemographic factors may improve long-term outcomes including functional disability.