Factors Explaining the Discrepancy Between Physician and Patient Global Assessment of Joint and Skin Disease Activity in Psoriatic Arthritis Patients

Discordance between patient and physician global assessments of psoriatic arthritis activity: an observational study in 13 Arab countries

Discordance between physicians and patients in assessing psoriatic arthritis (PsA) activity is common and might impact treatment adherence and decision-making. Cultural and belief systems may influence this discordance. This study aimed to assess the extent of patient-physician discordance in PsA in Arab countries and its association with demographic and disease characteristics.The TACTIC study was a cross-sectional observational study across 13 Arab countries in 2022. Patient and physician global assessments (PGA, PhGA) of disease activity (0-10 scale) were collected, along with demographic and disease data, Disease Activity in Psoriatic Arthritis (DAPSA), and Psoriatic Arthritis Impact of Disease (PsAID). Discordance was defined as an absolute difference of |PGA-PhGA|> 2. Its association with patient characteristics was analyzed through multivariable multinomial logistic regression. In 538 patients (317 females, 58.9%), with a mean age of 45.5 ± 13.2 years and PsA duration of 8.8 ± 7.3 years, the disease was moderately active (mean DAPSA 19.3 ± 16.1; mean PsAID 3.86 ± 2.33). Mean PGA was higher than mean PhGA (4.7 ± 2.5 versus 4.0 ± 2.4, p < 0.001) with an absolute difference of 1.30 ± 1.41 and a high correlation between global assessments (r = 0.74). Discordance was infrequent, occurring in 84 patients (15.6%), and was mostly due to higher PGA (70/84, 83.3%). Discordance (one-point increase) was associated with a lower PhGA (Odds ratio (OR) 3.03 [95%CI 2.18-4.22]), positive fibromyalgia screening (OR 1.28 [95%CI 1.03-1.58]), higher DAPSA (OR 1.16 [95%CI 1.03-1.09]), and higher PsAID scores (OR 2.63 [95%CI 1.96-3.54]). Discordance was primarily identified in patients with moderate disease activity. Discordance between PGA and PhGA was infrequent in Arab countries, suggesting strong patient-physician alignment. Expectations and disease perceptions may play a role in this discordance.

Relationships between patient and physician global assessments in anti-neutrophil cytoplasmic antibody-associated vasculitis

INTRODUCTION/OBJECTIVES

Patients with anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) experience reduced health-related quality of life (HRQoL). Global assessment tools use visual analogue scales to provide patients' and physicians' views on disease activity or the patient's overall health and well-being. The aim of this study was to examine the relationships between patient and physician global assessments (PtGA and PhGa) as they relate to overall health in people with AAV.

METHODS

Patients with AAV attending a tertiary vasculitis clinic participated in this prospective observational study. The primary outcome measured was PtGA and PhGA scores, with higher scores representing better health. SF-36 assessed HRQoL. Discordant scores were defined as an absolute difference of ≥ 20 between PhGA and PtGA.

RESULTS

Ninety-seven patients (mean age 58 years, 46% male) participated. Most were taking immunosuppressive therapy (88%) and had kidney involvement (79%). The mean PhGa and PtGA were similar (mean difference - 2.6, [CI] 0.5, 4.7). Physicians' global assessments were lower in the 43 (44%) patients with active disease, with a trend towards a lower PtGA in this group. Patients' global assessments were ≥ 20 points higher than PhGAs in 16 patients and ≥ 20 points lower in 10 patients. Negatively discordant patients (PtGA < PhGA) were older and less likely to have active disease than positively discordant patients.

CONCLUSIONS

Physicians did not systematically overestimate patients' global health when using the global assessment tool. Discordance rates were 26%, within which, physicians were more likely to assess the patient's health lower than patients themselves. Key Points • There remains an unmet need for patient-reported outcomes assessing quality of life in AAV and other diseases. • The global assessment tool correlates with SF-36 which is commonly used as a tool for assessing quality of life. • Physicians do not tend to overestimate patient's global health both overall and within the discordant sub-group. • Assessing PtGA/PhGA discordance could identify unmet priorities for patients and improve shared physician-patient decision-making.

What Matters in Psoriatic Arthritis: A Comparison of Patient and Clinician Perspectives

OBJECTIVE

This study aimed to expand the understanding of the patient with psoriatic arthritis (PsA) experience and to compare/contrast patient and clinician prioritization of PsA dimensions.

METHODS

We conducted four patients with PsA focus groups across three US rheumatology practices using mixed methods to identify attributes of PsA important to patients. Combination with extant attributes of PsA identified by a steering committee created a comprehensive list of attributes. In separate patient and physician Delphi exercises, participants distributed 100 points across items on the list according to importance as a dimension of PsA.

RESULTS

Fifty-one items describing PsA were generated. Thirty-eight patients and 13 clinicians completed the last Delphi rating exercise. Patients distributed points across a wider range of items than physicians. Using group mean score per item, prioritization was compared between groups. Items with the top 10 mean scores for both groups included arthritis, disease activity, pain, fatigue, physical function, and spine symptoms. Other prioritized domains showed disparity: access to care, daily activities, stiffness, future health uncertainty, and sleep quality for patients versus specific disease skin and joint manifestations, comorbidities, structural damage, and disease management goals for clinicians.

CONCLUSION

Although concordance between patient and clinician perspectives regarding "what matters" in PsA was seen, significant areas of discordance were uncovered. Patients highlighted concerns about care access and uncertainty about the future and impact on aspects of life beyond physical symptoms, issues not usually discussed in a clinical visit. These differential prioritizations highlight opportunities for improvement in patient-clinician communications and delineate the need for more patient-centered research.

Association between patient's psychological health and discordance in patient-physician assessment of psoriatic arthritis

OBJECTIVES

This study aimed to evaluate the discordance in patient-physician assessment of psoriatic arthritis disease activity and its association with the patient's psychological health.

METHODS

This cross-sectional study recruited 135 patients with PsA from Xiangya Hospital of China between October 2021 and July 2022. The visual analogue scale was used to assess the disease activity of PsA, and an absolute difference of ≥ 10 points between the patient-physician global assessment on visual analogue scale was regarded as a clinically relevant discordance. In addition, the patients' clinical data and self-reported questionnaire responses were collected to screen depressive and anxiety symptoms.

RESULTS

Discordance in patient-physician assessment of psoriatic arthritis activity occurred in 88 (65.2%) patients, while concordance occurred in 47 (34.8%) patients. Depressive symptoms (AOR: 4.43, 95% CI:1.85-10.61), as well as anxiety symptoms (AOR: 3.95, 95% CI:1.70-9.16), were associated with the discordance in disease activity assessment between the patients and physicians.

CONCLUSION

This study suggests that the discordance in patient-physician assessment of psoriatic arthritis activity is associated with the patient's psychological health. Therefore, sufficient assessment of patient's psychological health is indispensable from a comprehensive understanding of the disease activity in patients with psoriatic arthritis. Key Points • This is the first study to evaluate the discordance in patient-physician assessment of psoriatic arthritis disease activity and its association with the patient's psychological health.

Patient-Reported and Economic Racial and Ethnic Disparities in Patients with Psoriatic Arthritis: Results from the National Health and Wellness Survey

INTRODUCTION

Psoriatic arthritis (PsA) is a chronic, autoimmune form of arthritis that is associated with a substantial humanistic and economic burden. Potential differences in patient-reported outcomes (PROs) and economic outcomes among groups of varying PsA severity and different races/ethnicities have not been well studied.

METHODS

This cross-sectional study assessed sociodemographic data, PROs, and economic outcomes for participants with PsA from the National Health and Wellness Survey (2018-2020). Multivariable analyses were used to assess the association of self-reported PsA severity and race/ethnicity with health-related quality of life (HRQoL), work productivity and activity impairment (WPAI), healthcare resource utilization (HCRU), and medical costs.

RESULTS

This study included 1544 participants with PsA (1073 non-Hispanic white, 114 non-Hispanic Black, 223 Hispanic, and 134 Other). Self-reported moderate/severe PsA was associated with significantly worse HRQoL and WPAI, greater HCRU, and higher costs than self-reported mild PsA. Black participants reported more absenteeism (31.11% vs. 16.69%; P = 0.007) and activity impairment (54.27% vs. 47.96%; P = 0.047) than white participants, and fewer healthcare provider (5.93 vs. 7.42; P = 0.039) and rheumatologist visits (0.29 vs. 0.53; P = 0.028) over the past 6 months. No differences in outcomes were observed between Hispanic and white participants. Race/ethnicity moderated the association of perceived PsA severity and PROs and HCRU, such that white participants with self-reported moderate/severe PsA had a higher likelihood of depression (P < 0.001), lower HRQoL (P < 0.001), and more emergency room visits (P = 0.001) than those with self-reported mild PsA. Race/ethnicity did not moderate the relationship of PROs, HCRU, and economic outcomes among Black or Hispanic participants.

CONCLUSION

Participants with self-reported moderate/severe PsA reported a greater burden than those with self-reported mild PsA. Black participants had a greater humanistic burden than white participants but reported lower HCRU. Moderation results were driven by white participants, suggesting important differences in PROs, HCRU, and perception of PsA severity across race/ethnicity groups. Small sample sizes in Hispanic and non-Hispanic racial/ethnic groups limited ability to discern differences related to disease severity in these groups. Further research is needed to better understand the differential burden of PsA among individuals with varying perceptions of PsA severity across different racial/ethnic groups.

The Development and Validation of a Novel Training Infographic for the Physician Global Visual Analog Scale in Psoriatic Arthritis

OBJECTIVE

Psoriatic arthritis (PsA) is a heterogenous condition with musculoskeletal and skin manifestations. The physician global visual analog scale (VAS) is an important component of many composite scores used in clinical trials and observational studies. Currently, no training material exists to standardize this assessment.

METHODS

The Psoriatic Arthritis Validation of Physician Global VAS (PAVLOVAS) project describes the development of a novel training infographic with stakeholder involvement, which was then evaluated in a Latin square design in which 20 patients with PsA were assessed by 10 clinicians. For each group of 10 patients, 5 assessors conducted traditional assessment (consisting of 66/68-joint count, body surface area, Leeds Enthesitis Index, and dactylitis and nail counts) and 5 assessors conducted a standardized, thorough general examination informed by the infographic. Assessors switched assessment type between groups. The 3-item (3VAS) and 4VAS informed by traditional and infographic methods were compared, alongside other composite scores.

RESULTS

There was strong agreement between traditional and infographic physician global VAS (intraclass correlation coefficient [ICC] 0.69, P = 0.01). This improved to very strong agreement when incorporated into the 3VAS (ICC 0.99, P < 0.001) and 4VAS (ICC 0.99, P < 0.001). The duration of assessment was significantly less for the infographic vs traditional groups (6.5 vs 7.8 mins, P < 0.001). There was moderately high agreement between the 3VAS and 4VAS categories of disease activity, with the same categories defined by Psoriatic Arthritis Disease Activity Score (PASDAS) and Disease Activity Index for Psoriatic Arthritis (DAPSA; χ2 17.0, P = 0.049).

CONCLUSION

Our group developed and validated a novel training infographic that informs a briefer assessment of the physician global VAS than traditional assessments. This tool has potential applications in training and routine clinical practice.

Impact of Disease Burden of Patients with Psoriasis on Biologic Therapy Switching: Real-World Evidence from the CorEvitas Psoriasis Registry

INTRODUCTION

Due to variable psoriasis symptoms, disease progression, and individual responses to therapy, patients may start, stop, or switch biologic therapies. Real-world data on the associated disease burden of patients with psoriasis who do and do not switch biologics are incomplete.

METHODS

This study compared disease burden among patients from the CorEvitas Psoriasis Registry (July 2017-December 2021) who switched biologics and those who did not within 4-12 months following initiation. Disease-related patient-reported outcomes (PROs) were recorded, including skin pain, itching, activity impairment, and effects on health-related quality of life (HRQoL). Disease severity was measured by body surface area (BSA) and Psoriasis Area and Severity Index (PASI). Unadjusted and adjusted regression models were used to compare study outcome measures between the two groups.

RESULTS

This study included 2145 patients, with 159 classified as switchers and 1986 as non-switchers. The most common reason for switching therapy was failure to maintain initial response (51.7%; n = 78). Moderate-to-severe disease (BSA ≥ 3) was found among 83.0% (n = 132) of switchers versus 26.1% (n = 516) of non-switchers. PASI > 5 was reported among 49.7% (n = 79) of switchers versus 8.6% (n = 171) of non-switchers. Differences in skin pain, itching, and effects on HRQoL between switchers and non-switchers were larger in magnitude for bio-experienced patients.

CONCLUSIONS

Patients who switched biologic therapy experienced a greater disease burden of psoriasis across PROs than non-switchers. Patient-centered factors may be important drivers of biologic switching. Our findings suggest the association between switching and disease burden may be stronger among patients with prior biologic therapy experience.

Filling the "GAP" in Real-World Assessment of Psoriatic Arthritis Disease Activity: Performance Characteristics of a Global/Pain Composite Endpoint

INTRODUCTION

Some retrospective data sources, such as electronic health records in the USA, report composite outcome measures not fully validated in psoriatic arthritis (PsA). However, they often contain global assessments, such as a Physician Global Assessment (PhGA) and Patient Global Assessment (PatGA), along with patient-reported pain scores, which individually are considered validated in PsA. This research described the performance characteristics of a 3-item global assessment and pain (GAP) composite endpoint using data from the ixekizumab phase 3 PsA clinical trial program.

METHODS

Discrimination of GAP was assessed by comparing placebo to active treatment arms. The magnitude of treatment effect and responsiveness were compared to Disease Activity Index for PsA (DAPSA), clinical DAPSA, DAPSA28, and Psoriatic Arthritis Disease Activity Score (PASDAS) using effect size (ES) and standardized response mean (SRM), respectively. Construct validity was evaluated through correlation among the composite endpoints, and with other physician- and patient-reported outcomes. Change in GAP was compared in patients who reached low disease activity (LDA) levels based on DAPSA, cDAPSA, and PASDAS vs those who did not.

RESULTS

GAP discriminated between active treatment and placebo with statistically significant separation as early as week 1. The largest ES/SRM was seen with GAP (2.29/1.74) and PASDAS (2.47/1.68). GAP had the strongest correlation with PASDAS (0.81-0.92) and showed moderate correlations with patient-assessed physical function, low correlations with physician-assessed skin and nail psoriasis, and low to moderate correlation with physician-assessed enthesitis. A significantly greater improvement in GAP was seen in the groups achieving LDA states compared to those not (p < 0.001).

CONCLUSION

The GAP composite, an abbreviated endpoint comprising measures common in electronic health records, has promising performance characteristics and could be used to address important clinical questions regarding outcomes and impact of PsA in existing datasets. CLINTRIALS.

GOV IDENTIFIER

NCT01695239; NCT02349295.

Gender Differences in Perceptions of Psoriatic Arthritis Disease Impact, Management, and Physician Interactions: Results from a Global Patient Survey

INTRODUCTION

We evaluated the impact of gender on disease severity, health-related quality of life (HRQoL), treatment management, and patient-healthcare professional (HCP) interactions from the perspectives of patients with psoriatic arthritis (PsA).

METHODS

Data were collected from a global online patient survey conducted by The Harris Poll (November 2, 2017 to March 12, 2018). Eligible patients were aged ≥ 18 years, with a self-reported diagnosis of PsA for > 1 year, had visited a rheumatologist/dermatologist in the past 12 months, and had reported previously using ≥ 1 conventional synthetic or biologic disease-modifying antirheumatic drug. Data were stratified by gender and analyzed descriptively, inferentially by binomial (chi-square) tests, and by multivariate logistic regression models.

RESULTS

Data from 1286 patients who participated were included: 52% were female, 48% were male. Varying perceptions of disease severity between males and females were indicated by differences in symptoms leading to a diagnosis of PsA, and in symptoms reported despite treatment; more females than males reported joint tenderness, skin patches/plaques, and enthesitis. More females than males reported a major/moderate impact of PsA on their physical activity and emotional/mental well-being. Reasons for switching medication differed between genders, with more females switching because they perceived their medication to not be effective enough related to their joint symptoms. More females than males were very satisfied with their communication with their rheumatologist and were more likely to discuss the impact of PsA on their daily lives, their treatment satisfaction, and treatment goals with their rheumatologist.

CONCLUSIONS

Patients' perceptions of the impact of PsA on HRQoL, treatment management, and interactions with HCPs varied between males and females. More females than males reported major/moderate physical and emotional impacts of PsA. When treating patients, it is important for HCPs to consider the potential impact of gender on patients' experience of PsA and its symptoms. Graphical plain language summary available for this article.

Impact of Disease Factors of Patients with Psoriasis and Psoriatic Arthritis on Biologic Therapy Switching: Real-World Evidence from the CorEvitas Psoriasis Registry

INTRODUCTION

Patients with psoriasis (PSO) and psoriatic arthritis (PsA) may frequently switch biologic therapies over the course of treatment because of symptom variability and individual responses. Real-world studies analyzing patient characteristics and clinical factors associated with biologic switching are limited.

METHODS

This longitudinal cohort study used real-world data from the CorEvitas Psoriasis Registry to evaluate the relationship between associated disease factors and biologic switching among patients with PSO and PsA in the United States (US) and Canada following initiation of a biologic. Patients were evaluated between April 2015-August 2022. Combinations of disease severity (as measured by Psoriasis Area Severity Index [PASI]) and Dermatology Life Quality Index (DLQI) as a measure of health-related quality of life (HRQoL) were assessed, and the association with time to switching was calculated using Cox proportional hazards regression modeling.

RESULTS

Among 2580 patient-initiations (instances of patients initiating a biologic), 504 (19.5%) switched biologics within 30 months of initiation. Switching was more frequent when either PASI > 10 or DLQI > 5 compared with PASI ≤ 10 or DLQI ≤ 5 at follow-up. Patients with higher skin involvement (PASI > 10) and impact on HRQoL (DLQI > 5) were 14 times more likely to switch (hazard ratio = 14.2, 95% confidence interval: 10.7, 18.9) than those with lower skin involvement (PASI ≤ 10) and HRQoL (DLQI ≤ 5).

CONCLUSIONS

Patients with PSO and PsA treated in a real-world dermatology setting with substantial disease factors following biologic initiation were more likely to switch therapies. Those with PASI > 10 and DLQI > 5 switched more frequently than those with PASI ≤ 10 and DLQI ≤ 5.

Mind the gap: Concordance between perceptions regarding vaccination as declared by patients and their evaluation by their general practitioner

BACKGROUND

The high level of vaccine hesitancy reported in the French population may lead general practitioners to anticipate difficult discussions on this topic. We aimed to assess the extent to which general practitioners' evaluation of their patients' vaccine hesitancy was correlated with the real vaccine hesitancy expressed by these patients.

METHODS

The study was based on two brief paper questionnaires completed in private by the general practitioner and the patient at the beginning of a medical appointment: one for the physician to evaluate on three quantitative and non-graduated visual scales (then analysed as a 0-100 scale) their patients' perceptions regarding vaccine safety, vaccine efficacy and 'being in favour of vaccination'; and one for the patient to express their perceptions for the same three axes using the same scales.

RESULTS

Overall, 31 physicians participated in the study, with 540 physician-patient pairs being included. The physicians' evaluation of patient perceptions was more positive when the physician was male (vs female), when the patient was male (vs female) and when both were males (vs both females). The median differences (in absolute values) between the physician evaluations and the patient perceptions were between 9 and 11 (on the 0-100 scale) for the three axes (vaccine safety, vaccine efficacy and 'being in favour'). A correlation was observed between the physicians' evaluation and the patients' declaration (Kendall test: vaccine efficacy: tau = 0.199, p < 0.001; vaccine safety: tau = 0.234, p < 0.001; being in favour of vaccination: tau = 0.365, p < 0.001). Physicians correctly classified 83.4 % of the patients with high perceptions of vaccine safety and efficacy (>75/100 for both scales) but only 54.5 % of those with low perceptions (<75/100 for both scales).

CONCLUSION

Physicians tend to correctly identify patients with the most favourable perceptions about vaccination but not those with the least favourable perceptions.

Flares in IIMs and the timeline following COVID-19 vaccination: a combined analysis of the COVAD-1 and -2 surveys

OBJECTIVES

Disease flares in the post-coronavirus disease 2019 (COVID-19) vaccination period represent a prominent concern, though risk factors are poorly understood. We studied these flares among patients with idiopathic inflammatory myopathies (IIMs) and other autoimmune rheumatic diseases (AIRDs).

METHODS

The COVAD-1 and -2 global surveys were circulated in early 2021 and 2022, respectively, and we captured demographics, comorbidities, AIRDs details, COVID-19 infection history and vaccination details. Flares of IIMs were defined as (a) patient self-reported, (b) immunosuppression (IS) denoted, (c) clinical sign directed and (d) with >7.9-point minimal clinically significant improvement difference worsening of Patient-Reported Outcomes Measurement Information System (PROMIS) PROMISPF10a score. Risk factors of flares were analysed using regression models.

RESULTS

Of 15 165 total respondents, 1278 IIMs (age 63 years, 70.3% female, 80.8% Caucasians) and 3453 AIRDs were included. Flares of IIM were seen in 9.6%, 12.7%, 8.7% and 19.6% patients by definitions (a) to (d), respectively, with a median time to flare of 71.5 (10.7-235) days, similar to AIRDs. Patients with active IIMs pre-vaccination (OR 1.2; 95% CI 1.03, 1.6, P = 0.025) were prone to flares, while those receiving rituximab (OR 0.3; 95% CI 0.1, 0.7, P = 0.010) and AZA (OR 0.3, 95% CI 0.1, 0.8, P = 0.016) were at lower risk. Female gender and comorbidities predisposed to flares requiring changes in IS. Asthma (OR 1.62; 95% CI 1.05, 2.50, P = 0.028) and higher pain visual analogue score (OR 1.19; 95% CI 1.11, 1.27, P < 0.001) were associated with disparity between self-reported and IS-denoted flares.

CONCLUSION

A diagnosis of IIMs confers an equal risk of flares in the post-COVID-19 vaccination period to AIRDs, with active disease, female gender and comorbidities conferring a higher risk. Disparity between patient- and physician-reported outcomes represents a future avenue for exploration.

Difficult to treat psoriatic arthritis - how should we manage?

Psoriatic arthritis (PsA) is a chronic, multi-domain immune-mediated inflammatory arthritis with a high disease burden. PsA patients have significant co-morbidities like obesity, depression, fibromyalgia which can impact disease activity assessment. The management of PsA has undergone a paradigm shift over the last decade due to the availability of multiple biologic and targeted synthetic disease modifying anti-rheumatic drugs. Despite the availability of multiple therapeutic agents, it is not uncommon to find patients not responding adequately and continuing to have active disease and/or high disease burden. In our review, we propose what is "difficult to treat PsA", discuss differential diagnosis, commonly overlooked factors, co-morbidities that affect treatment responses, and suggest a stepwise algorithm to manage these patients.

The effect of risankizumab on achieving minimal clinically important differences in patient-reported outcomes in patients with psoriatic arthritis: results from KEEPsAKE 1 and 2

BACKGROUND

Psoriatic arthritis (PsA) is a chronic inflammatory disease that reduces the quality of life. This study assessed the effects of risankizumab (RZB) on the achievement of minimal clinically important differences (MCID) in patient-reported outcomes (PROs).

METHODS

KEEPsAKE-1 and -2 are randomized, placebo-controlled Phase 3 clinical studies assessing RZB (150 mg) vs. placebo (PBO) in adult patients with PsA with inadequate response or intolerance to disease-modifying antirheumatic drugs and/or biologics. Patients were randomized 1:1 to receive RZB or PBO for 24 weeks; starting at Week 24, all patients received RZB 150 mg through Week 52. PROs assessed were Patient's Global Assessment of Disease Activity (PtGA), Patient's Assessment of Pain, Health Assessment Questionnaire-Disability Index (HAQ-DI), Short-Form 36 Physical and Mental Component Summary scores (PCS and MCS, respectively), 5-Level EQ-5D (EQ-5D-5L), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue), and Work Productivity and Activity Impairment (WPAI). The proportion of patients achieving MCID at Weeks 24 and 52 are reported. Odds ratios of achieving MCID with RZB treatment at Week 24, relative to PBO, were estimated by logistic regression controlling for baseline and stratification factors.

RESULTS

In KEEPsAKE-1, RZB- vs. PBO-treated patients were more likely to report MCID in all PROs at Week 24; similar results were obtained in KEEPsAKE-2, except for SF-36 MCS and WPAI presenteeism domain. In KEEPsAKE-1 and KEEPsAKE-2, 65% and 62% of RZB-treated patients, respectively, reported MCID in PtGA at Week 24, which increased to 74% and 68%, respectively, at Week 52. Approximately 48% of all PBO-treated patients reported MCID in PtGA at Week 24 and, after initiating RZB, >65% reported MCID at Week 52. Results were similar in the remaining PROs.

CONCLUSIONS

These data demonstrate that patients with PsA receiving RZB treatment are more likely to report clinically important improvements in PROs compared with patients receiving PBO.

Comparative performance of composite measures from two phase III clinical trials of ixekizumab in psoriatic arthritis

Background/objective

The aim of this study was to evaluate relative performance of composite measures in psoriatic arthritis and assess the impact of structural damage and functional disability on outcomes during ixekizumab treatment.

Methods

Data from SPIRIT-P1 and SPIRIT-P2 were analysed to evaluate the effect of ixekizumab on achievement of low disease activity (LDA) and remission with the minimal disease activity (MDA) and very low disease activity (VLDA) composite, Disease Activity index for Psoriatic Arthritis (DAPSA), Psoriatic Arthritis Disease Activity Score, GRAppa Composite ScorE and modified Composite Psoriatic Disease Activity Index (mCPDAI). Performance was compared by quantifying residual symptom burden and the impact of structural damage and functional disability.

Results

Significantly more ixekizumab-treated patients achieved treatment targets at week 24 versus placebo assessed with all composites. More patients achieved targets assessed by mCPDAI and DAPSA than other composites. Residual disease activity was similar between composites, but residual high patient-reported outcomes (PROs) and functional disability were more frequent when assessed with mCPDAI and DAPSA. Achievement of treatment targets was reduced by high baseline levels of structural damage and functional disability.

Conclusion

Residual disease activity was similar in patients achieving treatment targets assessed with all composites, but residual high PROs and functional disability were more common when assessed with mCPDAI and DAPSA, most likely due to the absence/attenuated functional assessment in these composites. High baseline levels of structural damage and functional disability attenuated response rates with all composites, affecting MDA/VLDA most prominently; LDA may be the most appropriate target in these patients.

Trial registration number

NCT01695239.

Patient Perception of Medical Care for Psoriatic Arthritis in North America and Europe: Results from a Global Patient Survey

Introduction

To compare perceptions of disease control and treatment satisfaction between patients with psoriatic arthritis (PsA) in North America and Europe, and between participating countries within each region.

Methods

Data were collected from patients with self-reported PsA diagnoses using an online survey. Results from questions on perceptions of overall health, disease severity, PsA symptoms, PsA impacts, and treatment satisfaction/preferences were reported using descriptive statistics and Chi-square tests.

Results

A total of 456 patients from North America (Canada, n = 155; US, n = 301) and 417 patients from Europe (France, n = 123; Spain, n = 135; UK, n = 159) were included in this analysis. Patients in North America were more likely to rate their overall health as excellent/good compared with those in Europe (49 vs. 14%), but also rate their disease as severe (27 vs. 15%). Despite treatment, patients in North America and Europe still experienced musculoskeletal (92 vs. 91%) and skin/nail (62 vs. 58%) symptoms. Similar proportions of patients in North America vs. Europe experienced a social impact (81 vs. 85%); more patients in Europe vs. North America experienced PsA-related work impacts (83 vs. 74%). Satisfaction with PsA medication was more common in North America (89%) vs. Europe (79%), and more common in Spain (91%) vs. the UK (82%) or France (66%). Across all regions and countries, ≥ 75% of patients agreed that symptoms were controlled. However, ≥ 66% wished they had more medication choices, and ≥ 84% wanted to change something about their medication.

Conclusions

Although perception of overall health and disease severity varied, many patients from both regions still experienced symptoms despite receiving medications for PsA, wished they had greater choice of medications, and/or would like to change an aspect of their medications. While these survey findings are subject to selection bias, they do indicate there is scope to improve the treatment of PsA.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-022-00435-y.

Psoriatic arthritis (PsA) is a disease that can cause joint pain and stiffness, and is often associated with a skin rash called psoriasis. These symptoms can affect quality of life, and patients and doctors should work together when choosing treatment. There has not been a lot of information on what patients think about their disease and their medicines. We found that patients from different regions and countries had different opinions, and that treatment of PsA can be improved. For example, patients in North America were more likely to say that their overall health was excellent or good, compared with patients in Europe. However, more patients in North America than in Europe described their PsA disease as severe. Similar numbers of patients in both regions experienced impacts on their social life due to their PsA, but patients in Europe were more likely to report that PsA affected their work life compared with patients in North America. More patients in North America than in Europe were satisfied with their medicines, but patients across all regions and countries still had symptoms even when they took medicines. Many patients also wished they had more options and wanted to change something about their medicines. These findings were based on an online survey. Patients from North America (Canada and the US) and Europe (France, Spain, and the UK) answered questions about their PsA disease and medicines. We only compared answers between patients from North America and Europe, and between countries within each region.

Experiences and Treatment Preferences in Patients With Psoriatic Arthritis: A Cross-Sectional Study in the ArthritisPower Registry

Introduction

Despite recent advances in treatment for psoriatic arthritis (PsA), many patients experience inadequate response or intolerance to therapy, indicating that unmet treatment-related needs remain. To further characterize these unmet needs, we evaluated patients’ experiences regarding the burden of PsA symptoms and disease impacts, and patients’ preferences for treatment.

Methods

Patients from ArthritisPower, a rheumatology research registry, completed a web-based survey. Object case best–worst scaling (BWS) was used to evaluate the relative burden of 11 PsA-related symptoms and the relative importance of improvement in nine PsA-related disease impacts. BWS data were analyzed using a random-parameters logit model. Patient demographics, preferences for mode and frequency of therapy, and preferences for methotrexate were analyzed descriptively.

Results

Among the 332 participants, most were White (94%), female (80%), with mean age of 54 years (SD 11.4). In the BWS, joint pain was the most bothersome symptom, followed by other musculoskeletal pain and fatigue. The BWS for disease impacts found that improvements in the ability to perform physical activities were most important, followed by improvements in the ability to function independently, sleep quality, and the ability to perform daily activities. The most burdensome symptoms and desired disease impact improvements were similar in patients regardless of their experience with biologic disease-modifying antirheumatic drugs. The most preferred mode and frequency of treatment administration was oral, once-daily medication (preferred by 38% of respondents), and 74% prioritized therapies that significantly improved joint-related symptoms versus psoriasis-related symptoms. The majority of respondents (65%) preferred PsA treatment regimens that did not include methotrexate.

Conclusions

Patients with PsA from a rheumatology registry found musculoskeletal pain symptoms to be the most bothersome and prioritized improvements to functional impacts of their disease. These findings can better inform development of new therapies and guide shared patient-provider treatment decision-making.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-022-00436-x.

Relationship between patient acceptable symptom state and disease scores in psoriasis

Patient acceptable symptom state (PASS) is a patient-reported outcome that reflects patients' perspective well. The relationship between the PASS and disease scores in psoriasis has not been described. The aim of the present study was to investigate the association of PASS with Psoriasis Area and Severity Index (PASI) and body surface area (BSA) affected by lesions in patients with psoriasis. A sectional study was conducted. PASS was evaluated by a binary question on the patient's feeling that they have about their symptoms. Clinical data including PASI, BSA, and other patient characteristics were collected. Logistic regression was used to investigate the associations. Receiver-operator curve (ROC) analysis was utilized to determine the PASI/BSA thresholds for PASS. A total of 198 participants (27.8% female, mean age 41.9 ± 12.6 years, mean disease duration 10.2 ± 8.6 years) completed this study. Of patients with mild psoriasis, 71.4% based on PASI and 76.3% based on BSA considered their symptom state acceptable. Female sex (adjusted odds ratio [OR] = 0.47; 95% confidence interval [CI = 0.42-0.92) and patients with exposed skin involved (adjusted OR = 0.38; 95% CI = 0.19-0.76) were less likely to report acceptable symptom state. The threshold for differentiating psoriasis patients in PASS was 3.85 (area under the curve [AUC], 0.67; sensitivity, 0.67; specificity, 0.60) for PASI and 2.85% (AUC, 0.66; sensitivity, 0.79; specificity, 0.54) for BSA, respectively. These results showed that mild psoriasis based on PASI/BSA score align well with PASS status. Female and exposed skin involved are risk factors for acceptable status. Both PASI and BSA have limited capability in differentiating acceptable symptom state in psoriasis.

Maintained activity in ankylosing spondylitis patients treated with TNFi and/or NSAID for at least 12 weeks: a cross-sectional study in Brazil

BACKGROUND

The aim of this study was to evaluate disease activity among patients with axial spondyloarthritis (AS) treated with tumor necrosis factor inhibitors (TNFi) and/or nonsteroidal anti-inflammatory drugs (NSAIDs) for at least 12 weeks in private outpatient settings in Brazil.

METHODS

This was a cross-sectional, real-world study conducted in 17 Brazilian private health care institutes. Patients were selected if diagnosed with AS or axial radiographic spondyloarthritis (AxSpA) and treated with NSAIDs or TNFi for at least 12 weeks within the last 26 weeks prior to enrollment. The data were collected from interviewed-based and self-administered questionnaires from patients and physicians. Disease activity was defined as active (≥ 4), low /suboptimal (≥ 2 and < 4) and inactive (< 4) by Bath AS Disease Activity Index (BASDAI) and/or very high (≥ 3.5), high (≥ 2.1 to < 3.5), low (≥ 1.3 to < 2.1), and inactive (< 1.3) by AS Disease Activity Score (ASDAS-CRP). Both patients and physicians' perceptions of disease control were assessed using a numeric rating scale (NRS; 0-inactive to 10-very active disease).

RESULTS

The cohort included 378 patients with a mean age of 46 years, and the median time since diagnosis until enrollment was 5.4 years (interquartile range 2.7-10.5). Most patients were treated with TNFi alone (74%), followed by TNFi in combination with NSAID (15%), and NSAID alone (11%). About half AS patients showed active disease and 24% of patients showed low activity/suboptimal disease control despite having been treated for at least 12 weeks. Although TNFi showed better disease control than NSAID, inactive disease was experienced by few patients. The NRS (mean [standard deviation]) score for disease perception was 4.24 (3.3) and 2.85 (2.6) for patients and physicians, respectively.

CONCLUSION

This real-world study showed that most AS patients on TNFi and/or NSAID had not achieved an adequate disease control, as almost 75% of them exhibited active disease or low activity/suboptimal disease control. There remains a need for improved disease management among patients with AS.

Change in psoriatic arthritis outcome measures impacts SF-36 physical and mental component scores differently: an observational cohort study

Objective

The objective was to investigate interplay and physical and mental component scores between change (Δ) in health-related quality of life (HRQoL) quantified by the physical component score (PCS) and mental component score (MCS) retrieved from short-form health survey (SF-36), change in disease activity (ΔDAS28CRP) and manifestations of PsA.

Methods

PsA patients initiating new medical therapy were enrolled. Independent disease measures evaluating disease activity, enthesitis, psoriasis, pain and fatigue were collected at treatment initiation and after 4 months. Interplay between independent disease measures and dependent outcome measures, ΔPCS and ΔMCS, was described with univariate regression analyses. Multivariate regression analyses were applied to assess the impact of independent variables, such as individual disease outcome measures vs ΔDAS28CRP on ΔPCS and ΔMCS.

Results

One hundred and eight PsA patients were included. In the univariate regression analyses, improvement in fatigue, pain and disability were associated with improvement in ΔPCS (β; -2.08, -0.18 and -13.00, respectively; all P < 0.001) and ΔMCS (β; -1.59, -0.12 and -6.07, respectively; P < 0.001, P < 0.001 and P = 0.003, respectively). When patient-reported outcomes were included in the final multivariate models, improvements in ΔPCS and ΔMCS were associated with improvements in pain, fatigue and disability (P < 0.001). Improvement in enthesitis impacted ΔPCS positively (β -0.31, P < 0.001). No association was found between change in skin psoriasis, ΔPCS and ΔMCS (β 0.15, P = 0.056 and β 0.05, P = 0.561, respectively).

Conclusion

In this PsA patient cohort, diminishing pain, disability and fatigue improved PCS and MCS significantly. Changes in enthesitis and psoriasis did not grossly impact HRQoL compared with DAS28CRP. Individual PsA manifestations influence HRQoL differently, which is important clinically when targeting treatment.

Trial registration

ClinicalTrials.gov, http://clinicaltrials.gov, NCT02572700.

A qualitative study of dermatology patients and providers to understand discordant perceptions of symptom burden and disease severity

BACKGROUND

Patients often present with symptoms that are disproportionate to the observed disease state, and grade disease severity differently from healthcare providers (HPs). This discordant symptom burden and severity grading (DSG) results in poorer patient care. Current research on DSG is limited, relying on structured models that are theoretically incomplete.

OBJECTIVE

To fully understand the factors driving DSG.

METHODS

Qualitative study of dermatology patients and HPs. Interview data were analyzed using grounded theory to derive a model of the causes of DSG.

RESULTS

Eighteen patients and 12 HPs were interviewed. Results reflect a tendency for patients to grade their conditions more severely than HPs. Factors driving DSG are related to emotional and cognitive disparities in the constructs used to grade severity, varying consequences of disease due to differing resilience and coping methods, socio-psychological factors influencing how patients report their symptoms, and the context of the consult.

CONCLUSION

A better understanding of DSG is required for achieving mutual understanding and patient-centered collaborative care. It is easy to label a patient with high symptom burden as having a low threshold for discomfort, or for a patient to presume that the doctor is unempathetic. This study suggests the causes of DSG are nuanced and multifactorial.

Guselkumab demonstrated an independent treatment effect in reducing fatigue after adjustment for clinical response-results from two phase 3 clinical trials of 1120 patients with active psoriatic arthritis

Background

The interleukin-23p19-subunit inhibitor guselkumab effectively treats signs and symptoms of psoriatic arthritis (PsA). We evaluated the effect of guselkumab on fatigue.

Methods

Across two phase 3 trials of guselkumab (DISCOVER-1, DISCOVER-2), patients with active PsA despite standard therapy were randomized to subcutaneous injections of guselkumab 100 mg every 4 weeks (Q4W, N = 373); guselkumab 100 mg at week 0, week 4, and then Q8W (N = 375); or placebo (N = 372) through week 24, after which patients in the placebo group crossed over to guselkumab Q4W. Fatigue was measured as a secondary endpoint using the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue instrument (range 0–52, higher scores indicate less fatigue). Least-squares mean changes in FACIT-Fatigue scores were compared between treatments using a mixed-effect model for repeated measures. Mediation analysis was used to adjust for indirect effects on fatigue deriving from improvement in other outcomes, including ≥20% improvement in American College of Rheumatology criteria (ACR20; prespecified), minimal disease activity (MDA; post hoc), or C-reactive protein (CRP; post hoc).

Results

Baseline mean (SD) FACIT-Fatigue scores in DISCOVER-1 (N = 381) and DISCOVER-2 (N = 739), ranging from 29.1 (9.5) to 31.4 (10.1), indicated substantial levels of fatigue relative to the United States general population (43.6 [9.4]). Across studies, mean improvements, and proportions of patients with ≥4-point improvements, in FACIT-Fatigue scores at week 24 with guselkumab Q4W and Q8W (5.6–7.6 and 54–63%, respectively) were larger vs placebo (2.2–3.6 and 35–46%). Improvement in FACIT-Fatigue scores with guselkumab was sustained from week 24 to week 52, with moderate-to-large effect sizes (Cohen’s d = 0.52–0.81 at week 24; 0.66–0.91 at week 52). Mediation analyses demonstrated that substantial proportions of the effects of guselkumab vs placebo on fatigue were direct effect, after adjusting for achievement of ACR20 (Q4W 69–70%, Q8W 12–36% direct effect) or MDA (72–92% across dosing regimens) response or for change in serum CRP concentrations (82–88% across dosing regimens).

Conclusions

In patients with active PsA, guselkumab 100 mg Q4W or Q8W led to clinically meaningful and sustained improvements in fatigue through 1 year. A substantial portion of the improvement in FACIT-Fatigue scores induced by guselkumab was independent of effects on the achievement of other select outcomes.

Trial registration

Name of the registry: ClinicalTrials.gov

Trial registrations: DISCOVER-1, NCT03162796; DISCOVER-2, NCT03158285

Date of registration: DISCOVER-1, May 22, 2017; DISCOVER-2, May 18, 2017

URLs of the trial registry record:

DISCOVER-1, https://clinicaltrials.gov/ct2/show/NCT03162796?term=NCT03162796&draw=1&rank=1

DISCOVER-2, https://clinicaltrials.gov/ct2/show/NCT03158285?term=NCT03158285&draw=2&rank=1

Development of an Instrument for Patient Self-assessment in Psoriatic Arthritis

OBJECTIVE

Due to the recent pandemic caused by the coronavirus disease 2019 (COVID-19), in-person scheduled rheumatology appointments in many countries have been reserved for urgent cases only. Here we report the development of a multidimensional, patient-completed disease assessment tool for use in psoriatic arthritis (PsA).

METHODS

A focus group development and education method was used, followed by a paired observation design to assess feasibility and validity. The Psoriatic Arthritis Disease Activity Score (PASDAS) was used as the basis for the clinical assessments, but elements of this tool were modified during the focus group sessions.

RESULTS

A preliminary tool assessed tender and swollen joint counts, enthesitis, dactylitis, area of skin involved by psoriasis, and scores for global disease activity, fatigue, and spinal pain. In parallel assessments, good agreement was found between subject and healthcare professional (HCP) assessors, although overall disease activity was low.

CONCLUSION

A self-assessment tool for disease activity in PsA has been developed in conjunction with patients, demonstrating generally good agreement between patients and HCPs; however, further validation is needed before it can be recommended for clinical practice.

Diagnosis, classification, and assessment in psoriatic arthritis

There have been considerable advances in the classification and assessment of psoriatic arthritis (PsA). In this report, we give an overview of historic and current classification criteria and discuss its role and limitations in research and clinical practice. We discuss the most commonly used assessment instruments for arthritis, psoriasis, onychodystrophy, enthesitis, dactylitis and axial PsA with a focus on clinical practice. We pay particular attention to the current evidence for the use of composite outcome measures, and their use in randomised controlled trials and routine care.

Using Bayesian Networks to identify musculoskeletal symptoms influencing the risk of developing Psoriatic Arthritis in people with psoriasis

Objectives

The aim of this study was to explore the use of Bayesian networks (BNs) to understand the relationships between musculoskeletal symptoms and the development of PsA in people with psoriasis.

Methods

Incident cases of psoriasis were identified for 1998 to 2015 from the UK Clinical Research Practice Datalink. Musculoskeletal symptoms (identified by Medcodes) were concatenated into primary groups, each made up of several subgroups. Baseline demographics for gender, age, BMI, psoriasis severity, alcohol use and smoking status were also extracted. Several BN structures were composed using a combination of expert knowledge and data-oriented modelling based on: (i) primary musculoskeletal symptom groups; (ii) musculoskeletal symptom subgroups and (iii) demographic variables. Predictive ability of the networks using the area under the receiver operating characteristic curve was calculated.

Results

Over one million musculoskeletal symptoms were extracted for the 90 189 incident cases of psoriasis identified, of which 1409 developed PsA. The BN analysis yielded direct relationships between gender, BMI, arthralgia, finger pain, fatigue, hand pain, hip pain, knee pain, swelling, back pain, myalgia and PsA. The best BN, achieved by using the more site-specific musculoskeletal symptom subgroups, was 76% accurate in predicting the development of PsA in a test set and had an area under the receiver operating characteristic curve of 0.73 (95% CI: 0.70, 0.75).

Conclusion

The presented BN model may be a useful method to identify clusters of symptoms that predict the development of PsA with reasonable accuracy. Using a BN approach, we have shown that there are several symptoms which are predecessors of PsA, including fatigue, specific types of pain and swelling.

A 12-point recommendation framework to support advancement of the multidisciplinary care of psoriatic arthritis: A call to action

OBJECTIVE

Making a differential diagnosis of psoriatic arthritis (PsA) is not straightforward. This is partly because of its heterogeneous presentation and partly because many patients with PsA are initially diagnosed with psoriasis and treated in primary care or by dermatologists, with referral to rheumatologists being delayed. Once diagnosed, optimal disease control requires frequent specialist monitoring, adjustment or switching of therapies, and management of comorbidities and concomitant diseases, as well as attention to patients' overall well-being. Given the breadth of expertise that diagnosis and management of PsA requires, we sought to define a collaborative, structured framework that supports the optimisation of multidisciplinary care for patients with PsA in Europe.

METHODS

An expert panel comprising four rheumatologists, three dermatologists, two specialist nurses and one psychologist-from Spain, the United Kingdom, The Netherlands, Germany, France and Italy-met face-to-face to take part in a modified Delphi exercise.

RESULTS

The result of this exercise is a set of recommendations that are based on combining published evidence with the panel's extensive clinical experience. Recommendations can be implemented in a number of ways, but the central call-to-action of this framework is the need for improved collaboration between dermatologists (or primary care physicians) and rheumatologists. This could occur in a variety of different formats: standard referral pathways, multidisciplinary physician meetings to discuss patient cases, or 'one stop', combined clinics.

CONCLUSION

We anticipate that when the majority of patients with PsA receive regular multidisciplinary care, improved patient outcomes will follow, although robust research is needed to explore this assumption.

Which factors predict discordance between a patient and physician on a gout flare?

OBJECTIVE

To investigate the factors associated with discordance between patient and physician on the presence of a gout flare.

METHODS

Patients' self-reports of current gout flares were assessed with the question, 'Are you having a gout flare today?' which was then compared with a concurrent, blinded, physician's assessment. Based on agreement or disagreement with physicians on the presence of a gout flare, flares were divided into concordant and discordant groups, respectively. Within the discordant group, two subgroups-patient-reported flare but the physician disagreed and physician-reported flare but the patient disagreed-were identified. The factors associated with discordance were analysed with multivariable logistic regression analysis.

RESULTS

Of 268 gout flares, 81 (30.2%) flares were discordant, with either patient or physician disagreeing on the presence of a flare. Of the discordant flares, in 57 (70.4%) the patient reported a flare but the physician disagreed. In multivariable logistic regression analysis adjusted for demographics, disagreement among patients and physicians on the presence of a gout flare was associated with lower pain scores at rest [odds ratio (OR) for each point increase on 0-10 point pain scale 0.81 (95% Wald CI 0.73, 0.90), P < 0.0001] and less presence of joint swelling [OR 0.24 (95% CI 0.10, 0.61), P = 0.003] or joint warmth [OR 0.39 (95% CI 0.20, 0.75), P = 0.005].

CONCLUSION

Although patients and physicians generally agree about the presence of gout flare, discordance may occur in the setting of low pain scores and in the absence of swollen or warm joints.

Conducting research in psoriatic arthritis: the emerging role of patient research partners

Since 2003, patients have become increasingly involved in research endeavours related to psoriatic arthritis (PsA), progressing into a patient research partner (PRP) role. This paper reviews the general considerations related to PRP involvement in research endeavours and more specifically, the evolution of PRP contributions related to PsA research. The addition of the perspective from individuals with lived experience of PsA can bring unique insights to the research process, and increase the likelihood that the results of research are meaningful and relevant to PsA patients. There are also potential issues to address when incorporating PRPs, such as the need for additional time and effort to identify, train, and collaborate with PRPs as members of a research team. Overall, while there are challenges to overcome, and the opportunities to include PRPs are sometimes overlooked, efforts to include PRPs in PsA research should offer significant benefits to patients, researchers, and trials.

Assessment of Widespread and Extraarticular Pain in Psoriatic Arthritis: A Case-control Study

OBJECTIVE

A remarkable lack of detailed knowledge on pain areas in psoriatic arthritis (PsA) is present, and their clinical relevance is quite unknown. The main aim of the study was to explore pain areas in PsA, comparing them with those involved in patients with fibromyalgia (FM). In addition, a secondary aim was to investigate any possible association between pain areas and outcome measures in PsA.

METHODS

This was a case-control study on patients with PsA satisfying Classification Criteria for Psoriatic Arthritis criteria and patients with FM. In all patients with PsA and FM, a body chart filled in by the patient reporting pain areas in 80 body locations was performed. The Widespread Pain Index (WPI) was performed in all patients with PsA and FM. In all patients with PsA, an assessment of disease activity, treatment target, function, and impact of disease was carried out.

RESULTS

Fifty patients with PsA and 50 FM controls were evaluated. A significantly higher number of pain areas in the body chart and higher WPI scores were found in patients with FM when compared to patients with PsA. In PsA, the number of areas reported in the body chart significantly correlated with the Disease Activity Index for PsA, Health Assessment Questionnaire-Disability Index, and PsA Impact of Disease. Patients who showed a significantly high number of extraarticular pain areas involved were those who were not in remission/minimal disease activity, or who did not have a greater impact of disease or reduced function.

CONCLUSION

The main results showed that widespread and extraarticular pain was present in patients with PsA, showing that this nonarticular pain had an impact on important disease domains. The present study could contribute to an important aspect of this challenging and multifaceted disease-namely, the assessment of widespread pain.

Validation and clinical interpretability of PsAID - psoriatic arthritis impact of disease

BACKGROUND

Psoriatic arthritis (PsA) is a chronic inflammatory disease of widely varying presentation, which determines functional and psychological impairment, with a high negative impact on patients' quality of life. Therefore, knowing the patient's perception of their health status is of fundamental importance for understanding the real impact of PsA. Given this context, the European League Against Rheumatism (EULAR) recently developed the Psoriatic Arthritis Impact of Disease (PsAID) - instrument to specifically assess the impact of PsA for the patient.

OBJECTIVE

Validate the brazilian portuguese version of PsAID-12 (Psoriatic Arthritis Impact of Disease) and to verify its interpretability in clinical practice, through its relation with measures of psoriatic arthritis activity.

METHODS

A multicenter cross-sectional study, which recruited 160 patients, who met the Classification criteria for Psoriatic Arthritis (CASPAR), in six Brazilian centers of rheumatology. Reliability was assessed by Cronbach's alpha coefficient and by the intraclass correlation coefficient (ICC). The construct validity was evaluated by exploratory factorial analysis and also by Spearman correlation with other PROMs and measures of disease activity evaluation.

RESULTS

Of the total number of participants, 50% were female, with a mean age (SD) of 54.0 ± 11.2 years; 68% had only peripheral arthritis and 32% had pure or mixed axial involvement. The majority (67.7%) of the patients were using biological treatment. The reliability of internal consistency (alpha-Cronbach = 0.93) and test-retest (ICC = 0.996) were good. Factor analysis revealed two factors, named physical and psychosocial, which included the skin evaluation item. PsAID-12 correlated significantly with other PROMs, demonstrating good construct validity. PsAID-12 was also significantly associated with the disease activity assessment instruments (DAS28-ESR, ASDAS, and BASDAI) and the MDA status: "Minimum Disease Activity". Fibromyalgia did not significantly affect the final PsAID-12 score.

CONCLUSION

The brazilian version of PsAID-12 has been shown to be a reliable and valid measure of the impact of the disease in patients with psoriatic arthritis. Moreover, it associated significantly with the scores of disease activity assessment.

Prevalence and variables associated with fatigue in psoriatic arthritis: a cross-sectional study

OBJECTIVE

To describe the prevalence of and evaluate the factors associated with fatigue patients with psoriatic arthritis (PsA) in an Asian population.

METHODS

We used baseline data from a registry of patients with PsA attending an outpatient clinic of a tertiary hospital in Singapore. Demographic data and disease characteristics were evaluated. Fatigue was assessed by question one of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI-F) and the vitality domain of the Medical Outcome Survey, Short-Form 36 (SF-36 VT). We evaluated clusters of variables, and individual variables in association with fatigue.

RESULTS

We included 131 patients (50.4% men, 63.4% Chinese, median PsA duration 21.0 months) with completed data for fatigue. Forty-five patients (34%) experienced severe fatigue (defined by BASDAI-F > 5/10). We used principal component analysis and identified five clusters of variables that explained 62.9% of the variance of all factors. Of these, disease activity and impact, and disease chronicity were significantly associated with BASDAI-F and SF-36 VT. In multivariable analyses, back pain, peripheral joint pain and patient global assessment were associated with BASDAI-F, whereas peripheral joint pain and mental health were associated with SF-36 VT.

CONCLUSION

PsA-associated fatigue is prevalent in this Asian PsA cohort and is associated with disease activity, impact and chronicity.

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

Introduction

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

Objective

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

Methods

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

Results

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

Conclusions

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

The relationship between patient acceptable symptom state and disease activity in patients with psoriatic arthritis

OBJECTIVES

The Psoriatic Arthritis Disease Activity Score (PASDAS) and Disease Activity Index for Psoriatic Arthritis (DAPSA) are composite PsA disease activity measures. We sought to identify the PASDAS and DAPSA cut-off points consistent with patient acceptable symptom state (PASS), the threshold of symptoms beyond which patients consider themselves well, and examine PASS across published PASDAS and DAPSA thresholds for low, moderate and high disease activity.

METHODS

We used a standard protocol including physician assessment and patient-reported outcomes to prospectively record measures required to calculate PASDAS and DAPSA. We identified PASS thresholds for the PASDAS and DAPSA using receiver operating characteristics curve analyses. We assessed the frequency of reporting acceptable symptom state across disease activity thresholds for PASDAS and DAPSA scores.

RESULTS

A total of 229 patients (58.5% male, mean age 55.5 years, mean disease duration 17.1 years) were recruited. The PASS threshold for the PASDAS was 3.79 [area under the curve (AUC) 0.86, sensitivity 0.75, specificity 0.82] and for the DAPSA was 11.10 (AUC 0.91, sensitivity 0.89, specificity 0.82). With the PASDAS, 90% of patients defined as having low disease activity considered their symptom state acceptable, compared with 55% and 17% among those with moderate and high disease activity, respectively. With the DAPSA, 98% of patients in disease remission considered their symptom state acceptable compared with 85, 22 and 18% among those with low, moderate and high disease activity, respectively.

CONCLUSION

We have defined PASS thresholds for PASDAS and DAPSA. The PASDAS target for low disease activity and DAPSA targets of low disease activity or remission align well with PASS.

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.

Patient and physician discordance of global disease assessment in juvenile dermatomyositis: findings from the Childhood Arthritis & Rheumatology Research Alliance Legacy Registry

BACKGROUND

Global disease activity scores (gVAS) capture patient or family (PF) and physician (MD) assessments of disease. This study sought to measure discordance between PF and MD global activity scores in juvenile dermatomyositis (JDM), and determine factors associated with discordance.

METHODS

Patients with JDM were included from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Legacy Registry (N = 563). PF and MD gVAS were assessed for discordance, defined as a ≥ 2-point difference. Factors associated with discordant gVAS were compared in univariate analysis. Multivariable regression analysis was used to identify predictors of discordance.

RESULTS

Almost 40% (N = 219) of PF and MD gVAS were discordant. Among discordant scores, 68% of PF rated gVAS ≥2-points above MD, which was associated with calcinosis and lower quality of life and functional scores (p < 0.01). MD gVAS rated ≥2-points above PF in 32%, which was associated with abnormal laboratory results, weakness, arthritis, rash and other skin changes, and current intravenous steroid treatment (p < 0.01). In multivariate analysis, predictors for higher PF rating included calcinosis, lower quality of life and functional scores, while predictors for higher MD rating included rash, calcinosis, nailfold capillaroscopy changes, and current intravenous steroid treatment.

CONCLUSIONS

Discordance between PF and MD gVAS was common in this JDM cohort. Overall, higher PF rating was associated with poorer patient reported outcome (PRO) scores, while higher MD rating was associated with poorer objective measures. This suggests PF and MD assessments of gVAS may be measuring different aspects of disease, highlighting the importance of integrating PROs into clinical practice and research.

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.

Predictors of Achieving Remission among Patients with Psoriatic Arthritis Initiating a Tumor Necrosis Factor Inhibitor

Objective.

To examine predictors of remission among patients with psoriatic arthritis (PsA) initiating a tumor necrosis factor (TNF) inhibitor.

Methods.

Patients with PsA enrolled in the Corrona Registry between 2005 and 2013 were followed from initiation of a TNF inhibitor (TNFi; etanercept, adalimumab, infliximab, certolizumab, or golimumab) to the visit closest to 12 months. Additional inclusion criteria included 3 tender or 3 swollen joints. Outcomes of interest were Clinical Disease Activity Index (CDAI) ≤ 2.8 (remission), low disease activity (LDA; CDAI ≤ 10), change in the modified Health Assessment Questionnaire (mHAQ) ≥ 0.35 and achievement of mHAQ < 0.30. Predictors were measured on or before TNFi initiation. Covariates significant in univariable logistic regression models and ≤ 5% missing values were included in a multivariable model and removed individually until all remaining variables were significant (p < 0.05).

Results.

Among 1832 TNFi initiations, 774 initiations (624 patients) met inclusion criteria. Median age at initiation was 52 years [interquartile range (IQR) 44–60], 56% were female, median PsA duration was 4 years (IQR 2–11), and median CDAI at baseline was 20 (IQR 14.5–28). Remission was achieved by 14% and LDA (or remission) by 37%. Achieving remission was positively associated with college education (OR 1.88, 95% CI 1.11–3.19) but negatively associated with female sex (0.62, 95% CI 0.40–0.97), obese body mass index (0.51, 95% CI 0.32–0.81), hypertension (0.55, 95% CI 0.32–0.95), previous biologic use (0.41, 95% CI 0.26–0.65), and baseline pain (0.80 per 10 mm visual analog scale, 95% CI 0.73–0.87). Predictors for LDA, mHAQ < 0.30, and mHAQ change were similar.

Conclusion.

Few patients with PsA in a US-based registry achieved remission by CDAI criteria. Female sex, obesity, comorbidities, and education influence achievement of remission on a TNFi.

Treating psoriatic arthritis to target: discordance between physicians and patients' assessment, non-adherence, and restricted access to drugs precluded therapy escalation in a real-world cohort

The treat-to-target strategy (T2T) was associated with better outcomes in psoriatic arthritis (PsA) compared to standard care in clinical trials. This study aimed to analyze factors precluding treatment optimization in a T2T strategy conducted in a real-world cohort of PsA patients. A retrospective cross-sectional study nested in a cohort was conducted. Medical records of patients ≥ 18 years old, fulfilling CASPAR criteria and with at least one visit in the PsA clinic, were reviewed. Demographic data, current medication, and minimal disease activity (MDA) criteria were recorded. Reasons for the non-escalation of therapy in patients who were not classified as MDA were reported as absolute and relative frequencies. In the 8-month period, 131 visits (corresponding to 74 patients) were conducted. The MDA criteria were available in 113 visits (86.3%) and patients were classified as MDA in 31.0% of the visits (N = 35/113). Although in 69.0% of the visits patients were not in MDA, (N = 78/113), therapy was adjusted in only 42.3% (N = 33/78). Reasons precluding treatment escalation in non-MDA subjects were physician's impression of remission (57.7%, N = 26), non-adherence to previous prescription (17.8%, N = 8), restricted access to drugs (17.8%, N = 8), adverse events (11.1%, N = 5), poor understanding of medication instructions (6.7%, N = 3), patient's refusal to escalate therapy (4.4%, N = 2), and recent change in therapy (2.2%, N = 1). Discordance between the physician's clinical evaluation and the MDA criteria, non-adherence to prescription, and poor access to drugs were the main factors precluding escalation of therapy in a T2T strategy in a real-world PsA cohort.

Discordance of global assessment by patients and physicians is higher in osteoarthritis than in rheumatoid arthritis: a cross-sectional study from routine care

The study compares patient-physician discordance in global assessment in patients with osteoarthritis (OA) versus patients with rheumatoid arthritis (RA) seen in routine care. This is a cross-sectional study conducted at an academic rheumatology center at which all patients are asked to complete a Multi-Dimensional Health Assessment Questionnaire (MDHAQ), which includes a patient global assessment (PATGL). Rheumatologists are encouraged to complete a physician questionnaire, which includes a physician global assessment (DOCGL). Patients with either OA or RA were identified using ICD9 codes and classified as positive discordance (PATGL-DOCGL ≥ 2), negative discordance (PATGL-DOCGL≤ - 2), and concordance (absolute difference between the two assessments < 2). Discordance was assessed by diagnosis. Agreement between patient and physician global assessments was evaluated using intraclass correlations. Logistic regression was performed to identify explanatory variables for positive discordance. The analysis included 243 OA and 216 RA patients. Mean PATGL was higher in OA versus RA (5.4 versus 4.2, p = 0.005), while mean DOCGL was similar (4.0 versus 3.8, p = 0.23) leading to a higher patient-physician discordance in OA (1.35 versus 0.43, p < 0.001). Positive discordance occurred in 34% of OA versus 18% of RA patients (p < 0.001). Intraclass correlation coefficients were 0.43 in OA versus 0.60 in RA patients. In logistic regressions, pain was the only statistically significant explanatory variable for discordance in both OA (OR 1.34, 95% CI 1.12-1.78) and RA (OR 1.47 95% CI 1.04-2.07). Patients with OA are more likely to be discordant with their rheumatologists than patients with RA because of a higher PATGL. Similarly to RA, the most important explanatory variable for discordance was higher pain.

"Like No One Is Listening to Me": A Qualitative Study of Patient-Provider Discordance Between Global Assessments of Disease Activity in Rheumatoid Arthritis

OBJECTIVE

To explore the perspectives and experiences of patients with rheumatoid arthritis (RA) whose assessments of their disease differ from those of their rheumatology care provider.

METHODS

A total of 20 adult RA patients with patient-provider discordance at their most recent rheumatology appointment (within 4 weeks) were recruited. Discordance was defined by an absolute difference of 25 or more between patient and provider global assessments on a visual analog scale (VAS) of disease activity. For descriptive purposes, participants completed the Health Assessment Questionnaire II, pain VAS, and Patient Health Questionnaire 9 depression scale. Interviews were conducted in person and individually with each patient with a semistructured interview guide. Topics ranged widely, including participants' perspectives and experiences with living with RA, clinical disease assessments, patient-provider communication, and psychosocial or other needs. Data from the interviews were analyzed using interpretive phenomenological analysis.

RESULTS

Six major themes emerged from the patient interviews describing patient-provider discordance and disease assessment: being misunderstood by others, limitations of provider assessments, discrepancy with provider findings, inadequate active listening on the part of health care providers, unmet psychosocial needs, and lack of patient empowerment.

CONCLUSION

Patients described discordance in terms of symptom assessment and understanding how RA affects everyday life. Typical clinical assessments did not capture their experience. The resulting conceptual framework should inform future interventional studies seeking to enhance concordance of patient-physician communication and to optimize satisfaction with care and health-related quality-of-life outcomes for patients with RA.

Novel Concepts in Psoriatic Arthritis Management: Can We Treat to Target?

PURPOSE OF REVIEW

Psoriatic arthritis (PsA) is a chronic inflammatory spondyloarthritis that can cause progressive joint damage and irreversible disability. Advances in modern therapies, now mean a target of remission is an achievable goal in PsA. There is strong and consistent evidence that a treat-to-target (T2T) approach to PsA management results in better patient outcomes; however, the practicalities of incorporating this strategy into routine clinical practice remain a challenge. The heterogeneous nature of this condition and the need for validated outcome measures have to-date hampered consensus on a definition of remission. This review aims to summarise the current T2T research landscape in PsA and highlight potential roles for biomarkers and imaging advances in revolutionising the T2T concept.

RECENT FINDINGS

There is a growing body of evidence to support the implementation of a T2T strategy, using a pre-defined target in PsA management, with significant benefits in disease outcome, physical function and quality of life. Whilst remission is the ultimately goal for PsA patients and their clinicians, further comparative studies of different treatment targets are needed to establish a widely acceptable definition of remission.

Classification and Outcome Measures for Psoriatic Arthritis

Psoriatic arthritis (PsA) is an inflammatory arthritis with multiple manifestations: peripheral/axial arthritis, enthesitis, dactylitis, psoriasis, and nail involvement. From having an agreed upon classification criteria in 2006, the assessment of PsA has advanced from uncertainties to development and validation of numerous specific outcome measures. The Group for Research and Assessment of Psoriasis and Psoriatic arthritis (GRAPPA) has spearheaded the development of a core domain set and is now working on a core outcome measurement set to standardize outcome measures for PsA, that will provide guidance for use of instruments in randomized controlled trials (RCTs) and longitudinal observational studies (LOS). This article summarizes and updates these work processes to improve assessment of this multisystem complex rheumatologic disease.

Remission in psoriatic arthritis-where are we now?

Advances in treatments and treatment strategies for PsA have led to many patients responding well to management of their disease, and targeting remission as a treatment goal is now a possibility. Treat to target is a strategy aimed at maximizing benefit, irrespective of the type of medication used, by monitoring disease activity and using it to guide therapy. The measurement of response to treatment has been the subject of wide discussions among experts for some time, and many instruments exist. Comparisons of the different measures and their different strengths and weaknesses is ongoing. The impact of modern imaging techniques on monitoring disease progression is also evolving, and advanced techniques using both MRI and US have the potential to improve management of PsA through identification of risk factors for poor prognosis as well as accurate assessment of inflammation and damage, including subclinical disease. Increased understanding of the pathways that drive the pathogenesis of PsA will be key to identifying specific biomarkers for the disease and developing effective treatment strategies. Targets for response, considerations for use of a treat to target strategy in PsA, different imaging techniques and serological aspects of remission are all discussed in this review, and areas for further research are identified.

Patient Reported Improvement After Patch Testing and Allergen Avoidance Counseling: A Retrospective Analysis

Introduction

Our objectives were to assess patient-reported improvement after patch testing at the 2–3-month follow-up visit in patients referred for patch testing with relevant positive patch test reactions at the University of California, San Francisco.

Methods

Cross-sectional analyses of patients patch tested between 2013 and 2016 who returned for a follow-up visit approximately 2–3 months after patch testing. We examined positive patch test results considered of definite, probable or possible relevance to the patient’s eczematous eruptions. Patients reported improvement after patch testing as a percentage: 0–100%. Patients were categorized into four groups: (1) those that reported no improvement or worsened, (2) those that reported > 0% and ≤ 60% improvement, (3) those that reported > 60% but < 100% improvement and (4) those that reported 100% improvement. Secondary measures included the association of allergens, gender, age and location of the rash.

Results

The majority (81%) of patients seen at follow-up reported improvement after patch testing. Women reported more improvement than men with statistical significance. Notably, there does not appear to be a statistically significant relationship in patient-reported improvement and age, atopy, strength of a the patient’s positive reactions, number of positive reactions and follow-up time or with potential systemic contact allergens (i.e., balsam of Peru, nickel, chrome and cobalt).

Conclusion

We find the large percentage of patients that self-report global benefit from patch testing encouraging, as we believe this to be a powerful measure of disease and symptom activity, as well as quality of life. The gender differences we found contradict the previous literature.