A comparison of two methods of assessing disease activity in the joints

Physical articular examination in the activity of rheumatoid arthritis: a systematic review of the literature : Systematic review of the literature regarding physical examination in rheumatoid arthritis

To summarize evidence concerning the articular examination needed to determine rheumatoid arthritis (RA) activity (follow-up or control) via a systematic review. A search of Medline, Embase, Lilacs, SciELO, the Web of Science, the National Technical Reports Library, and the reference lists of relevant studies through March 2017 was conducted using a systematic methodology to identify studies of patients with RA older than 18 years in which a detailed description of the physical examination or a description of the components of the articular examination was provided. Of 8322 references, 74 studies were included according to the selection criteria, and 6 references were ultimately included at the end of the review. Most of the included studies (n = 5) were associated with a moderate risk of bias. There was great variability among the studies and the articular examination methods used. Some studies presented the examination with a complete specification of the technique (n = 2), the consensus of rheumatologists (n = 2), or training through audiovisual materials and face-to-face courses (n = 2), but none of the studies explicitly showed the technique by which the physical examination was performed. Despite the importance of the clinical evaluation and physical examination of patients with RA for diagnosis, prognosis, clinimetrics, and follow-up, evidence concerning how to perform the articular examination is scarce.

Validating the 28-tender joint count using item response theory

OBJECTIVE

To examine the construct validity of the 28-tender joint count (TJC-28) using item response theory (IRT)-based methods.

METHODS

A total of 457 patients with early stage rheumatoid arthritis (RA) were included. Internal construct validity of the TJC-28 was evaluated by determining whether the TJC-28 fit a 2-measure logistic IRT model. As well, we tested whether the discrimination and difficulty parameters of the joints properly reflected the known left-right symmetry of joint involvement. External validity was evaluated by correlations with other established measures of disease activity, including pain, disability, general health, erythrocyte sedimentation rate (ESR), and the 28-swollen joint count.

RESULTS

The TJC-28 showed a good fit with the 2-parameter logistic model, with no relevant differential item functioning across sex, age, and time and with excellent reliability. The 28 joints covered a reasonable range of disease activity, even though they were mainly targeted at patients with moderate or high disease activity levels. The joint parameters reflected the left-right symmetry of joint involvement for all pairs of joints except one. All disease activity measures, except ESR, were significantly correlated with the TJC-28. Most correlations were of the expected magnitude.

CONCLUSION

The TJC-28 showed good internal and acceptable external construct validity for patients with early-stage RA. The IRT analyses did point to some potential limitations of the instrument, a major problem being its limited measurement range. Future research should examine whether instrument modifications might lead to a more robust assessment of disease activity in patients with RA.

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

OBJECTIVE

Patient self-report outcomes and physician-performed joint counts are important measures of disease activity and treatment response. This metaanalysis examines the degree of concordance in joint counts between trained assessors and patients with rheumatoid arthritis (RA).

METHODS

Studies eligible for inclusion met the following criteria: English language; compared patient with trained assessor joint counts; peer-reviewed; and RA diagnosis determined by board-certified or board-eligible specialist or met 1987 American College of Rheumatology criteria. We searched PubMed and Embase to identify articles between 1966 and January 1, 2008. We compared measures of correlation between patients and assessors for either tender/painful or swollen joint counts. We used metaanalysis methods to calculate summary correlation estimates.

RESULTS

We retrieved 462 articles and 18 were included. Self-report joint counts were obtained by a text and/or mannequin (picture) format. The summary estimates for the Pearson correlation coefficients for tender joint counts were 0.61 (0.47 lower, 0.75 upper) and for swollen joint counts 0.44 (0.15, 0.73). Summary results for the Spearman correlation coefficients were 0.60 (0.30, 0.90) for tender joint counts and 0.54 (0.35, 0.73) for swollen joint counts.

CONCLUSION

A self-report tender joint count has moderate to marked correlation with those performed by a trained assessor. In contrast, swollen joint counts demonstrate lower levels of correlation. Future research should explore whether integrating self-report tender joint counts into routine care can improve efficiency and quality of care, while directly involving patients in assessment of RA disease activity.

Precision of health-related quality-of-life data compared with other clinical measures

To many clinicians, the assessment of health-related quality of life (HRQL) seems more art than science. This belief is due in part to the lack of formal training available to clinicians regarding HRQL measurement and interpretation. When HRQL is used systematically, it has been shown to improve patient-physician communication, clinical decision making, and satisfaction with care. Nevertheless, clinicians rarely use formal HRQL data in their practices. One major reason is unfamiliarity with the interpretation and potential utility of the data. This unfamiliarity causes a lack of appreciation for the reliability of data generated by formal HRQL assessment and a tendency to regard HRQL data as having insufficient precision for individual use. This article discusses HRQL in the larger context of health indicators and health outcome measurement and is targeted to the practicing clinician who has not had the opportunity to understand and use HRQL data. The concept and measurement of reliability are explained and applied to HRQL and common clinical measures simultaneously, and these results are compared with one another. By offering a juxtaposition of common medical measurements and their associated error with HRQL measurement error, we note that HRQL instruments are comparable with commonly used clinical data. We further discuss the necessary requirements for clinicians to adopt formal, routine HRQL assessment into their practices.

Electronic and computer-generated patient questionnaires in standard care

Patient-derived measures of disease activity have been proven to be reliable, valid, sensitive to change, and less susceptible to placebo effects in the assessment of many rheumatic diseases. Traditionally, paper forms have been used to capture this information but with advances in technology and a growing number of computer users, computerized versions have been developed. The computerized patient-derived questionnaires have been shown to be valid and reliable in many studies. Despite a concern for the usability and acceptability among inexperienced computer users and certain subgroups, such as older persons, a majority of patients queried preferred the electronic versions and found them easy to use. In addition, these computerized versions offer several advantages over the paper format, including improved data capture with less ambiguity, less long-term cost, immediate scoring and availability of the results, and--most importantly--the ability for more frequent disease activity, efficacy, and safety assessments.

Touch-screen computer systems in the rheumatology clinic offer a reliable and user-friendly means of collecting quality-of-life and outcome data from patients with rheumatoid arthritis

OBJECTIVES

To investigate the feasibility of collecting rheumatoid arthritis (RA) patient self-administered outcome data using touch-screen computers in a routine out-patient clinic.

METHODS

Forty patients with RA completed the touch-screen and paper Rheumatoid Arthritis Quality of Life Questionnaire (RAQol) in the clinic and rated ease of use and preference. Forty-five others completed the Stanford Health Assessment Questionnaire (HAQ) and visual analogue scales (VASs) for pain, fatigue and global arthritis activity on touch screen and paper and a joint assessment on touch screen. They rated ease of use and willingness to complete the assessment again. Joints were independently assessed, and completion times and technical problems recorded.

RESULTS

No technical problems were encountered. The touch-screen RAQol took no longer to complete, was preferred by 64% (33% had no preference) and was rated significantly higher for ease of use (two-tailed P=0.003, n=40) even by computer naïve patients (two-tailed P=0.031, n=24). Intraclass correlation coefficients between methods were high for RAQol (0.986) and tender joint counts (0.918), and as high for the pain, fatigue and global activity (0.855, 0.741, 0.881) as for test-retest of the paper versions (0.865, 0.746, 0.863). Ninety-eight per cent rated the touch screen very/quite easy for HAQ and VAS, and 90% for joint assessment. Ninety-six per cent stated a willingness to complete the touch-screen assessment in clinic again.

CONCLUSIONS

Touch-screen questionnaires in the clinic can produce comparable results to paper, eliminate the need for data entry and afford immediate access to results. It is an acceptable, and in many cases a preferable, option to paper, regardless of age and previous experience of computers.