The Reporting of Patient-reported Outcomes in Studies of Patients with Rheumatoid Arthritis: A Systematic Review of 250 Articles

Correlation between disease activity and patient-reported health-related quality of life in rheumatoid arthritis: a cross-sectional study

OBJECTIVE

We aimed to provide a comprehensive assessment of health-related quality of life (HRQoL) in patients with rheumatoid arthritis (RA) of different activities and to evaluate the correlation between clinical activity measures and HRQoL instruments. This research also analysed the extent to which different aspects of HRQoL (physical, psychological and social) were affected.

DESIGN

Cross-sectional, observational, non-interventional study.

SETTING

The study was conducted at the Department of Rheumatology and Immunology, Qilu Hospital, Shandong University.

METHODS

From December 2019 to October 2020, a total of 340 RA patients participated in the survey using convenient sampling. Three generic instruments, EQ-5D-5L,SF-12 and the AQoL-4D, as well as an RA-specific instrument,the Stanford Health Assessment Questionnaire Disability Index (HAQ-DI), were administered to assess patients' HRQoL. The Disease Activity Score 28-Erythrocyte Sedimentation Rate (DAS28-ESR) was used by doctors to measure patients' clinical activity. Multivariable linear regression was used to compare patients' HRQoL across different levels of activity. Spearman's correlation was used to assess the correlation between doctor-reported clinical activity and HRQoL.

RESULTS

A total of 314 patients with RA participated in this study. The mean score of HAQ-DI was 0.87 (SD: 0.91). Using patients in the clinical remission group as a reference, patients in the moderate and high disease activity groups showed significantly reduced health state utility values and HRQoL scores (all p<0.05). On the contrary, there was an increase in HAQ-DI scores, indicating more impairment (p<0.05). All instruments included in the study tended to differentiate disease activity based on multiple criteria, with scores showing a moderate to strong correlation with RA activity (|rs|=0.50 to 0.65). Among them, the disease-specific instrument had the highest correlation.

CONCLUSIONS

RA can have considerable impairment on patients' HRQoL, both in terms of physical and psychosocial functioning. Given the strong correlation between clinical activity and HRQoL scores, and the fact that HRQoL can be an important clinical supplement. The EQ-5D-5L is probably the most appropriate generic measurement instrument for measuring HRQoL in RA patients.

A systematic review of 454 randomized controlled trials using the Dermatology Life Quality Index: experience in 69 diseases and 43 countries

BACKGROUND

Over 29 years of clinical application, the Dermatology Life Quality Index (DLQI) has remained the most used patient-reported outcome (PRO) in dermatology due to its robustness, simplicity and ease of use.

OBJECTIVES

To generate further evidence of the DLQI's utility in randomized controlled trials (RCTs) and to cover all diseases and interventions.

METHODS

The methodology followed PRISMA guidelines and included seven bibliographical databases, searching articles published from 1 January 1994 until 16 November 2021. Articles were reviewed independently by two assessors, and an adjudicator resolved any opinion differences.

RESULTS

Of 3220 screened publications, 454 articles meeting the eligibility criteria for inclusion, describing research on 198 190 patients, were analysed. DLQI scores were primary endpoints in 24 (5.3%) of studies. Most studies were of psoriasis (54.1%), although 69 different diseases were studied. Most study drugs were systemic (85.1%), with biologics comprising 55.9% of all pharmacological interventions. Topical treatments comprised 17.0% of total pharmacological interventions. Nonpharmacological interventions, mainly laser therapy and ultraviolet radiation treatment, comprised 12.2% of the total number of interventions. The majority of studies (63.7%) were multicentric, with trials conducted in at least 42 different countries; 40.2% were conducted in multiple countries. The minimal clinically importance difference (MCID) was reported in the analysis of 15.0% of studies, but only 1.3% considered full score meaning banding of the DLQI. Forty-seven (10.4%) of the studies investigated statistical correlation of the DLQI with clinical severity assessment or other PRO/quality of life tools; and 61-86% of studies had within-group scores differences greater than the MCID in 'active treatment arms'. The Jadad risk-of-bias scale showed that bias was generally low, as 91.8% of the studies had Jadad scores of ≥ 3; only 0.4% of studies showed a high risk of bias from randomization. Thirteen per cent had a high risk of bias from blinding and 10.1% had a high risk of bias from unknown outcomes of all participants in the studies. In 18.5% of the studies the authors declared that they followed an intention-to-treat protocol; imputation for missing DLQI data was used in 34.4% of studies.

CONCLUSIONS

This systematic review provides a wealth of evidence of the use of the DLQI in clinical trials to inform researchers' and -clinicians' decisions for its further use. Recommendations are also made for improving the reporting of data from future RCTs using the DLQI.

Improvement in RAID questionnaire results in patients with rheumatoid arthritis treated with advanced therapies

OBJECTIVES

To analyse the changes in patient-reported outcomes after starting advanced antirheumatic treatment.

METHODS

The study included all patients who started self-administered biological or targeted synthetic treatments for rheumatoid arthritis between February and November 2020. The patients were given the RAID quality of life questionnaire to complete before starting the treatment and after 4 months. Univariate and multivariate analyses were performed to determine the association between patients' clinical and sociodemographic characteristics and quality of life improvement. The level of significance was set at 0.05.

RESULTS

Forty-six patients were included. Their ratings in the RAID questionnaire were improved after 4 months of treatment, both in the final overall total, which improved by 1.63±2.29 points, and in the different subtopics of the questionnaire (range 0-10). Pain was the domain that improved the most (2.33±2.82 points), followed by functional disability (2.15±2.51) and physical well-being (1.96±3.18). The improvement was statistically significant in all domains except the sleep score, which showed no statistically significant difference between the two time points analysed.

CONCLUSIONS

Advanced antirheumatic treatment improves the quality of life of patients after 4 months of treatment.

Effects of Disease-Worsening Following Withdrawal of Etanercept or Methotrexate on Patient-Reported Outcomes in Patients With Rheumatoid Arthritis: Results From the SEAM-RA Trial

BACKGROUND/OBJECTIVE

The effect of treatment withdrawal on patient-reported outcomes (PROs) in patients with rheumatoid arthritis (RA) whose disease is in sustained remission has not been well described. This analysis aimed to compare PRO changes in patients with RA following medication withdrawal and disease worsening.

METHODS

SEAM-RA (Study of Etanercept and Methotrexate in Combination or as Monotherapy in Subjects With Rheumatoid Arthritis) was a phase 3, multicenter, randomized withdrawal, double-blind controlled study in patients with RA taking methotrexate plus etanercept and in remission (Simple Disease Activity Index ≤3.3). Patient's Global Assessment of Disease Activity, Patient's Assessment of Joint Pain, Health Assessment Questionnaire-Disability Index, and 36-Item Short-Form Health Survey were evaluated for 48 weeks following methotrexate or etanercept withdrawal. Treatment differences for patients with versus without disease worsening were evaluated using a 2-sample t test for continuous end points and log-rank test for time-to-event end points.

RESULTS

Of 253 patients, 121 experienced disease worsening and 132 did not. All PRO scores were similar to those of a general population at baseline and deteriorated over time across the study population. The PtGA and Patient's Assessment of Joint Pain values deteriorated less in those on etanercept monotherapy compared with methotrexate monotherapy. More patients with versus without disease worsening experienced deterioration that was greater than the minimal clinically important difference (MCID) for all PROs tested. In patients with disease worsening, PtGA deterioration more than the MCID preceded Simple Disease Activity Index disease worsening.

CONCLUSIONS

Etanercept monotherapy showed benefit over methotrexate in maintaining PRO scores. Patients with disease worsening experienced a more rapid worsening of PtGA beyond the MCID versus patients without disease worsening.Categories: autoinflammatory disease, biological therapy, DMARDs, rheumatoid arthritis.

Defining the relationship between pain intensity and disease activity in patients with rheumatoid arthritis: a secondary analysis of six studies

Background

Pain is the main concern of patients with rheumatoid arthritis (RA) while reducing disease activity dominates specialist management. Disease activity assessments like the disease activity score for 28 joints with the erythrocyte sedimentation rate (DAS28-ESR) omit pain creating an apparent paradox between patients’ concerns and specialists’ treatment goals. We evaluated the relationship of pain intensity and disease activity in RA with three aims: defining associations between pain intensity and disease activity and its components, evaluating discordance between pain intensity and disease activity, and assessing temporal changes in pain intensity and disease activity.

Methods

We undertook secondary analyses of five trials and one observational study of RA patients followed for 12 months. The patients had early and established active disease or sustained low disease activity or remission. Pain was measured using 100-mm visual analogue scales. Individual patient data was pooled across all studies and by types of patients (early active, established active and established remission). Associations of pain intensity and disease activity were evaluated by correlations (Spearman’s), linear regression methods and Bland-Altman plots. Discordance was assessed by Kappa statistics (for patients grouped into high and low pain intensity and disease activity). Temporal changes were assessed 6 monthly in different patient groups.

Results

A total of 1132 patients were studied: 490 had early active RA, 469 had established active RA and 173 were in remission/low disease activity. Our analyses showed, firstly, that pain intensity is associated with disease activity in general, and particularly with patient global assessments, across all patient groups. Patient global assessments were a reasonable proxy for pain intensity. Secondly, there was some discordance between pain intensity and disease activity across all disease activity levels, reflecting similar discrepancies in patient global assessments. Thirdly, there were strong temporal relationships between changes in disease activity and pain intensity. When mean disease activity fell, mean pain intensity scores also fell; when mean disease activity increased, there were comparable increases in pain intensity.

Conclusions

These findings show pain intensity is an integral part of disease activity, though it is not measured directly in DAS28-ESR. Reducing disease activity is crucial for reducing pain intensity in RA.

Quality of Life, Social Support, Coping Strategies, and Psychiatric Morbidity in Patients with Rheumatoid Arthritis

Background and Objectives  Patients with rheumatoid arthritis (RA) have greater psychological morbidity, despite that research in this area is scarce from developing countries. This study was aimed to assess the association of quality of life, social support, coping strategies, and psychological morbidity in patients with RA.

Materials and Methods  In this cross-sectional study, 40 patients with RA, who were not receiving steroids or disease modifying antirheumatic drugs, were recruited through purposive sampling. Social support questionnaire, coping strategy check list, and World Health Organization quality of life-BREF (WHOQOL-BREF) were administered to assess social support, coping, and quality of life, respectively.

Results  More than half of the patients had psychiatric disorders (60%), with depression being the commonest disorder (52.5%). Internalization coping and disease severity indicators like tender joints counts, swollen joints counts, pain, and disease activity were found as significant predictors for psychiatric disorders, while externalization coping, quality of life (all domains), and physical functions were found to protect against psychiatric morbidity.

Conclusions  Coping, quality of life, disease severity, and physical functions predicted the psychiatric disorders in RA. Multipronged interventions to enhance quality of life with promoting adaptive coping and timely treatment may further improve their mental health and overall disease course.

The impact of different (rheumatoid) arthritis phenotypes on patients' lives

Objectives

To compare patient-reported outcome (PRO) domains between three arthritis phenotypes [undifferentiated arthritis (UA), autoantibody-negative RA (RA⁻) and autoantibody-positive RA (RA⁺)] at diagnosis, after 2 years and over time.

Methods

All UA (n = 130), RA⁻ (n = 176) and RA⁺ (n = 331) patients from the tREACH trial, a stratified single-blinded trial with a treat-to-target approach, were used. PRO comparisons between phenotypes at baseline and after 2 years were performed with analysis of variance, while a linear mixed model compared them over time. Effect sizes were weighted against the minimal clinically important differences (MCIDs) for each PRO.

Results

RA⁻ patients had a higher disease burden compared with RA⁺ and UA. At baseline and after 2 years, RA⁻ patients had more functional impairment and a poorer Physical Component Summary (PCS) compared with the other phenotypes, while they only scored worse for general health and morning stiffness duration at baseline. The MCIDs were exceeded at baseline, except for functional ability between RA⁺ and UA, while after 2 years only the MCID of the PCS was exceeded by RA⁻ compared with UA and RA. After 2 years the PROs of all phenotypes improved, but PROs measuring functioning were still worse compared with the general population, even when patients had low disease activity.

Conclusion

RA⁻ patients had the highest disease burden of all phenotypes. Although most patients have low disease activity after treatment, all clinical phenotypes still have a similar significant impact on patients’ lives, which is mainly physical. Therefore it is important to assess and address PROs in daily practice because of persistent disease burden despite low disease activity.

Trial registration

ISRCTN26791028.

Tele-health interventions to support self-management in adults with rheumatoid arthritis: a systematic review

Rheumatoid arthritis (RA), a long-term auto-immune condition is a challenging condition for patients to manage. Goals of treatment include reducing pain, decreasing inflammation, and improving an individual's overall function. Increasingly technology is being utilised to support patients to self-manage their condition. The aim of this systematic narrative review was to synthesise and critically appraise published evidence concerning the effectiveness of tele-health interventions to support self-management in RA. Bibliographic databases searched from 2014 to March 2020 included MedLINE, Embase, Cochrane Library. Search strategy combined the following concepts: (1) rheumatoid arthritis, (2) tele-health interventions, and (3) self-management. Only randomised controlled trials (RCTs) involving adults with RA were included. Titles, abstracts, full-text articles were screened, any discrepancies were checked by a second reviewer. Risk of bias was assessed using Cochrane risk of bias tool and data were extracted utilising the Cochrane data collection form for RCT interventions along with the TiDier checklist. Due to high heterogeneity, results were not meta-analysed and instead data were synthesised narratively. The search identified 98 articles, seven were included. The completed RCTs varied in the nature of the interventions, duration/severity of RA, outcomes measured and effectiveness of the interventions. The completed RCTs included a total of 791 participants Disease duration was largely between 4 and 10 years and disease severity on average was moderate. There was extensive variation in intervention components, theories underpinning theories and outcomes measured. Five RCTs reported a positive effect on factors such as disease activity, medication adherence, physical activity and self-efficacy levels. This study suggests that tele-health interventions that are well-designed, tailored and multi-faceted can help to achieve positive self-management outcomes in RA. None of the studies showed evidence of harm.

Is it possible to develop a new measurement tool to assess the functional status in patients with rheumatoid arthritis?

Objectives

This study aims to develop measurement tools for assessing patients' functional status with rheumatoid arthritis (RA) in terms of upper and lower extremity function and to evaluate the tools' construct validities with classical and modern psychometric approaches.

Patients and methods

Between April 2010 and April 2012, a total of 300 patients with RA (77 males, 223 females; mean age: 52.3±11.5 years; range, 18 to 82 years) who answered items from a range of widely used instruments were included. After examining initial dimensionality with exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and Rasch analysis were used to evaluate the tools' construct validities. The data-model fit was evaluated with goodness-of-fit (GoF) statistics in CFA, while the tools were examined in terms of item and person fit, unidimensionality and differential item functioning (DIF) from the perspective of Rasch analysis.

Results

According to EFA, two dimensions were identified and named as "self-care-mobility-household activities related to lower extremity" and "self-care-mobility-household activities related to upper extremity" taking into account the factor loadings and the clinical classifications. While the clinical classification was tested with CFA, all items were loaded on their pre-defined dimensions with the factor loadings of ≥0.40 and GoF statistics were within the acceptable ranges. When the "self-care-mobility-household activities related to upper extremity" and "self-care-mobility-household activities related to lower extremity" tools were evaluated via the Rasch analysis, both tools were found to fit the Rasch model expectations, with a mean item fit statistics of -0.528 logit (standard deviation [SD]: 1.365) and -0.213 (SD: 1.168; mean person fit statistics of -0.412 logit (SD: 1.160) and -0.303 logit (SD: 0.859), respectively.

Conclusion

For the evaluation of a scale's construct validity, it is recommended to use the Rasch analysis in tandem with factor analytic methods, as the Rasch analysis explores a scale's construct validity in terms of item and person fit, DIF and unidimensionality which is the only aspect of the factor analysis.

Patient-reported outcomes from a randomized, double-blind, placebo controlled, phase III study of baricitinib versus placebo in patients with moderately to severely active rheumatoid arthritis and an inadequate response to methotrexate therapy: results from the RA-BALANCE study

INTRODUCTION

To assess the effect of baricitinib on patient-reported outcomes (PROs) in patients with moderately to severely active rheumatoid arthritis (RA) who had an inadequate response to methotrexate (MTX).

METHODS

This was a 52-week, randomized, double-blind, placebo controlled, phase III study in patients with RA who had an inadequate response to MTX. Patients (n = 290) receiving stable background MTX were randomly assigned (1:1) to receive placebo or baricitinib 4 mg once daily with a primary endpoint at week 12. PROs assessed included Health Assessment Questionnaire-Disability Index (HAQ-DI), Patient's Global Assessment of Disease Activity, patient's assessment of pain, Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), European Quality of Life-5 Dimensions-5 Level index scores and visual analogue scale, and measures collected in electronic patient daily diaries: duration of morning joint stiffness, Worst Tiredness, and Worst Joint Pain. Treatment comparisons were made with logistic regression and analysis of covariance models for categorical and continuous variables, respectively.

RESULTS

Statistically significant (p ⩽ 0.05) improvements in all PROs were observed in the baricitinib 4 mg group compared to placebo as early as week 1 to week 4; and were sustained to week 24. These improvements were maintained until week 52 for the baricitinib group. A significantly larger proportion of patients met or exceeded the minimum clinically important difference for HAQ-DI (⩾0.22) and FACIT-F (3.56) profiles in the baricitinib group.

CONCLUSION

Baricitinib provided significant improvements in PROs compared to placebo to 52 weeks of treatment in patients with RA who had an inadequate response to MTX.Clinicaltrials.gov identifier: https://clinicaltrials.gov/ct2/show/NCT02265705; NCT02265705; RA-BALANCE. Registered 13 October 2014.

'It can't be zero!' Difficulties in completing patient global assessment in rheumatoid arthritis: a mixed methods study

OBJECTIVES

Patient global assessment (PGA) is purported to add the patient's perspective in the composite measures of RA. However, PGA is not standardized and it is not known whether patients' interpretation of the measure is consistent with its intended purpose. This study aimed to explore difficulties experienced by patients with RA in completing PGA, and to assess the impact of a structured explanation in improving its validity and reliability.

METHODS

This was a mixed methods study, using interviews, focus groups and PGA data. During interviews, patients (convenience sample, n = 33) completed three often-used PGA formulations. Then a nurse provided structured explanation about what PGA is and why it is used. After further discussion, patients completed one PGA version again. Interviews were recorded, transcribed and analysed using inductive thematic analysis. We compared PGA scores pre- and post-explanation (Wilcoxon signed-ranks) and the proportion of patients achieving RA remission with PGA ⩽1 (McNemar's tests).

RESULTS

Three themes emerged: understanding the meaning of PGA, the purpose of PGA and measurement difficulties. The difficulties caused systematic errors in PGA completion such as marking higher when feeling well, marking near the centre or away from zero. The structured explanation was helpful. Following the explanation, the median PGA score decreased from 3.0 to 2.1 cm, and the proportion of non-remission solely due to PGA >1 from 52% to 41%; none of these changes was statistically significant.

CONCLUSION

Many patients have difficulties in completing PGA. Standardization of PGA and a structured explanation may improve its clarity, validity and reliability.

Modified Disease Activity Score at 3 Months Is a Significant Predictor for Rapid Radiographic Progression at 12 Months Compared With Other Measures in Patients With Rheumatoid Arthritis

OBJECTIVE

Progressive rheumatoid arthritis (RA) is responsible for joint damage causing disabilities, but there is no agreement on which disease measures best predict radiographic progression. We aimed to determine which disease activity measures, including the disease activity score, the modified disease activity score in 28 joints with C-reactive protein testing (M-DAS28-CRP), the Clinical Disease Activity Index, and the Health Assessment Questionnaire Disability Index, at baseline and 3 months best predicted rapid radiographic progression (RRP) in patients with early RA.

METHODS

Data were used from PREMIER, a 2-year, multicenter, double-blind, active comparator controlled study with methotrexate (MTX)-naïve patients with RA and active disease for less than 3 years. Treatments included adalimumab plus oral MTX, adalimumab, or oral MTX. Only patients in the MTX arm were analyzed in this study. RRP was defined as a change in the modified total Sharp score of less than 3.5 at month 12. The logistic regression analysis assessed the impact of measures at baseline and 3 months on RRP at 12 months. Best cutoff points of the M-DAS28-CRP were also estimated by using area under the receiver operating characteristic curve.

RESULTS

A total of 149 patients were included (female patients: n = 113 [75.8%]; positive rheumatoid factor: n = 127 [85.2%]; mean [SD] age: 52.9 [13.3] years; mean [SD] disease duration: 0.8 [0.9] year; mean [SD] M-DAS28-CRP: 6.3 [0.9]). After adjusting for potential confounders, only the M-DAS28-CRP at baseline (adjusted odds ratio [AOR] = 3.29; 95% confidence interval [CI]: 1.70-6.36) and 3 months (AOR = 2.56; 95% CI: 1.43-4.56) strongly predicted RRP at 12 months. M-DAS28-CRP of 4.5 and 2.6 at baseline and 3 months, respectively, maximized positive and negative predictive values for prediction of RRP.

CONCLUSION

The M-DAS28-CRP was a stronger predictor at baseline and 3 months for RRP compared with other disease activity measures. Removing tender joint count and patient global assessment from the DAS28-CRP improves prediction of RRP.

Clinical Improvements as Predictors of Improvements in Patient-Reported Outcomes: Post Hoc Analysis of a Randomized, Open-Label Study of Etanercept in Latin American Patients with Rheumatoid Arthritis

Background

In rheumatoid arthritis (RA), little is known about clinical responses to treatment as predictors of patient-reported outcome (PRO) changes. In this post hoc analysis, we examined the relationship between clinical outcomes at week 12 and PRO changes at week 24 in patients with RA.

Methods

In an open-label study, Latin American patients with moderate-to-severe RA and an inadequate response to methotrexate (MTX) were randomized to receive etanercept 50 mg/week plus MTX (ETN+MTX; n=281) or an additional conventional disease-modifying anti-rheumatic drug (DMARD) plus MTX (DMARD+MTX; n=142) for 24 weeks. The PROs included Health Assessment Questionnaire Disability Index (HAQ-DI), 36-item Short Form (SF-36), Physician and Patient Global Assessment scores (PGA, PtGA), Physician and Patient Satisfaction, and an activity impairment assessment. PRO changes at week 24 were calculated by week-12 improvements using the American College of Rheumatology criteria (ACR <20, ≥20 to <50, ≥50 to <70, and ≥70) and the 28-joint Disease Activity Scores (DAS28 ≥3.2, ≥2.6 to <3.2, and <2.6). Observed-cases data were analyzed using an ANCOVA model with linear contrast, adjusted for baseline PRO and ACR/DAS28 values.

Results

For both ETN+MTX- and DMARD+MTX-treated patients, there was a significant linear trend between week-12 changes in ACR and DAS28 responses and week-24 changes in HAQ-DI (P<0.001 for all), with numerical improvements generally favoring ETN+MTX. Similar relationships were observed for SF-36, PGA, PtGA, Physician Satisfaction, Patient Satisfaction, and activity impairment.

Conclusions

In patients with RA, clinical response after 12 weeks of treatment with ETN+MTX or DMARD+MTX could be a predictor of week-24 response for several PROs.

Trial registration

ClinicalTrials.gov, NCT00848354.

Simplification of Validated Patient-Reported Outcome Instruments in Inflammatory Bowel Disease

Objectives

Improving health-related quality of life (HRQoL) is a major treatment goal for inflammatory bowel disease (IBD) patients. Tools to measure HRQoL, including the Pittsburgh Sleep Quality Index and the Short Inflammatory Bowel Diseases Questionnaire, are lengthy and rely on recall. This prospective, proof-of-concept pilot study assessed the feasibility, reliability, and validity of daily, simplified HRQoL and sleep quality data collection using mobile technologies in patients with IBD.

Methods

Adult IBD patients were recruited from our center. Daily HRQoL and sleep quality were assessed using visual analog scale (VAS) surveys, and pain was assessed using the Wong-Baker FACES Pain Rating Scale (WBS). HRQoL and sleep were assessed on days 1, 14, and 28 of the study using the short IBD Questionnaire (SIBDQ) and Pittsburgh Sleep Quality Index (PSQI). Correlation between the daily instruments and the biweekly validated instruments were assessed using the Pearson correlation coefficient.

Results

One hundred patients were enrolled. The correlation between mean global assessment VAS score over 2 weeks and PSQI score taken at 14 days was moderate (r = 0.62, P &lt; 0.0001). The correlation over the same time interval between mean WBS score and SIBDQ score was strong (r = −0.71, P &lt; 0.0001), and the correlation between mean sleep VAS score and PSQI score was moderate (r = −0.55, P &lt; 0.0001).

Conclusions

This study demonstrates the potential for electronic quality of life, sleep quality, and pain assessments as feasible, reliable, and valid tools in IBD patients. Intermittent administration of these simplified electronic assessments may be useful in further reducing patient survey burden without significantly compromising their utility.

Taking the patient and the patient's perspective into account to improve outcomes of care of patients with musculoskeletal diseases

Patient-reported outcome measures are commonly used in the assessment of patients with musculoskeletal diseases. The present review provides an overview of historic and recent developments, including core set recommendations for assessing patient-reported outcomes in patients with fibromyalgia, osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis. The evidence supporting commonly used patient-reported outcomes measures is reviewed. Furthermore, various methodological approaches that can be utilized to evaluate validity and measurement precision of patient reported outcomes are introduced. Commonly used methods based on the classical test theory as well as modern approaches based on item response theory will be discussed. The review finally describes the increasing use of item response theory-based approaches used in patient-reported outcomes assessment in the musculoskeletal diseases.

Are globals for health, well-being and quality of life interchangeable? A mixed methods study in ankylosing spondylitis patients and controls

Objective

Patients' experience of overall health is often assessed through a single-item global question. Here, we evaluated among patients with AS and population controls whether single-item questions on the constructs health, well-being and quality of life (QoL) are interchangeable.

Methods

In a mixed quantitative and qualitative approach, all subjects scored the three single-item globals on a numeric rating scale (0-10, best). Next, they indicated for each of the questions which aspects they had been considering when scoring. After forced reflection, globals were scored again. Dissimilarities in scores among constructs, between patients and controls, and before or after reflection were tested using mixed linear models. Themes identified per construct in the qualitative part were linked to the International Classification of Functioning, Disability and Health. The type of themes per construct was compared between patients and controls.

Results

Sixty-eight AS patients and 84 controls completed the questionnaire. Patients scored significantly worse on each global than controls (mean 6.1-6.3 vs 7.2-7.6, all P < 0.01). Within groups, however, no significant differences in scores on each construct, or in scores before or after forced reflection were found. Health-related themes were relevant to each construct for patients, but were less relevant for controls when considering well-being and QoL. Emotional functions were relevant to well-being in all participants. Social roles and financial situation were more frequently related to well-being and QoL in controls.

Conclusion

While patients and controls identified content-related dissimilarities between the three constructs studied, this was not reflected in different scores of the globals.

Sarilumab: patient-reported outcomes in rheumatoid arthritis

In the last few decades, strategies for the management of rheumatoid arthritis (RA) have been increasingly oriented toward more comprehensive control of the disease, taking into account even RA extra-articular manifestations, comorbidities, and the patient’s perception about the disease. The need for improving the shared decision-making process suggested by European League Against Rheumatism recommendations is leading to an increasing interest in the role of patient-reported outcomes (PROs) beside the usual more objective criteria for defining clinical response based on disease-activity composite indices. Measurement of such PROs as pain or fatigue may be significantly influenced by mood disorders often complicating RA, the pathogenesis of which is deeply interconnected with phlogistic processes mediated by proinflammatory cytokines. IL6 is a pleiotropic mediator involved in neuroendocrine and neuropsychological processes, besides its well known effects on immune, cardiovascular, and metabolic systems. Therefore, there is a growing body of evidence about the efficacy of IL6 blockade in PRO improvement in RA patients. Sarilumab is a monoclonal antibody binding both soluble and membrane-bound IL6Rα, inhibiting the IL6-mediated signaling pathway with favorable efficacy and safety profile. This review analyzes the importance of PROs in strategies for the management of RA and the pathogenic mechanisms linking IL6 with the patient’s perception of the disease. Moreover, the main findings from sarilumab randomized controlled trials are summarized in detail, emphasizing the potential role of this IL6 blocker in the holistic treatment of RA.

"A body in transformation"-An empirical phenomenological study about fear-avoidance beliefs towards physical activity among persons experiencing moderate-to-severe rheumatic pain

Aims and objectives

To gain a better understanding of fear‐avoidance beliefs towards physical activity and body awareness in people experiencing moderate‐to‐severe rheumatic pain.

Background

Rheumatoid arthritis and psoriatic arthritis are long‐term conditions with pain as the prominent symptom. Health‐promoting physical activity is recommended and can have an analgesic effect. High self‐rated pain has previously been reported to be associated with increased fear‐avoidance behaviour in relation to physical activity. Body awareness, which includes attentional focus and awareness of internal body sensations, could be valuable in the nursing care of long‐term diseases.

Design

Empirical phenomenological.

Methods

An empirical phenomenological psychological method was applied. The interviews took place between autumn 2016–spring 2017 with 11 informants (eight women and three men, age range 44–71 years) who were diagnosed with rheumatoid arthritis (n = 7) or psoriatic arthritis (n = 4), with a disease duration ranging from 3–35 years. The mean visual analogue scale score in the study sample was 60 mm.

Results

Three typologies were identified: “My relatively fragile physical status”, “I am an active creator” and “Part of something bigger than myself.”

Conclusions

The current findings indicated that pain anticipation and fear‐avoidance beliefs towards physical activity sometimes affected the behaviour of individuals with long‐term rheumatic pain syndromes. People experiencing moderate‐to‐severe rheumatic pain tended to focus on their fragile physical and emotional state. By adopting a more favourable attitude towards the self, the body could be restored to a state of calm and balance.

Relevance to clinical practice

The current findings are relevant for healthcare professionals engaged in health‐promotion clinical practice.

Determinants of happiness and quality of life in patients with rheumatoid arthritis: a structural equation modelling approach

Objectives

Besides increasing longevity, the ultimate goal of medical care is to improve patients’ enjoyment of life, a concept akin to happiness. This study examined the determinants of happiness and quality of life (QoL) in patients with rheumatoid arthritis (RA).

Methods

In this observational, cross-sectional study, patients were assessed on disease activity, disease impact, personality, QoL and happiness. Structural equation modelling estimation was used to analyse the associations between these dimensions, pursuing three hypotheses: H₁—disease activity and perceived impact of disease are negatively associated with overall QoL and happiness in patients with RA; H₂—‘positive’ personality traits are related to happiness both directly and indirectly through perceived disease impact; H₃—happiness has a mediating effect in the relation between impact of disease and QoL.

Results

Data from 213 patients were analysed. Results supported all driving hypotheses. Happiness was positively related to ‘positive’ personality and, to a lesser extent, negatively related to impact of disease. Impact of disease, in turn, was positively related to disease activity and mitigated by ‘positive’ personality traits. Impact of disease had a much stronger relation with QoL than with happiness. Happiness mitigated the negative effect of disease impact on QoL.

Conclusion

Optimisation of QoL and happiness of people with RA requires effective control of the disease process and also improvement of the disease impact domains. Personality seems to play a pivotal mediating role in these relations.

The McMaster Toronto Arthritis patient preference questionnaire (MACTAR): a methodological study of reliability and minimal detectable change after a 6 week-period of acupuncture treatment in patients with rheumatoid arthritis

Objectives

The McMaster Toronto Arthritis patient preference questionnaire (MACTAR) is a semi-structured interview consisting of a baseline and a follow-up interview. The MACTAR baseline is reliable and valid, however the reliability of the MACTAR follow-up is scarcely described. The aim of this study was to describe aspects of reliability and ability to detect changes of the Swedish MACTAR follow-up following acupuncture treatment in individuals with rheumatoid arthritis.

Results

The study was of Single Subject Experimental Design, with a 2-week non-interventional A-phase and a 6-week intervention B-phase. Eight individuals with RA, age 30–68 years, were included. MACTAR baseline was performed once followed by five assessments with MACTAR follow-up during the A-phase and another ten assessments during the B-phase. Reliability statistics were calculated for measurements 1–3 during the A-phase and the ability to detect effects of acupuncture treatment was tested by celeration lines in the B-phase. The MACTAR follow-up was highly reliable (ICC = 0.7–0.9, SEM = 2.3–4.3, and SDD = 6.2–11.7). Visual and statistical analyses indicated that the MACTAR follow-up could detect effects on individual- and group levels after acupuncture treatment, indicating that the MACTAR follow-up seems to be reliable and is able to detect effects of acupuncture treatment in RA.

Electronic supplementary material

The online version of this article (10.1186/s13104-017-2991-0) contains supplementary material, which is available to authorized users.

Development and psychometric validation of a patient-reported outcome measure to assess fears in rheumatoid arthritis and axial spondyloarthritis: the Fear Assessment in Inflammatory Rheumatic diseases (FAIR) questionnaire

Objectives

To develop and validate an outcome measure for assessing fears in patients with rheumatoid arthritis (RA) and axial spondyloarthritis (axSpA).

Methods

Fears were identified in a qualitative study, and reformulated as assertions with which participants could rate their agreement (on a 0–10 numeric rating scale). A cross-sectional validation study was performed including patients diagnosed with RA or axSpA. Redundant items (correlation >0.65) were excluded. Internal consistency (Cronbach’s α) and factorial structure (principal component analysis) were assessed. Patients were classified into fear levels (cluster analysis). Associations between patient variables and fear levels were evaluated using multiple logistic regression.

Results

672 patients were included in the validation study (432 RA, 240 axSpA); most had moderate disease activity and were prescribed biologics. The final questionnaire included 10 questions with high internal consistency (α: 0.89) and a single dimension. Mean scores (±SD) were 51.2 (±25.4) in RA and 60.5 (±22.9) in axSpA. Groups of patients with high (17.2%), moderate (41.1%) and low (41.7%) fear scores were identified. High fear scores were associated with high Arthritis Helplessness Index scores (OR 6.85, 95% CI (3.95 to 11.87)); high Hospital Anxiety and Depression Scale anxiety (OR 5.80, 95% CI (1.19 to 4.22)) and depression (OR 2.37, 95% CI (1.29 to 4.37)) scores; low education level (OR 3.48, 95% CI (1.37 to 8.83)); and high perceived disease activity (OR 2.36, 95% CI (1.10 to 5.04)).

Conclusions

Overall, 17.2% of patients had high fear scores, although disease was often well controlled. High fear scores were associated with psychological distress. This questionnaire could be useful both in routine practice and clinical trials.

Quality of life in patients with established rheumatoid arthritis: A phenomenographic study

Objective:

Patients with rheumatoid arthritis perceive reduced quality of life in several domains, such as physical health, level of independence, environment and personal beliefs, compared with the healthy population. There is an increasing interest in quality of life in clinical and medical interventions. Few studies have explored patients’ individual conceptions of quality of life, and interviews can thus complement quantitative studies. There is a need for a deeper understanding of the patients’ experiences of quality of life, with regard to living with a long-term condition such as rheumatoid arthritis. The aim of this study was to explore the variation of ways in which patients with established rheumatoid arthritis understand the concept of quality of life.

Methods:

The study had a qualitative design with a phenomenographic approach, which was used to describe variations in how individuals experience their quality of life. The study is based on interviews with 22 patients with established rheumatoid arthritis enrolled in the BARFOT (better anti-rheumatic pharmacotherapy) study.

Results:

The concept of quality of life could be understood in three different ways: (1) independence in terms of physical functioning and personal finances, (2) empowerment in how to manage life and (3) participation as an experience of belonging in a social context.

Conclusion:

The different conceptions of quality of life reflect the complexity in the concept, including physical, psychological and social aspects. This complexity is important to have in mind when health professionals support patients in enhancing their quality of life.

Development of a core outcome set for clinical trials in childhood constipation: a study using a Delphi technique

OBJECTIVE

Patients, their parents and healthcare professionals (HCPs) have a different perception regarding the symptoms of functional constipation (FC). Consequently, a lack of agreement exists on definitions and outcomes used in therapeutic trials of FC. Therefore, our aim was to develop a core outcome set (COS) for FC for children aged 0-1 year and 1-18 years.

DESIGN AND SETTING

Prospective study design: primary, secondary and tertiary care settings.

METHODS

This COS was developed using a Delphi technique. First, HCPs, parents of children with FC and patients aged ≥12-18 years were asked to list up to five outcomes they considered relevant in the treatment of FC. Outcomes mentioned by >10% of participants were included in a shortlist. In the next phase, outcomes on this shortlist were rated and prioritised by HCPs, parents and patients. Outcomes with the highest scores were included in a draft COS. In a face-to-face expert meeting, the final COS was determined.

RESULTS

The first phase was completed by 109 HCPs, 165 parents and 50 children. Fifty HCPs, 80 parents and 50 children completed the subsequent phase. The response rate was between 63% and 100% in both steps. The final COS for all ages consisted of: defecation frequency, stool consistency, painful defecation, quality of life, side effects of treatment, faecal incontinence, abdominal pain and school attendance.

CONCLUSION

The use of this COS for FC will decrease study heterogeneity and improve comparability of studies. Therefore, researchers are recommended to use this COS in future therapeutic trials on childhood FC.

Pixel or Paper? Validation of a Mobile Technology for Collecting Patient-Reported Outcomes in Rheumatoid Arthritis

BACKGROUND

In the management of chronic disease, new models for telemonitoring of patients combined with the choice of electronic patient-reported outcomes (ePRO) are being encouraged, with a clear improvement of both patients' and parents' quality of life. An Italian study demonstrated that ePRO were welcome in patients with rheumatoid arthritis (RA), with excellent matching data.

OBJECTIVE

The aim of this study is to evaluate the level of agreement between electronic and paper-and-pencil questionnaire responses.

METHODS

This is an observational prospective study. Patients were randomly assigned to first complete the questionnaire by paper and pencil and then by tablet or in the opposite order. The questionnaire consisted of 3 independent self-assessment visual rating scales (Visual Analog Scale, Global Health score, Patient Global Assessment of Disease Activity) commonly used in different adult patients, including those with rheumatic diseases.

RESULTS

A total of 185 consecutive RA patients were admitted to hospital and were enrolled and completed the questionnaire both on paper and on electronic versions. For all the evaluated items, the intrarater degree of agreement between 2 approaches was found to be excellent (intraclass correlation coefficient>0.75, P<.001).

CONCLUSIONS

An electronic questionnaire is uploaded in a dedicated Web-based tool that could implement a telemonitoring system aimed at improving the follow-up of RA patients. High intrarater reliability between paper and electronic methods of data collection encourage the use of a new digital app with consequent benefit for the overall health care system.

Patient global assessment in measuring disease activity in rheumatoid arthritis: a review of the literature

Patient-reported outcomes (PROs) reflect the patient’s perspective and are used in rheumatoid arthritis (RA) routine clinical practice. Patient global assessment (PGA) is one of the most widely used PROs in RA practice and research and is included in several composite scores such as the 28-joint Disease Activity Score (DAS28). PGA is often assessed by a single question with a 0–10 or 0–100 response. The content can vary and relates either to global health (e.g., how is your health overall) or to disease activity (e.g., how active is your arthritis). The wordings used as anchors, i.e., for the score of 0, 10, or 100 according to the scale used, and the timing (i.e., this day or this week) also vary. The different possible ways of measuring PGA translate into variations in its interpretation and reporting and may impact on measures of disease activity and consequently achievement of treat-to-target goals. Furthermore, although PGA is associated with objective measures of disease activity, it is also associated with other aspects of health, such as psychological distress or comorbidities, which leads to situations of discordance between objective RA assessments and PGA. Focusing on the role of PGA, its use and interpretation in RA, this review explores its validity and correlations with other disease measures and its overall value for research and routine clinical practice.