PROMIS-29 in rheumatoid arthritis patients who screen positive or negative for fibromyalgia on MDHAQ FAST4 (fibromyalgia assessment screening tool) or 2011 fibromyalgia criteria

BACKGROUND

PROMIS-29 T-scores query health-related quality of life (HRQL) in 7 domains, physical function, pain, fatigue, anxiety, depression, sleep quality, and social participation, to establish population norms. An MDHAQ (multidimensional health assessment questionnaire) scores these 7 domains and includes medical information such as a FAST4 (fibromyalgia assessment screening tool) index. We analyzed PROMIS-29 T-scores in rheumatoid arthritis (RA) patients vs population norms and for positive vs negative fibromyalgia (FM) screens and compared PROMIS-29 T-scores to MDHAQ scores to assess HRQL.

METHODS

A cross-sectional study was performed at one routine visit of 213 RA patients, who completed MDHAQ, PROMIS-29, and reference 2011 FM Criteria. PROMIS-29 T-scores were compared in RA vs population norms and in FM+ vs FM- RA patients, based on MDHAQ/FAST4 and reference criteria. Possible associations between PROMIS-29 T-scores and corresponding MDHAQ scores were analyzed using Spearman correlations and multiple regressions.

RESULTS

Median PROMIS-29 T-scores indicated clinically and statistically significantly poorer status in 26-29% FM+ vs FM- RA patients, with larger differences than in RA patients vs population norms for 6/7 domains. MDHAQ scores were correlated significantly with each of 7 corresponding PROMIS-29 domains (|rho|≥0.62, p<0.001). Linear regressions explained 55-73% of PROMIS-29 T-score variation by MDHAQ scores and 56%-70% of MDHAQ score variation by PROMIS-29 T-scores.

CONCLUSIONS

Scores for 7 PROMIS-29 domains and MDHAQ were highly correlated. The MDHAQ is effective to assess HRQL and offers incremental medical information, including FAST4 screening. The results indicate the importance of assessing comorbidities such as fibromyalgia screening in interpreting PROMIS-29 T-scores.

Elevated DAS28-ESR in patients with rheumatoid arthritis who have comorbid fibromyalgia is associated more with tender joint counts than with patient global assessment or swollen joint counts: implications for assessment of inflammatory activity

OBJECTIVES

More than 20% of rheumatoid arthritis (RA) patients have comorbid fibromyalgia (FM+), which may elevate DAS28-ESR (disease activity score 28-erythrocyte sedimentation rate) and other indices, resulting in challenges to assess inflammatory disease activity. Although several reports indicate that elevated patient global assessment (PATGL) may elevate DAS28 in the absence of inflammatory activity, less information is available concerning the other three components, tender joint count (TJC), swollen joint count (SJC), and erythrocyte sedimentation rate (ESR), to possibly elevate DAS28 in FM+ vs. FM- RA patients.

METHODS

A PubMed search identified 14 reports which presented comparisons of DAS28-ESR and its four components in RA FM+ vs. FM- groups. Median DAS28, component arithmetic differences, pooled effect sizes and 95% confidence intervals were analysed in the FM+ vs. FM- groups.

RESULTS

In FM+ vs. FM- groups, median DAS28 was 5.3 vs. 4.2, SJC 4.0 vs. 3.0, TJC 13.2 vs. 5.3, PATGL 61.6 vs. 39.9, ESR 26.3 vs. 26.5. DAS28-ESR was classified as "high" (>5.1) in 11/14 FM+ groups and "moderate" (3.2-5.1) in all 14 FM- groups. Effect sizes in FM+ vs. FM- groups for DAS28-ESR, SJC, TJC, PATGL, and ESR were large (≥0.8) in 10/14, 1/13, 12/13, 7/13, and 1/13 comparisons, respectively, and pooled effect sizes 0.84 (0.3, 1.4), 0.33 (-0.4, 1.0), 1.27 (0.01, 2.5), 0.91 (-0.6, 2.4), and 0.07 (-0.6, 0.7), respectively.

CONCLUSIONS

DAS28-ESR is elevated significantly in FM+ vs. FM- RA patients; pooled effect sizes were highest for TJC, followed by PATGL, SJC and ESR. The findings appear relevant to response and remission criteria, treat-to-target, and general management of RA.

RheuMetric Quantitative 0 to 10 Physician Estimates of Inflammation, Damage, and Distress in Rheumatoid Arthritis: Validation Against Reference Measures

OBJECTIVE

To analyze a RheuMetric checklist, which includes four feasible physician 0 to 10 scores for DOCGL, inflammation (DOCINF), damage (DOCDAM), and distress (DOCSTR) for criterion and discriminant validity against standard reference measures.

METHODS

A prospective, cross-sectional assessment was performed at one routine care visit at Liverpool Hospital, Sydney, Australia. Rheumatologists recorded DOCGL, DOCINF, DOCDAM, DOCSTR, and 28 joint counts for swelling (SJC), tenderness (TJC), and limited motion/deformity (DJC). Patients completed a multidimensional health assessment questionnaire (MDHAQ), which includes routine assessment of patient index data (RAPID3), fibromyalgia assessment screening tool (FAST4), and MDHAQ depression screen (MDS2). Laboratory tests and radiographic scores were recorded. RheuMetric estimates of inflammation, damage, and distress were compared with reference and other measures using correlations and linear regressions.

RESULTS

In 173 patients with RA, variation in RheuMetric DOCINF was explained significantly by SJC and inversely by disease duration; variation in DOCDAM was explained significantly by DJC, radiographic scores, and physical function; and variation in DOCSTR was explained significantly by fibromyalgia and depression.

CONCLUSION

RheuMetric DOCINF, DOCDAM, and DOCSTR estimates were correlated significantly and specifically with reference measures of inflammation, damage, and distress, documenting criterion and discriminant validity.

Further Simplified Clinimetry Using a Multidimensional Health Assessment Questionnaire

We agree that it is "good to simplify clinimetry in chronic inflammatory joint diseases," as suggested by DiCarlo and Salaffi in a recent editorial1 concerning an article by Schneeberger et al, which showed that a Simplified Ankylosing Spondylitis Disease Activity Score (SASDAS) was similar to an ASDAS.2 We note that the very high correlations of the SASDAS with the ASDAS2 are largely predictable, as the 5 measures in the 2 indices are identical, albeit with weighting in the ASDAS, although confirmation is reassuring.

Patient global assessment is elevated by up to 5 of 10 units in patients with inflammatory arthritis who screen positive for fibromyalgia (by FAST4) and/or depression (by MDS2) on a single MDHAQ

BACKGROUND

Patient global assessment (PATGL) is a component of rheumatoid arthritis (RA) and spondyloarthritis (SpA) activity indices, reflecting inflammation in selected clinical trial patients. In routine care, PATGL often may be elevated independently of inflammatory activity by fibromyalgia (FM) and/or depression, leading to complexities in interpretation. A feasible method to screen for FM and/or depression could help to clarify interpretation of high PATGL and index scores, including explanation of apparent limited responses to anti-inflammatory therapies.

PATIENTS AND METHODS

Patients with RA or SpA in routine care in Barcelona, Chicago, and Sydney complete a 2-page multidimensional health assessment questionnaire (MDHAQ) in 5-10 min. The MDHAQ includes PATGL and three indices, RAPID3 (routine assessment of patient index data) to assess clinical status, FAST4 (0-4 fibromyalgia assessment screening tool) and MDS2 (0-2 MDHAQ depression screen). PATGL was compared for each diagnosis at each site and pooled data in FAST4 positive (+) vs negative (-) and/or MDS2+ vs MDS2- patients using medians and median regressions.

RESULTS

Median PATGL was 5.0 in 393 RA and 175 SpA patients; 2.0-3.0 in 305 (58.9%) FAST4-,MDS2- patients, 5.5-6.0 in 71 (13.7%) FAST4-,MDS2+ patients, 7.0-7.5 in 50 (9.7%) FAST4+,MDS2- patients, and 7.0-8.0 in 92 (17.8%) FAST4+,MDS2+ patients. Positive FAST4 and/or MDS2 screens were seen in 41% of patients. Results were similar in RA and SpA at 3 settings on 3 continents.

CONCLUSION

Median 0-10 PATGL varied from 2-3/10 to 5.5-8/10, according to negative vs positive screening for FM and/or depression on a single MDHAQ for busy clinical settings.

Patients' and clinicians' perspectives towards primary care consultations for shoulder pain: qualitative findings from the Prognostic and Diagnostic Assessment of the Shoulder (PANDA-S) programme

BACKGROUND

Clinical management of musculoskeletal shoulder pain can be challenging due to diagnostic uncertainty, variable prognosis and limited evidence for long-term treatment benefits. The UK-based PANDA-S programme (Prognostic And Diagnostic Assessment of the Shoulder) is investigating short and long-term shoulder pain outcomes. This paper reports linked qualitative research exploring patients' and clinicians' views towards primary care consultations for shoulder pain.

METHODS

Semi-structured interviews were conducted with 24 patients and 15 primary care clinicians. Twenty-two interviews (11 patients, 11 clinicians) were conducted as matched patient-clinician 'dyads'. Data were analysed thematically.

RESULTS

Clinicians reported attempts to involve patients in management decisions; however, there was variation in whether patients preferred treatment choice, or for decisions to be clinician-led. Some patients felt uncertain about the decisions made, due to a lack of discussion about available management options. Many General Practitioners expressed a lack of confidence in diagnosing the underlying cause of shoulder pain. Patients reported either not being given a diagnosis, or receiving different diagnoses from different professionals, resulting in confusion. Whilst clinicians reported routinely discussing prognosis of shoulder pain, patients reported that prognosis was not raised. Patients also expressed concern that their shoulder pain could be caused by serious pathology; however, clinicians felt that this was not a common concern for patients.

CONCLUSIONS

Findings showed disparities between patients' and clinicians' views towards shoulder pain consultations, indicating a need for improved patient-clinician communication. Findings will inform the design of an intervention to support treatment and referral decisions for shoulder pain that will be tested in a randomised controlled trial.

Satisfaction With a Virtual Learning Collaborative Aimed at Implementing Treat-to-Target in Rheumatoid Arthritis

OBJECTIVE

Limited information is available concerning experiences of participants in a virtual learning collaborative (LC), and little qualitative data or participant feedback on how this format can be improved. One prior in-person LC in rheumatology successfully improved adherence with treat-to-target (TTT) for RA. We conducted a virtual LC on TTT and herein report on participant satisfaction.

METHODS

We conducted a virtual LC with 18 rheumatology practices from across the United States during 2020 to 2021. The LC included a virtual kickoff meeting and monthly videoconferences, accompanied by data submission and feedback. At the conclusion of the LC, we surveyed the 45 LC participants concerning individual experience and satisfaction.

RESULTS

All sites and 78% of participants responded to the surveys. The LC included small and large practices, 14 academic and 4 nonacademic, and respondents ranged in their roles: 24 physicians, 5 nurses or nurse practitioners, 3 administrators, and 3 other roles. Overall, 94% of respondents indicated they were either somewhat or very satisfied with the LC, and 94% said they would recommend a similar LC to a colleague. Aspects of the LC described as "very useful" included a kickoff meeting, intersite discussion, and monthly speakers; however, digital tools such as the Web site and meeting recordings were not found useful.

CONCLUSIONS

Virtual LCs are feasible, and participants reported strong satisfaction. Virtual LCs were highly valued by rheumatologists, trainees, and their practice staffs. Potential topics were identified for future LCs that could improve the quality of care delivered to rheumatology patients.

AB0786 Self-reported disease burden is greater in spondyloarthritis than in rheumatoid arthritis patients according to multidimensional questionnaire (MDHAQ / RAPID3) scores, despite fewer females, who generally have higher scores on patient questionnaires

Background

Female patients generally have higher scores than males on most items on self-report questionnaires, including MDHAQ/RAPID3 (multi-dimensional health assessment questionnaire/routine assessment of patient index data)1. MDHAQ/RAPID3 was validated in patients with rheumatoid arthritis (RA), but is informative in all diseases studied, including spondyloarthritis (SpA)2. More SpA patients are men than RA patients, suggesting lower scores, but MDHAQ scores are higher in SpA than RA.

Objectives

We compared self-report MDHAQ/RAPID3 scores in RA vs SpA patients according to gender.

Methods

Patients who met classification criteria for RA or SpA (axial SpA and psoriatic arthritis) completed MDHAQ at a routine rheumatology visit. The MDHAQ includes 10 activities for physical function (FN) (8 identical to HAQ), scored 0-3, total 0-30, divided by 3 for a 0-10 score, 3 0-10 visual numeric scales (VNS) for pain (PN), patient global assessment (PATGL), and fatigue (FT), a 60-symptom checklist (ROS60) and a RADAI self-report of painful joints (0-48). RAPID3 is a 0-30 index of FN + PN + PATGL. Means and standard deviations (SDs) of age, education, and 7 MDHAQ scores were computed in patients with RA versus SpA, and in subsets of female versus male patients with either RA or SpA. Unadjusted differences were evaluated using Student’s t and chi-square tests; mean differences were adjusted for age, gender and education using analysis of covariance.

Results

170 patients were studied, 102 with RA and 68 with SpA. 82% of patients with RA and 47% of patients with SpA were female (p<0.001); age and education did not differ between the 2 groups (Table 1). All 7 mean MDHAQ scores analyzed were higher in patients with SpA than in those with RA, although only differences for FN were statistically significant (Table 1). Within both the RA and SpA groups, however, all 7 scores were higher in women than in men, statistically significant for PN, PATGL, RAPID3 and fatigue in RA, and only for fatigue in SpA. In analyses adjusted for gender, FN, PATGL, FT, and RAPID3 were statistically significantly higher in SpA than in RA (Table 1).

Table 1.

Mean differences in the MDHAQ scores between RA and SpA patients.

Total, n=170 patientsRA, n=102SpA, n=68RA: Female(n=84)/Male (n=18)SpA: Female (n=32)/ Male n=36)Mean difference: RA–SpA (95% CIs)UnadjustedMean difference: RA–SpA (95% CIs)Adjusted for age, gender, and educationAge, mean (SD)58.8 (12.2)55.7 (12.2)Gender, female (%)84 (82.4%)32 (47.1%)*Years of education, mean (SD)11.8 (4.3)11.4 (3.7)MDHAQ variables, mean (SD)Physical function (0-10)2.4 (1.8)3.0 (2.1)2.5 (1.8)/ 1.9 (1.6)3.1 (2.0)/ 2.9 (2.2)-0.6 (-1.2, -0.02)-0.7 (-1.3, -0.05)Pain (0-10 VNS)4.5 (2.8)4.9 (3.0)4.8 (2.8)/ 3.3 (2.4)*5.5 (2.9)/ 4.4 (3.0)-0.4 (-1.3, 0.5)-0.8 (-1.7, 0.1)Patient global assessment (0-10 VNS)4.6 (2.8)5.3 (2.9)4.9 (2.8)/ 3.4 (2.6)*5.9 (2.8)/ 4.7 (3.0)-0.6 (-1.5, 0.2)-1.1 (-2.0, -0.2)RAPID3 (0-30)11.6 (6.8)13.3 (7.3)12.3 (6.8)/ 8.5 (6.1)*14.6 (7.2)/ 12.2 (7.3)-1.7 (-3.8, 0.4)-2.7 (-4.9, -0.5)Fatigue (0-10 VNS)4.2 (2.9)4.5 (3.1)4.7 (2.9)/ 2.0 (2.1)*5.5 (3.1)/ 3.6 (2.9)*-0.3 (-1.2, 0.6)-1.0 (-1.9, -0.04)Self-report RADAI painful joint count (0-48)12.4 (11.0)13.4 (11.9)13.2 (11.4)/ 8.6 (8.5)15.6 (13.1)/ 11.5 (10.6)-1.0 (-4.5, 2.4)-2.2 (-5.8, 1.4)60-symptom checklist (0-60)12.6 (10.0)15.2 (10.9)13.3 (10.3)/ 9.4 (7.8)16.0 (10.3)/ 14.6 (11.6)-2.6 (-5.8, 0.6)-2.5 (-5.8, 0.7)

*= p<0.05.

Conclusion

The self-reported disease burden measured by MDHAQ / RAPID3 was higher in patients with SpA than in those with RA, despite having a lower proportion of women, who generally have higher scores on all patient self-report questionnaires, including MDHAQ/RAPID3, within both the RA and SpA groups. Gender differences may lead to underestimation of the greater disease burden in SpA compared to RA.

References

[1]Sokka T. Arthritis Res Therapy. 2009; 11: R7. 2. Castrejon I. Bull Hosp Jt Dis. 2017;75(2):93-100.

Disclosure of Interests

None declared

AB1477 MEDIAN 0-10 PATIENT GLOBAL ASSESSMENT WAS 2.5-5 POINTS HIGHER IN INFLAMMATORY ARTHRITIS PATIENTS POSITIVE VS NEGATIVE FOR FAST4 (FIBROMYALGIA ASSESSMENT SCREENING TOOL) AND/OR MSD2 (MDHAQ DEPRESSION SCREEN): 2 EASILY-SCORED MULTIDIMENSIONAL HEALTH ASSESSMENT QUESTIONNAIRE (MDHAQ) INDICES

Background

Patient global assessment (PATGL) is included in DAS28, CDAI, ASDAS, DAPSA, and other indices to assess rheumatoid arthritis (RA) or spondyloarthropathy (SpA). PATGL reflects inflammatory activity in many patients, but may be elevated by comorbid fibromyalgia (FM) and/or depression (Dep), which are often unrecognized in others, complicating interpretation and use in treat-to-target. A 2-page multidimensional health assessment questionnaire (MDHAQ) includes PATGL and two easily scored cumulative indices, FAST4 (0-4 FM assessment screening tool) and MDS2 (0-2 MDHAQ Dep screen), which agree more than 80% with reference 2011 revised FM criteria, HADS-D and PHQ-9,1-3 and may clarify interpretation of high PATGL and index scores, particularly in busy clinical settings.

Objectives

Analysis of PATGL in patients with RA or SpA according to MDHAQ FAST4 and/or MDS2 positivity (+) or negativity (-).

Methods

MDHAQ was completed at a routine care visit at 3 sites in Australia, Spain, and USA. Medians and interquartile ranges (IQRs) for PATGL were computed for RA and SpA, according to FAST4 + or – and/or MDS2 + or -. Differences between medians of PATGL with 95% confidence intervals (CIs) for FAST4 and/or MDS2 were estimated from median regression models that included FAST4 and MDS2 for each setting, and setting for pooled analyses.

Results

Among 393 RA and 175 SpA patients, 23.0%-32.7% were FAST4+ and 29.4%-36.7% MDS2+, with 41.1% positive for either FAST4 or MDS2 (data not shown). PATGL medians were 4.8-5.0 in all RA and 3.0-6.0 in SpA, 2.0-3.0 in FAST4-/MDS2-, 5.5-6.0 in FAST4-/MDS2+, 7.0-7.5 in FAST4+/MDS2-, and 7.0-8.0 in FAST4+/MDS2+ patients, similar in RA and SpA at 3 settings in 3 continents (Table 1). Adjusted median differences were 3.0–3.5 for FAST4 + vs - (twice the level for FAST4 -, MDS2 -) and 2.0–2.5 for MDS2 + vs - groups (Table 1).

Table 1.

Median scores and interquartile ranges for PATGL according to positive or negative FAST4 and/or MDS2

Primary ICD10 diagnosisTotalFAST4 NEG MDS2 NEGFAST4 NEG MDS2 POSFAST4 POS MDS2 NEGFAST4 POS MDS2 POSAdjusted median difference (95% CI) (FAST4 POS – FAST4 NEG)Adjusted median difference (95% CI) (MDS2 POS – MDS2 NEG)Three sites pooledn=518n=305 (58.9%)n=71 (13.7%)n=50 (9.7%)n=92 (17.8%)RA3553.0 (1.0, 5.0)5.5 (3.6, 6.5)7.5 (6.5, 8.5)8.0 (7.0, 9.0)3.5 (2.8, 4.2)2.0 (1.4, 2.6)SpA1632.5 (1.0, 5.0)6.0 (4.0, 6.5)7.3 (6.8, 8.5)8.0 (6.5, 10.0)3.0 (2.1, 3.9)2.5 (1.5, 3.5)Australian=257n=155 (60.3%)n=35 (13.6%)n=22 (8.6%)n=45 (17.5%)RA1823.0 (1.0, 5.0)5.5 (4.5, 6.5)7.5 (7.0, 8.0)8.0 (7.0, 9.0)4.0 (3.0, 5.0)1.5 (0.5, 2.5)SpA752.5 (1.0, 5.0)4.5 (2.0, 6.8)9.0 (7.0, 9.5)8.0 (7.0, 8.5)4.0 (2.2, 5.8)1.0 (-0.8, 2.8)Spainn=169n=90 (53.3%)n=27 (16.0%)n=18 (10.7%)n=34 (20.1%)RA1013.0 (1.0, 4.5)5.5 (3.6, 6.8)6.0 (5.5, 7.0)8.5 (8.0, 8.5)3.0 (2.1, 3.9)2.5 (1.7, 3.3)SpA683.0 (0.8, 5.0)6.5 (6.0, 7.0)7.3 (6.5, 8.0)7.5 (6.5, 10.0)3.0 (1.1, 4.9)2.5 (0.9, 4.1)USAn=92n=60 (65.2%)n=9 (9.8%)n=10 (10.9%)n=13 (14.1%)RA723.0 (1.0, 6.0)6.0 (3.5, 7.0)8.5 (8.0, 9.5)7.0 (7.0, 9.0)5.0 (2.7, 7.3)1.0 (-1.3, 3.3)SpA202.0 (1.0, 4.5)2.0 (1.0, 3.0)7.0 (7.0, 7.0)*8.5 (5.5, 10.0)5.0 (0.5,10.5)0 (-3.3, 3.3)*

NEG = negative, POS = positive, NA=Not available (No patients or the adjusted median differences cannot be estimated due to the small number of patients), *=Only one patient in category.

Conclusion

Median 0-10 PATGL was 2-3-fold higher in 41.1% of RA or SpA patients with positive MDHAQ FM and/or DEP screening indices vs 59% with 2 negative indices. Differences were greater according to FM than Dep. MDHAQ may clarify interpretation of PATGL and indices, including in treat–to–target, using a single, brief, feasible questionnaire in research and busy clinical settings.

References

[1]Schmukler et al. ACR Open Rheumatol. 2019;1:516-25.

[2]Gibson et al, J Rheumatol. 2020;47:761-9.

[3]Morla et al, Arthritis Care & Research. 2021;73:120-9.

Disclosure of Interests

Tengfei Li: None declared, Kathryn Gibson Grant/research support from: Dr. Gibson has received honoraria from UCB, Novartis, and Janssen and grants support from Novartis., Employee of: Dr. Gibson is a part-time employee of Eli Lilly but no financial or other support was received from Eli Lilly in the creation of this abstract., Theodore Pincus: None declared, Juan Schmukler: None declared, Rosa Morlà: None declared, George Luta: None declared

AB1203 DAS28 (DISEASE ACTIVITY SCORE) ELEVATIONS IN PATIENTS WITH RHEUMATOID ARTHRITIS (RA) WHO HAVE COMORBID FIBROMYALGIA ARE EXPLAINED BY ELEVATED TENDER JOINT COUNTS AS MUCH AS BY ELEVATED PATIENT GLOBAL ASSESSMENT

Background

DAS28 (disease activity score 28) is elevated in the 20-30% of patients with rheumatoid arthritis (RA) who have comorbid fibromyalgia (FM), largely on the basis of tender joint count (TJC) and patient global assessment (PATGL) [rather than swollen joint count (SJC) or erythrocyte sedimentation rate (ESR)].1 High DAS28 in the absence of clinical inflammatory activity may suggest inappropriate treatment escalation and/or changes in a treat-to-target approach. Some reports suggest removal of PATGL from criteria for remission2.

Objectives

We analyzed the 4 DAS28-ESR component measures in reports of FM+ or FM- RA patients, to recognize the possible contribution of each to elevated DAS28 in patients with FM.

Methods

We reviewed reports from a meta-analysis of elevated DAS28 in RA patients with comorbid FM,1 and conducted a PubMed search for further reports of DAS28-ESR in FM+ or FM- RA patients in routine care. We analyzed reports that presented the 4 individual DAS-28-ESR components in FM+ vs FM- RA patients, calculated overall medians of published mean or median results, and calculated ratios of each component measure in FM+ and FM- patients.

Results

Eleven reports were identified. Mean disease duration was 5-12.8 years. Median DAS28-ESR of means/medians in FM+ RA patients was 5.3, and >5.1 in 9 of 11 studies, suggesting high disease activity (moderate in 2 studies) (Table 1). By contrast, median DAS28-ESR of means/medians in FM- RA patients was 4.1, moderate (3.2–5.1) in all 11 studies (Table 1). Medians of individual DAS28-ESR components were 28.5 vs 26 for ESR, 3.25 vs 3 for SJC, 12.3 vs 5.5 for TJC, and 62.7 vs 40 for PATGL in FM+ vs FM- RA patients, respectively. Ratios of DAS28 components in FM +/FM - patients were 2.7 for TJC, 1.6 for PATGL, 1.1 for ESR, and 1.0 for SJC.

Table 1.

DAS28 and component measures In RA patients who have or do not have comorbid fibromyalgia and ratio of means in the two groups (FM+/FM-)

MEASURESDAS28ESRSJCTJCPATGLSTUDYFM+/FM+/FM+/FM+/FM+/FM+/FM+/FM+/FM+/FM+/FM-FM-FM-FM-FM-FM-FM-FM-FM-FM-Ranzolin5.4, 4.01.329*,251.163.5*,2.0*1.79.5*,3*3.276*,40*1.92009Pollard6, 4.31.439,271.44.0,4.0117,62.866,401.62010Toms5.3, 3.71.439.4,28.51.44.9,3.01.614.1,2.94.960.4,32.61.82010Zammurrad 20135.3, 3.91.338.9,311.22.8,1.71.613.1,4.13.262.7,381.6Nawito5.6, 4.51.238.2,41.80.92.8,3.00.912.3,4.52.738.2,41.80.92013Ghib5.6, 4.61.223,221.15.0,6.00.815,5.52.766,44.51.52015*Joharatnam4.8, 4.41.119,171.11.0,1.0111,61.870,421.62015*Mian5.2, 4.11.320.5,19.11.11.8,2.80.615.6,7.32.157,49.51.12016Chakr5.3, 3.91.328.5,261.13.9,2.4*1.610*,3*3.356.5*,31.5*1.82017Salaffi4.5, 3.81.224,320.73.0,4.00.712,6280,701.12018*Provan5.2, 4.21.223,211.18.4,6.41.310.7,6.41.755,301.82019Median-11 Studies5.3, 4.11.328.5,261.13.2,5.3112.3,5.52.762.7,401.6

* All values were reported means other than medians noted by asterisk (*).

Conclusion

Mean DAS28-ESR indicated high vs moderate disease activity in 9 of 11 FM+ RA patient groups vs all 11 FM- RA groups, respectively. Among the 4 DAS28 component measures, TJC differed most in FM+ vs FM- RA patients followed by PATGL, while SJC and ESR were similar in both groups. The impact of TJC likely is underestimated as the DAS28 formula weights TJC twice as SJC. Elevated DAS28 in the absence of inflammation in RA FM+ patients may result as much or more from TJC as from PATGL.

References

[1]Duffield et al Rheumatology (Oxford). 2018;57(8):1453-1460.

[2]Ferreira et al J Rheumatol. 2021.

Disclosure of Interests

None declared

AB0174 MOST RHEUMATOID ARTHRITIS PATIENTS IN POST–2010 REPORTS FROM ROUTINE CARE REMAIN IN DAS28, CDAI OR RAPID3 MODERATE ACTIVITY/SEVERITY, NOT LOW/REMISSION: EXPLAINED IN PART BY LIMITS OF INDICES AND/OR STRATEGIES FOR DIAGNOSIS AND TREATMENT?

Background

Availability of powerful biological agents to treat rheumatoid arthritis (RA) has led to a strategy of treat-to-target toward remission or low disease activity according to a quantitative index, although higher levels of disease activity according to shared decisions are recognized as appropriate for certain patients.1 Substantial improvement in patient status was documented quantitatively in 2000 compared to 1985,2 maintained in 20083 and 20104, but few reports in recent years compare patient status in routine care to earlier data.

Objectives

To analyze post-2010 reports concerning mean or median or categories of DAS28, CDAI, and RAPID3 to depict patient status, and compared to pre-2011 reports.

Methods

PubMed searches were conducted for 2011-2021 reports for “DAS28 (disease activity score) categories not trial,” and repeated twice, replacing “DAS28” with “CDAI” (clinical disease activity index) and “RAPID3” (routine assessment of patient index data). Activity/severity levels for high, moderate, low, and remission, respectively, are: DAS28 (0-10) >5.1, 3.2–5.1, 2.6–3.2, ≤2.6; CDAI (0-76) >22, 10.1–22, 2.9-10, ≤2.8; RAPID3 (0-30) >12, 6.1–12, 3.1-6, ≤3.0. Mean and/or median DAS28, CDAI, or RAPID3, and/or proportions of patients who were in remission, low, moderate, and high activity/severity were compiled. Results were compared to 3 pre-2011 reports, 2 of which included all 3 indices.2-4

Results

Results from 1985 vs 2000 indicate >50% improvement in swollen joints and physical function,2 maintained in 20083 and 20104 (data not shown). The search identified 32 reports with 98 comparisons of 1, 2, or 3 indices for mean or median levels or activity/severity categories (Table). Analyses of 57 means or medians indicated 10 high, 39 moderate, 8 low; for DAS28-ESR 2, 18, 2; for DAS28-CRP 1, 6, 3; for CDAI 4, 9, 3; and for RAPID3 3, 6, 0 (Table). Analyses of 41 reports of comparisons of disease activity/severity categories indicated more high/moderate in 35 vs low/remission in 6, 1 of 5 for DAS28–CRP and 5 of 15 for CDAI (Table). Remission according to DAS28, CDAI, or RAPID3 was reported in 17.1%, 10.2%, and 13.7% of patients, respectively, and low activity/severity or remission in 33.3%, 39.6%, and 29.7%, respectively (data not shown).

Table 1.

Means and/or Medians and categories of DAS28-ESR, DAS28-CRP, CDAI and RAPID3.

Index:# of compa-risonsDAS28-ESRDAS28-CRPCDAIRAPID3Mean/Median of IndexTotal means and medians572210169High activity/severity102143Moderate activity/severity3918696Low activity/severity82330Remission00000Categories of High or Moderate Activity/Severity vs Low or RemissionTotal classified by categories41125159High or Moderate>Low or Remission35124109Low or Remission>High or Moderate60150

Conclusion

Most RA patients in post 2011 reports from routine care were in moderate activity according to means or medians or categories, unchanged from 2008 and 2010. Only a minority were classified as in remission or low activity/severity. Optimal RA treatment may require modification of treatment goals, further recognition of differences between patients in clinical trials and routine care, and possible new strategies for earlier identification of RA patients for treatment, in addition to new therapeutic agents.

References

[1]Smolen JS et al. Ann Rheumatic Dis. 2010;69(4):631-7.

[2]Pincus T et al. Arthritis and Rheumatism. 2005;52(4):1009-19.

[3]Pincus T et al. J Rheumatol. 2008;35(11):2136-47.

[4]Pincus T et al. Arthritis Care & Research. 2010;62(2):181-9.

Disclosure of Interests

None declared

Implementing Treat to Target (TTT) for Rheumatoid Arthritis (RA) During COVID: Results of a Virtual Learning Collaborative (LC) Program

Objective

A treat‐to‐target (TTT) approach improves outcomes in rheumatoid arthritis (RA). In prior work, we found that a learning collaborative (LC) program improved implementation of TTT. We conducted a shorter virtual LC to assess the feasibility and effectiveness of this model for quality improvement and to assess TTT during virtual visits.

Methods

We tested a 6‐month virtual LC in ambulatory care. The LC was conducted during the 2020–2021 COVID‐19 pandemic when many patient visits were conducted virtually. All LC meetings used videoconferencing and a website to share data. The LC comprised a 6‐hour kickoff session and 6 monthly webinars. The LC discussed TTT in RA, its rationale, and rapid cycle improvement as a method for implementing TTT. Practices provided de‐identified patient visit data. Monthly webinars reinforced topics and demonstrated data on TTT adherence. This was measured as the percentage of TTT processes completed. We compared TTT adherence between in‐person visits versus virtual visits.

Results

Eighteen sites participated in the LC, representing 45 rheumatology clinicians. Sites inputted data on 1,826 patient visits, 78% of which were conducted in‐person and 22% of which were held in a virtual setting. Adherence with TTT improved from a mean of 51% at baseline to 84% at month 6 (P for trend < 0.001). Each aspect of TTT also improved. Adherence with TTT during virtual visits was lower (65%) than during in‐person visits (79%) (P < 0.0001).

Conclusion

Implementation of TTT for RA can be improved through a relatively low‐cost virtual LC. This improvement in TTT implementation was observed despite the COVID‐19 pandemic, but we did observe differences in TTT adherence between in‐person visits and virtual visits.

Should Quantitative Measures and Management of Rheumatoid Arthritis Include More Than Control of Inflammatory Activity?

We agree strongly with Kremer et al that "metrics are essential for evaluating disease activity in patients with rheumatoid arthritis (RA)."¹ Nonetheless, data reported from the Corrona and the Brigham and Women's Rheumatoid Arthritis Sequential Study (BRASS) registries for Clinical Disease Activity Index (CDAI) and Routine Assessment of Patient Index Data 3 (RAPID3) are quite similar to those reported in the initial 2008 RAPID3 report.².

A Self-Report Multidimensional Health Assessment Questionnaire (MDHAQ) for Face-To-Face or Telemedicine Encounters to Assess Clinical Severity (RAPID3) and Screen for Fibromyalgia (FAST) and Depression (DEP)

Purpose of Review

To update the clinical value of a patient self-report multidimensional health assessment questionnaire (MDHAQ).

Recent Findings

The MDHAQ includes 10 individual quantitative scores for physical function, pain, patient global assessment, fatigue, sleep, anxiety, depression, morning stiffness, change in status, and exercise status, and 5 indices, RAPID3 (routine assessment of patient index data) to assess clinical status in all diseases studied, FAST3 (fibromyalgia assessment screening tool) and MDHAQ-Dep (depression) to screen for fibromyalgia and/or depression, RADAI self-report of specific painful joints and joint count, and a symptom checklist for review of systems, and recognition of flares and medication adverse events. The MDHAQ also uniquely queries traditional “medical” information concerning comorbidities, falls, trauma, new symptoms, illnesses, surgeries, hospitalizations, emergencies, medication changes, and medication side effects. Three MDHAQ versions include long for new patients, short for new and return patients, and telemedicine. An electronic MDHAQ (eMDHAQ) has been developed with software that can interface with any electronic medical record (EMR) through the HL7 FHIR standard. However, EMR collaboration and implementation have proven difficult.

Summary

An MDHAQ provides a quantitative overview of patient status with far more information and documentation than an interview, involving minimal extra work for the physician.

Multidimensional Health Assessment Questionnaire as an Effective Tool to Screen for Depression in Routine Rheumatology Care

OBJECTIVE

To analyze the use of the Multidimensional Health Assessment Questionnaire (MDHAQ) to screen for depression, as compared to 2 reference standards, the Patient Health Questionnaire 9 (PHQ-9) and the Hospital Anxiety and Depression Scale depression domain (HADS-D).

METHODS

Patients from Barcelona with a primary diagnosis of rheumatoid arthritis (RA) or spondyloarthritis (SpA) completed the MDHAQ, the PHQ-9 (depression ≥10), and the HADS-D (depression ≥8) measures. The MDHAQ includes 2 depression items, 1 in the patient-friendly HAQ, scored in a 4-point format from 0 to 3.3, and a yes/no item on a 60-symptom checklist. Percentage agreement and kappa statistics quantified the agreement between 6 screening criteria: yes on the 60-symptom checklist, a score of ≥1.1, a score of ≥2.2 on a 4-point scale, and either a response of yes on the 60-symptom checklist or scores of ≥2.2, PHQ-9 ≥10, and HADS-D ≥8.

RESULTS

Depression screening was positive according to 6 criteria in 19.6-32.4% of 102 patients with RA, and 27.9-44.8% of 68 with SpA (total = 170). All MDHAQ scores, including depression items, were higher in patients with SpA compared to patients with RA, and within each diagnostic group in patients who met PHQ-9 ≥10 and HADS-D ≥8 depression screening criteria. The highest percentage agreement between an MDHAQ screening criterion versus PHQ-9 ≥10 was 83.3% for either an answer of yes on the 60-symptom checklist or a score of ≥2.2 on a 4-point scale, which we have termed MDHAQ-Dep. The agreement of MDHAQ-Dep versus HADS-D ≥8 was 81.7%, similar to the agreement of PHQ-9 ≥10 versus HADS-D ≥8, which was 82.2%. Kappa measures of agreement were 0.63 for MDHAQ-Dep versus PHQ-9 ≥10, 0.60 for MDHAQ-Dep versus HADS-D ≥8, and 0.62 for PHQ-9 ≥10 versus HADS-D ≥8.

CONCLUSION

A positive MDHAQ-Dep response (either an answer of yes on a 60-symptom checklist or a score of ≥2.2 on a 4-point scale) yielded similar results to PHQ-9 ≥10 or HADS-D ≥8 to screen for depression in these RA and SpA patients.

FRI0587 A NEW APPROACH TO EARLY DETECTION OF ADVERSE EVENTS OF HIGH-RISK MEDICATIONS USING A STRUCTURED, STANDARD, PROTOCOL DRIVEN WEEKLY REMOTE ELECTRONIC MDHAQ 60-SYMPTOM CHECKLIST

Background:

A multidimensional health assessment questionnaire (MDHAQ) includes RAPID3, which distinguishes active from control treatments in rheumatoid arthritis clinical trials, and documents change comparably to disease-specific indices in all diseases studied. The MDHAQ also includes a standard, structured 60-symptom checklist, to recognize comorbidities, provide a review of systems, and serve on a fibromyalgia assessment screening tool (FAST3) as a clue to identify patients with fibromyalgia. A new MDHAQ application is to recognize adverse events to high-risk medications on a standard, structured, protocol-driven MDHAQ 60-symptom checklist. A structured list, rather than a “subjective” narrative medical history, is needed as many adverse events are common symptoms, e.g., headache, fatigue; prior negative data facilitates recognition of a new symptom as a possible adverse event. Similar strategies have been reported in oncology, pulmonology and other specialties, but not in rheumatology.

Objectives:

To use a remote electronic MDHAQ, completed weekly at home, to recognize RAPID3 clinical status changes and adverse events on the 60-symptom checklist, for early detection of medication adverse events.

Methods:

All patients with all diagnoses complete an MDHAQ at all visits in routine care at one rheumatology site. An electronic flowsheet (Table) is used to monitor 0-30 RAPID3, its components, and report of specific symptoms on the 60-symptom checklist, which appears required to document earlier absence of a common symptom and signal that a common symptom may be an adverse event. Results are depicted for an individual patient with pulmonary fibrosis, seen because of a positive rheumatoid factor.

Results:

A flowsheet of a pulmonary fibrosis patient over 2018 indicates initial RAPID3 of 14/30 and 10 symptoms at first visit of 19 Jan (Flowsheet). Treatment with low-dose methotrexate (MTX) and prednisone (PRED) led to substantial improvement over 6 months - RAPID3 3.5 and 6 symptoms on 2 Aug. On 15 Aug, MTX and PRED were discontinued by another physician, who prescribed pirfenidone. The patient telephoned on 24 Sep indicating distress. A home-completed remote MDHAQ indicated RAPID3 of 19.5 and 15 symptoms - 7 not reported on 2 Aug were among 16 listed pirfenidone adverse events. Discontinuation of pirfenidone and resumption of PRED and MTX with weekly remote electronic MDHAQ monitoring documented improvement of RAPID3 to 4.2 and 6 symptoms, including resolution of pirfenidone-specific symptoms, on 24 Dec (Flowsheet).

Conclusion:

Weekly remote electronic MHDAQ monitoring after initiation of a high-risk medication to monitor treatment responses and adverse events may provide a cost-effective approach to reduce morbidity and mortality of adverse events, involving about 10 minutes weekly (2 hours over 12 weeks) of patient time.

78-year-old man monitored over 2018–all data from self-report on MDHAQ –

pirfenidone highlighted (many entries deleted for space considerations)

Date19Jan201825Jan20182Aug201815-29Aug201824Sep201826Sep20184Oct20189Oct20189Nov201825Nov201828Dec2018Site of MDHAQClinicClinicClinicNoneHomeHomeHomeHomeHomeHomeHomeRAPID3 (0-30)*14.010.23.5?19.510.26.76.54.86.04.2Prednisone mg/dayB 40↓20↓6D/C 0R 10555555Methotrexate mg/w20D/C 00000R 101010pirfenidoneB3-9/d9/dD/C003/DD/C0#Symptoms (0-60)*105615151313686Weight loss++++++Feeling sickly+Unusual fatigue+++++++Loss of appetite++++++Stuffy nose+++++++++Dry mouth+++++++++Problems with smell/taste+++++Cough++++++++++Dyspnea++++++++++Heartburn/gas+++++Joint pain+++++Back pain++Sleep problems++

*Actual total - a few less relevant symptoms deleted for abstract requirements

Table 1.

RF diagnostic performance in rheumatic diseases

GroupnIsotype**Cut-offUR/mlSignificanceAUC (95% CI)Sensitivity %Specificity %Youden IndexSensitivity %Manufacturercut-off +Specificity %Manufacturercut-off +RA22IgM135.30.060.722(0.604 to 0.839)60%85.20.4568.255.5Psa44IgA47.20.0740.698(0.553 to 0.842)54.581.80.3554.577.3ASP44IgA39.50.0800.668(0.511 to 0.826)54.588.60.4354.979.5SS44IgM180.60.0880.535(0.088 to 0.708)54.574.40.2868.29.3Healthy44IgM16.30.0460.896(0.806 to 0.986)77.388.90.6668.297.8SLE41IgA42.60.0730.701(0.557 to 0.845)54.585.30.3954.573.5FBM35IgM68.60.0710.752(0.612 to 0.892)63.682.80.4668.251.7OA38IgM48.00.0530.873(0.770 to 0.976)63.6960.5968.288PG20IgM117.00.0760.758(0.609 to 0.908)59.189.50.4968.263.2Total332

** The isotype with the best AUC for each clinical scenario. + Manufacturer cut-off value: 20UR/ml

Disclosure of Interests:

Theodore Pincus Shareholder of:

Dr. Pincus holds a copyright and trademark on MDHAQ and RAPID3 for which he receives royalties and license fees from profit-making organizations, all of which are used to support further development of quantitative clinical measures for patients and health professionals., Niels Steen Krogh: None declared

FRI0517 POSSIBLE EARLY DETECTION OF ADVERSE EVENTS USING A STRUCTURED, STANDARD, 60-SYMPTOM CHECKLIST ON A MULTIDIMENSIONAL HEALTH ASSESSMENT QUESTIONNAIRE (MDHAQ)

Background:

Adverse events of medications are reported to account for 5% of hospital admissions in the USA, including 10% in the elderly, despite extensive warnings to patients by health professionals and pharmacies concerning the problem. Some adverse events are relatively obvious, such as a severe rash or severely abnormal laboratory test. However, many adverse events are common symptoms, such as headache or fatigue, which may not necessarily be recognized as adverse events, particularly in elderly patients with many comorbidities. In clinical trials and other clinical research, a structured, standard, protocol-driven symptom checklist is recorded according to the “scientific method.” In routine care, by contrast, recognition and recording of adverse events is elicited by health professionals at patient encounters or contact initiated by patients between visits, as “subjective” medical history information, which may be highly variable. Use of a standard symptom checklist on an electronic patient questionnaire has been reported in oncology, pulmonology and other specialties, but not in rheumatology. A multidimensional health assessment questionnaire (MDHAQ) includes a standard 60-symptom checklist, to recognize comorbidities, provide a review of systems, and serve on a fibromyalgia assessment screening tool (FAST3) as a clue to identify patients with fibromyalgia. The MDHAQ 60–symptom checklist can identify new symptoms after initiation of a medication which may be adverse events.

Objectives:

To analyze an MDHAQ 60-symptom checklist as a cost-effective approach to recognize medication-associated adverse events.

Methods:

All patients at one site complete an MDHAQ at each visit, which includes a standard, structured 60-symptom checklist, in addition to RAPID3 (routine assessment of patient index data) and FAST3. Paper MDHAQs from routine care are scanned into an Epic electronic medical record (EMR) and copied into a data repository for retrospective analyses. A list of common adverse events of many specific DMARDs (disease-modifying antirheumatic drugs) and biological agents used to treat rheumatoid arthritis (RA) was compiled from websites of the FDA, pharmaceutical companies, and Up-to-date.® Most listed symptoms are found on the structured MDHAQ 60-symptom checklist. A retrospective review of scanned MDHAQs at the first visit was conducted to recognize the presence or absence of self-reported symptoms which were listed as common adverse events for specific DMARDs on the MDHAQ 60-symptom checklist, using simple descriptive statistics. Only methotrexate (Mtx) is presented here due to space limitations.

Results:

All symptoms listed as adverse events of specific DMARDs were reported at higher frequencies in 379 DMARD-treated RA patients or 153 Mtx-treated patients, compared to 149 DMARD-naïve patients (Table). More than 30% of DMARD-treated patients reported headache and/or unusual fatigue, 27% anxiety; 10-20% cough, dizziness, hair loss, nausea, skin rash or hives, stomach pain or cramps, eye problems, and/or weight loss; and 5-10% diarrhea, fever, and/or mouth sores (Table). Similar proportions were seen for Mtx-treated patients, although anxiety and cough were not listed as specific adverse events.

Conclusion:

The MDHAQ symptom checklist may prove valuable to detect adverse events of high-risk medications, including on an electronic MDHAQ, which could be completed at home for 12 weeks after initiation of a new medication as a cost-effective approach for early detection of adverse events.

Symptom listed on MDHAQ/MEDI60DMARD naïveN=149(28%)DMARD treatedN=379(72%)MethotrexateN=153(29%)Headache28%36%36%Unusual fatigue31%33%34%Anxiety23%27%Cough16%18%Dizziness14%18%20%Hair loss10%17%19%Nausea11%13%18%Skin rash or hives11%14%13%Stomach pain/cramps9%16%15%Eye problems9%13%14%Anorexia/weight loss10%16%17%Diarrhea5%9%8%Fever5%8%7%Mouth sores3%7%8%

Disclosure of Interests:

Kyle Schroeder: None declared, Sara Abu Mehsen: None declared, Isabel Castrejon: None declared, Theodore Pincus Shareholder of:

Dr. Pincus holds a copyright and trademark on MDHAQ and RAPID3 for which he receives royalties and license fees from profit-making organizations, all of which are used to support further development of quantitative clinical measures for patients and health professionals.

AB1194 STRIKING DIFFERENCES IN THE COURSE OF OSTEOARTHRITIS (OA) COMPARED TO RHEUMATOID ARTHRITIS (RA) OVER THE FIRST 24 MONTHS OF RHEUMATOLOGY CARE AT ONE PRIVATE PRACTICE SETTING

Background:

Recent reports indicate that disease burden in osteoarthritis (OA) is similar to or greater than in rheumatoid arthritis (RA) when an identical measure is used to assess patients with either disease, generally an MDHAQ/RAPID3 (multidimensional health assessment questionnaire/routine assessment of patient index data). The data suggest that a traditional view that RA is more severe than OA no longer is valid at this time. One concern is that similar disease burdens in OA vs RA may result entirely from superior treatments for RA, and RA may be considerably more severe than OA at initial presentation.

Objectives:

To analyze MDHAQ disease burden in patients with OA vs RA at initial visit and at 24-month follow-up in routine care at a single solo-rheumatologist private practice setting.

Methods:

All patients at this setting complete an MDHAQ at each visit in the waiting area, prior to seeing the rheumatologist. The MDHAQ includes three 0-10 scores for physical function, pain visual numeric scale (VNS), and patient global VNS, which may be compiled into a 0–30 RAPID3, as well as a 0-10 fatigue VNS, and 0-16 rheumatoid arthritis disease activity index (RADAI) self-report painful joint count. Mean MDHAQ scores were analyzed for all 73 OA and 116 RA patients seen for an initial visit between 2011 and 2017. Mean scores at initial and 24-month visits were compared for all 25 OA and 63 RA patients seen at 24 month (21-27 month) follow-up visits, using paired t tests.

Results:

Mean MDHAQ scores at first visit were similar for all 73 OA and 116 RA patients, and also for 25 OA and 63 RA patients who were also seen 24 months later, e.g., mean RAPID3 was 12.0-14.2. However, mean changes over 2 years were strikingly different in OA versus RA patients (Table). Almost all mean scores in OA were somewhat higher, while all mean scores in RA were clinically and statistically significantly improved at 24 months, e.g., mean RAPID3 worsened from 13.0 to 15.2 (+2.2 units, 17%) in OA patients, compared to improvement from 12.5 to 8.2 (-4.3 units, -34%) in RA patients. The smallest mean change in RA patients involved the joint count (7.7 to 6.1, -21%) (Table), suggesting possible control of inflammation, but continued damage to specific joints. An important limitation is that the data do not include follow-up on patients not seen over the 24 month “window,” because of substantially better or poorer status, joint surgery, or other reasons, although the data present an accurate characterization of one rheumatology practice setting.

Mean values of patient MDHAQ scores in patients with OA or RA at first visit and 24-month follow-up

MDHAQ score:OA first visit of those seen at 24 months(n=25)OA 24- month visit (n=25)% change, over 24 monthsRA first visit of those seen at 24 months(n=63)RA 24- month visit (n=63)% change, over 24 monthsRAPID313.015.2+2.2, +17%12.58.2-4.3, -34%Function0.810.77-0.04, -5%0.710.50-0.21, -29%Pain5.26.4+1.2, +23%5.13.2-1.9, -37%Patient global5.15.9+0.8, +16%5.13.3-1.8, -35%Fatigue4.14.4+0.3, +7%4.83.5-1.3, -27%Pt joint count7.57.8+0.3, +4%7.76.1-1.6, -21%

Abbreviations: MDHAQ=multidimensional health assessment questionnaire, OA=osteoarthritis, RA=rheumatoid arthritis, RAPID3=routine assessment of patient index data.

In change data, negative numbers indicate improvement, positive numbers indicate worsening.

Conclusion:

Mean MDHAQ/RAPID3 scores were similar in RA or OA at the initial visit. Over 24 months, scores worsened slightly in OA and improved considerably in RA, resulting in considerably poorer status in OA versus RA, likely reflecting superior treatments for RA vs OA. At an individual level, patients with primary OA may have better or poorer status than patients with primary RA. Nonetheless, at a group level, the severity of disease burden in OA appears similar to RA, and becomes greater over the next 24 months, likely as a result of better treatments. The severity of OA is underrated, suggesting a need for increased resources for research toward better treatments for OA.

Disclosure of Interests:

Kyle Schroeder: None declared, Theodore Pincus Shareholder of:

Dr. Pincus holds a copyright and trademark on MDHAQ and RAPID3 for which he receives royalties and license fees from profit-making organizations, all of which are used to support further development of quantitative clinical measures for patients and health professionals., Martin Bergman Shareholder of: Johnson & Johnson – stockholder, Consultant of: AbbVie, BMS, Celgene Corporation, Genentech, Janssen, Merck, Novartis, Pfizer, Sanofi – consultant, Speakers bureau: AbbVie, Celgene Corporation, Novartis, Pfizer, Sanofi – speakers bureau

Reliability, Feasibility, and Patient Acceptance of an Electronic Version of a Multidimensional Health Assessment Questionnaire for Routine Rheumatology Care: Validation and Patient Preference Study

BACKGROUND

A multidimensional health assessment questionnaire (MDHAQ) that was developed primarily for routine rheumatology care has advanced clinical research concerning disease burden, disability, and mortality in rheumatic diseases. Routine Assessment of Patient Index Data 3 (RAPID3), an index within the MDHAQ, is the most widely used index to assess rheumatoid arthritis (RA) in clinical care in the United States, and it recognizes clinical status changes in all studied rheumatic diseases. MDHAQ physical function scores are far more significant in the prognosis of premature RA mortality than laboratory or imaging data. However, electronic medical records (EMRs) generally do not include patient questionnaires. An electronic MDHAQ (eMDHAQ), linked by fast healthcare interoperability resources (FIHR) to an EMR, can facilitate clinical and research advances.

OBJECTIVE

This study analyzed the reliability, feasibility, and patient acceptance of an eMDHAQ.

METHODS

Since 2006, all Rush University Medical Center rheumatology patients with all diagnoses have been asked to complete a paper MDHAQ at each routine care encounter. In April 2019, patients were invited to complete an eMDHAQ at the conclusion of the encounter. Analyses were conducted to determine the reliability of eMDHAQ versus paper MDHAQ scores, arithmetically and by intraclass correlation coefficient (ICC). The feasibility of the eMDHAQ was analyzed based on the time for patient completion. The patient preference for the electronic or paper version was analyzed through a patient paper questionnaire.

RESULTS

The 98 study patients were a typical routine rheumatology patient group. Seven paper versus eMDHAQ scores were within 2%, differences neither clinically nor statistically significant. ICCs of 0.86-0.98 also indicated good to excellent reliability. Mean eMDHAQ completion time was a feasible 8.2 minutes. The eMDHAQ was preferred by 72% of patients; preferences were similar according to age and educational level.

CONCLUSIONS

The results on a paper MDHAQ versus eMDHAQ were similar. Most patients preferred an eMDHAQ.

Fibromyalgia Assessment Screening Tool: Clues to Fibromyalgia on a Multidimensional Health Assessment Questionnaire for Routine Care

OBJECTIVE

To develop feasible indices as clues to comorbid fibromyalgia (FM) in routine care of patients with various rheumatic diseases based only on self-report multidimensional Health Assessment Questionnaire (MDHAQ) scores, which are informative in all rheumatic diagnoses studied.

METHODS

All patients with all diagnoses complete an MDHAQ at each visit; the 2011 FM criteria questionnaire was added to the standard MDHAQ between February 2013 and August 2016. The proportion of patients who met 2011 FM criteria or had a clinical diagnosis of FM was calculated. Individual candidate MDHAQ measures were compared to 2011 FM criteria using receiver-operating characteristic (ROC) curves; cutpoints to recognize FM were selected from the area under the curve (AUC) for optimal tradeoff between sensitivity and specificity. Cumulative indices of 3 or 4 MDHAQ measures were analyzed as fibromyalgia assessment screening tools (FAST).

RESULTS

In 148 patients, the highest AUC in ROC analyses versus 2011 FM criteria were seen for MDHAQ symptom checklist, self-report painful joint count, pain visual analog scale (VAS), and fatigue VAS. The optimal cutpoints were ≥ 16/60 for symptom checklist, ≥ 16/48 for self-report painful joint count, and ≥ 6/10 for both pain and fatigue VAS. Cumulative FAST indices of 2/3 or 3/4 MDHAQ measures correctly classified 89.4-91.7% of patients who met 2011 FM criteria.

CONCLUSION

FAST3 and FAST4 cumulative indices from only MDHAQ scores correctly identify most patients who meet 2011 FM criteria. FAST indices can assist clinicians in routine care as clues to FM with a general rheumatology rather than FM-specific questionnaire.

Osteoarthritis is as severe as rheumatoid arthritis: evidence over 40 years according to the same measure in each disease

Osteoarthritis (OA) may be associated with substantial work disability, morbidity, costs, and increased mortality rates, often similar to rheumatoid arthritis (RA), documented in many published reports over the last 4 decades. However, OA generally has been viewed as less severe than RA. This discrepancy may be explained in part by:a) RA may have been considerably more severe in the past, prior to effective therapies.b) most older individuals have radiographic joint damage, which often is not associated with clinical symptoms.c) RA is associated with abnormal laboratory tests, which are regarded as conveying greater significance than symptoms of pain and disability according to a "biomedical model," the dominant paradigm of modern medicine.d) Most reports of OA and RA have emphasised differences between the 2 diseases even beyond laboratory abnormalities in pathogenesis, physical findings, and imaging.e) Even pain and functional disability seen in both diseases are assessed using different patient self-report questionnaires, a WOMAC (Western Ontario McMaster Universities osteoarthritis index) in OA, and HAQ (health assessment questionnaire) in RA.An identical measure is required for optimal direct comparisons, which has been used in 8 studies performed between 1979 and 2019 at 8 sites in North America, Europe, and Australia. These studies were primarily based on retrospective analyses at sites which collected a patient questionnaire in routine clinical care by all patients at all visits to inform clinical decisions. A pain visual analogue scale (VAS) was higher in OA compared to RA in 11/12 patient groups, while physical function on a HAQ (health assessment questionnaire) or derivative MDHAQ (multidimensional HAQ) and RAPID3 (routine assessment of patient index data) were slightly higher in RA before 2013 and higher in OA in later reports. Furthermore, a study of population-based data from the 1978 US Health Interview Survey indicated similar levels of disability and earnings losses according to surrogate variables for OA and RA. Therefore, at least over the last 40 years, pain and functional disability in OA have appeared to be severe and similar to RA. These observations also-illustrate the potential value of using an identical patient questionnaire in all patients at all visits in routine care settings, analogous to using the same laboratory tests such as erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) in all rheumatic diseases, and maintaining a database of the results for later analyses.

Low socioeconomic status and patient questionnaires in osteoarthritis: challenges to a "biomedical model" and value of a complementary "biopsychosocial model"

Modern medical care is based largely on a paradigm known as a "biomedical model," in which "objective," high-technology biomarkers guide clinical care, and most health outcomes are determined by health professionals rather than individuals, using drugs as the primary therapy. The biomedical model is spectacularly effective in the acute care inpatient hospital, the setting for 95% of medical education and training, and to guide management of many chronic diseases, such as hypertension and diabetes, for which a "gold standard" biomarker is a major determinant of clinical decisions. This model also has contributed importantly to knowledge of biomarkers, biochemical and structural abnormalities in osteoarthritis (OA) and other rheumatic diseases. However, a biomedical model has many limitations in understanding the long-term course of OA and many chronic diseases in outpatient medicine, the setting of 95% of activities that determine long-term health outcomes. Patient self-report questionnaires provide the most informative data concerning OA patient status and changes in status, and more significant data in the prognosis of outcomes such as mortality than laboratory or radiographic measures. Furthermore, the incidence, prevalence, morbidity, and mortality of OA is considerably greater in individuals of low versus high socioeconomic status. These associations are not unique to OA, and are seen in many diseases, including comorbid conditions which are the acute causes of death in OA. Associations of low socioeconomic and poor health are explained only in small part by limited access to medical services, the conventional explanation. Strong evidence suggests that socioeconomic status is a surrogate marker for patient self-management, actions and environment, in addition to actions of health professionals, in the pathogenesis, course and outcomes of chronic diseases. These observations suggest the value of a complementary "biopsychosocial model" to better understand pathogenesis, principles of treatments, and outcomes in OA and other chronic diseases. Inclusion of clinical information from patient questionnaires and socioeconomic status variables in clinical and research settings could add new understanding of biomarkers and pain in OA for both basic and clinical investigators. Furthermore, the data indicate that poor physical function assessed on a self-report questionnaire might be regarded as an important reversible risk factor in public health and research agendas, for which the OA community might be strong advocates.

Patient questionnaires in osteoarthritis: what patients teach doctors about their osteoarthritis on a multidimensional health assessment questionnaire (MDHAQ) in clinical trials and clinical care

A patient history generally provides the most important information in diagnosis and management of patients with most rheumatic diseases, including osteoarthritis (OA). Patient history components can be expressed as quantitative, structured, "scientific" data, rather than "subjective" narrative descriptions, using patient self-report questionnaires. The Western Ontario McMaster (WOMAC) questionnaire is used in all OA clinical trials, and the health assessment questionnaire (HAQ) in all rheumatoid arthritis (RA) clinical trials, as "disease-specific" questionnaires. However, both questionnaires include scores for physical function function and pain; physical function scores are correlated highly significantly at r=0.78 in both RA and OA patients, while WOMAC pain scores are correlated with HAQ visual analogue scale (VAS) pain scores at r=0.73 in OA and r=0.71 in RA. Therefore, the WOMAC and HAQ may be regarded as largely "generic" questionnaires, at least for people with arthritis. Since it is not feasible to ask patients with different diagnoses to complete different care questionnaires in busy clinical settings, a single multidimensional HAQ (MDHAQ), derived from the HAQ and largely similar and informative in all rheumatic diseases, has been used in all rheumatology patients in several settings. The MDHAQ also has been incorporated into two OA clinical trials, with virtually identical results to the WOMAC. In routine clinical care, MDHAQ scores have documented that the disease burden of OA is comparable to RA in terms of scores for pain, physical function, and RAPID3 (routine assessment of patient index data) an index of pain, function and patient global assessment. Further observations indicate capacity of the MDHAQ to recognise fibromyalgia similarly to formal fibromyalgia criteria, as well as the ineffectiveness of opioids in OA, and similar prevalence of depression and other psychological issues in OA to RA. These findings also illustrate the value of a database of MDHAQ data for retrospective analysis of serendipitous observations from routine clinical care.

Fibromyalgia Assessment Screening Tools (FAST) Based on Only Multidimensional Health Assessment Questionnaire (MDHAQ) Scores as Clues to Fibromyalgia

Objective

The study was designed to develop fibromyalgia assessment screening tool (FAST) indices based only on multidimensional health assessment questionnaire (MDHAQ) scores as clues to fibromyalgia (FM), analyzed for possible agreement with the 2011 FM criteria.

Methods

All patients with all diagnoses complete an MDHAQ at each visit in routine care. The MDHAQ includes scores for physical function, pain, global assessment, fatigue, self-report painful joint count, and a 60-symptom checklist. MDHAQ items similar or identical to the 2011 FM criteria symptom severity scale (SSS) and widespread pain index (WPI) components of a polysymptomatic distress scale (PSD) were compiled into continuous MDHAQ-FM-SSS, MDHAQ-FM-WPI, and MDHAQ-FM-PSD indices. Ten candidate MDHAQ scores were analyzed against the 2011 FM criteria using descriptive statistics, Spearman correlations, kappa statistics, and receiver operating characteristic curves for the area under the curve (AUC). MDHAQ candidate variables with the highest AUC were compiled into cumulative MDHAQ-FAST indices of three (FAST3) or four (FAST4) scores.

Results

The highest AUCs among MDHAQ scores were seen for symptom checklist, painful joint count, fatigue, and pain, which are included in FAST4; FAST3-F excludes pain, and FAST3-P excludes fatigue. AUCs for FAST3-P, FAST3-F, and FAST4, as well as continuous MDHAQ-FM scores, all were greater than 0.92, indicating excellent criterion validity. Kappa statistics versus the 2011 criteria were 0.63-0.68, higher than 0.41-0.47 versus physician ICD-10 diagnoses.

Conclusion

Pragmatic FAST3, FAST4, and MDHAQ-FM indices are similar to FM criteria to screen for FM in routine care. It is more feasible to collect the same MDHAQ, which is informative in all rheumatic diseases studied, from each patient than to ask different patients with different diagnoses to complete different questionnaires.

Disease Burden in Osteoarthritis Is Similar to That of Rheumatoid Arthritis at Initial Rheumatology Visit and Significantly Greater Six Months Later

OBJECTIVE

To analyze disease burden in osteoarthritis (OA) according to Multidimensional Health Assessment Questionnaire (MDHAQ)/Routine Assessment of Patient Index Data 3 (RAPID3) scores at the initial visit and the 6-month follow-up visit, compared with rheumatoid arthritis (RA) as a benchmark for high disease burden.

METHODS

All patients with all diagnoses at the Rush University Medical Center Division of Rheumatology complete a paper MDHAQ at all visits, saved as a PDF in the electronic health record. MDHAQ 0-10 scores for physical function, pain, and patient global assessment (compiled into RAPID3 0-30 scores) and additional scales at the initial and 6-month follow-up visits, for new OA and RA patients seen from 2011 to 2017, were compared. OA and RA patients were classified as self-referred or physician-referred, and RA patients were classified as disease-modifying antirheumatic drug (DMARD)-naive or having prior-DMARD treatment. Patient groups were compared using t-tests and analysis of variance, adjusted for age, disease duration, body mass index (BMI), education, and ethnicity.

RESULTS

Compared with RA patients, OA patients had higher age, BMI, and disease duration. At initial visit, the mean RAPID3 did not differ significantly in OA versus DMARD-naive RA patients, whether self- or physician-referred (range 14.8-16.4 [P = 0.38]), or in all OA patients versus DMARD-naive RA patients versus prior-DMARD RA patients (15.0, 15.7, and 15.8, respectively [P = 0.49]). After 6 months, RAPID3 was improved to 13.3, 10.3, and 10.8, respectively, which represented substantially greater improvement in RA patients than OA patients (P < 0.001). Similar results were seen for most self-reported measures and in adjusted analyses.

CONCLUSION

MDHAQ/RAPID3 scores are similar in OA and RA patients at the initial visit, but higher in OA patients than in RA patients 6 months later, reflecting superior RA treatments. The same MDHAQ/RAPID3 allows comparisons of disease burdens in different diseases.

Diagnosis of Fibromyalgia: Disagreement Between Fibromyalgia Criteria and Clinician-Based Fibromyalgia Diagnosis in a University Clinic

OBJECTIVE

Recent studies have suggested that fibromyalgia is inaccurately diagnosed in the community, and that ~75% of persons reporting a physician diagnosis of fibromyalgia would not satisfy published criteria. To investigate possible diagnostic misclassification, we compared expert physician diagnosis with published criteria.

METHODS

In a university rheumatology clinic, 497 patients completed the Multidimensional Health Assessment Questionnaire (MD-HAQ) and the 2010 American College of Rheumatology preliminary diagnostic criteria modified for self-administration during their ordinary medical visits. Patients were evaluated and diagnosed by university rheumatology staff.

RESULTS

Of the 497 patients, 121 (24.3%) satisfied the fibromyalgia criteria, while 104 (20.9%) received a clinician International Classification of Diseases (ICD) diagnosis of fibromyalgia. The agreement between clinicians and criteria was 79.2%. However, agreement beyond chance was only fair (κ = 0.41). Physicians failed to identify 60 criteria-positive patients (49.6%) and incorrectly identified 43 criteria-negative patients (11.4%). In a subset of 88 patients with rheumatoid arthritis (RA), the kappa value was 0.32, indicating slight to fair agreement. Universally, higher polysymptomatic distress scores and criteria-based diagnosis were associated with more abnormal MD-HAQ clinical scores. Women and patients with more symptoms but fewer pain areas were more likely to receive a clinician's diagnosis than to satisfy fibromyalgia criteria.

CONCLUSION

There is considerable disagreement between ICD clinical diagnosis and criteria-based diagnosis of fibromyalgia, calling into question ICD-based studies. Fibromyalgia criteria were easy to use, but problems regarding clinician bias, meaning of a fibromyalgia diagnosis, and the validity of physician diagnosis were substantial.

Minimal Clinically Important Improvement of Routine Assessment of Patient Index Data 3 in Rheumatoid Arthritis

OBJECTIVE

To estimate minimal clinically important improvement (MCII) of RAPID-3 (Routine Assessment of Patient Index Data 3) in rheumatoid arthritis (RA).

METHODS

RAPID-3 was computed before and after treatment escalation in a prospective study of adults with active RA. Patient judgment of improvement was used as the standard for a receiver-operating characteristic curve, from which MCII was estimated.

RESULTS

Mean RAPID-3 improved from 16.3 to 11.1 between visits. MCII was -3.8 based on simultaneously optimized sensitivity and specificity, -3.5 using the 0.80 specificity criterion, and -4.1 using the Youden index.

CONCLUSION

RAPID-3 improvement of 3.8/30 units appears clinically meaningful.

Value of the Routine Assessment of Patient Index Data 3 in Patients With Psoriatic Arthritis: Results From a Tight-Control Clinical Trial and an Observational Cohort

OBJECTIVE

To analyze the Routine Assessment of Patient Index Data 3 (RAPID3), a patient-reported, composite index, designed initially for feasibility in clinical care. RAPID3 was developed in rheumatoid arthritis, but has been found useful in many rheumatic diseases. We analyzed RAPID3 in patients with psoriatic arthritis (PsA).

METHODS

Post hoc analyses were performed on 2 independent data sets, the Tight Control of Psoriatic Arthritis (TICOPA) clinical trial, and the Long-Term Outcome in Psoriatic Arthritis Study (LOPAS II), an observational cohort. RAPID3 (range 0-30) is the total of three 0-10 scores for the Health Assessment Questionnaire disability index (recalculated from 0-3), pain visual analog scale (VAS), and global VAS. RAPID3 scores were compared to the Psoriatic Arthritis Disease Activity Score (PASDAS), the Disease Activity in Psoriatic Arthritis (DAPSA), and other available clinical measures, according to Spearman's correlation coefficients, standardized response mean, SEM, smallest detectible difference, minimally important difference (in patients who improved), and receiver operating characteristic curves. RAPID3 remission was compared to criteria for both standard minimal disease activity (MDA) and very low disease activity (VLDA).

RESULTS

RAPID3 was correlated significantly with PASDAS in TICOPA (r = 0.79, P < 0.01) and with DAPSA in LOPAS II (ρ = 0.59, P < 0.01), and with most other measures in both data sets. RAPID3 discriminated between tight control and standard care in TICOPA at 48 weeks at levels comparable to DAPSA and the PASDAS (P < 0.01). RAPID3 remission discriminated treatment groups in TICOPA intermediate between MDA and VLDA criteria.

CONCLUSION

RAPID3 appears comparably informative to PASDAS and DAPSA in PsA, with greater feasibility for routine clinical care.

The feasibility and acceptability of a physical activity intervention for older people with chronic musculoskeletal pain: The iPOPP pilot trial protocol

INTRODUCTION

This pilot trial will inform the design and methods of a future full-scale randomized controlled trial (RCT) and examine the feasibility, acceptability and fidelity of the Increasing Physical activity in Older People with chronic Pain (iPOPP) intervention, a healthcare assistant (HCA)-supported intervention to promote walking in older adults with chronic musculoskeletal pain in a primary care setting.

METHODS AND ANALYSIS

The iPOPP study is an individually randomized, multicentre, three-parallel-arm pilot RCT. A total of 150 participants aged ≥65 years with chronic pain in one or more index sites will be recruited and randomized using random permuted blocks, stratified by general practice, to: (i) usual care plus written information; (ii) pedometer plus usual care and written information; or (iii) the iPOPP intervention. A theoretically informed mixed-methods approach will be employed using semi-structured interviews, audio recordings of the HCA consultations, self-reported questionnaires, case report forms and objective physical activity data collection (accelerometry). Follow-up will be conducted 12 weeks post-randomization. Collection of the quantitative data and statistical analysis will be performed blinded to treatment allocation, and analysis will be exploratory to inform the design and methods of a future RCT. Analysis of the HCA consultation recordings will focus on the use of a checklist to determine the fidelity of the iPOPP intervention delivery, and the interview data will be analysed using a constant comparison approach in order to generate conceptual themes focused around the acceptability and feasibility of the trial, and then mapped to the Theoretical Domains Framework to understand barriers and facilitators to behaviour change. A triangulation protocol will be used to integrate quantitative and qualitative data and findings.

Pain and other self-report scores in patients with osteoarthritis indicate generally similar disease burden to patients with rheumatoid arthritis

OBJECTIVES

Osteoarthritis (OA) is regarded as a less severe form of arthritis than rheumatoid arthritis (RA) by health professionals and the general public, based largely on laboratory findings of autoantibodies and acute phase reactants. Relatively few studies have reported data from the patient's perspective to compare directly OA versus RA using the same self-report questionnaire measure. We aimed to summarise reports that compare OA versus RA patient pain scores and other indicators of disease burden according to the same self-report questionnaire.

METHODS

A retrospective review identified 5 published reports at 8 rheumatology sites in 4 countries from 1989 to 2017 in which patients with OA versus RA completed the same patient self-report questionnaire for pain and other variables. Most comparisons involved a health assessment questionnaire (HAQ) and derivative multidimensional HAQ (MDHAQ), which include physical function, pain visual analogue scale (VAS) and patient global assessment VAS. Other questionnaires were included in one or two reported studies.

RESULTS

Mean or median pain VAS was in a similar range in OA versus RA, though somewhat higher in OA at 7 of 8 sites studied (included in 1989). Physical function and other scores also were in a similar range for RA versus OA. Evidence of higher scores for physical function in RA relative to OA in earlier than more recent studies was seen, although all studies indicated a clinically important disease burden in OA.

CONCLUSIONS

OA presents a severe disease burden to patients, which appears similar to RA. The findings suggest revision of current clinical and public policy views concerning OA.

Assessment of pain and other patient symptoms in routine clinical care as quantitative, standardised, "scientific" data

Pain is the most common basis for visits to a rheumatologist, and reduction of pain is a primary goal of clinical care. Pain is assessed optimally by the patient on a self-report questionnaire. In clinical trials and other clinical research concerning pain and pain relief, detailed questionnaires are generally completed by patients. However, in routine clinical care, pain is generally assessed only according to narrative descriptions by the physician, and only a minority of settings assess pain using a standard, quantitative measure. Accurate, standard, quantitative assessment of pain in routine care is easily assessed in all patients with all diagnoses on a 0-10 visual analogue scale (VAS), by asking each patient to complete a 2-page multidimensional health assessment questionnaire/routine assessment of patient index data 3 (MDHAQ/RAPID3) at all visits. The MDHAQ includes VAS for pain, patient global assessment, and fatigue, as well as a quantitative physical function scale, RAPID3, review of systems, and recent medical history. The questionnaire provides the doctor with a 10-15 second overview of medical history data that otherwise would require about 10-15 minutes of conversation, saving time for the doctor and patient to focus on the most prominent concerns for the visit. MDHAQ scores from patients with 10 different rheumatic diagnoses, and specific data indicating similarity of scores in patients with osteoarthritis versus rheumatoid arthritis on the same questionnaire, are presented to illustrate the value of the MDHAQ in routine care.

A RheuMetric physician checklist to quantitate levels of inflammation, damage and distress on 0-10 visual analogue scales

A physician global assessment of patient status (DOCGL) was designed initially to quantitate inflammatory activity in rheumatoid arthritis (RA) clinical trials, in which patients are selected for high levels of activity. However, in patients seen in routine care with various diagnoses, and even in some RA patients selected for clinical trials, DOCGL also may be affected by joint damage and/or patient distress. To clarify DOCGL on a 0-10 visual analogue scale (VAS), 3 additional 0-10 VAS have been developed to record physician estimates of inflammation (DOCINF), damage (DOCDAM), and distress (DOCSTR) (such as fibromyalgia (FM)/depression). Results from 3 locales for these 4 VASs are summarised, including 478 initial-visit patients from Tennessee in 1996 to 2007, 197 initial-visit patients from Pennsylvania in 2008 to 2012, and a random visit of 739 patients from Illinois in 2014 to 2015. Highest DOCGL estimates were seen at the 3 sites in FM, followed by RA and osteoarthritis (OA), spondyloarthropathies (SpA), gout, and systemic lupus erythematosus (SLE). Highest DOCINF (inflammation) estimates were seen in RA and SpA, followed by gout, SLE, FM, and OA. Highest DOCDAM (damage) estimates were in OA, followed by RA, SpA, gout, SLE and FM. Highest DOCSTR (distress) estimates were in FM, followed by OA, RA, SpA, SLE, and gout. In the 2 earlier series, DOCDAM was considerably higher than DOCINF only in OA, and lower in the other diagnoses, although within 50% of DOCINF. In more recent patients from Illinois, mean DOCDAM was higher than DOCINF in all 6 diagnoses. The 0-10 physician VASs depict the expertise of a rheumatologist to distinguish between inflammation, damage and distress in an individual patient and rate levels as quantitative data beyond narrative descriptions. These VASs appear informative for rheumatology care, documentation, and research.

MDHAQ/RAPID3 scores in patients with osteoarthritis are similar to or higher than in patients with rheumatoid arthritis: a cross-sectional study from current routine rheumatology care at four sites

Objective

To compare patients with a primary diagnosis of osteoarthritis (OA) versus rheumatoid arthritis (RA) for scores on a patient self-report MDHAQ/RAPID3 (Multidimensional Health Assessment Questionnaire/Routine Assessment of Patient Index Data 3), and for physician global assessment (DOCGL).

Methods

All patients with all diagnoses complete an MDHAQ/RAPID3 at all routine rheumatology visits in the waiting area before seeing a rheumatologist at four sites, one in Australia and three in the USA. The two-page MDHAQ includes 0–10 scores for physical function (in 10 activities), pain and patient global assessment [on 0–10 visual analogue scales (VAS)], compiled into a 0–30 RAPID3, as well as fatigue and self-report painful joint count scales. Rheumatologists estimate a 0–10 DOCGL VAS. Demographic, MDHAQ/RAPID3 and DOCGL data from a random visit were compared in patients with RA versus patients with OA using multivariate analysis of variance, adjusted for age, disease duration and formal education level.

Results

Median RAPID3 was higher in OA versus RA at all four sites (11.7–16.8 vs 6.2–11.8) (p<0.001 at three sites). Median DOCGL in OA versus RA was 5 vs 4, 4 vs 3.7, 2.2 vs 2.5 and 2 vs 1. Patterns were similar for individual RAPID3 items, fatigue and painful joint scales, and in stratified analyses of patients aged 55–70.

Conclusion

Patient MDHAQ/RAPID3 and physician DOCGL indicate similar or higher disease burden in OA versus RA. Routine MDHAQ/RAPID3 allows direct comparisons of the two diseases. The findings suggest possible revision of current clinical and public policy views concerning OA.

Implementation of Treat-to-Target in Rheumatoid Arthritis Through a Learning Collaborative: Results of a Randomized Controlled Trial

OBJECTIVE

Treat-to-target (TTT) is an accepted paradigm for the management of rheumatoid arthritis (RA), but some evidence suggests poor adherence. The purpose of this study was to test the effects of a group-based multisite improvement learning collaborative on adherence to TTT.

METHODS

We conducted a cluster-randomized quality-improvement trial with waitlist control across 11 rheumatology sites in the US. The intervention entailed a 9-month group-based learning collaborative that incorporated rapid-cycle improvement methods. A composite TTT implementation score was calculated as the percentage of 4 required items documented in the visit notes for each patient at 2 time points, as evaluated by trained staff. The mean change in the implementation score for TTT across all patients for the intervention sites was compared with that for the control sites after accounting for intracluster correlation using linear mixed models.

RESULTS

Five sites with a total of 23 participating rheumatology providers were randomized to intervention and 6 sites with 23 participating rheumatology providers were randomized to the waitlist control. The intervention included 320 patients, and the control included 321 patients. At baseline, the mean TTT implementation score was 11% in both arms; after the 9-month intervention, the mean TTT implementation score was 57% in the intervention group and 25% in the control group (change in score of 46% for intervention and 14% for control; P = 0.004). We did not observe excessive use of resources or excessive occurrence of adverse events in the intervention arm.

CONCLUSION

A learning collaborative resulted in substantial improvements in adherence to TTT for the management of RA. This study supports the use of an educational collaborative to improve quality.

Pragmatic assessment of exercise in routine care using an MDHAQ: associations with changes in RAPID3 and other clinical variables

Background

Exercise is associated with major benefits in patients with rheumatic diseases for both cardiovascular and rheumatic status. However, information about exercise generally is not collected systematically in routine rheumatology care. A multidimensional health assessment questionnaire (MDHAQ), which was designed for busy clinical settings, includes a query about exercise status. We analyzed possible associations between change in MDHAQ exercise scores and other MDHAQ measures in patients with various rheumatic diseases over one year.

Methods

In one rheumatology clinical setting, all patients, regardless of diagnosis, complete an MDHAQ before seeing a rheumatologist. The MDHAQ includes scores for physical function, pain, and patient global estimate, compiled into an index, routine assessment of patient index data (RAPID3), as well as a self-report joint count and a query about exercise. Patients were classified into four groups according to their exercise status at baseline and one year later as: EXER-Yes (regular exercise), EXER-Yes; EXER-No (no regular exercise), EXER-Yes; EXER-Yes, EXER-No; and EXER-No, EXER-No. These groups were compared using the chi square and Kruskal-Wallis tests and analysis of variance (ANOVA).

Results

Patients who reported regular exercise at baseline were younger, had higher formal education, and better clinical status than other patients. The EXER-No, EXER-Yes group had greater improvement in other MDHAQ variables than patients in the other three groups. By contrast, the EXER-Yes, EXER-No group was the only group with poorer status one year later.

Conclusions

The MDHAQ exercise query indicates that regular exercise is associated with better clinical status. Patients in the EXER-No, EXER-Yes group reported the best clinical improvement, although it is not known whether exercise preceded or followed the improved clinical status.

Assessment of fatigue in routine care on a Multidimensional Health Assessment Questionnaire (MDHAQ): a cross-sectional study of associations with RAPID3 and other variables in different rheumatic diseases

OBJECTIVES

To characterise associations of fatigue with other variables within a multidimensional health assessment questionnaire (MDHAQ) in routine care of patients with different rheumatic diagnoses.

METHODS

All patients complete MDHAQ, which includes fatigue on a 0-10 visual analogue scale (VAS), and routine assessment of patient index data (RAPID3), a composite of function, pain, and patient global. Physicians complete a RheuMetric checklist which includes 4 VAS for overall global status (DOCGL), inflammation, damage, and distress. Median score for fatigue and other MDHAQ and RheuMetric scores were compared in 4 diagnosis groups: rheumatoid arthritis (RA), osteoarthritis (OA), systemic lupus erythematosus (SLE), and fibromyalgia (FM), using a Kruskall-Wallis test. Associations of fatigue with other variables were analysed using Spearman correlations and multivariate regressions.

RESULTS

612 patients were included: 173 RA, 199 with OA, 146 with SLE, and 94 with FM. Median fatigue was significantly higher in FM (7) than in RA (4), OA (5), and SLE (5). Fatigue was correlated significantly with all other MDHAQ scores, at higher levels in RA and SLE versus OA and FM. Fatigue was correlated significantly with DOCGL in RA, OA, SLE, but not FM. In multivariate analyses, fatigue scores were explained independently by higher pain and symptom number in RA; lower age and higher symptom number in OA; only higher pain in SLE; and none of the variables in FM.

CONCLUSIONS

Fatigue is common in rheumatic diseases and strongly associated with higher pain and number of symptoms. The MDHAQ provides a useful tool to assess fatigue in clinical settings.

Electronic eRAPID3 (Routine Assessment of Patient Index Data): opportunities and complexities

RAPID3 (routine assessment of patient index data) is an index found within a multi-dimensional health assessment questionnaire (MDHAQ) for routine clinical care, composed only of 3 self-report scores for physical function, pain, and patient global estimate, each scored 0-10, for a total of 0-30. RAPID3 is correlated significantly with DAS28 (Disease Activity Score) and CDAI (Clinical Disease Activity Index), and distinguishes active from control treatments as efficiently as these indices in clinical trials involving adalimumab, abatacept, certolizumab, infliximab, and rituximab. Many versions of an electronic RAPID3 (eRAPID3) have been developed, which are incompatible with one another, as seen for electronic medical records (EMR). Therefore, opportunities are lost to pool data from many sites for advancement of patient care and outcomes. Interfaces for linkage to EMRs and pooling of data are available as Health Level Seven (HL7) standards, FHIR (Fast Health Interoperability Resources), and innovative open platforms like SMART (Substitutable Medical Apps, Reusable Technology), but many eRAPID3 versions do not have this capacity. RAPID3 scores may be elevated in many patients due to damage or distress, rather than, or in addition to, inflammation, a problem that also affects DAS28, CDAI, and all RA indices which include a patient global estimate, even if they include a formal joint count. A full MDHAQ, of which RAPID3 is a component, provides clues to the presence of damage, and/or distress and adds much further information, with no more work for the health professional and little more time for the patient. A RheuMetric physician checklist of global scores for inflammation, damage, and distress is also useful to recognise damage and/or distress, but not available with most available eRAPID3 versions. Many eRAPID3 versions also are limited by the absence of flowsheets to monitor scores over time, the absence of strategies to convey data to health professionals to improve care, and the absence of advanced features for patients and doctors which are available in some versions of an eRAPID3. It is recommended that eRAPID3 should include a full MDHAQ, RheuMetric checklist, a longitudinal flowsheet of scores, and a defined strategy for management of the data to be available to the physician for improved patient care, to enhance value and quantitative interpretation of RAPID3 scores.