Background Patients can potentially monitor disease activity in rheumatoid arthritis (RA) by performing self-assessment of joint counts. However, reliability of self-assessed swollen joint count is generally poor .
Objectives To evaluate the use of education by using feedback from ultrasound (US) images on the ability of patients to assess swollen joints in RA.
Methods Study design: 6-month single centre unblinded randomized controlled trial, stratified by age and disease activity. Patients: Consecutive patients with established RA. Intervention: (i) education on self-assessment of joints: initial brief patient training on tender (TJC) and swollen (SJC) joint counts, followed by US feedback for areas of active synovitis every 3 months (EUS) versus (ii) standard care (no education on self-assessment and feedback with US). Patient and physician independently performed 28-joint counts at each study visit, with US feedback for areas of active synovitis provided for patients in the intervention arm only, at end of each visit. Outcome variables: Primary: Agreement at “joint” level - Proportion of patients with good agreement with physician derived swollen joints (i.e. prevalence-adjusted bias adjusted kappa, PABAK more than 0.6). Secondary: Agreement at “patient” level: i.e. SJC between patients and physician using Bland and Altman 95% limits of agreement, disease activity indices between the 2 groups, proportion of patients achieving remission, feasibility and patient satisfaction survey according to a 5-point Likert scale on the joint count training method by US.
Results Ninety-two out of 101 patients completed the study (n=48 EUS, n=44 standard care). There were no differences in baseline characteristics. Mean age was 54.5±12.8 yrs, disease duration 6.3±6.0 yrs, with mean Disease Activity Score (DAS28) 3.3±1.1 (26% in DAS28 remission). At 6 months, the proportion of patients with swollen joint PABAK>0.6 was greater in the EUS arm compared to standard care (98% vs. 82%, p=0.009). The Bland and Altman limits of agreement for SJC difference between physician and patients were reduced only in the EUS arm. At 6 months, there were no significant inter-group differences in disease activity although a trend to higher DAS28 remission in the EUS arm (46% vs. 28% in standard care, p=0.08). Training with US was considered feasible (15-20 minutes) with 94% of patients reporting it as useful for appreciating their own disease activity.
Conclusions A short course of patient education with US feedback can improve patient-physician reliability for the assessment of swollen joints. Larger studies with longer follow up are required to evaluate the clinical benefits.
Cheung et al. Sem Arthritis Rheum 2013 (nov 13) [Epub ahead of print]
Disclosure of Interest None declared