Background Assessment of RA flare has become increasingly relevant to manage treatment optimization. The French Strategy of Treatment of Patients with RA (STPR) group validated FLARE (Flare Assessment in RhEumatoid Arthritis), a patient-centered tool to detect RA flares occurring between clinic visits. FLARE is available as an English (UK) translation.1 Each item represents an internationally agreed RA flare domain, to be answered on a scale (NRS) of 0 to 10,2, as follows:1) stiffness;2) pain;3) swollen joints;4) sleep;5) global arthritis;6) increase pain killers;7) increase prednisone;8) tiredness;9) daily activity;10) irritability;11) depression;12) withdrawal;13) need for help.1
Objectives To determine the understandability and usability of the English FLARE (E-FLARE) among American English speaking RA patients; to recommend evidenced-based wording changes preliminary to validation studies.
Methods American English-speaking RA pts were recruited to a protocol designed to assess E-FLARE using a semi-structured interview process. Pt understanding and response to each item were noted on case report forms, and when possible, recorded. Pts also completed E-FLARE pre and post-interview according to their most recent flare. Responses were tabulated as actual answer to each item based on flare status as well as proportion of patients who knew how to answer each item. Patient-suggested wording changes were systematically identified.
Results We interviewed 25 RA patients: 92% female, mean age 52, mean disease duration 9.96 yrs; 20% remission/low, 48% moderate, and 32% high disease activity. 80% of patients self-reported flare within previous 3 months. Mean responses for pts with current/recent flare were comparable, with 4 pts without recent flare tending to respond higher. For 8 of 13 items, <70% of pts understood question words well enough to confidently answer on an NRS scale. All patients reported that E-FLARE items needed wording changes to accurately reflect their flare experience. Themes included:1) confusion by anchors “absolutely true/absolutely untrue” causing most pts to respond yes/no instead of capturing intensity on NRS; 2) statements often unclear, with pts preferring questions that were anchored according to symptom described in the item (e.g. fatigue - none vs extremely exhausted); 3) items for prednisone or analgesics increase couldn't be answered on NRS; 4) time frames were inconsistent relative to the initial instructions and not very specific, making responses difficult for some patients and even excluding others 5) unclear if questions explicitly ask about a flare or about RA.
Conclusions Because of confusion regarding key words in most items, wording changes are desirable to assure reliable measurement properties for E-FLARE. Items in emotion domains scored lower in patients with current or recent flare, suggesting that these items may score differently compared to French RA patients.
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Lie E, Woodworth TG, Christensen R,et al. Validation of the OMERACT preliminary rheumatoid arthritis flare domains in NOR-DMARD. Ann Rheum Dis. 2014;73(10):1781-7.
Disclosure of Interest None declared