Background Disease activity (DA) is the most important factor in the treatment decision/monitoring during rheumatoid arthritis (RA) patient's follow-up. In routine clinical practice, it is recommended to regularly evaluate DA level from patients with RA. Musculoskeletal ultrasound has been suggested to add value to establish the level of DA; evaluations that assess a reduced number of joints, as the German ultrasound score of 7 joints (GUS-7) are easy to incorporate in clinical practice (1).
Objectives To explore the real impact of GUS-7 in the treatment recommendation to RA outpatients, currently attending an Early Arthritis Clinic (EAC). The primary objective was to determine the proportion of patients in whom treatment recommendation differed after GUS-7 examination. We additionally tested the variations of GUS-7 impact according to the physician's experience (senior rheumatologist [SR] vs. trainee in rheumatology [TR]).
Methods A sample size of 84 evaluations was calculated to achieve the primary objective. Eighty-seven consecutive and randomly selected RA outpatients were invited to participate; 2 patients denied because of administrative reasons and the 85 patients left underwent 170 assessments (85 each by the SR and the TR). At first, both physicians (blinded to each other evaluations) performed a clinical evaluation that included DAS28 scoring and recommended a RA-treatment. Then, patients underwent GUS-7 by a blinded (to clinical evaluations) rheumatologist that additionally determined the sonographic disease activity. In the final step, the TR and the SR integrated the US findings to their previous evaluation and reviewed their prescription; GUS-7 findings, pre- and post-GUS-7 treatments were recorded on standardized formats. Patients received final recommendation only from the SR. All the patients signed informed consent and were instructed about the process. Descriptive statistics was used.
Results Patients were primarily middle-aged [(mean±SD) 45.13±12.4 years] female (91.4%), with (mean±SD) disease duration of 7.5±3.9 years. Most of the patients (69.2% according to TR and 71.8% to SR) were in DAS28-ESR-remission, although the four levels of DA were represented. Agreement between both physicians was good (Kappa: 0.82, p≤0.001). Most frequent GUS-7 findings were grey scale synovitis in at least one joint in 98.8% of the patients, among whom 22.6% had Power Doppler activity (PD); one third of the patients had tenosynovitis although few (12%) had PD; erosions were detected in 38.8% of the patients.
In 34 of 170 clinical scenarios (20%), GUS-7 findings modified treatment; treatment changes (after GUS-7 findings were incorporated to clinical findings) consisted of an increase in 24 (70.6%) scenarios, a decrease in 8 (23.5%) and joint injection with corticosteroids in 2 (5.9%). Interestingly, 24 of the 34 clinical scenarios with GUS-7 treatment impact were performed by the TR vs. 10 performed by the SR: 70.5% vs. 29.5%, p=0.01. Treatment changes (increase, decrease and joint injection) were similar among both specialists.
Conclusions In routine clinical practice of RA patients, GUS-7 assessments impacted treatment decision in 20% of the patients; the impact was stronger among TR than among SR.
Backhaus et al. Arthritis Rheum 2009; 61: 1194–201.
Disclosure of Interest None declared