Background Disease activity (DA) is the most important factor in the treatment decision during rheumatoid arthritis (RA) patient's follow-up. In routine clinical practice, it is recommended to regularly evaluate DA and musculoskeletal ultrasound has been suggested to add value to establish the level of DA. Nevertheless, the final treatment proposal also requires considering additional factors. In a previous clinical study performed in the setting of an early arthritis clinic, we found that in 20% of the clinical scenarios evaluated, the German ultrasound score of 7 joints (GUS-7) (1) findings impacted the rheumatologist 's treatment proposal; the impact was more frequent among the trainee in rheumatology (TR) than among the senior rheumatologist (SR).
Objectives To determine and rate, which among the following factors were determinant to recommend a treatment in the same population of RA patients above described: the clinical assessment, the GUS-7, comorbidities, treatment-related adverse events, DMARDs costs/availability, patient's preference and DMARD maximum dose. We also compared if factors differed between both physicians.
Methods Eighty-seven consecutive and randomly selected RA outpatients were invited to participate; 2 patients denied and 85 patients underwent 170 assessments (85 each by the SR and the TR); at first, both physicians (blinded to each other) 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. In the final step, the TR and the SR integrated the US findings to their previous evaluation and reviewed their prescription; also, both physicians recorded and rated on a standardized format which of the factors above described were determinant in the final treatment proposal. Patients signed informed consent and were instructed about the process. Only the SR met each patient for the final recommendation. Descriptive statistics was used.
Results Patients were primarily middle-aged female (91.4%) and had (mean±SD) follow-up of 7.5±3.9 years. The majority of them were in DAS28-remission (72%). Clinical assessment (DAS28) was rated as determinant in the totality of the clinical scenarios (100%), followed by GUS-7 in 84.7%, DMARD maximum dose in 41.2%, comorbidities in 23.5%, DMARD cost/availability in 21.2%, treatment-related adverse events in 20% and patient's preference in 14.1% of them. The SR and the TR differed in their selection: GUS-7 and treatment-related adverse events were more frequently considered determinant for the TR (45.9% vs. 38.8%, p=0.01 and 12.9% vs. 7.1%, p=0.08), meanwhile the opposite figure was true for DMARD cost/availability (4.7% vs. 16.5%, p≤0.001) and DMARDs maximum doses (17.1% vs. 24.1%, p=0.08).
Conclusions in a real clinical setting, DA assessed by DAS28 and by musculoskeletal ultrasound were the most important factors to determine the treatment of RA outpatients; additional factors were considered and differently rated by TR and SR.
Backhaus et al. Evaluation of a novel 7-joint ultrasound score in daily rheumatologic practice: a pilot project. Arthritis Rheum. 2009;61: 1194–201.
Disclosure of Interest None declared