Background Quantitative assessment in rheumatoid arthritis (RA) is directed to inflammatory activity (INF) and not to joint damage (DAM) and distress (STR - seen as fibromyalgia, depression, etc.). However, DAM and STR may affect clinical management and outcomes of treatment in many RA patients. For example, an RA patient with well-controlled INF who has secondary fibromyalgia may have 0 swollen joints (SJC) and an ESR≥ of 15, but nonetheless have a DAS28 of 5.1, CDAI of ≥22, and RAPID3 of ≥16 (indicating high activity), based on 14/28 tender joints and a patient global assessment of 80/100. Therefore, quantitative estimates of DAM, and STR, as well as INF may clarify patient status and clinical management decisions.
Objectives To analyze physician quantitative estimates for the proportion of management decisions attributed to INF, DAM, or STR (total=100%) in RA patients seen in routine care.
Methods At one academic rheumatology center, the rheumatologist completes four 0–10 visual analog scales (VAS) for overall global assessment (DOCGL), INF, DAM, and STR. In patients with DOCGL ≥2, the proportion of management decisions are estimated as %INF+%DAM+%STR=100%. Cross-tabulations were computed for various phenotypes in 5 INF+DAM and INF+STR categories, 0, 1–20%, 21–40%, 42–60%, and 61–100%.
Results Among the 77 RA patients, >40% of clinical management decisions were attributed to INF in only 31 (40%), versus >40% to DAM in 33 (43%), and >40% to STR in 17 (22%) (Table). No category of INF+DAM or INF+STR included more than 20% of the patients, and patients were found in 17 of 25 possible categories for combinations of INF+DAM and INF+STR. The 13 patients (17%) in whom INF was estimated to contribute 0% to management included 3 of 5 DAM and 5 of 5 STR categories (Table). The 23 patients with 1–20% of management attributed to INF included 4/5 DAM and 5/5 STR categories. The 10 with 21–40% INF included 4/5 DAM and 4 STR categories. The 16 with 41–60% attributed to INF included 3 DAM and 2 STR categories. Only 15 of the 77 patients (19%) had >60% attributed to INF.
Conclusions Quantitative physician estimates of the proportion of clinical management decisions attributed INF, DAM, and STR may help clarify RA patient status and document a basis for clinical decisions. High levels of DAM and/or STR may explain in part why a target of RA remission often is not met in many patients seen in routine clinical care.1
Tymms et al, Arth Care & Res 66:190–196, 2014.
Disclosure of Interest K. Gibson: None declared, I. Castrejon: None declared, T. Pincus Shareholder of: Health Report Services, Inc