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Testing different thresholds for patient global assessment in defining remission for rheumatoid arthritis: are the current ACR/EULAR Boolean criteria optimal?
  1. Paul Studenic1,
  2. David Felson2,3,
  3. Maarten de Wit4,
  4. Farideh Alasti1,
  5. Tanja A Stamm5,
  6. Josef S Smolen1,
  7. Daniel Aletaha1
  1. 1 Department of Internal Medicine 3, Division of Rheumatology, Medical University of Vienna, Wien, Austria
  2. 2 Section of Rheumatology, Boston University School of Medicine, Boston, Massachusetts, USA
  3. 3 Centre for Epidemiology, The University of Manchester, Manchester, UK
  4. 4 Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), EULAR, Zurich, Switzerland
  5. 5 Center for Medical Statistics, Informatics, and Intelligent Systems, Section for Outcomes Research, Medical University of Vienna, Wien, Austria
  1. Correspondence to Professor Daniel Aletaha, Department of Internal Medicine 3, Division of Rheumatology, Medical University of Vienna, Wien 1090, Austria; daniel.aletaha{at}


Objectives This study aimed to evaluate different patient global assessment (PGA) cut-offs required in the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) Boolean remission definition for their utility in rheumatoid arthritis (RA).

Methods We used data from six randomised controlled trials in early and established RA. We increased the threshold for the 0–10 score for PGA gradually from 1 to 3 in steps of 0.5 (Boolean1.5 to Boolean3.0) and omitted PGA completely (BooleanX) at 6 and 12 months. Agreement with the index-based (Simplified Disease Activity Index (SDAI)) remission definition was analysed using kappa, recursive partitioning (classification and regression tree (CART)) and receiver operating characteristics. The impact of achieving each definition on functional and radiographic outcomes after 1 year was explored.

Results Data from 1680 patients with early RA and 920 patients with established RA were included. The proportion of patients achieving Boolean remission increased with higher thresholds for PGA from 12.4% to 19.7% in early and 5.9% to 12.3% in established RA at 6 months. Best agreement with SDAI remission occurred at PGA cut-offs of 1.5 and 2.0, while agreement decreased with higher PGA (CART: optimal agreement at PGA≤1.6 cm; sensitivity of PGA≤1.5 95%). Changing PGA thresholds at 6 months did not affect radiographic progression at 12 months (mean ꙙsmTSS for Boolean, 1.5, 2.0, 2.5, 3.0, BooleanX: 0.35±5.4, 0.38±5.14, 0.41±5.1, 0.37±4.9, 0.34±4.9, 0.27±4.7). However, the proportion attaining HAQ≤0.5 was 90.2%, 87.9%, 85.2%, 81.1%, 80.7% and 73.1% for the respective Boolean definitions.

Conclusion Increasing the PGA cut-off to 1.5 cm would provide high consistency between Boolean with the index-based remission; the integer cut-off of 2.0 cm performed similarly.

  • rheumatoid arthritis
  • outcomes research
  • patient perspective
  • disease activity

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  • Handling editor Gerd R Burmester

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  • Contributors Study design: PS, DF, JSS and DA. Analyses of data: PS, FA and TAS. Interpretation of data: PS, DF, MdW, FA, TA, JSS and DA. Writing and editing of the manuscript: PS, DF, MdW, TAS, JSS and DA.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval No additional review board approval was obtained due to secondary data analysis of pooled clinical trial data.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data may be obtained from a third party and are not publicly available. Data have been provided by the respective sponsors of the trials. Any requests for individual patient level data will have to be addressed to these sponsors directly.