Skip to main content

Advertisement

SpringerLink
Log in

Belgian rheumatologists’ preferences regarding measures of disease activity in patients with rheumatoid arthritis: results from a mixed-methods study

  • Observational Research
  • Published:
Rheumatology International Aims and scope Submit manuscript

Abstract

The reliability and clinical usefulness of the different composite disease activity scores and their individual components in Rheumatoid Arthritis (RA) are still debated. This study investigated which measures of disease activity were preferred by rheumatologists. A mixed-method study was performed. First, ten Belgian rheumatologists were invited for individual interviews on their current practice and preferences for measurement of RA disease activity. Results of this qualitative study and evidence from literature served as input for developing a survey. This survey asked rheumatologists to rate preferred standard disease activity score(s), their individual components, ultrasound and related patient-reported outcomes (PROs), by maximum difference scaling. The relative importance score (RIS) for each indicator was calculated using hierarchical Bayes modeling. The qualitative study included 6/10 invited rheumatologists. Composite scores and components were perceived as useful, while PROs were found subjective. Interestingly, ultrasound was used to mediate discrepancies between physician and patient. The survey based on this was sent to 244 Belgian rheumatologists, 83/244 (34%) responded, including 66/83 (80%) complete and 17/83 (20%) incomplete surveys (two missing essential information). Most rheumatologists (75/81, 93%) used a disease activity score and 68/81 (84%) preferred the DAS28-CRP. Swollen joint count obtained the highest mean ± SD RIS (22.54 ± 2.64), followed by DAS28 ESR/CRP (20.61 ± 4.06), ultrasound (16.47 ± 7.97), CRP (13.34 ± 6.11) and physician’s global assessment (12.59 ± 7.83). PROs including fatigue, pain, and patient’s global assessment, and Health Assessment Questionnaire, obtained the lowest mean RIS (0.34–2.54). Rheumatologists place more faith in self-assessed disease activity components or in laboratory tests. Trust in PROs to evaluate disease activity is low in clinical practice.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Availability of data and material

The data source is available upon reasonable request by authors.

Code availability

The survey was constructed and partly analyzed using the Sawtooth Software’s SSI Web platform (version 9.8.1), for which an academic grant was acquired. Additional analyses were performed in Microsoft Excel, Statdisk and VassarStats.

References

  1. Smolen JS, Landewe RBM, Bijlsma JWJ, Burmester GR, Dougados M, Kerschbaumer A et al (2020) EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs:2019 update. Ann Rheum Dis. https://doi.org/10.1136/annrheumdis-2019-216655

    Article  PubMed  Google Scholar 

  2. England BR, Tiong BK, Bergman MJ, Curtis JR, Kazi S, Mikuls TR et al (2019) Update of the american college of rheumatology recommended rheumatoid arthritis disease activity measures. Arthritis Care Res (Hoboken) 71(12):1540–1555. https://doi.org/10.1002/acr.24042

    Article  Google Scholar 

  3. van der Heijde DM, van’t Hof M, van Riel PL, van de Putte LB (1993) Development of a disease activity score based on judgment in clinical practice by rheumatologists. J Rheumatol 20(3):579–581

    PubMed  Google Scholar 

  4. Fransen J, Moens HB, Speyer I, van Riel PL (2005) Effectiveness of systematic monitoring of rheumatoid arthritis disease activity in daily practice: a multicentre, cluster randomised controlled trial. Ann Rheum Dis 64(9):1294–1298. https://doi.org/10.1136/ard.2004.030924

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Landewe RBM (2018) Overdiagnosis and overtreatment in rheumatology: a little caution is in order. Ann Rheum Dis 77(10):1394–1396. https://doi.org/10.1136/annrheumdis-2018-213700

    Article  PubMed  Google Scholar 

  6. Boers M (2020) Patient global assessment to define remission in rheumatoid arthritis: quo vadis? Ann Rheum Dis. https://doi.org/10.1136/annrheumdis-2020-218802

    Article  PubMed  Google Scholar 

  7. Aletaha D, Wang X, Zhong S, Florentinus S, Monastiriakos K, Smolen JS (2020) Differences in disease activity measures in patients with rheumatoid arthritis who achieved DAS, SDAI, or CDAI remission but not Boolean remission. Semin Arthritis Rheum 50(4):643–644. https://doi.org/10.1016/j.semarthrit.2020.03.022

    Article  PubMed  Google Scholar 

  8. Bray C, Bell LN, Liang H, Haykal R, Kaiksow F, Mazza JJ et al (2016) Erythrocyte sedimentation rate and C-reactive protein measurements and their relevance in clinical medicine. WMJ 115(6):317–321

    PubMed  Google Scholar 

  9. Keenan RT, Swearingen CJ, Yazici Y (2008) Erythrocyte sedimentation rate and C-reactive protein levels are poorly correlated with clinical measures of disease activity in rheumatoid arthritis, systemic lupus erythematosus and osteoarthritis patients. Clin Exp Rheumatol 26(5):814–819

    CAS  PubMed  Google Scholar 

  10. Kneepkens EL, van den Oever I, Plasencia CH, Pascual-Salcedo D, de Vries A, Hart M et al (2017) Serum tocilizumab trough concentration can be used to monitor systemic IL-6 receptor blockade in patients with rheumatoid arthritis: a prospective observational cohort study. Scand J Rheumatol 46(2):87–94. https://doi.org/10.1080/03009742.2016.1183039

    Article  CAS  PubMed  Google Scholar 

  11. Cheung PP, Gossec L, Mak A, March L (2014) Reliability of joint count assessment in rheumatoid arthritis: a systematic literature review. Semin Arthritis Rheum 43(6):721–729. https://doi.org/10.1016/j.semarthrit.2013.11.003

    Article  PubMed  Google Scholar 

  12. French T, Hewlett S, Kirwan J, Sanderson T (2013) Different wording of the patient global visual analogue scale (PG-VAS) affects rheumatoid arthritis patients’ scoring and the overall disease activity score (DAS28): a cross-sectional study. Musculoskeletal Care 11(4):229–237. https://doi.org/10.1002/msc.1046

    Article  PubMed  Google Scholar 

  13. Ferreira RJO, Eugenio G, Ndosi M, Silva C, Medeiros C, Duarte C et al (2018) Influence of the different “patient global assessment” formulations on disease activity score by different indices in rheumatoid arthritis. Clin Rheumatol 37(7):1963–1969. https://doi.org/10.1007/s10067-018-4063-9

    Article  PubMed  Google Scholar 

  14. Hirsh J, Wood P, Keniston A, Peng M, Ramaswami S, Caplan L et al (2019) Limited health literacy and patient confusion about rheumatoid arthritis patient global assessments and model disease states. Arthritis Care Res (Hoboken) 71(5):611–619. https://doi.org/10.1002/acr.23692

    Article  Google Scholar 

  15. De Cock D, Hirsh J (2020) The rheumatoid arthritis patient global assessment: improve it or lose it! Rheumatology (Oxford) 59(5):923–924. https://doi.org/10.1093/rheumatology/kez566

    Article  Google Scholar 

  16. Ferreira RJO, de Wit M, Henriques M, Pinto AF, Duarte C, Mateus E et al (2020) ‘It can’t be zero!’ difficulties in completing patient global assessment in rheumatoid arthritis: a mixed methods study. Rheumatology (Oxford) 59(5):1137–1147. https://doi.org/10.1093/rheumatology/kez467

    Article  Google Scholar 

  17. Hensor EM, Emery P, Bingham SJ, Conaghan PG, Consortium Y (2010) Discrepancies in categorizing rheumatoid arthritis patients by DAS-28(ESR) and DAS-28(CRP): can they be reduced? Rheumatology (Oxford) 49(8):1521–1529. https://doi.org/10.1093/rheumatology/keq117

    Article  Google Scholar 

  18. Matsui T, Kuga Y, Kaneko A, Nishino J, Eto Y, Chiba N et al (2007) Disease Activity Score 28 (DAS28) using C-reactive protein underestimates disease activity and overestimates EULAR response criteria compared with DAS28 using erythrocyte sedimentation rate in a large observational cohort of rheumatoid arthritis patients in Japan. Ann Rheum Dis 66(9):1221–1226. https://doi.org/10.1136/ard.2006.063834

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Ferreira RJO, Welsing PMJ, Jacobs JWG, Gossec L, Ndosi M, Machado PM et al (2020) Revisiting the use of remission criteria for rheumatoid arthritis by excluding patient global assessment: an individual meta-analysis of 5792 patients. Ann Rheum Dis. https://doi.org/10.1136/annrheumdis-2020-217171

    Article  PubMed  Google Scholar 

  20. Ferreira RJO, Santos E, Gossec L, da Silva JAP (2020) The patient global assessment in RA precludes the majority of patients otherwise in remission to reach this status in clinical practice. Should we continue to ignore this? Semin Arthritis Rheum 50(4):583–585. https://doi.org/10.1016/j.semarthrit.2020.03.014

    Article  PubMed  Google Scholar 

  21. Dierckx de Casterle B, Gastmans C, Bryon E, Denier Y (2020) QUAGOL: a guide for qualitative data analysis. Int J Nurs Stud 49(3):360–371. https://doi.org/10.1016/j.ijnurstu.2011.09.012

    Article  Google Scholar 

  22. Spijk-de Jonge MJ, Weijers JM, Boerboom LWM, Huis AMP, Atsma F, Van Hulst LTC et al (2020) Disease activity-based management of rheumatoid arthritis in Dutch daily clinical practice has improved over the past decade. Clin Rheumatol 39(4):1131–1139. https://doi.org/10.1007/s10067-019-04913-7

    Article  PubMed  Google Scholar 

  23. Taylor A, Bagga H (2011) Measures of rheumatoid arthritis disease activity in Australian clinical practice. ISRN Rheumatol 2011:437281. https://doi.org/10.5402/2011/437281

    Article  PubMed  PubMed Central  Google Scholar 

  24. Curtis JR, Chen L, Danila MI, Saag KG, Parham KL, Cush JJ (2018) Routine use of quantitative disease activity measurements among US rheumatologists: implications for treat-to-target management strategies in rheumatoid arthritis. J Rheumatol 45(1):40–44. https://doi.org/10.3899/jrheum.170548

    Article  PubMed  Google Scholar 

  25. Yu Z, Lu B, Agosti J, Bitton A, Corrigan C, Fraenkel L et al (2018) Implementation of treat-to-target for rheumatoid arthritis in the US: analysis of baseline data from a randomized controlled trial. Arthritis Care Res (Hoboken) 70(5):801–806. https://doi.org/10.1002/acr.23343

    Article  Google Scholar 

  26. Gazitt T, Oren S, Reitblat T, Lidar M, Gurman AB, Rosner I et al (2019) Treat-to-target concept implementation for evaluating rheumatoid arthritis patients in daily practice. Eur J Rheumatol 6(3):136–141. https://doi.org/10.5152/eurjrheum.2019.18195

    Article  PubMed  PubMed Central  Google Scholar 

  27. van Hulst LT, Kievit W, van Bommel R, van Riel PL, Fraenkel L (2011) Rheumatoid arthritis patients and rheumatologists approach the decision to escalate care differently: results of a maximum difference scaling experiment. Arthritis Care Res (Hoboken) 63(10):1407–1414. https://doi.org/10.1002/acr.20551

    Article  Google Scholar 

  28. Studenic P, Radner H, Smolen JS, Aletaha D (2012) Discrepancies between patients and physicians in their perceptions of rheumatoid arthritis disease activity. Arthritis Rheum 64(9):2814–2823. https://doi.org/10.1002/art.34543

    Article  PubMed  Google Scholar 

  29. Schoemaker CG, de Wit MPT (2020) Treat-to-target from the patient perspective is bowling for a perfect strike. Arthritis Rheumatol. https://doi.org/10.1002/art.41461

    Article  PubMed  PubMed Central  Google Scholar 

  30. Ferreira RJO, Ndosi M, de Wit M, Santos EJF, Duarte C, Jacobs JWG et al (2019) Dual target strategy: a proposal to mitigate the risk of overtreatment and enhance patient satisfaction in rheumatoid arthritis. Ann Rheum Dis 78(10):e109. https://doi.org/10.1136/annrheumdis-2018-214199

    Article  PubMed  Google Scholar 

  31. Haavardsholm EA, Aga AB, Olsen IC, Lillegraven S, Hammer HB, Uhlig T et al (2016) Ultrasound in management of rheumatoid arthritis: ARCTIC randomised controlled strategy trial. BMJ 354:i4205. https://doi.org/10.1136/bmj.i4205

    Article  PubMed  PubMed Central  Google Scholar 

  32. Meyfroidt S, van Hulst L, De Cock D, Van der Elst K, Joly J, Westhovens R et al (2014) Factors influencing the prescription of intensive combination treatment strategies for early rheumatoid arthritis. Scand J Rheumatol 43(4):265–272. https://doi.org/10.3109/03009742.2013.863382

    Article  CAS  PubMed  Google Scholar 

  33. Gaur PS, Zimba O, Agarwal V, Gupta L (2020) Reporting survey based studies—a primer for authors. J Korean Med Sci 35(45):e398. https://doi.org/10.3346/jkms.2020.35.e398

    Article  PubMed  PubMed Central  Google Scholar 

  34. Pazmino S, Lovik A, Boonen A, De Cock D, Stouten V, Joly J et al (2021) Does including pain, fatigue, and physical function when assessing patients with early rheumatoid arthritis provide a comprehensive picture of disease burden? J Rheumatol 48(2):174–178. https://doi.org/10.3899/jrheum.200758

    Article  PubMed  Google Scholar 

  35. Lemmey AB, Wilkinson TJ, Clayton RJ, Sheikh F, Whale J, Jones HS et al (2016) Tight control of disease activity fails to improve body composition or physical function in rheumatoid arthritis patients. Rheumatology (Oxford) 55(10):1736–1745. https://doi.org/10.1093/rheumatology/kew243

    Article  Google Scholar 

Download references

Acknowledgements

We would like to thank Sawtooth Software, Inc for providing us a student licence to use their software. We would like to thank Catherine Bailleux for her support in contacting the rheumatologists.

Funding

No specific funding for this study was obtained.

Author information

Author notes

  1. D. De Cock and E. Buckinx share a first co-authorship.

Authors and Affiliations

  1. Skeletal Biology and Engineering Research Centre, KU Leuven, ON IV Herestraat 49, P. O. Box 813, 3000, Leuven, Belgium

    D. De Cock, E. Buckinx, S. Pazmino, D. Bertrand, V. Stouten, R. Westhovens & P. Verschueren

  2. Department of Rheumatology, University Hospitals of Leuven, 3000, Leuven, Belgium

    R. Westhovens & P. Verschueren

Authors
  1. D. De Cock
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. E. Buckinx
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. S. Pazmino
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. D. Bertrand
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. V. Stouten
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. R. Westhovens
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. P. Verschueren
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

DDC, EB, RW and PV designed the study. DDC and EB drafted the manuscript. All authors supported the analysis of the results, revised the paper critically for important intellectual content; approved the final version of the draft and agreed to be accountable for all aspects of the work.

Corresponding author

Correspondence to D. De Cock.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethics approval

The Ethical Committee of the KU Leuven approved this study (MP011755) on 23/12/2019. Participants had to indicate to have read and accept an information letter before starting this anonymous survey.

Informed consent

Authors reporting on experimental work on humans should, where relevant, submit evidence that the work has been approved by an institutional clinical research panel or its equivalent.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

De Cock, D., Buckinx, E., Pazmino, S. et al. Belgian rheumatologists’ preferences regarding measures of disease activity in patients with rheumatoid arthritis: results from a mixed-methods study. Rheumatol Int 42, 815–823 (2022). https://doi.org/10.1007/s00296-021-05020-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00296-021-05020-0

Keywords

Search

Navigation