The ACR recently published two manuscripts related to the clinical management of rheumatoid arthritis (RA).1,2 One paper provides the ACR’s first recommendations for patient-reported functional status assessment measures for routine clinical use with patients with RA.1 The other updates the ACR’s 2012 recommendations on RA disease activity measures.2,3
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A workgroup of rheumatologists and rheumatology professionals was selected to evaluate the best available evidence for each set of measures. Each group conducted a systematic literature review to identify relevant measures and evaluated them on the basis of study quality, level of evidence and implementation feasibility. From this analysis, the groups developed a list of recommendations for measures preferred for regular use in the clinical management of most patients with RA. They also identified additional measures that met a minimum standard for regular use in most clinic settings.
The senior author of both papers, Kaleb Michaud, PhD, associate professor in the Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Neb., says the recommendations were generated to help rheumatologists choose from among the many measures currently available for assessing disease activity and functional status. He cites the more than 60 measures found in the 2012 recommendations for measuring RA disease activity and underscores that some measures are better than others.
“Our task was not to say which is the best, but to say which is the best for everyday use in the clinic,” says Dr. Michaud. “We really needed a process to help recommend the measures for everyday use, especially when doctors want to track the health of their patients over time and get reimbursed.”
Most rheumatology practices already measure RA disease activity and functional status in their patients, Dr. Michaud notes. The feasibility of implementing the preferred measures varies among rheumatology practices given time constraints, experience and comfort level. By including measures that meet a minimum standard for everyday use, the recommendations aim to provide flexibility and additional choices for rheumatologists in a variety of practices, he says. A major goal of the new recommendations is to provide guidance for rheumatologists who aren’t measuring RA disease activity and functional status on a regular basis.
RA Disease Activity Measures: Updated Recommendations
The updated recommendations for RA disease activity measures were based on a systematic review of literature published since the 2012 recommendations.3 The working group found 110 articles that met study criteria, from which they identified 46 RA disease activity measures.1
The workgroup scored each disease activity measure based on the level of evidence for each measure, study quality, prior literature for each measure and feasibility. Following a modified Delphi process, the workgroup identified four preferred measures (Table 1) and an additional seven measures that fulfilled the minimum standard for regular use (Table 2). In addition to these recommendations, the ACR Quality Measures Subcommittee added Patient Activity Scale II (PAS-II) as a preferred measure. This decision was based on the PAS-II feasibility, current use, strength of its inclusion in prior ACR recommendations that included evidence not captured in the current analysis, and alignment with the functional status assessment project.
Of note, Patient Activity Scale (PAS), which was included in the 2012 recommendations, is no longer a recommended disease activity measure for RA. All recommended RA disease activity measures can be calculated through the ACR website.
|Table 1: Preferred RA Disease Activity Measures|
|Clinical Disease Activity Index (CDAI)|
|Simplified Disease Activity Index (SDAI)|
|Disease Activity Score in 28 Joints with Erythrocyte Sedimentation Rate or C-Reactive Protein Level (DAS28-ESR/CRP)|
|Patient Activity Scale II (PAS-II)|
|Routine Assessment of Patient Index Data 3 (RAPID3)|
The lead author of the updated disease activity measure recommendations, Bryant England, MD, assistant professor in the Division of Rheumatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Neb., emphasizes the need to incorporate the updated preferred measures into regular clinical care to facilitate assessment of disease activity as part of the treat-to-target strategy for RA, as highlighted in the 2015 ACR RA clinical practice guideline.4
However, for clinicians who may have experience with other measures or a practice environment better suited for other measures, he points to the list of measures meeting the minimum standard for regular use (Table 2).
|Table 2: Additional RA Disease Activity Measures Meeting Minimum Standard for Regular Use|
|Disease Activity Score (DAS)|
|Patient Derived DAS28|
|Hospital Universitario La Princesa Index (HUPI)|
|Multi-Biomarker Disease Activity Score (MBDA score)|
|Rheumatoid Arthritis Disease Activity Index (RADAI)|
|Rheumatoid Arthritis Disease Activity Index 5 (RADAI-5)|
|Assessment of Patient Index 5 (RAPID5)|
“We recognize that providers may already have many years of experience using a particular RA disease activity measure, and that practices differ in their ability to implement different disease activity measures,” Dr. England says. “Therefore, rather than forcing providers to switch to a specific disease activity measure, we wanted to provide them with the evidence for these measures and a recommendation on which measures are best for regular use.”
Overall, he emphasizes, the updated recommendations are designed to help clinicians make informed decisions when selecting RA disease activity measures to use in their everyday clinical practice.
The recommended measures were evaluated based on regular use in most clinic settings. Patient populations with alternate indications, such as those with comorbid conditions such as fibromyalgia or obesity, are not covered by the current recommendations.
RA Patient-Reported Functional Status Assessment Measures: New Recommendations
The recommendations for measuring RA patient-reported functional status are the first developed by the ACR.2 A systematic review of relevant literature published through Mar. 16, 2017, identified 56 articles meeting study criteria. The working group used the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) four-point scoring method to assess each functional status assessment measure used in the articles.
Similar to the approach used to evaluate RA disease activity measures, the working group used a modified Delphi process to select a set of preferred measures and a set of measures that fulfilled the minimum standard for regular use. Overall, seven functional status assessment measures were identified that met the minimum standard for regular use; of these, three measures were preferred (Tables 3 & 4).
Of note, the Health Assessment Questionnaire (HAQ)—a measure once considered the gold standard for measuring functional status in RA—is not recommended as a preferred measure for everyday use. According to Dr. Michaud, this is primarily due to the length of the test, which at more than 40 items was not considered feasible for everyday use. The three measures selected as preferred recommendations have fewer questions.
|Table 3: Preferred RA Functional Status Assessment Measures|
|Patient-Reported Outcomes Measurement Information System physical function 10-item short form (PROMIS PF10a)|
|Health Assessment Questionnaire II (HAQ-II)|
|Multi-Dimensional Health Assessment Questionnaire (MDHAQ)|
According to lead author of the functional status assessment recommendations, Claire E.H. Barber, MD, assistant professor in the Division of Rheumatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada, four other measures did not receive a consensus for recommendation as preferred measures, but fulfilled the criteria for minimum standard for regular use in most clinical settings (Table 4).
|Table 4: Additional RA Functional Status Assessment Measures Meeting Minimum Standard for Regular Use|
|Health Assessment Questionnaire Disability Index (HAQ DI)|
|Modified HAQ (MHAQ)|
|PROMIS Physical Function 20-item form (PF20a)|
|PROMIS Physical Function Computer Adaptive Test (PF CAT)|
“These recommendations should not preclude the use of the measures that only met the minimum standard, but rather encourage the use of measures with the most evidence of favorable psychometric properties and highest feasibility for day-to-day clinical use,” Dr. Barber says. She adds that the ACR plans to monitor non-preferred measures for possible inclusion in ACR-preferred lists in the future .
Dr. Michaud encourages researchers to continue working on additional disease activity and functional status assessment measures in RA. No single assessment has yet been able to meet all RA management needs, he says, highlighting the ongoing need to continue developing better measurements over time.
Mary Beth Nierengarten is a freelance medical journalist based in Minneapolis.
- England BR, Tiong BK, Bergman MJ, et al. 2019 Update of the American College of Rheumatology recommended rheumatoid arthritis disease activity measures. Arthritis Care Res. 2019 Dec;71(12):1540–1555.
- Barber CEH, Zell J, Yazdany J, et al. 2019 American College of Rheumatology Recommended Patient-Reported Functional Status Assessment Measures in Rheumatoid Arthritis. Arthritis Care Res. 2019 Dec;71(12):1531–1539.
- Anderson J, Caplan L, Yazdany J, et al. Rheumatoid arthritis disease activity measures: American College of Rheumatology recommendations for use in clinical practice. Arthritis Care Res. 2012 May;64(5):640–647.
- Singh JA, Saag KG, Bridges SL Jr., et al. 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Rheumatol. 2016;68:1–26.