Feasibility and validity of the RADAI, a self-administered rheumatoid arthritis disease activity index

OBJECTIVE: The goal of the Rheumatoid Arthritis Disease Activity Index (RADAI) is to provide an easy to use assessment of disease activity. It is a self-administered questionnaire that combines five items into a single index: current and past global disease activity, pain, morning stiffness and a joint count. METHODS: A sample of 484 rheumatoid arthritis (RA) patients was used to assess the internal consistency and the convergent validity of the RADAI. This was achieved by calculating Cronbach's alpha and RADAI item and total score correlations with core set measures and DAS28. RESULTS: Cronbach's alpha was 0.87, supporting the summation of the items into a single index. The index correlated best with physicians' global assessment (r = 0.59; P < 0.0001), the Health Assessment Questionnaire (r = 0.55; P < 0.0001) and the number of tender joints (r = 0.55; P < 0.0001). Correlation with the erythrocyte sedimentation rate was low (r = 0.27; P < 0.0001). The RADAI and the DAS28 were correlated (r = 0.53; P < 0.0001), but there was low agreement. CONCLUSIONS: The RADAI is valid to assess disease activity in RA patients. However, the RADAI may not automatically replace other measures of disease activity, such as the DAS28.     

A prospective study of pregnant patients with rheumatoid arthritis and ankylosing spondylitis using validated clinical instruments

OBJECTIVE: : To analyse the disease course of patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS) during and after pregnancy by validated clinical instruments for measurement of disease activity, and assess their usefulness in pregnant patients. METHODS: Included were 10 patients with RA and 9 with AS (10 pregnancies). Clinical examination and blood/urine sampling was performed before conception, at each trimester, and weeks 6, 12, and 24 post partum. Assessment of RA was by the RA Disease Activity Index (RADAI), the 44 joint count, and the Health Assessment Questionnaire; assessment of AS by the Bath Ankylosing Spondylitis Activity Index (BASDAI), the Dougados Functional and Articular Index, and a night pain index. Common for all patients were the patient's and physician's global assessment. RESULTS: : Most patients with RA showed sustained or increased improvement of disease activity during pregnancy. Higher disease activity scores were found in the patients with AS with a frequent increase of disease activity in the second trimester and mitigation of symptoms in the third trimester. Analysis specifically for the patient's assessment of pain showed continuously higher pain scores in the patients with AS than in those with RA. Rank correlation showed good to moderate correlation between most clinical measurements and RADAI or BASDAI, respectively. Functional indices were confounded by physiological changes of late pregnancy. CONCLUSION: RA can be monitored during and after pregnancy by the swollen joint count and RADAI without interference from pregnancy related symptoms, whereas usual measures of disease activity are not always applicable in pregnant patients with AS.     

Responsiveness of the self-assessed rheumatoid arthritis disease activity index to a flare of disease activity

OBJECTIVE: To assess the responsiveness of the Rheumatoid Arthritis Disease Activity Index (RADAI) to increases in disease activity, using the occurrence of a flare of disease activity as an external standard. METHODS: A post hoc analysis was performed on data from a randomized, double-blind, controlled trial of methotrexate versus type II collagen in 92 patients with rheumatoid arthritis (RA). Responsiveness was analyzed by 1) correlating change in the RADAI score with change in the Disease Activity Score (DAS28), 2) determining the RADAI's ability to detect a disease flare by plotting a receiver operating characteristic (ROC) curve, and 3) using a responsiveness statistic, the standardized effect size (SES). The contribution of the single RADAI items to the change in total RADAI score was analyzed by the item score change in absolute value, the item responsiveness by the standardized response mean, and the correlation of item score change with total RADAI score change by Cronbach's alpha. RESULTS: Changes in the RADAI score correlated strongly with changes in the DAS28 (R2 = 0.70, P < 0.0001). The area under the ROC curve for the RADAI was 0.88 (95% confidence interval 0.78-0.95), which was similar to that for the DAS28. The SES for the RADAI was 1.56, which was also similar to that for the DAS28. The RADAI items of past global disease activity and morning stiffness contributed least to the total score change. CONCLUSION: This study provides evidence that the RADAI is sensitive to relevant increases in disease activity in RA patients. The RADAI may complement clinical measures in clinical studies, or may be used as a proxy for disease activity in epidemiologic studies.     

Clinical quality management in rheumatoid arthritis: putting theory into practice. Swiss Clinical Quality Management in Rheumatoid Arthritis

Clinical quality management (CQM) in rheumatoid arthritis (RA) aims to reduce inflammatory activity and pain in the short term, and damage, and consequently disability, in the long term. Within CQM as used in Switzerland rheumatologists are provided with a measurement feedback system with which they can regularly follow their patients. Inflammatory activity is measured with the Disease Activity Score (DAS28) and the Rheumatoid Arthritis Disease Activity Index questionnaire (RADAI), damage with an X-ray score and disability with the Stanford Health Assessment Questionnaire (HAQ). Feedback is used to optimize therapy, which in the short term allows the activity of the inflammatory process to be adjusted or 'titrated'. In the long term, the therapy result for the individual patient is monitored by the course of disability and damage. In this paper we present a series of cases to illustrate the usefulness of the CQM system in the management of individual RA patients. CQM in RA may be helpful when making decisions about adjustment of treatment, and to document and communicate these decisions based on quantitative data.     

Cross-cultural adaptation and validation of the Thai version of the Rheumatoid Arthritis Disease Activity Index (RADAI)

The objective of this study was to translate and evaluate the psychometric properties of the Thai version of the Rheumatoid Arthritis Disease Activity Index (RADAI) in patients with rheumatoid arthritis (RA). We translated and modified the original RADAI into the Thai version. A total of 116 Thai patients with RA were consecutively recruited. For test–retest reliability, 115 patients undertook RADAI questionnaires for 2 consecutive days. To test construct validity, the correlation of the single RADAI items and RADAI total scores with measures of disease activity and functional status was evaluated. Reliability was assessed using Cronbach’s alpha and intra-class correlation (ICC). The number of missing items and time-to-complete questionnaire were collected to estimate its feasibility. The RADAI significantly correlated with disease activity measured by the Clinical Disease Activity Index (CDAI) (r = 0.71), the Disease Activity Score 28 (DAS28) (r = 0.56), patient global assessment of disease activity (r = 0.71), and physician global assessment of disease activity (r = 0.66) and functional status measured by the Health Assessment Questionnaire (r = 0.52). The RADAI had a moderate internal consistency (Cronbach’s alpha = 0.69) and high test–retest reliability (ICC = 0.83). Ninety-one percentage completed questionnaires without missing an item. Mean time-to-complete questionnaire (±SD) was 4.82 (±1.86) min. The Thai RADAI questionnaire is valid, reliable, and easy to use for assessing disease activity in daily practice and epidemiologic research. Its psychometric properties were comparable to the original version.     

The ICIDH-2 as a framework for the assessment of functioning and disability in rheumatoid arthritis

OBJECTIVE: To investigate by a cross sectional study in patients with rheumatoid arthritis (RA) the relationship between measures of impairment, activity limitation, and participation of the model of functioning and disability (ICIDH-2). METHODS: Inclusion data of patients with RA (n=803) from the Swiss Clinical Quality Management Group were used. Impairments were measured by the Short Form-36 (SF-36) bodily pain scale, rheumatoid arthritis disease activity index (RADAI), disease activity score (DAS28), and radiographic scoring (x ray). Activity limitation was measured with the Health Assessment Questionnaire (HAQ) and the SF-36 physical functioning scale. Participation was measured with the SF-36 role and social functioning scales. Spearman (partial) correlations were used for analysis. RESULTS: Impairment and activity limitation dimensions of the ICIDH-2 model are related; correlations with the HAQ were: SF-36 bodily pain (r(s)=-0.61), RADAI (r(s)=0.58), DAS28 (r(s)=0.49), and x ray (r(s)=0.35). Similar correlations were found for SF-36 physical functioning. Activity limitation and participation restriction dimensions are also related: the HAQ correlates well with SF-36 role-physical (r(s)=-0.53) and SF-36 social functioning (r(s)=-0.43); SF-36 physical functioning correlates similarly. For impairment and participation restriction dimensions only SF-36 bodily pain is substantially correlated (r(s)=0.47 and 0.48) with SF-36 role-physical, after correcting for the influence of the activity limitation dimension (HAQ and SF-36 physical functioning). CONCLUSIONS: In this cross sectional study of patients with RA, impairments are associated with activity limitations, and activity limitations are associated with participation restrictions. Pain is the only impairment directly associated with participation restrictions. Based on the results of this study, it is strongly recommended that the ICIDH-2 framework is used in clinical trials and observational studies including the assessment of disease consequences in RA.     

Responsiveness of the self‐assessed rheumatoid arthritis disease activity index to a flare of disease activity

Objective

To assess the responsiveness of the Rheumatoid Arthritis Disease Activity Index (RADAI) to increases in disease activity, using the occurrence of a flare of disease activity as an external standard.

Methods

A post hoc analysis was performed on data from a randomized, double‐blind, controlled trial of methotrexate versus type II collagen in 92 patients with rheumatoid arthritis (RA). Responsiveness was analyzed by 1) correlating change in the RADAI score with change in the Disease Activity Score (DAS28), 2) determining the RADAI's ability to detect a disease flare by plotting a receiver operating characteristic (ROC) curve, and 3) using a responsiveness statistic, the standardized effect size (SES). The contribution of the single RADAI items to the change in total RADAI score was analyzed by the item score change in absolute value, the item responsiveness by the standardized response mean, and the correlation of item score change with total RADAI score change by Cronbach's alpha.

Results

Changes in the RADAI score correlated strongly with changes in the DAS28 (R² = 0.70, P < 0.0001). The area under the ROC curve for the RADAI was 0.88 (95% confidence interval 0.78–0.95), which was similar to that for the DAS28. The SES for the RADAI was 1.56, which was also similar to that for the DAS28. The RADAI items of past global disease activity and morning stiffness contributed least to the total score change.

Conclusion

This study provides evidence that the RADAI is sensitive to relevant increases in disease activity in RA patients. The RADAI may complement clinical measures in clinical studies, or may be used as a proxy for disease activity in epidemiologic studies.

     

Addressing rural and remote access disparities for patients with inflammatory arthritis through video‐conferencing and innovative inter‐professional care models

Objective

The aim of the present study was to evaluate whether rheumatoid arthritis (RA) patients followed longitudinally using video‐conferencing and inter‐professional care support have comparable disease control to those followed in traditional in‐person rheumatology clinics.

Methods

This was a randomized controlled trial for 85 RA patients allocated to either traditional in‐person rheumatology follow‐up or video‐conferenced follow‐up with urban‐based rheumatologists and rural in‐person physical therapist examiners. Follow‐up was every 3 months for 9 months. Outcome measures included disease activity metrics (disease activity in 28 joints with CRP measure score [DAS28‐CRP], and RA disease activity index [RADAI]), modified health assessment questionnaire (mHAQ), quality of life (EuroQOL five dimensions questionnaire [EQ5D]) and patient satisfaction (nine‐item visit‐specific satisfaction questionnaire [VSQ9]).

Results

Of 85 participants, 54 were randomized to the video‐conferencing team model and 31 to the traditional clinic (control group). Dropout rates were high, with only 31 (57%) from the video‐conferencing and 23 (74%) from the control group completing the study. The mean age for study participants was 56 years; 20% were male. Mean RA disease duration was 13.9 years. There were no significant between‐group differences in DAS28‐CRP, RADAI, mHAQ or EQ5D scores at baseline or over the study period. Satisfaction rates were high in both groups.

Conclusions

We found no evidence of a difference in effectiveness between inter‐professional video‐conferencing and traditional rheumatology clinic for both the provision of effective follow‐up care and patient satisfaction for established RA patients. High dropout rates reinforce the need for consultation with patients' needs and preferences in developing models of care. While use of video‐conferencing/telehealth technologies may be a distinct advantage for some patients, there may be loss of travel‐related auxiliary benefits for others.     

Bronchiectasis and rheumatoid arthritis: a clinical study.

OBJECTIVES--To examine the relation between rheumatoid arthritis (RA) and bronchiectasis (BR). METHODS--Disease activity, outcome, extra-articular manifestations, and laboratory features were compared in 32 patients with BR and RA (RA-BR group), 32 matched patients with RA without BR (RA group), and 31 patients with BR but without arthritis (BR group). RESULTS--In 30 of the 32 (94%) patients with RA-BR, BR preceded RA. There was no functional or radiological difference between the RA-BR and RA groups, and except for xerophthalmia, which was more common in patients with RA-BR than patients with RA, there was no difference in extra-articular or laboratory features. CONCLUSIONS--Bronchiectasis does not lead to a more aggressive disease course in RA and, despite the recognised association, BR is not an extra-articular manifestation of rheumatoid disease.     

A prospective study for outcome and prediction of early arthritis: a tertiary care centre observation

IntroductionEarly undifferentiated arthritis has varied outcome: majority remits spontaneously and about 1/3^rdevolve into rheumatoid arthritis (RA).ObjectiveTo find out the clinical feature of early arthritis, its outcome, predictors of its evolution into rheumatoid arthritis and of its spontaneous remission and the outcome of treatment of early rheumatoid arthritis.MethodFifty-three patients (37 females) were recruited. Logistic-regression analysis was done to find out independent predictors of early arthritis evolving into RA or remitting spontaneously and the Receiving Operating Characteristic curve analysis was done to examine the validity of the Prediction rule.ResultAbout half of the patients had spontaneous remission and rest evolved into RA. The majority (31.4%) of patients with early arthritis presented with symmetric arthritis involving both upper and lower limbs. A low DAS28 (odds ratio 0.384, P=0.002) at presentation was the predictor of evolution into RA whereas anti-CCP antibody negativity (odds ratio 0.222, P= 0.044) was predictor of spontaneous resolution.ConclusionThe anti-CCP antibody predicted disease remission whereas low disease activity predicted disease persistence. Larger sample size with longer duration of follow-up is needed.     

Chronic comorbidity in patients with early rheumatoid arthritis: a descriptive study

OBJECTIVE: To study the presence of chronic coexisting diseases in patients with rheumatoid arthritis (RA) and its effect on RA treatment, disease course, and outcome during the first years of the disease. METHODS: From January 1985 to December 1990, 186 patients with recent onset RA were enrolled in a prospective longitudinal study. Between January 1991 and November 1992 patients were interviewed on the basis of a comorbidity questionnaire. For analysis the diseases were coded according to the International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) medical diagnoses. Disease activity during the period of followup was measured by the Disease Activity Score. Outcome in terms of physical disability (Health Assessment Questionnaire) and radiological damage (Sharp's modified version) over 3 and 6 year periods was determined. RESULTS: In the group of 186 patients, with mean disease duration of 4.3 years at January 1991, 50 patients (27%) reported at least one chronic coexisting disease. The most frequently reported coexisting diseases were of cardiovascular (29%), respiratory (18%), or dermatological (11%) origin. For the major part (66%) chronic coexisting diseases were already present before onset of RA. No statistically significant differences in use of disease modifying antirheumatic drugs or corticosteroids were observed between RA patients with and without chronic coexisting diseases. No statistically significant differences were found in disease activity or in outcome in terms of physical disability and radiological damage over 3 and 6 year periods between the 2 groups with RA. CONCLUSION: The results showed that about 27% of patients with RA in this inception cohort had at least one chronic coexisting disease. Treatment, disease course, and outcome did not differ between patients with and without chronic coexisting diseases during the first years of the disease.     

Use of Isokinetic Muscle Strength as a Measure of Severity of Rheumatoid Arthritis: A Comparison of this Assessment Method for RA with other Assessment Methods for the Disease

The aim of this study was to study the association between isokinetic muscle strength (IMS) and other clinical indicators of disability and disease activity in patients with rheumatoid arthritis (RA). A cohort of 36 RA patients was followed over a 1-year period with five measurements of disease activity at regular intervals during this time. IMS was measured at seven angular velocities in both knees, on five separate occasions. The measurement was expressed by the level of the fitted line of the seven peak torque values – IMS₃₀. The association between IMS₃₀ and clinical indicators was stated. As an indicator of disability the score from the Stanford Health Assessment Questionnaire (HAQ) was used. As indicators of disease activity morning stiffness, an index of swelling and pain in the joint, erythrocyte sedimentation rate (ESR) and haemoglobin (Hb) were chosen. Larsen’s X-ray score was used as an indicator of bone destruction due to longer-lasting disease activity. IMS was significantly associated with the HAQ score, but not with indicators of disease activity or radiological findings. IMS was significantly associated with changes in indicators of disease activity, but not with the changes in the HAQ score, or in the X-ray-score. IMS showed the strongest association with changes in the degree of arthritis of the knee. In conclusion, IMS was associated with the HAQ score and can therefore be used when measuring outcome in a specific group of RA patients. Changes in IMS were associated with indicators of changes in disease activity, and are therefore usable as a measure of patient outcome. Of particular importance is that IMS decreased if a patient developed active arthritis in the knee, and normalised again when the inflammation decreased. Received: 9 October 2000 / Accepted: 18 June 2001     

Spontaneous ambulatory activity as a quantifiable outcome measure for rheumatoid arthritis

OBJECTIVE: To validate the objective monitoring of ambulatory activity as an outcome measure for rheumatoid arthritis (RA). METHODS: We have compared ambulatory activity to a range of currently favoured outcome measures, ranging from subjective opinions to X-ray damage, in a population of 93 RA sufferers. RESULTS: Correlations were stronger with measures of joint damage and disability, and less strong with measures of disease activity. Sensitivity to change was good. Three different interventions were compared for the quantity of the response, and the results agree with clinical experience, with steroid injection of the knee and use of non-steroidal anti-inflammatory drugs (NSAIDs) having a similar response and the provision of surgical shoes producing a more modest increase in ambulation. CONCLUSION: The measurement of ambulatory activity has validity for RA assessment. It provides different but related data to the currently used measures. It is objective, relevant, quantifiable and of unlimited scale. It could be used to quantify interventions aimed at increasing ambulation, in carefully constructed studies.     

Ist das Therapieansprechen bei ?lteren Patienten mit rheumatoider Arthritis reduziert?

Background

With increasing age DMARD and TNF-α-Inhibitors are less frequently used. The goal of this work was to investigate whether the therapeutic response in elderly patients with rheumatoid arthritis (RA) is diminished.

Methods

In total, 192 patients admitted to hospital because of active RA were prospectively studied. The improvements in disease activity (RADAI), pain and function (FFbH) three months after release were measured and compared between two age groups.

Results

Patients <65 and ≥65 years of age (n=104 and 88, mean age of 52±10 and 72±5.6 years, respectively) showed comparable improvements of disease activity and pain in the complete group as well as in those who received newly administered DMARD or TNF-α-inhibitors (71.2% and 62.6%, respectively, for the two groups). A significant difference was demonstrated for the change in function: While patients <65 years of age in the mean had a moderate improvement of the FFbH, this could not be shown for the older patients (p=0.04). A close correlation of the improvements of RADAI and FFbH could be shown for the younger patients only.

Conclusions

DMARD or TNF-α-inhibitors improve disease activity and pain in elderly patients with RA no less than in younger patients. However, in contrast to the younger patients, the older patients profit less in terms of functional impairment.     

Prediction of mortality in rheumatoid arthritis based on disease activity markers

OBJECTIVE: The risks and predictors for mortality in patients with rheumatoid arthritis (RA) were examined in a cohort of 152 consecutive outpatients (119 women, 33 men) seen in a 2 month period. METHODS: We evaluated 4 measures of disease activity: erythrocyte sedimentation rate (ESR), physician and patient global assessment of disease activity, and the Ritchie Articular Index (RAI) as mortality predictors, adjusting for disease severity, treatment, and cardiovascular disease (CVD) comorbidity. RESULTS: During followup from 1978 through 1998, 111 patients (86 women, 25 men) died, and only one was lost to followup. The standardized mortality ratio for women was 161 (95% confidence interval 129-199), for men 152 (95% CI 99-223), and for both sexes combined 156 (95% CI 128-188). In a proportional hazards model adjusted for age and sex, at the beginning of the period and for the whole group, significant predictors of mortality were Steinbrocker functional class, Larsen index, CVD comorbidity, use of corticosteroids ever, ESR, and the physician and patient global assessment of disease activity; but the rheumatoid factor (RF), RAI, and use of disease modifying antirheumatic drugs were not significant predictors. When evaluating the 4 assessments of disease activity adjusting for confounders, only physician global assessment hazard ratio (HR) = 1.32 per 1 SD (95% CI 1.00-1.74) and ESR HR = 1.47 per 1 SD (95% CI 1.11-1.93) were significant predictors. CONCLUSION: This longterm followup study of a single clinical patient cohort showed a significant increase in mortality among patients with RA compared to the general population in Malm?. In addition to disease damage and CVD comorbidity, measures of disease activity independently predicted mortality, which supports the hypothesis that improving these variables may also improve longterm outcome.     

Outcome of second line therapy in rheumatoid arthritis.

OBJECTIVES--To study the functional outcome in patients with rheumatoid arthritis (RA) who tolerate second line drug therapy for five years. METHODS--We enrolled into prospective controlled trials, 190 patients with rheumatoid arthritis who tolerated 'disease modifying' antirheumatic drug therapy for five years. Demographic data were recorded. Disease activity was measured every six months for two years and annually thereafter, using clinical and laboratory variables. Patient function was measured using the modified Health Assessment Questionnaire. The change in each variable was analysed using paired Wilcoxon tests. RESULTS--Patient function improved significantly compared with baseline. The improvement was maximal after one to two years, and thereafter function started to decline slowly. After five years of treatment the patients' function was still significantly better than before treatment had started. There were highly significant improvements in all variables measured to assess disease activity, which remained well controlled throughout the five year period. CONCLUSION--Good control of disease activity and improved function can be achieved long term in approximately 30% of RA patients treated with injectable gold, sulphasalazine or penicillamine.     

Comparison of long term outcome of patients with rheumatoid arthritis presenting with undifferentiated arthritis or with rheumatoid arthritis: an observational cohort study

BACKGROUND: The outcome of undifferentiated arthritis (UA) ranges from remission to rheumatoid arthritis (RA) fulfilling the American College of Rheumatology (ACR) classification criteria. OBJECTIVES: To report the outcome of UA after 1 year of follow up and compare the disease course of patients who presented with UA, but evolved into RA within 1 year (UA-RA group), with that of patients who presented with RA fulfilling the ACR criteria (RA-RA group). METHODS: The diagnosis of 330 patients who presented with UA was recorded at 1 year. The UA-RA and RA-RA groups were then followed up for 3 more years. Outcome measurements were radiographic progression, disease activity, and functional capacity. RESULTS: From 330 patients who were diagnosed UA, 91 had evolved into RA at 1 year; 62 patients had presented with RA. No significant differences were detected between the UA-RA and RA-RA groups in median Sharp/van der Heijde score at baseline, radiographic progression rates, disease activity, and functional capacity. However, significantly more disease modifying antirheumatic drugs were prescribed in the RA-RA group. CONCLUSION: The disease outcome of patients who present with UA that evolves into RA within 1 year is the same as that of patients who present with RA as measured by radiographic progression, disease activity, and functional capacity.     

Acute lower respiratory tract infections in patients with rheumatoid arthritis

OBJECTIVE: To determine whether drugs used in the treatment of rheumatoid arthritis (RA) contribute to the increased risk of respiratory infection or influence its outcome. METHODS: We identified all episodes of lower respiratory tract infection (LRTI) in our RA population over a 12 month period. A detailed drug history was recorded in each case, together with the clinical outcome. Premorbid illnesses and admission data were collected and analyzed to assess the influence of oral steroids and disease modifying antirheumatic drugs (DMARD) on outcome. RESULTS: The overall annual incidence of LRTI in patients with RA was 2.3% with a mortality rate of 22.5%. Demographic factors predicting LRTI included older age and male sex. Oral steroids and not taking DMARD were also associated with an increased risk of hospital admission with LRTI. Being male and having RA for over 10 years trended to the prediction of death as a result of infection. Taking DMARD was not associated with any adverse outcome. CONCLUSION: Respiratory infection is common in patients with RA and carries a high mortality. Oral steroids predispose to infection, while DMARD do not. Increasing age and male sex also predispose to respiratory tract infection.