Factors Contributing to Discordance between the 2011 ACR/EULAR Criteria and Physician Clinical Judgment for the Identification of Remission in Patients with Rheumatoid Arthritis

Abstract

Remission is a primary end point of in clinical practice and trials of treatments for rheumatoid arthritis (RA). The 2011 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) remission criteria were developed to provide a consensus definition of remission. This study aimed to assess the concordance between the new remission criteria and the physician’s clinical judgment of remission and also to identify factors that affect the discordance between these two approaches. A total of 3,209 patients with RA were included from the KORean Observational Study Network for Arthritis (KORONA) database. The frequency of remission was evaluated based on each approach. The agreement between the results was estimated by Cohen’s kappa (κ). Patients with remission according to the 2011 ACR/EULAR criteria (i.e. the Boolean criteria) and/or physician judgment (n = 855) were divided into three groups: concordant remission, the Boolean criteria only, and physician judgment only. Multinomial logistic regression analysis was used to identify factors responsible for the assignment of patients with remission to one of the discordant groups rather than the concordant group. The remission rates using the Boolean criteria and physician judgment were 10.5% and 19.9%, respectively. The agreement between two approaches for remission was low (κ = 0.226) and the concordant remission rate was only 5.5% (n = 177). Pain affected classification in both discordant groups, whereas fatigue was associated with remission only by physician clinical judgment. The Boolean criteria were more stringent than clinical judgment. Patient subjective symptoms such as pain and fatigue were associated with discordance between the two approaches.

Comparison of remission criteria in patients with rheumatoid arthritis treated with biologic or targeted synthetic disease-modifying anti-rheumatic drugs: results from a nationwide registry

“…The remission rate of a multicenter cohort of patients between 2009 and 2016, most of whom (93%) used csDMARDs, was highest when it was based on the DAS28-CRP score (47.1%), followed by DAS28-ESR (28.6%), SDAI (18.0%), CDAI (17.6%), and the Boolean definition (12.2%). 29 The other study, which included 16% bDMARD users, investigated remission rates between 2012 and 2014, and found the remission rate to be even lower: DAS28-CRP, 27.5%; DAS28-ESR, 14.5%; SDAI, 11.0%; and CDAI, 5.4%. 30 While significant treatment advances have been made over several decades, remission according to the most stringent definition was not achieved in the majority of Korean RA patients.…”

Pain, sleep and emotional well-being explain the lack of agreement between physician- and patient-perceived remission in early rheumatoid arthritis

“…Since rheumatoid arthritis (RA) patients are at risk for joint damage due to inflammation [1], the treatment goal in these patients is to attain a state of absence of disease activity, or remission [2]. However, clinical response and remission are defined in multiple ways and measured with different instruments, resulting in substantial variation of the proportion of patients classified as being in remission [3, 4]. A particularly common difference is seen between the physician and the patients view on the RA disease activity [5–9].…”

Treat-to-Target Strategy for Asian Patients with Early Rheumatoid Arthritis: Result of a Multicenter Trial in Korea

“…There are several obstacles to implementing the T2T strategy in Korea. Considering the fact that physician's clinical judgement for remission has low concordant rate with the Boolean criteria in the Korean Observational Study Network for Arthritis (KORONA) cohort,18 it is necessary to set the treatment target. Given the busy daily schedule in Korean clinics, it is difficult to evaluate complex indicators of treatment target, such as DAS28.…”