Impact of Patient's Global Assessment on Achieving Remission in Patients With Rheumatoid Arthritis: A Multinational Study Using the METEOR Database

Abstract

Objective There is an ongoing debate about excluding patient's global assessment (PtGA) from composite and Boolean‐based definitions of rheumatoid arthritis (RA) remission. This study aimed at determining the influence of PtGA on RA disease states, exploring differences across countries, and understanding the association between PtGA, measures of disease impact (symptoms), and markers of disease activity (inflammation). Methods Cross‐sectional data from the Measurement of Efficacy of Treatment in the Era of Outcome in Rheumatology international database were used. We calculated the proportion of patients failing American College of Rheumatology/European League Against Rheumatism Boolean‐based remission (4‐variable remission) solely due to PtGA (PtGA‐near‐remission) in the overall sample and in the most representative countries (i.e., those with >3,000 patients in the database). Multivariable linear regression models were used to identify the main determinants of PtGA, grouped in predominantly inflammatory impact factors (28 tender joint counts, 28 swollen joint counts, and C‐reactive protein level) and disease impact factors (pain and function). Results This study included 27,768 patients. Excluding PtGA from the Boolean‐based definition (3‐variable remission) increased the remission rate from 5.8% to 15.8%. The rate of PtGA‐near‐remission varied considerably between countries, from 1.7% in India to 17.9% in Portugal. One‐third of the patients in PtGA‐near‐remission group scored PtGA >4 of 10. Pain and function were the main correlates of PtGA, with inflammation‐related variables contributing less to the model (R2 = 0.57). Conclusion PtGA is moderately related to joint inflammation overall, but only weakly so in low levels of disease activity. A considerable proportion of patients otherwise in biologic remission still perceive high PtGA, putting them at risk of excessive immunosuppressive treatment.

Shared decision‐making in people with chronic disease: Integrating the biological, social and lived experiences is a key responsibility of nurses

“…First, we demonstrated that there were almost twice as many patients in PGA-near-remission status as those in "full" remission in an international cohort (Ferreira, Carvalho, et al, 2019), and up to 37% of all patients in some settings . Among these PGA-near-remission patients, about one-third scored a PGA >4/10 (Ferreira, Carvalho, et al, 2019). This demonstrates that, despite having no measurable signs of inflammation, many patients perceive considerable disease impact.…”

“…Finally, we showed that PGA from patients in near‐remission is not associated with disease activity but rather with fatigue, pain, anxiety, depression, physical well‐being and functional limitations (Ferreira et al, ; Ferreira, Duarte, et al, , Ferreira, Carvalho, et al, ).…”

“…Personality traits have a considerable influence on the perception of the disruption caused by the disease, with decisive consequences on QoL and happiness (Santos, Duarte, et al, ). Accordingly, treatment strategies focusing solely on the control of the disease process have a limited effect on disease symptoms and QoL, and probably a minor effect on happiness (Ferreira et al, , Ferreira, Carvalho, et al, ; Santos, Duarte, et al, ; Santos et al, 2019a; Silva, Duarte, Ferreira, Santos, & da Silva, ). To grasp fully the dimensions affected by the disease and the psychosocial context, a more holistic assessment of patients is needed as a basis for subsequent interventions that go beyond pharmacological treatment and control of the pathological process (Santos, Duarte, et al, ).…”

Is It Time to Banish Composite Measures for Remission in Rheumatoid Arthritis?

“…In this issue of Arthritis Care & Research , Ferreira et al have reported a study on how the patient's global assessment (PtGA) impacts remission in rheumatoid arthritis (RA) . This study calls into question the use of certain components within the American College of Rheumatology (ACR)/European League Against Rheumatism Boolean definition for RA remission .…”

“…The PtGA was related more to pain and function and less to inflammation or active disease. Interestingly, eliminating the PtGA in patients with near‐remission boosts the proportion in remission in various ways, depending on the country, with India only increasing remission by <2% and The Netherlands and some other countries by nearly 14% . The swollen joint count (SJC) score also affected near‐remission overall by 5%, and this result had virtually no variation by country.…”