Common Evaluations of Disease Activity in Rheumatoid Arthritis Reach Discordant Classifications across Different Populations

Abstract

ObjectivesThe classification of disease activity states in rheumatoid arthritis (RA) can be achieved through disease activity indices, such as the Disease Activity Score in 28 joints erythrocyte sedimentation rate (DAS28-ESR), the Simplified Disease Activity Index (SDAI), and the Clinical Disease Activity Index (CDAI). Subjective measurements, such as patient reported outcomes have been incorporated into several of these indices alongside more objective assessments, such as increases in the ESR and C-reactive protein. Moreover, while they use similar criteria, different indices weight these criteria to different extents. Therefore, the classifications based on each evaluation may not always be the same. We aim to compare the performance of the three indices and their individual components in two different populations.MethodsData from Dutch and Portuguese adherent centers were extracted from the METEOR database, a multinational collaboration on RA. We included a total of 24,605 visits from Dutch centers (from 5,870 patients) and 20,120 visits from Portuguese centers (from 3,185 patients). We compared the disease activity states as evaluated by the DAS28-ESR, CDAI, and SDAI across the two populations. In addition, we analyzed the individual components of each evaluation, including their respective contributions to the outcome, in each population.ResultsWe found significant differences in the disease activity states classified with the DAS28-ESR between the two populations. SDAI and CDAI had more congruous results. While the proportion of visits to Dutch and Portuguese centers that were classified as “in remission” was very similar between the CDAI and SDAI, the DAS28-ESR gave discordant results. Dutch patients had lower ESRs, which is more heavily weighted in the DAS28-ESR. In addition, even though the mean physicians’ global assessment values did not vary significantly for Dutch vs Portuguese physicians, we found that doctors at Portuguese centers overall scored the physician’s global assessment lower than Dutch physicians for patient visits classified by disease activity state.ConclusionWhile the CDAI and SDAI assigned disease activity states that were largely similar, the DAS28-ESR was often discordant across the two populations. Moreover, we found that physicians, more than patients, evaluated disease activity differently among the Portuguese and Dutch populations.

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“…These data show a difference in the proportion of patients with low disease activity, as assessed by CDAI and SDAI, compared with DAS28‐ESR. A previous study analyzing Dutch and Portuguese patient data from the Measurement of Efficacy of Treatment in the Era of Rheumatology (METEOR) database found a discordance between low disease activity defined by DAS28‐ESR and low disease activity defined by SDAI and CDAI . These differences may be due to the different weighting of the individual components between the assessment indices, including the heavier weighting of patient’s global assessment of disease activity in the CDAI and SDAI than in the DAS28‐ESR.…”

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“…By taking into account the swollen joint count (of 28 joints), tender joint count (of 28 joints), and the global assessments of disease activity (scored 0–10 on a visual analog scale) by both patient and clinician, the CDAI is scored on a scale ranging from 0 to 76 points [ 25 ]. The level of disease activity can be interpreted as low (2.9 ≤ CDAI ≤ 10), moderate (10 < CDAI ≤ 22), or high (22 < CDAI), while CDAI ≤ 2.8 indicates the state of remission [ 49 ]. A decrease in CDAI of at least 1 for patients with low disease activity; of at least 6 for patients with moderate disease activity; and of at least 12 for patients with high disease activity between two consecutive visits is considered as MCII in RA disease activity [ 24 ].…”

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“…However there is still discordance between them. It has been proposed that the DAS28-ESR and the CDAI/SDAI weights their individual components differently, which sometimes 22 We have used all the scoring systems and if found high score in any one of them we labelled the patient as having high disease activity. Anaemia was found in 69% of the population and 91.6% in the subset of patients of high disease activity, which was similar to observational study carried out by Goyal et al on 59 patients of RA in India which showed 67.8% of the patients had anaemia and 90% in the subset of patients of high disease activity.…”