Interplay between patient global assessment, pain, and fatigue and influence of other clinical disease activity measures in patients with active rheumatoid arthritis

Abstract

The interplay between patient-reported outcome measures in rheumatology is not well clarified. The objective of the study was to examine associations on the group level and concordance on the individual patient level between patient global assessment (PaGl), pain, and fatigue as scored on visual analog scales (VAS) in the daily clinic by patients with active rheumatoid arthritis (RA). Associations with other measures of disease activity were also examined. Traditional disease activity data on 221 RA patients with active disease planned to initiate biological treatment were extracted from the Danish DANBIO registry. Associations between VAS PaGl, pain, and fatigue (0-100) were examined using multiple regression analysis. Concordance between the VAS scores was expressed as the bias (mean difference between intra-individual scores) and the 95% lower and upper limits of agreement (LLoA; ULoA) according to the Bland-Altman method. Mean age was 57 ± 14 years, mean Disease Activity Score (DAS28-CRP4) 5.0 ± 0.9, and mean PaGl 63.6 ± 22.6. PaGl was most strongly predicted by pain and fatigue, pain by PaGl and fatigue, and fatigue by PaGl and pain (beta ranging from 0.17 to 0.69, p < 0.01-0.0001). More objective measures were not or far less predictive. LLoA;ULoA [bias] for PaGl vs. pain was -19.1; 29.5 [5.2], for PaGl vs. fatigue -22.8; 28.6 [2.9], and for fatigue vs. pain -29.2; 33.8 [2.3]. In conclusion, PaGl, pain, and fatigue were most strongly explained by each other, not by more objective clinical measures of disease activity and were nearly identical on the group level. On the individual patient level, however, differences between the scores varied considerably. The findings highlight the challenge of understanding and dealing with traditional patient-reported VAS measures when it comes to individual RA patients in the daily clinic.

Suppressing Inflammation in Rheumatoid Arthritis: Does Patient Global Assessment Blur the Target? A Practice‐Based Call for a Paradigm Change

“…In other studies , pain has been shown to be the best predictor of PGA, regardless of remission state. In the current study, pain was second to fatigue in explaining PGA in near‐remission.…”

“…Another point against PGA is its difficult interpretation . Until now, most studies suggested that PGA essentially reflects pain, function, and fatigue , which in turn have shown a variable correlation with inflammatory markers, in studies that did include psychosocial dimensions or perform multivariable analyses. Considerable percentages of PGA remain unexplained (>22%) , and few studies have explored its relationship with the underlying level of disease activity , or with the patient's psychological profile .…”

Pain appraisal and quality of life in 108 outpatients with rheumatoid arthritis

“…Moreover, many studies have reported that pain is a crucial and distressing symptom of RA (Jia & Jackson, 2016;Sturgeon et al, 2016). However, most of these studies have failed to show a strong relationship between pain in RA and objective measures of inflammation (Egsmose & Madsen, 2015;Hammer, Michelsen, Provan et al, 2018). In the past few years, more studies have discovered the influence of several pain appraisal variables, including cognitive beliefs, and behavioral and social responses, to explain the impact of RA on HRQoL (Morgan, 2013;Santos, Duarte, Ferreira, Pinto, Geenen & da Silva, 2018;Sturgeon et al, 2016).…”

Comparison of the construct validity and reproducibility of four different types of patient-reported outcome measures (PROMs) in patients with rheumatoid arthritis

“…Rheumatoid arthritis (RA) is an inflammatory autoimmune disease characterised by chronic joint inflammation, which leads to pain, stiffness, function loss, and fatigue [1][2][3]. All of the mentioned complaints can be measured with patient-reported outcome measures (PROMs) like the visual analogue scale (VAS), the Likert scale, the verbal rating scale (VRS) and the numerical rating scale (NRS) [4][5][6]. During outpatient visits, PROMs are taking a more central place because they directly apply to the patients' personal perception and can identify key concerns that need to be addressed [7][8][9][10].…”

“…Recently, PROMs have become increasingly important in managing RA in daily clinical practice [6,10,15]. Using PROMs offers opportunities to improve understanding of patients' experiences and responses to therapy, which would otherwise be missed [7,8,16].…”