Do we need to lower the cut point of the 2010 ACR/EULAR classification criteria for diagnosing rheumatoid arthritis?

OBJECTIVE: In this study we aimed to evaluate the effect of lowering the cut point of the 2010 criteria to identify more patients with RA among early inflammatory arthritis patients. METHODS: We included early arthritis patients from the Rotterdam Early Arthritis Cohort with at least one joint with clinical synovitis and symptoms for <1 year, with no other explanation for their symptoms. The demographic and clinical characteristics of each patient were recorded at baseline. Patients were classified as case or non-case at the 1-year follow-up by the definition used in the development of the 2010 criteria (MTX initiation). To assess the diagnostic performance of the 2010 criteria, the sensitivity and specificity at each cut point were determined. RESULTS: We included 557 patients in our analysis. At the 1-year follow-up, 253 patients (45%) were classified as case (MTX use). In the group of patients who scored 0-5 points (n = 328), 98 patients (30%) were classified as case (MTX use). The sensitivity and specificity of the 2010 criteria using the cut point of 6 were 61% and 76%, respectively. With the cut point of 5, the sensitivity would increase to 76% and the specificity would decrease to 68%. CONCLUSION: By lowering the cut point of the 2010 criteria from 6 to 5 points, we were able to identify 15% more RA patients at the cost of 8% more false-positive patients.

Best cost-effectiveness and worker productivity with initial triple DMARD therapy compared with methotrexate monotherapy in early rheumatoid arthritis: cost-utility analysis of the tREACH trial.

OBJECTIVE: To evaluate direct and indirect costs per quality adjusted life year (QALY) for different initial treatment strategies in very early RA. METHODS: The 1-year data of the treatment in the Rotterdam Early Arthritis Cohort trial were used. Patients with a high probability (>70%) according to their likelihood of progressing to persistent arthritis, based on the prediction model of Visser, were randomized into one of following initial treatment strategies: (A) initial triple DMARD therapy (iTDT) with glucocorticoids (GCs) intramuscular (n = 91); (B) iTDT with an oral GC tapering scheme (n = 93); and (C) initial MTX monotherapy (iMM) with GCs similar to B (n = 97). Data on QALYs, measured with the Dutch EuroQol, and direct and indirect cost were used. Direct costs are costs of treatment and medical consumption, whereas indirect costs are costs due to loss of productivity. RESULTS: Average QALYs (sd) for A, B and C were, respectively, 0.75 (0.12), 0.75 (0.10) and 0.73 (0.13) for Dutch EuroQol. Highest total costs per QALY (sd) were, respectively, €12748 (€18767), €10 380 (€15 608) and €17 408 (€21 828) for strategy A, B and C (P = 0.012, B vs C). Direct as well as indirect costs were higher with iMM (strategy C) compared with iTDT (strategy B). Higher direct costs were due to ∼40% more biologic usage over time. Higher indirect costs, on the other hand, were caused by more long-term sickness and reduction in contract hours. iTDT was >95% cost-effective across all willingness-to-pay thresholds compared with iMM. CONCLUSION: iTDT was more cost-effective and had better worker productivity compared with iMM.

A high physical workload and high job demands hamper the good prognosis in physical functioning in persons with early inflammatory joint conditions.

OBJECTIVE: To determine the influence of job characteristics on the prognosis of patients with early inflammatory joint conditions. METHODS: In a prospective cohort study of 210 workers with inflammatory joint conditions present for <12 months, data were collected by questionnaires and medical examination at baseline and after 6 and 12 months. Outcomes were self-reported pain and physical functioning, and the presence of at least one swollen joint. Generalized estimation equations were used to study the influence of job characteristics on prognosis in pain and function, and logistic regression analysis to study prognosis in swollen joints. RESULTS: Pain and physical functioning strongly improved during the first 6-month period (40 and 14%, respectively), and improvement slowed considerably in the second 6-month period. The proportion of workers with swollen joints dramatically decreased from 58 to 20 then 7%. The good prognosis in pain and physical functioning in the first 6 months was hampered by persistent high levels of inflammation, older age, low perceived health control and low social support. Job characteristics had no influence on the prognosis of pain and swollen joints, whereas workers with frequent manual material handling or high job demands improved ∼50% less in physical functioning. CONCLUSIONS: Job characteristics had no influence on the disease characteristics pain and swollen joints, but strongly affected the consequences of disease in physical functioning. Among patients with early inflammatory joint conditions, who do not recover in functional abilities, adjustments in working conditions may be imperative.

Predictors of sick leave and reduced productivity at work among persons with early inflammatory joint conditions.

OBJECTIVES: This study attempted to identify predictors of sick leave and reduced productivity at work among persons with early inflammatory joint conditions. METHODS: In a prospective cohort study of 210 workers with inflammatory joint conditions present for less than 12 months, data were collected by a medical examination and questionnaires at baseline and after 6 and 12 months. The outcomes were sick leave and reduced productivity at work. Generalized estimation equations (6-month time-lag model) were used to study predictors. RESULTS: Sick leave was predicted by high levels of pain [odds ratio (OR) 3.2], poor physical functioning (OR 4.4), and frequent manual materials handling (OR 2.0), whereas supervisors had a lower likelihood of sick leave (OR 0.2). The predictors of reduced productivity at work were intermediate levels of pain (OR 3.1), poor physical functioning (OR 2.8), poor mental health (OR 2.1), and low support from colleagues (OR 2.2), whereas the workers classified as having nonrheumatoid arthritis were less likely to report reduced productivity than those with inflammatory joint complaints without clinical synovitis (OR 0.4). CONCLUSIONS: Among the workers with early inflammatory joint conditions, self-reported pain and physical functioning affected performance at work, together with manual materials handling and lack of support from colleagues. Early treatment should target pain and physical functioning, and job interventions should aim at reducing physical workload and increasing coworker support.

Quality of life and health care use in patients with arthralgias without synovitis compared with patients diagnosed with early rheumatoid arthritis: data from an early arthritis cohort.

OBJECTIVE: To compare the burden of disease and its development over time in patients referred to an early arthritis cohort who were diagnosed either as having arthralgias without synovitis or as having rheumatoid arthritis (RA). METHODS: Patients diagnosed as having arthralgias without synovitis or RA were selected from the Rotterdam Early Arthritis Cohort. Data on clinical and psychological characteristics, demographics, pain scores (Rheumatoid Arthritis Disease Activity Index), functional ability (Health Assessment Questionnaire), health-related quality of life (HRQOL; Short Form 36), fatigue (visual analog scale and Fatigue Assessment Scale), and health care utilization (HCU) were collected at baseline and at 6 and 12 months of followup. The burden of disease measures (pain, functional ability, fatigue, and HRQOL) and HCU levels were plotted over time for both groups. A Poisson regression model for repeated data was used to identify determinants of HCU for both groups. RESULTS: At baseline, 330 patients with arthralgias without synovitis (nonsynovitis [NS] group) and 244 RA patients (RA group) were included. Overall, the burden of disease measures and HCU levels were very similar between groups. Both groups showed improvement over time with respect to pain scores, functional ability, HRQOL, and HCU levels. Independent predictors of high HCU were identified as more pain, worse physical health, and external locus of control in the NS group and as shorter duration of symptoms, low chance locus of control, and worse physical functioning in the RA group. CONCLUSION: Despite the absence of an inflammatory diagnosis, patients with arthralgias without synovitis experienced a similar burden of disease compared with RA patients.

Work and sick leave among patients with early inflammatory joint conditions.

OBJECTIVE: To study the occurrence of sick leave and to identify work characteristics related to sick leave in patients with early inflammatory joint conditions. METHODS: Patients with inflammatory joint conditions present for <12 months were included in this cross-sectional study. Approximately 85% of patients satisfying the criteria participated. Data collection included demographics, clinical characteristics, pain, physical functioning and mental health (Short Form 36), fatigue, and behavioral coping (Coping of Rheumatic Stressors questionnaire). Work characteristics included physical load, psychosocial load, job control, and support at work. Outcome was defined as sick leave for >2 weeks during the past 6 months. Multiple logistic regression analysis was conducted. RESULTS: Sick leave was reported by 54 (26%) of 210 employed patients, with 75% of the sick leave periods attributed to joint conditions. Of these 210 patients, 23% were classified as having rheumatoid arthritis (RA), 35% as having non-RA arthritis, and 42% as having inflammatory joint conditions without synovitis. Pain, poor physical functioning, and passive behavioral coping were related to increased sick leave, whereas diagnostic group was not. Low job control, i.e., low control over planning and pacing of activities within the job, was associated with increased sick leave (odds ratio [OR] 2.74), whereas being a supervisor (OR 0.21) and clerical work (OR 0.45) were related to reduced sick leave. CONCLUSION: Substantial sick leave in the past 6 months was reported by 26% of patients with early inflammatory joint conditions. Pain, functional limitations, and fewer opportunities to determine one's work activities were associated with the occurrence of sick leave.