Roberto Caporali, Italy | Nov 19, 2020
As our understanding of RA and the available treatment options to address this disease continue to evolve, it is becoming increasingly clear that patient perspectives should be considered when assessing the efficacy of a therapy and making treatment decisions. As physicians, I believe we should be invested in a patient's physical, social, and mental well-being and not merely the absence of disease. However, without patient input, we can't measure many of these aspects of overall health. I regularly use a variety of patient assessments in my clinical practice, and it is becoming more common for clinical trials to include patient-reported outcomes (PROS) to assess the impact of the treatment on patients' quality of life (QOL).
Including the patient perspective was a common theme at EULAR 2021 congress; some sessions featured patients who shared their personal viewpoints. As discussed at EULAR 2021, guidelines recommend that treatment decisions be based on both patient and rheumatologist input.1,2 Aspects I'd like to highlight from EULAR 2021 are (1) what we can learn from the discordance between patient/physician assessments and (2) how advances in technology are being applied in the field.
Disagreement between patient and physician assessments (defined as a >2-cm difference on a 10-cm visual analog scale from patient or physician global assessments) has long been documented, with discordance occurring in over 1 of 3 of RA cases.3 This is not a new concept; however, it is a topic that was assessed further at EULAR 2021, and the discussion provided us with ideas as to how and why the rates are so high. One poster presentation, which confirmed a discordance rate of 33% in global assessments between patients and physicians, found that the most likely sources of the discordance were pain due to noninflammatory processes, functional disability, and compromised physical health.4 These results confirm the importance of addressing both inflammatory and noninflammatory parameters in clinical practice, including in patients with biological remission.4 Patient assessments such as RAID, SF-36, etc., can be useful tools in these cases. The findings from this study, and many others, correlate with my experiences in clinical practice showing pain to be a key factor of concern for patients; one study reported that two-thirds of patients ranked pain as their most important concern.5 Another analysis found that the early discordance between PROS and biologic or clinical RA factors can predict a patient's future QOL.6 The authors suggest that once a difference between patient and physician perspectives is noted, the physician should view this as a sign to expand the scope of the treat-to-target approach, which has been seen to result in higher patient satisfaction.6
One of the biggest and likely lasting changes that we've seen in the past year is an increase in telehealth appointments and novel virtual solutions to patient care due to the COVID-19 pandemic. Several innovations in PRO assessments were presented at EULAR 2021. One example is a PRO questionnaire delivery system that emails patients questionnaires at timed intervals specified by a patient's rheumatologist.7 Another example is an app-based platform that allows patients to self-report their health assessments using the RAPID3, along with joint measurements for DAS28 calculations. Both technologies improve patient feedback and provide clinicians with useful data to adjust treatment recommendations.7,8
A session on PRO measures also highlighted the possibility of detecting flares through wearable activity trackers and reported that ~60% of patients prefer a remote questionnaire over in-person assessments.1 Smartwatch apps and fitness trackers could enable patients to self-manage their disease and take a more active role in their disease assessment and decision-making.9 Apps can provide pain management strategies, such as fitness-level tracking or videos on relaxation techniques. Apps that allow patients to set treatment goals, communicate directly with their physician, track treatment progress, etc., are also under development.9 Novel assessment methods such as these will be useful for gaining patient perspectives, and I urge all physicians, including myself, to be open to new technologies for assessing PROS to better serve their patients' needs.
Patient perspectives, which were widely discussed at EULAR 2021, are an important aspect of care for RA and deserve continued attention. I encourage all rheumatologists to continue to evaluate and improve methods for integrating patient feedback into their clinical practice, which will ultimately improve patient satisfaction and overall health.
DAS28, Disease Activity Score in 28 Joints; EULAR, European League Against Rheumatism; PROS, patient-reported outcomes; QOL, quality of life; RA, rheumatoid arthritis; RAID, rheumatoid impact of disease; RAPID3, Routine Assessment of Patient Index Data 3; SF-36, 36-Item Short Form Health Survey.
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