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Relationship between health outcomes in Spondyloarthritis and Rheumatoid arthritis
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The inflammatory articular rheumatic diseases are a broad group of conditions of which Spondyloarthritis (SpA) and Rheumatoid arthritis (RA) are disease prototypes given their higher prevalence and potential to impair a broad group of joints. Inflammation associated with SpA and RA may have significant consequences on several dimensions of patients’ lives. The understanding of the impact of the disease on quality of life, physical function and work productivity, as well as their interplay, is of utmost importance for clinicians to undertake the most appropriated and valuable assessments in their clinical practice, and for allowing governments and scientific societies to estimate the economic burden of such diseases. The contribution of disease activity to disability had already been described in literature, both for SpA and RA. However, several knowledge gaps remained to be studied. In SpA, the evidence on early disease remained scarce, namely regarding the association of disease activity with mobility and work productivity. In RA, despite the broad use of Patient’s global assessment (PtGA) as part of some disease activity indices in clinical practice, its role remained unclear, namely in patients with low levels of disease activity. The measurement of improvements in Health Related Quality of life (HRQoL) is a key concept in terms of public health, however data on HRQoL is not always available. The possibility of using other health domains, such as disease activity and disability, to estimate the impact on HRQoL, may be useful for clinical and regulatory purposes. The main objective of our work was to study the relationship between distinct health outcomes, namely disease activity, disability and HRQoL, in SpA and RA.
We used data from international observational cohorts, namely Devenir des Spondylarthropathies Indifferénciées Récentes (DESIR) and COMOrbidities in SPondyloArthritis (COMOSPA) for SpA, and Measurement of Efficacy of Treatment in the Era of Outcome in Rheumatology (METEOR) and COMOrbidities in Rheumatoid Arthritis (COMORA) for RA. The study of such cohorts allowed the analysis of a large number of patients followed in routine clinical practice, at various disease stages, namely early axSpA (in the case of data from the DESIR cohort). We used validated tools to assess a broad range of health outcomes, namely EuroQOL 5-dimension 3-level (EQ-5D-3L) for HRQoL; Bath Ankylosing Spondylitis Functional Index (BASFI), Modified Health Assessment Questionnaire (MHAQ) and Health Assessment Questionnaire (HAQ) remission for physical function; Work Productivity and Activity Impairment questionnaire (WPAI) and occurrence of sick leave for work productivity; Ankylosing Spondylitis Disease Activity Score with C-reactive protein (ASDASCRP), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Disease Activity Score with 28-joint counts using the C-reactive protein level and 3 variables (DAS28-CRP-3v) and several definitions of remission for disease activity.
To study correlations between Patient’s global assessment (PtGA) and SJC28, TJC28, C-reactive protein (CRP) level, DAS28-CRP-3v, pain scores, and function, Pearson’s correlation coefficients were calculated. Multivariable linear regression models were used in cross-sectional studies to assess associations between the variables of interest. Univariable and multivariable Generalized estimating equations (GEE) models were used to study associations between variables in longitudinal cohort studies. Models were adjusted for potential confounders in multivariable analyses, and sensitivity analysis were performed when appropriated. In order to study the hierarchical relationship between variables the Chi-square automatic interaction detector (CHAID) method was used to build decision trees. Time-varying Cox survival analysis was used to study time-to-event data (in the case of this thesis, time to sick leave).
We have demonstrated a longitudinal association between disease activity and disability in early axial SpA. Disease activity was shown to be hierarchically superior to any other variable or disease domain, however enthesitis, gender and spinal mobility were also key factors associated with disability in early axial SpA. ASDAS-CRP and its cut offs further confirmed their validity to assess disease activity and proved to be able to discriminate between different profiles of disability in early axial SpA. ASDAS-CRP, enthesitis and MRI spinal inflammation were critical factors associated with spinal mobility in early axial SpA. Disease activity together with lower education, older age and female gender were associated with the incidence of Sick leave (SL) in this early disease population.
The various remission definitions in RA confirmed their association with physical function in a clinical practice setting. PtGA was shown to be an important factor responsible for patients failing remission definitions that incorporate PtGA in their formula/algorithm, and PtGA was only moderately correlated with joint inflammation overall, and only weakly so at low levels of disease activity.
Disability followed by disease activity and work productivity were major contributors to HRQoL in patients with SpA and RA. These health outcomes proved to be hierarchically superior to any other demographic or clinical variables in terms of their contribution to HRQoL, both in SpA and RA.
In conclusion, our results suggest that there is a significant and consistent association between disease activity and disability in SpA and RA. Together with work productivity, they play the most important role on determining the level of HRQoL. The influence of other factors such as enthesitis and mobility impairment in SpA, and the influence of PtGA in RA should also be taken into account. Strategies to preserve quality of life in inflammatory articular rheumatic diseases should therefore be multidimensional, and include multiple health domains such as disease activity, disability, mobility and work productivity, and rheumatology healthcare teams should be proficient in these assessment as part of RA and SpA management. This will translate in better HRQoL outcomes and increased patient satisfaction and perceived value of care.