Patient global assessment is elevated by up to 5 of 10 units in patients with inflammatory arthritis who screen positive for fibromyalgia (by FAST4) and/or depression (by MDS2) on a single MDHAQ

• Published in: Seminars in arthritis and rheumatism Vol. 58; p. 152151
• Main Authors: Schmukler, Juan, Li, Tengfei, Gibson, Kathryn A., Morla, Rosa M., Luta, George, Pincus, Theodore
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.02.2023
• Subjects: Arthritis, Rheumatoid - complications; Arthritis, Rheumatoid - diagnosis; Depression - diagnosis; Fibromyalgia - diagnosis; Humans; Inflammation; MDHAQ; Multidimensional health assessment questionnaire, FAST4, Fibromyalgia assessment screening tool, MDS2, Depression, RA, SpA, AxSpA, PsA; PATGL; Patient global assessment; Severity of Illness Index; Surveys and Questionnaires; DAS28; FAST4; SpA; Patient global assessment; AxSpA; FM; PATGL; HADS-D; RA; RAPID3; MDS2; Multidimensional health assessment questionnaire, FAST4, Fibromyalgia assessment screening tool, MDS2, Depression, RA, SpA, AxSpA, PsA; CDAI; PHQ 9; MDHAQ; DAPSA; ASDAS; PsA
• ISSN: 0049-0172; 1532-866X
• DOI: 10.1016/j.semarthrit.2022.152151

•Evidence before this study: Patient global assessment (PATGL) was designed to assess disease activity, and is a component of most indices to assess patient status in inflammatory rheumatic diseases such as DAS28, CDAI, ASDAI, DAPSA, and others.  PATGL distinguishes active from control treatments in clinical trials as significantly as swollen or tender joint counts. However, clinical trial patients are selected for high inflammatory activity; more than 75% of all patients with a given diagnosis such as rheumatoid arthritis (RA) or spondyloarthritis (SpA) are excluded, primarily due to joint damage and comorbidities, notably fibromyalgia and/or depression, in addition to or in the absence of inflammatory activity. An elevated PATGL is recognized to prevent more RA patients from being in remission than other measures, but the basis for the elevations is not assessed according to quantitative data. Most long-term rheumatology databases do not include quantitative measures of joint damage or patient distress to recognize fibromyalgia and/or depression, which may be easily recognized in some patients but often are underrecognized. Elevation of PATGL by joint damage, fibromyalgia, and/or depression may affect interpretation of indices for a "treat-to-target” strategy, in which escalation of therapy is recommended for patients with moderate or high scores on an index that includes PATGL but may be inappropriate if inflammatory activity is low and index scores are raised by fibromyalgia and/or depression.•Added value of this study: A multidimensional health assessment questionnaire (MDHAQ) includes simple screening indices for fibromyalgia (FAST4) and/or depression (MDS2), which are positive in 41% of patients with rheumatoid arthritis (RA) or spondyloarthritis (SpA). These comorbidities elevate median 0–10 PATGL from 3 to 8, which often elevates indices to levels suggesting moderate or high index scores and possible inappropriate escalation of therapy with a high risk/benefit ratio. Similar findings in 3 settings on 3 continents suggest generalizability of the results. The MDHAQ is quite feasible in busy routine care clinical settings, unlike many reported patient questionnaires, completed by patients in 5–10 min and scored in 20–30 s, instantaneously with a computer, but not requiring a computer.•Implications of the available evidence: Simple MDHAQ screens for fibromyalgia and/or depression identify common comorbidities which often are underrecognized in patients with any diagnosis. Recognition of these comorbidities may help explain poor responses to powerful anti-inflammatory agents and reassure rheumatologists not to escalate therapy despite high index scores, a common situation, which may lead to initiation of powerful agents with a high risk/benefit ratio. The findings may be useful toward modification of recommended treatment strategies such as "treat-to-target," and promotion of quantitative assessment of joint damage and patient distress in routine care and long-term databases. Patient global assessment (PATGL) is a component of rheumatoid arthritis (RA) and spondyloarthritis (SpA) activity indices, reflecting inflammation in selected clinical trial patients. In routine care, PATGL often may be elevated independently of inflammatory activity by fibromyalgia (FM) and/or depression, leading to complexities in interpretation. A feasible method to screen for FM and/or depression could help to clarify interpretation of high PATGL and index scores, including explanation of apparent limited responses to anti-inflammatory therapies. Patients with RA or SpA in routine care in Barcelona, Chicago, and Sydney complete a 2-page multidimensional health assessment questionnaire (MDHAQ) in 5–10 min. The MDHAQ includes PATGL and three indices, RAPID3 (routine assessment of patient index data) to assess clinical status, FAST4 (0–4 fibromyalgia assessment screening tool) and MDS2 (0–2 MDHAQ depression screen). PATGL was compared for each diagnosis at each site and pooled data in FAST4 positive (+) vs negative (-) and/or MDS2+ vs MDS2- patients using medians and median regressions. Median PATGL was 5.0 in 393 RA and 175 SpA patients; 2.0–3.0 in 305 (58.9%) FAST4-,MDS2- patients, 5.5–6.0 in 71 (13.7%) FAST4-,MDS2+ patients, 7.0–7.5 in 50 (9.7%) FAST4+,MDS2- patients, and 7.0–8.0 in 92 (17.8%) FAST4+,MDS2+ patients. Positive FAST4 and/or MDS2 screens were seen in 41% of patients. Results were similar in RA and SpA at 3 settings on 3 continents. Median 0–10 PATGL varied from 2-3/10 to 5.5-8/10, according to negative vs positive screening for FM and/or depression on a single MDHAQ for busy clinical settings.