Abstract
Objective To evaluate the relevance of the Rheumatoid Arthritis Impact of Disease (RAID) score as a disease activity marker of rheumatoid arthritis (RA) in a teleconsultation setting.
Methods A prospective, observational, 24-month, single-center study involving patients with RA who underwent teleconsultations was performed. The RAID score was sent to all patients by email and completed the day before the scheduled session. The RAID questionnaire was also completed just prior to the next scheduled face-to-face consultation. The same physician performed teleconsultation/in-person consultations and was unaware of the RAID results.
Results We included 70 patients (mean age 50 [SD 14] yrs, mean disease duration 10 [SD 9] yrs). The RAID score correlated with the following items: patient global assessment (r 0.55, P < 0.001), patient-reported swollen joint count (r 0.50, P < 0.001), and Disease Activity Score in 28 joints based on C-reactive protein (DAS28-CRP) calculated with patient self-reported tender/swollen joints (r 0.74, P < 0.001). The RAID score completed during the next face-to-face consultation for 45 patients also correlated with the DAS28-CRP performed by the clinician (r 0.65, P < 0.001). A RAID score > 2 was associated with the best combination of sensitivity (94%) and specificity (43%) for the indication of rapid in-person consultation because of insufficiently controlled disease activity, with an area under the curve of 0.74. All 23 patients with RAID < 2 had no intercurrent flares; overall physician global assessment was 1.6 of 10 (SD 1.4), DAS28-CRP 1.5 (SD 0.2), and CRP 1.8 (SD 1.4) mg/L.
Conclusion Our findings reinforce the RAID score as a valuable tool in teleconsultation, exhibiting a good correlation with disease activity variables. Using a RAID score threshold of 2 during teleconsultations could distinguish patients with good disease control and those with the potential need for an in-person visit.
Teleconsultation, also referred to as telemedicine or telehealth, involves delivering healthcare services remotely through telecommunications technology. The rapid global emergence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) accelerated the adoption of telemedicine for managing patients with chronic inflammatory rheumatic diseases. This approach can be particularly advantageous for individuals with these conditions, offering the ability to consult with healthcare professionals without the need for in-person visits. This not only reduces the travel burden but also ensures continuity of care, especially in situations with a lower number of available physicians.
In a previous study, we demonstrated the feasibility of assessing patients with rheumatoid arthritis (RA) through teleconsultation during the coronavirus disease 2019 pandemic.1 We also established the reliability of clinician intervention in teleconsultation. However, a significant challenge in teleconsultation lies in the accurate assessment of disease activity, which is crucial for implementing a treat-to-target (T2T) strategy. Clinical evaluations of tender and swollen joints, which are essential for calculating composite activity indices, are often hindered in teleconsultation. Addressing the absence of a clinical examination poses challenges, as these objective variables are fundamental for determining disease activity. Incorrect disease assessment may lead to potential harmful consequences, such as overlooking disease flares or mistakenly suspecting disease progression in patients experiencing remission or low disease activity (LDA), but with persistent subjective symptoms like pain, fatigue, or loss of physical function. To mitigate the limitations of lacking a clinical examination, incorporating patient-reported data becomes crucial in defining disease activity in teleconsultation. The Rheumatoid Arthritis Impact of Disease (RAID) score, comprising 7 domains including pain, fatigue, physical function, sleep, physical well-being, emotional well-being, and coping,2 emerged as a promising candidate because of its strong correlation with the Disease Activity Score in 28 joints (DAS-28) in a face-to-face visit setting.3 Therefore, our objective was to evaluate the performance of the RAID score as a disease activity measure in the context of teleconsultation.
METHODS
Study design. A prospective monocentric observational study was conducted between November 2021 and November 2023 in the rheumatology department of Cochin Hospital.
Study population. We included all patients aged > 18 years with the diagnosis of RA according to the rheumatologist, seen in teleconsultation by video consultation.
All included patients agreed to participate in the study by written informed consent, which was recorded in the medical source file. The protocol and the informed consent document received institutional review board/independent ethics committee approval before initiation of the study (“Comité de Protection des Personnes” Ouest VI, n°202-A02933-36). All patients in our institution (AP-HP) are informed that their clinical data can be used for research and give their consent for the use of their data unless they decline.
Intervention. Teleconsultations were performed by video consultation by 3 different senior rheumatologists. The RAID questionnaire was sent by email by medical assistants and filled out by the patient the day before the teleconsultation.
The RAID questionnaire was completed again by a subset of these patients just prior the next scheduled routine face-to-face consultation following the teleconsultation. At this occasion, patients were evaluated by the same physician as in teleconsultation. Rheumatologists were blinded to the RAID results at the teleconsultation and at the next face-to-face consultation.
Data collection. Data were obtained from the review of the patients’ electronic medical records (EMR). The 3 rheumatologists involved in this study entered data of teleconsultations and face-to-face consultations in the EMR. For all teleconsultations, we collected demographic data, disease characteristics (disease duration, antibody status, presence of erosive disease), and ongoing RA therapy. Information on all available variables assessing disease status was also collected, including patient self-reported RA flares (defined as worsening of RA accompanied by ≥ 1 swollen and tender joint [ie, as perceived by the patient]), tender joints (presence or number of patient-reported tender joints), swollen joints (presence or number of patient-reported swollen joints), patient global assessment (PtGA), pain-related night awakenings, morning stiffness, values of erythrocyte sedimentation rate and C-reactive protein (CRP), and DAS28 based on CRP (DAS28-CRP; calculated by replacing provider swollen joint counts [SJCs] and tender joint counts [TJCs] with patient-reported SJCs and TJCs). The DAS28-CRP was also calculated at the next scheduled face-to-face follow-up consultation following the teleconsultation, integrating the clinical examination of tender and swollen joints.
Statistical analysis. All data were expressed as mean (SD) or median (range), unless stated otherwise. We first assessed the association between the RAID score and disease activity variables collected in teleconsultation or face-to-face consultation by Spearman rank correlation, Mann-Whitney U test, or Wilcoxon matched-pairs signed rank test, as appropriate. Secondly, we evaluated the value of the RAID score according to the occurrence of an intercurrent flare indication for rapid in-person consultation following the teleconsultation. This rapid in-person visit was the result of a shared patient/rheumatologist decision based on insufficiently controlled disease activity. The diagnostic value of the RAID score for the occurrence of flare and the need of in-person visit was assessed by receiver-operating characteristic (ROC) curve analysis.
We next evaluated whether a RAID score < 2, which has been reported to be highly correlated with the Patient Acceptable Symptom State (PASS),3 was associated with LDA. The PASS stems from the concept that feeling good is more important to patients than feeling better.4 This second analysis was performed by Mann-Whitney U test or chi-square test as appropriate. The diagnostic value of the RAID score for LDA was assessed by ROC curve analysis. A P value < 0.05 (all 2-sided) was considered significant. Statistical analysis was performed using MedCalc (v18.9.1; MedCalc Software Ltd.).
RESULTS
We included 70 patients (56 female [80%]) with a mean age of 50 (SD 14) years and a disease duration of 10 (SD 9) years. Rheumatoid factor and anticyclic citrullinated peptide antibodies were positive in 44 patients (63%) and 50 patients (71%), respectively, and 21 (30%) had bone erosions. Twenty-seven patients (39%) were treated with corticosteroids, 43 (61%) with methotrexate, and 35 (50%) with a targeted biologic or synthetic therapy (Table 1). The mean RAID score was 3.3 (SD 2.1), with 23 (33%) patients having a score < 2 (Supplementary Table S1, available from the authors upon request). A total of 11 patients reported intercurrent flares at the teleconsultation and 14 patients were seen afterward at a rapid in-person visit, including 10 who reported flares, and active disease was confirmed in all of these patients.
Patient characteristics.
The RAID score strongly correlated with the DAS28-CRP calculated with patient self-reported tender/swollen joints (r 0.74, P < 0.001), and moderately with the PtGA (r 0.55, P < 0.001) and the number of self-reported swollen joints (r 0.50, P < 0.001). Forty-five patients (64%) had a next scheduled routine face-to-face follow-up consultation, 6 (SD 2) months following the teleconsultation. The mean DAS28-CRP was 2.0 (SD 0.8) and did not differ from the DAS28-CRP performed during the previous teleconsultation with patient self-reported tender and swollen joints (2.1 [SD 0.9], P = 0.48). The RAID score collected during this face-to-face consultation was 3.2 (SD 2.3) and also correlated with the DAS28-CRP performed by the clinician (r 0.65, P < 0.001).
The RAID score was significantly higher in patients who reported in teleconsultation the occurrence of an intercurrent flare (5.2 [SD 2.0] vs 2.6 [SD 1.8], P < 0.01) and in patients who had an indication for rapid in-person consultation following the teleconsultation (5.2 [SD 1.8] vs 2.6 [SD 1.4], P < 0.01). The area under the curve (AUC) of the RAID score was 0.82 (95% CI 0.71-0.91) for the report in teleconsultation of an intercurrent flare (Figure 1A), and a RAID score > 3.8 was associated with the best combination of sensitivity (81%) and specificity (72%) for the occurrence of flare. The AUC of the RAID was 0.74 (95% CI 0.61-0.83) for the indication for in-person consultation (Figure 1B). A RAID score > 2 was associated with the best combination of sensitivity (94%) and specificity (43%) for the indication of rapid in-person consultation.
Merit of the RAID score to identify patients, through teleconsultation, with intercurrent flares or requesting in-person visit. ROC curve illustrating the diagnostic value of the RAID score for the identification of patients with (A) intercurrent self-reported flares (n = 11) and (B) indication of in-person visit (n = 14). AUC: area under the curve; RAID: Rheumatoid Arthritis Impact of Disease; ROC: receiver-operating curve.
All 23 patients with a RAID score < 2 had good disease control compared to the subset with a RAID score ≥ 2 (23%; Figure 2A). No intercurrent flares, nocturnal awakenings, or morning stiffness > 30 minutes were reported. No painful or swollen joints were reported for 20 patients (87%) and 23 patients (100%), respectively, and 3 patients (13%) had only 1 painful joint. In this group, the PtGA was 1.6 (SD 1.4), DAS28-CRP was 1.5 (SD 0.2), and CRP was 1.8 (SD 1.4) mg/L. Among the 47 patients with a RAID score ≥ 2, 30 patients (64%) had a DAS28-CRP < 3.2. These patients presented elevated values in specific domains like fatigue and emotional and physical well-being (Supplementary Table S1, available from the authors upon request). The AUC of the RAID was 0.82 (95% CI 0.68-0.91) for LDA defined by a DAS28-CRP < 3.2 (Figure 2B).
Merit of a RAID score < 2 to identify patients in LDA or remission in teleconsultation. (A) Spider chart representing the comparison of a RAID score < 2 or ≥ 2 for swollen joint count, patient global assessment (VAS score out of 10), pain VAS (score out of 10), DAS28-CRP, and CRP levels (mg/L). (B) ROC curve illustrating the diagnostic value of the RAID score for the identification of patients with LDA (DAS28-CRP < 3.2). AUC: area under the curve; CRP: C-reactive protein; DAS28-CRP: Disease Activity Score in 28 joints based on C-reactive protein; LDA: low disease activity; RAID: Rheumatoid Arthritis Impact of Disease; ROC: receiver-operating curve; VAS: visual analog scale.
DISCUSSION
Efficient teleconsultations are crucial for optimal control of RA. This study establishes the significance of the RAID score as a valuable tool in teleconsultations, closely correlated to disease activity variables. Notably, a RAID score < 2 could reflect good disease control in a teleconsultation setting.
The study reveals a strong correlation between RAID scores and the DAS28-CRP calculated in teleconsultation. The main criticism is that teleconsultation does not allow for the clinical evaluation of tender and swollen joints by the physician. We employed patient-reported swollen joints, based on the recommendation of a previous study that indicated a strong agreement between patients and clinicians regarding the TJCs and SJCs, particularly in instances of LDA.5 The American College of Rheumatology (ACR) has advised adapting RA disease activity measures for implementation in telehealth settings to enhance the provision of high-quality clinical care. Specifically, assessments necessitating formal joint counts can be computed by using patient-reported counts of swollen and tender joints.6 However, as self-reported joint counts are, by definition, dependent on the subjective interpretation of the patient, it is highly possible that a DAS28-CRP calculation based on these variables will correlate well with other patient-reported outcomes reflecting disease activity/impact, like the RAID score. Interestingly, in a subset of 45 patients, we found that the DAS28-CRP performed at the next scheduled routine face-to-face follow-up consultation was similar to the DAS28-CRP performed in teleconsultation, and still correlated with the RAID score performed by the patient just prior to this face-to-face consultation, aligning with previous findings from face-to-face visits.3 Thus, this modified DAS28-CRP used in teleconsultation received further confirmation in the face-to-face visit, with a reliable assessment of disease activity by the clinician. In addition, previous initiatives led by nurses involving patient self-assessment of joint counts and disease activity have demonstrated short-term advantages, suggesting the potential usefulness of incorporating TJCs and SJCs into teleconsultation.7,8
The RAID score proves diagnostically valuable in identifying self-reported flares, defined by worsening of RA along with at least 1 swollen and tender joint. This is significant, given that self-reported flares were previously recognized as a primary factor prompting clinician intervention during teleconsultations.1 The RAID score also proved effective in identifying patients necessitating rapid face-to-face reviews, all of whom confirmed active disease. A score cut-off > 2 provided the best combination of sensitivity and specificity, and may be considered an indicator of the need for in-person visit. Consequently, the RAID score emerges as a straightforward tool capable of pinpointing both active patients experiencing flare-ups and those requiring clinical evaluation.
A RAID score < 2 was linked to a state of good disease control, instilling significant confidence that in a telemedicine context, patients reporting a RAID score < 2 would likely have achieved the DAS28 T2T goal. Conversely, 64% had a DAS28-CRP < 3.2 and a RAID score ≥ 2. This notable percentage of patients experiencing symptoms (fatigue, reduced emotional and physical well-being) beyond acceptable levels, despite achieving current treatment targets for disease activity, serves as a cautionary note against excessive reliance on protocol-driven medical approaches in outpatient settings. It underscores the importance of incorporating patient-reported outcomes alongside composite scores of disease activity for a more comprehensive evaluation.9 This highlights that a patient with a RAID score ≥ 2 may need professional support, which can imply a pharmacological but also sometimes a nonpharmacological intervention. An in-person visit may be required in this situation since the identification of the exact nature of this need may be challenging by teleconsultation.
Numerous clinical studies provide ample evidence supporting the efficacy of a sustained, goal-oriented, T2T approach leading to enhanced and sustained clinical, functional, and radiographic outcomes.10 This highlights the need for regular and frequent patient assessments to fine-tune treatment until the targeted objective is met. Beyond occasionally challenging face-to-face appointments, the T2T strategy could encompass teleconsultation visits incorporating the RAID score. This approach enables the evaluation of whether targeted goals have been reached, and if not, adjustments to the treatment plan could be made through teleconsultation or during a face-to-face visit.
The RAID domains that had the largest proportion of individuals with the highest scores were fatigue and physical and emotional well-being. In the teleconsultation setting, reviewing scores across the RAID domains could expedite the identification of crucial unmet needs in individuals who have achieved the treatment target for disease activity. This would allow physicians to promptly initiate beneficial nonpharmacological management strategies, such as lifestyle advice and cognitive-behavioral therapy, both of which are adaptable to telemedicine delivery.
The study’s strengths lie in its prospective design, with the RAID score conducted prior to teleconsultations, ensuring the clinician’s blindness to the RAID score during these sessions. The RAID questionnaire is quick, taking < 5 minutes to complete. The efficiency and ease of use are particularly noteworthy, crucial for rheumatologists in healthcare systems with limited patient contact time. Additionally, the ability for patients to complete RAID questions before a telemedicine appointment has the potential to streamline consultations by focusing on the individual’s most significant health concerns. However, our study has certain limitations. Our study sample was limited and consisted mainly of patients with LDA. Thus, these results may not be generalizable to all patients with RA and requires further validation. Both patient and clinician satisfaction were not assessed, and we did not employ a validated questionnaire for gathering data on the number of tender and swollen joints. Although teleconsultation holds the potential to broaden the reach of rheumatology practice, it is acknowledged that some patients may lack the essential resources for such visits. This aspect was not explored in our study and warrants consideration in future research.
In summary, our study underscores the relevance of the RAID score in teleconsultation. A patient with a RAID score threshold < 2 has a low probability of experiencing sufficiently active disease to warrant treatment changes as per T2T recommendations. Moreover, a RAID score > 2 may be an indicator of the potential need for an in-person visit.
ACKNOWLEDGMENT
The authors wish to acknowledge Ms. Carole Desbas for expert secretarial assistance.
Footnotes
The authors declare no conflicts of interest relevant to this article.
- Accepted for publication May 14, 2024.
- Copyright © 2024 by the Journal of Rheumatology
