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The June 2017 RheumNow “Live Vote” surveyed US and non-US rheumatologists and patients about how they diagnose and treat rheumatoid arthritis (RA) and whether they rely on newer diagnostic criteria and management guidelines propagated by the American College of Rheumatology (ACR).
An email invitation was initially sent to over 1800 verified rheumatologists, with 253 responses (most voting in the first day) from verified rheumatologists in the RheumNow database. This included 207 US (82%) and 46 non-US rheumatologists from a total of 43 countries.
In the survey's second week, we sent out social media (Twitter) invitations for rheumatologists to answer the same 4 questions in our online survey. An additional 56 rheumatologist responses (29 US and 27 non-US) were received.
USA and non-USA rheumatologists' answers were highly similar and thus, the USA rheumatologist responses are shown below with commentary.
Question 1. Your diagnosis of RA is MOST based on?
Positive RF or CCP
Surprisingly, the majority of rheumatologists claim to base their diagnosis on 2010 diagnostic criteria. Only 12% prioritized positive serologies and 28% are more impressed by the number of swollen joints. These results are exceptional given the response below were 21% are unsure, and nearly 50% answered incorrectly, about the “point system” used in the ACR/EULAR criteria.
Number of swollen joints
Joint pain >12 weeks
ACR/EULAR 2010 Dx Criteria
Question 2. How many points do you get for high titer RF+ and CCP+ (ACR/EULAR Dx Criteria)
The correct answer is 3 points for being strongly positive for either RF or CCP (there are no added points for being double positive). For a low titer RF or CCP, you get 2 points. Only 21% of non-US rheumatologists got the right answer on Q2.
Question 3. In daily practice when you say “remission”, you mean:
Patient pain = 0
Although established in 2011 ( https://buff.ly/2iZgnj9 ) the ACR/EULAR remission criteria have little impact on practice, as most rheumatologists rely on finding no swollen or tender joints, or on the use of metric defined remission (RAPID3, CDAI, SDAI, DAS28). These results are in contrast to question 1, where ACR/EULAR criteria for diagnosis were given far greater importance.
ACR/EULAR Boolean Remission
No swollen, No tender joints
RAPID3 <3; CDAI <2.8; SDAI <3.3; DAS28 < 2.6
No synovitis on ultrasound or MRI
Question 4. Which most influences your treatment choices in RA?
Managed care rules
The rheumatologist’s clinical acumen and decision making is far more important than the 2015 guidelines, managed care or safety and comorbidity concerns. Patient preference apparently is seldom of influence.
2015 ACR RA treatment guidelines
Experience and judgement
Safety & comorbidity
The intent of this survey was to assess not just how rheumatologists diagnose and treat RA, but to see if they use current ACR/EULAR classification criteria (for diagnosis) or the 2015 RA treatment guidelines. Before you point out that ACR/EULAR classification criteria are for trials and studies and not for daily practice, you should note that such criteria contain elements important to daily practice and familiarity with these criteria is what is being questioned here.
With the exception of the initial question on RA diagnosis, rheumatologists are driven by clinical skills, judgment and experience in the diagnosis and treatment of RA. Overall, this a low reliance on both ACR/EULAR RA treatment guidelines and the ACR/EULAR remission criteria. While the belief that ACR/EULAR diagnostic criteria are most important (53%), this belies the respondent’s answers suggesting that 70% have an uncertain or incomplete knowledge of these same criteria.
Do Rheums really use the 2010 ACR/EULAR diagnostic criteria when diagnosing RA? I think not. I can only explain the 53% response by explain the error within the first question. My first rule of survey questions is to never ask a question for which there is a pre-conceived “correct” response. Undoubtedly the respondents will choose the pre-conceived “correct” response over the “real” answer because everyone wishes to look good on paper and get the answer “right”! It is likely that most viewed the first question as a challenge to how they diagnose RA, and thus answered what they believe to be the correct answer (as opposed to what they really do).
You may download the slides for these results under our daily download!