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Belgian rheumatologists’ preferences regarding measures of disease activity in patients with rheumatoid arthritis: results from a mixed-methods study

  • Observational Research
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The reliability and clinical usefulness of the different composite disease activity scores and their individual components in Rheumatoid Arthritis (RA) are still debated. This study investigated which measures of disease activity were preferred by rheumatologists. A mixed-method study was performed. First, ten Belgian rheumatologists were invited for individual interviews on their current practice and preferences for measurement of RA disease activity. Results of this qualitative study and evidence from literature served as input for developing a survey. This survey asked rheumatologists to rate preferred standard disease activity score(s), their individual components, ultrasound and related patient-reported outcomes (PROs), by maximum difference scaling. The relative importance score (RIS) for each indicator was calculated using hierarchical Bayes modeling. The qualitative study included 6/10 invited rheumatologists. Composite scores and components were perceived as useful, while PROs were found subjective. Interestingly, ultrasound was used to mediate discrepancies between physician and patient. The survey based on this was sent to 244 Belgian rheumatologists, 83/244 (34%) responded, including 66/83 (80%) complete and 17/83 (20%) incomplete surveys (two missing essential information). Most rheumatologists (75/81, 93%) used a disease activity score and 68/81 (84%) preferred the DAS28-CRP. Swollen joint count obtained the highest mean ± SD RIS (22.54 ± 2.64), followed by DAS28 ESR/CRP (20.61 ± 4.06), ultrasound (16.47 ± 7.97), CRP (13.34 ± 6.11) and physician’s global assessment (12.59 ± 7.83). PROs including fatigue, pain, and patient’s global assessment, and Health Assessment Questionnaire, obtained the lowest mean RIS (0.34–2.54). Rheumatologists place more faith in self-assessed disease activity components or in laboratory tests. Trust in PROs to evaluate disease activity is low in clinical practice.

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Availability of data and material

The data source is available upon reasonable request by authors.

Code availability

The survey was constructed and partly analyzed using the Sawtooth Software’s SSI Web platform (version 9.8.1), for which an academic grant was acquired. Additional analyses were performed in Microsoft Excel, Statdisk and VassarStats.


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We would like to thank Sawtooth Software, Inc for providing us a student licence to use their software. We would like to thank Catherine Bailleux for her support in contacting the rheumatologists.


No specific funding for this study was obtained.

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Authors and Affiliations



DDC, EB, RW and PV designed the study. DDC and EB drafted the manuscript. All authors supported the analysis of the results, revised the paper critically for important intellectual content; approved the final version of the draft and agreed to be accountable for all aspects of the work.

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Correspondence to D. De Cock.

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The authors declare that they have no conflict of interest.

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The Ethical Committee of the KU Leuven approved this study (MP011755) on 23/12/2019. Participants had to indicate to have read and accept an information letter before starting this anonymous survey.

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Authors reporting on experimental work on humans should, where relevant, submit evidence that the work has been approved by an institutional clinical research panel or its equivalent.

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De Cock, D., Buckinx, E., Pazmino, S. et al. Belgian rheumatologists’ preferences regarding measures of disease activity in patients with rheumatoid arthritis: results from a mixed-methods study. Rheumatol Int 42, 815–823 (2022).

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