Relative importance of doctor-reported outcomes vs patient-reported outcomes in DMARD intensification for rheumatoid arthritis: the DUO study

Objective. For optimal RA management, the current recommendation is to adapt DMARD therapy to the level of inflammation and not only of patient complaints. We designed the DUO (epidemiological study of treatment decison in RA: DROs and PROs) study to assess the relative weight of patient-reported outcomes (PROs) and doctor-reported outcomes (DROs) in DMARD intensification in RA patients. Methods. This French, observational, multicentre, cross-sectional study was conducted in 2009 on RA patients included by rheumatologists. The percentage of patients with DMARD intensification was evaluated with regard to the concomitant DAS28-ESR and Patient Acceptable Symptom State (PASS) questionnaire assessments. Logistic regression was used to find significant criteria of DMARD intensification. The relative weight of subjective/objective criteria was assessed using attributable risk fractions. Results. A total of 1107 patients were analysed (76% women; median disease duration 6 years); DMARD intensification was proposed to 15% of patients (24% of patients with DAS >3.2 and 33% of patients with non-acceptable PASS). DMARD intensification determinants comprised both DROs (high tender and swollen joint counts) and PROs (high patient global assessment of disease activity), but also short disease duration and rheumatologist characteristics (young, hospital based). Respectively, 61% and 42% of DMARD intensification were attributable to PROs and DROs. Conclusion. The DUO study showed DMARD intensification was predominantly based on PROs compared with DROs and influenced by disease duration and type of rheumatology practice. Most RA patients with DAS28 >3.2 had no DMARD intensification.