Mind the Gap: Patient-Reported PsA Impact Scores, Physician Treatment Decisions Misaligned

Although patients with a higher Psoriatic Arthritis (PsA) Impact of Disease questionnaire (PsAID-12) score were more likely to experience treatment escalation, most physicians reported that the scores did not influence treatment decisions, according to a recent Rheumatology study.¹

Due to the condition’s diverse clinical presentation and treatment responsiveness, personalized therapeutic approaches are often used for patients with PsA. However, little is currently known about the factors influencing treatment choices in routine practice.

Patient-reported outcome (PRO) measures were developed to monitor disease activity, which is used to guide treatment decisions and standardize outcomes in clinical research. For example, the PsAID is a disease-specific PRO used to measure the overall impact of PsA from the patient's perspective. It has 2 versions: a 9-item questionnaire for clinical trials and a longer 12-item questionnaire for use in clinical practice (PsAID-12).

Past research proposed PsAID as a standard tool for evaluating the impact of PsA disease on patients and making therapeutic decisions.² However, there are limited data on its use in routine practice.¹ Consequently, the researchers investigated the prescribing practice for PsA in routine care and whether using PsAID-12 impacted treatment decisions.

Physicians primarily relied on clinical assessments rather than patient-reported Psoriatic Arthritis (PsA) Impact of Disease questionnaire (PsAID-12) scores when making treatment decisions. | Image Credit: Jacques Hugo - stock.adobe.com

They conducted a cross-sectional analysis of adult patients with PsA attending face-to-face rheumatology appointments. Between July 2021 and March 2022, the researchers selected eligible patients from 24 centers across 5 countries (UK, Germany, France, Italy, and Spain) through systemic sampling. They chose a target sample size of 100 patients per country based on data that 32% of patients undergo a treatment change at a clinic appointment.

The study’s primary objective was to evaluate the influence of the PsAID-12 score on the likelihood of treatment escalation. The PsAID-12 assesses 12 domains critical to patients' health, each using a 0 to 10 numerical rating scale with varying weights.³ The final score ranges from 0 to 10, with 10 representing the worst health score. Patients completed the questionnaire before their appointments, and the scores were shared with the treating physician during their appointments.¹

Also, the researchers recorded patient and disease characteristics, current treatment methods, and decisions on treatment strategies (treatment unchanged, escalated, or reduced). They defined escalation as one or more of the following: increase in medication frequency; increase in current medication dose; change in administration route; addition of a new medication; and/or switch to a new medication.

The researchers recruited 503 patients from 24 centers. The study population had a mean age of 53, and 49.1% were women. Also, the mean (standard deviation [SD]) disease duration was 10.8 (9.28) years, with the most common PsA subtype in all countries being peripheral arthritis (83.7%).

Across countries, the mean physicians’ disease activity assessment was 3.0 (range, 0-9), indicating that disease severity was generally mild. Additionally, the level of disability was low, with a median swollen joint count of 0 and a median tender joint count of 2. Overall, the mean total PsAID score was 3.6. Both physician- and patient-reported outcomes in the UK demonstrated higher levels of disease activity and impact than the other European countries analyzed.

As for treatment methods, a higher percentage of patients in the UK received conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) than those in mainland Europe (66.4% vs 44.9%), while biologics were used more frequently in mainland Europe (68.1% vs 36.4%). The researchers determined that treatment was changed for 182 patients (36.2%), with the most common change being treatment escalation (n = 160; 88.8%).

These included medication addition (14.1%), medication switch (10.7%), or an increase in dose, frequency, or change in route (9.3%). Treatment escalation was more common among patients in the UK than in mainland Europe. Since treatment escalation is more likely to occur earlier in the disease course, the researchers emphasized that this may reflect the UK's higher level of physician- and patient-reported disease activity, predominant use of csDMARDs, or younger patient demographic.

At 22 of the 24 sites, the mean PsAID-12 score for those with treatment escalation was higher than the mean score of those without escalation. Therefore, the PsAID-12 score was associated with higher odds of treatment escalation (OR, 1.58; P < .0001); the estimated odds of treatment escalation increased by 58% with every 1-point increase in the PsAID-12 score. Despite this, clinicians reported that, in most cases, the PsAID score did not significantly influence their decision to escalate treatment. Instead, it was more likely to lead to a decrease in treatment.

Conversely, the researchers found that the physician’s disease activity assessment had the most statistically significant effect on the likelihood of treatment escalation, with an OR of 2.68 for each 1-point increase in the PsAID-12 score. Based on univariate regression, other factors associated with treatment escalation included patient and physician characteristics and disease impact.

The researchers acknowledged their study’s limitations, including recruiting patients from specialist PsA clinics with generally low disease activity. This population may differ from those at other rheumatology clinics, especially those with more severe skin disease. However, they expressed confidence in their findings.

“Overall, this study highlights the influence of multiple factors on decision-making when reviewing treatments for individuals with PsA,” the authors concluded. “This can help in providing insight into the management of patients with this complex condition.”

References

1. Coyle C, Watson L, Whately-Smith C, et al. How do patient-reported outcome measures affect treatment intensification and patient satisfaction in the management of psoriatic arthritis? A cross sectional study of 503 patients. Rheumatology (Oxford). 2025;64(1):242-251. doi:10.1093/rheumatology/kead679
2. Helliwell PS, FitzGerald O, Fransen J, et al. The development of candidate composite disease activity and responder indices for psoriatic arthritis (GRACE project). Ann Rheum Dis. 2013;72(6):986-991. doi:10.1136/annrheumdis-2012-201341
3. Salaffi F, Di Carlo M, Carotti M, Farah S, Gutierrez M. The Psoriatic Arthritis Impact of Disease 12-item questionnaire: equivalence, reliability, validity, and feasibility of the touch-screen administration versus the paper-and-pencil version. Ther Clin Risk Manag. 2016;12:631-642. doi:10.2147/TCRM.S101619