Tight Control of Disease Activity Among Patients With Rheumatoid Arthritis Based on a Systematic Telemedicine Treatment Strategy

Rheumatoid arthritis (RA) is a chronic disease affecting 0.5-1.0 % of the Danish population. Due to an expected growing population and a higher proportion of elderly the prevalence is likely to increase in the years to come.

Untreated RA will lead to joint destruction disabling the patients, but in recent years both treatment and treatment strategies have been markedly improved. According to international guidelines early start of medical treatment, quick escalation of doses, and adjustment of the dose throughout the whole disease course when there are signs of disease activity, are considered important elements in the RA treatment strategy. Consequently, the success of this strategy implies the possibility of regular routine testing of all RA patients, which could become a challenge to the health care system causing substandard treatment to RA patients in the future. This calls for reorganization of the routine care of RA, i.e. in form of a telemedicine intervention.

Telemedicine is considered to be the use of communication and information technologies to deliver clinical care where the individuals involved are not at the same location. No studies have yet investigated the effect of monitoring disease activity through a standardized telemedicine treatment strategy in patients with RA, and most of the evidence is derived from studies within chronic heart disease, chronic obstructive lung disease, asthma, diabetes and hypertension. This evidence indicates, however, that telemedicine interventions seem to be effective, time saving and associated with a high degree of patient satisfaction.

RA disease activity is measured using a composite score that includes both objective and subjective outcome parameters to measure present as well as past disease activity. These scores include: tender and swollen joint count together with the patient's global assessment, report of physical functioning, the measurement of an acute-phase reactant and serial radiographic assessment. The most commonly used instruments for measuring RA disease activity in daily clinical practice is the European League Against Rheumatism (EULAR) criteria, the Disease Activity Score 28 (DAS28).

However, in a telemedicine intervention there is no direct physical contact between the patient and the health professionals, making traditional disease activity measures unfit for use, as they imply an assessment of tender and swollen joints carried out by a health professional. It has been suggested to let the patients examine their joints. Still, it has been shown that patients tend to overestimate the presence of swollen joints which impairs the identification of synovitis - and thereby disease activity and flare. Hence, telemedicine disease activity monitoring in RA may be best supported by validated measures based on other kinds of patient self-assessment, i.e. the newly developed "Flare" instrument.