Background/Purpose: Psoriatic arthritis (PsA) is a heterogeneous disease, with involvement of at least five health domains: peripheral joint disease, enthesitis, dactylitis, axial involvement, and skin and nail psoriasis. Because of the heterogeneity of the disease, assessment of disease activity is challenging. One of the many single or composite outcome measures that has been developed is the Psoriatic Arthritis Disease Activity Score (PASDAS). The PASDAS is a comprehensive measure that takes arthritis (66/68 joint score), dactylitis, enthesitis, CRP, physician disease activity VAS score and patient-reported outcomes into account. Furthermore, it is a continuous outcome measure in contrast to the Minimal Disease Activity criteria (MDA), facilitating the longitudinal follow-up of disease activity. The PASDAS also has better parametric distribution and discriminative capacity compared to other outcome measures such as the Disease Activity for PSoriatic Arthritis score (DAPSA). However, feasibility of PASDAS use in routine clinical care has been questioned due to its complexity. It requires a CRP and filled-out SF36 form at time of assessment, does not include a formal skin assessment, is difficult to calculate and is time consuming for both patient and physician. Here we describe our efforts to mitigate these drawbacks and to implement routine measurement of the PASDAS for all 1200 PsA patients in our clinical practice.  

Methods: The implementation consisted of the following stages: 1) assessment of patients’ acceptability of measurement burden; 2) implementation of mathematical calculations of the PASDAS in our electronic health record; 3) PASDAS and skin assessment training of rheumatology nurses and rheumatologists; and 4) (logistic) adjustments to the outpatient visit.

Results: Our patient partners preferred comprehensive clinical assessment of skin and joints above a limited assessment, although the former would be more time consuming. For this reason, and to comply with international guidelines, we decided to also add assessment of skin disease, by using the Body Surface Area (BSA) and Physician Global Assessment score (PGA). Furthermore, research demonstrated that for the PASDAS calculation the physical component score (PCS) of the SF36 could be substituted by the SF12-PCS. As the SF12 is more concise, minimizing patient burden, we chose to implement the SF12 instead of the SF36. To enable hassle free calculation of the PASDAS, the scoring formulas including mannequins for joint, enthesitis and dactylitis scoring, and the SF12v1 together with the skin scores (BSA and PGA) were implemented in our electronic health record. Lastly, we set-up a three phase consultation that consists of laboratory tests and consultation with a rheumatology nurse who performs the physical measurements before each visit with the physician.

Conclusion: Standardized and routine measurement of the PASDAS and skin involvement at each outpatient visit of all our PsA patients before consultation with the treating rheumatologist was successfully implemented, underscoring the feasibility of this approach. In addition to improving clinical care, routine outcome measurements can be used for a variety of clinical studies.  

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/implementing-the-psoriatic-arthritis-disease-activity-score-pasdas-in-routine-clinical-practice-impossible/