Background/Purpose:

Joint count assessment is essential for the diagnosis and ongoing evaluation of Rheumatoid Arthritis (RA) disease activity. In our team based, interprofessional approach to arthritis care, the attending rheumatologist must be able to trust the joint count of fellow rheumatologists and allied health care providers (AHPs). Congruency and accuracy in joint count is imperative for effective collaboration to occur.

Inter-rater variability in assessing tender and swollen joint counts has been well documented, especially with a lack of consistency in swollen joint count (SJC), (ICC range 0.29 to 0.95)1.  As part of continuous quality improvement, we undergo annual joint count intervalidation.  In the Spring 2015, a joint count intervalidation event was held with all team members who routinely perform joint counts.  The aim of this study was two-fold: 1) to estimate the agreement between team members, and 2) to provide training for standardizing joint count assessments.  

Despite a growing interest to use patient-reported joint counts as an outcome measure, some argue (and we concur) that the physician/clinician joint count should remain the standard of care on which treatment decisions are based, and as such a joint count should be conducted at every visit.

Methods:

Ten assessors (4 rheumatologists, 2 physical therapists, 3 occupational therapists, 1 kinesiologist) and six patient volunteers with RA (2 diagnosed within past 12 months, 4 have longer term disease) attended the intervalidation session.  Patients were informed that the purpose of this event was quality assurance, not clinical care.  Assessors were instructed to be as objective as possible, by neglecting the historical comparison of joint status, and to measure counts based on swollen vs. not swollen.  All assessors and patient volunteers attended a debrief session afterwards when SJCs were compared and assessment techniques were discussed. A survey was administered to both assessors and patients to gather their feedback on the event.

Results:

Overall, inter-rater reliability between the 10 assessors on SJC for the 6 RA patients was moderate (ICC: 0.51, 95% CI: 0.30-0.91), with no difference between short and longer-term patients with RA (p>0.05).  Nonetheless, post-event questionnaires revealed that 100% of the rheumatologists and AHPs agreed or strongly agreed that intervalidation was a critical quality assurance initiative and a collaborative process for learning. All 4 rheumatologists reported increased confidence to co-manage RA patients with AHPs after attending the intervalidation session.

Conclusion:  

This is a unique quality assurance initiative designed to foster trust amongst a large interprofessional arthritis care team in a clinical care setting. In the framework of shared care and treat to target approaches, joint count intervalidation within networks of arthritis care providers may be valuable. Further research is necessary to identify opportunities to improve inter-rater agreement and more fully understand how assessor and patient-level factors may contribute to these findings.

1. Cheung PP. et al: Reliability of joint count assessment in rheumatoid arthritis: A systemic literature review.  Semin Arthritis Rheum 2014; 43:721-9

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/evaluating-inter-rater-reliability-in-joint-count-to-promote-quality-and-trust-in-a-clinical-arthritis-care-team/