Measuring Agreement in the Ultrasonographic Evaluation of Disease Activity in Rheumatoid Arthritis Patients. a Latin-American Multicenter Exercise Assessing the Influence of Sonographer Experience and Expertise

Tomas Cazenave¹, María Victoria Martire^2,3, Christian A. Waimann⁴, Edith Alarcón⁵, Lucio Ventura⁶, Walter J. Spindler⁷, Christina Hernandez-Diaz⁸, Javier Rosa⁹, Santiago Ruta⁹, Mara Guinsburg¹⁰, Gustavo Rodriguez Gil¹¹, Cecilia Urquiola¹², Guillermo Py¹³, Magalí Alva¹⁴, Patricio Tate¹⁵, Carmen Cerón¹⁶, Lida Santiago¹⁵, Ana Laura Alvarez del Castillo Araujo¹⁷, Maria Jezabel Haye Salinas¹⁸, Erika Catay¹⁹, Maximiliano Bravo¹⁹, Johana Zacariaz⁹, Clarisa Sandobal²⁰, Gonzalo Pacheco²¹, Mariana Benegas²², David Navarta²³, Verónica Arturi^24,25, Ana Bertoli²⁶, Marcelo Audisio²⁷, Carlos Pineda²⁸, Natalia Estrella²⁹, Carla Airoldi³⁰, Paula Kohan³¹, María Julia Santa Cruz³², Lina Saldarriaga Rivera³³, Romulo Wong³⁰, Ignacio Carrillo³⁴, Hugo Najera²¹, Julio García³⁵, Daniele Freitas Pereira³⁶, Fernanda Athayde Cardoso Linhares³⁷, José Alexandre Mendonça³⁸, Maritza Quintero³⁹, Anthony M. Reginato⁴⁰, Eliana Natalí Ayala Ledesma³⁵, Lorena Urioste⁴¹, Eugenio De Miguel⁴², María Soledad Gálvez Elkin⁴³, Carla Saucedo⁴⁴, Josefina Marin⁹, Rodolfo Arape⁴⁵, Marwin Gutierrez³³ and Marcos Rosenffet¹, ¹Instituto de Rehabilitación Psicofísica, Buenos Aires, Argentina, ²Rheumatology, Hospital Bernardino Rivadavia, Buenos Aires, Argentina, ³Rheumatology, Hospital Italiano de La Plata, La Plata, Argentina, ⁴Rheumatology, Hospital Dr. Hector Cura, Olavarria, Argentina, ⁵Hospital San Juan de Lurigancho, Lima, Peru, ⁶Instituto Nacional de Rehabilitación, Ciudad de México, Mexico, ⁷Centro Médico Privado de Reumatología, Tucuman, Argentina, ⁸Instituto Nacional de Rehabilitación, Mexico City, Mexico, ⁹Rheumatology Unit, Internal Medicine Service, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano de Buenos Aires, and Fundacion PM Catoggio, Buenos Aires, Argentina, ¹⁰Rheumatology, Hospital Municipal Dr. Leónidas Lucero, Bahia Blanca, Argentina, ¹¹Hospital Municipal de agudos Dr. Leonidas Lucero, Bahía Blanca, Argentina, ¹²Hospital Municipal Dr. Leónidas Lucero, Bahia Blanca, Argentina, ¹³Servicio de Reumatología del Hospital Nacional de Clínicas, Córdoba., Cordoba, Argentina, ¹⁴Hospital Rebagliati, Jesús María, Peru, ¹⁵Organizacion Médica de Investigación, Buenos Aires, Argentina, ¹⁶Medicarte IPS, Medellín, Colombia, ¹⁷IMSS HES 25, Monterrey, Mexico, ¹⁸Hospital Privado Centro Médico de Córdoba, Córdoba, Argentina, ¹⁹Consultorios Moreno, Formosa, Argentina, ²⁰Hospital José María Cullen, Santa Fe, Argentina, ²¹Hospital Durand, Buenos Aires, Argentina, ²²PSORIAHUE, Buenos Aires, Argentina, ²³Hospital Marcial Quiroga, San Juan, Argentina, ²⁴Hospital Italiano de La Plata, La Plata, Argentina, ²⁵Hospital Rossi, La Plata, Argentina, ²⁶Instituto Reumatológico Strusberg, Córdoba, Argentina, ²⁷Servicio de Reumatología del Hospital Nacional de Clínicas, Córdoba, Argentina, ²⁸Instituto Nacional de Rehabilitation, Mexico, Mexico, ²⁹Consultorio Privado, Buenos Aires, Argentina, ³⁰Hospital Provincial, Rosario, Argentina, ³¹Hospital Dr. E. Tornu, Buenos Aires, Argentina, ³²Hospital Dr. E. Tornú, Buenos Aires, Argentina, ³³Instituto Nacional de Rehabilitación, Mexico, Mexico, ³⁴Hospital Pablo Soria, San Salvador de Jujuy, Argentina, ³⁵Hospital Nacional Arzobispo Loayza, Lima, Peru, ³⁶Universidade Federal de São Paulo, São Paulo, Brazil, ³⁷Instituto Nacional de Reumatologia, Montevideo, Uruguay, ³⁸Hospital da Pontifícia Universidade Católica de Campinas., Campinas, Brazil, ³⁹Instituto Autónomo Hospital Universitario de Los Andes, Universidad de Los Andes, Mérida, Venezuela, ⁴⁰Rhode Island Hospital, The Warren Alpert School of Medicine at Brown University, Providence, RI, ⁴¹Reumatología Diagnóstica Especializada, Santa Cruz de la Sie, Bolivia, ⁴²Hospital Universitario La Paz, Madrid, Spain, ⁴³Instituto de Cardiologia, Santiago del Estero, Argentina, ⁴⁴Hospital Anita Elicagaray, Adolfo Gonzales Chaves, Argentina, ⁴⁵Centro Clínico La Isabelica, Carabobo, Venezuela

Meeting: 2016 ACR/ARHP Annual Meeting

Date of first publication: September 28, 2016

Keywords: rheumatoid arthritis (RA) and ultrasonography

Session Information

Date: Sunday, November 13, 2016

Title: Imaging of Rheumatic Diseases - Poster I: Ultrasound and Emerging Technologies

Session Type: ACR Poster Session A

Session Time: 9:00AM-11:00AM

Background/Purpose: Ultrasonography (US) is an important tool in rheumatology practice. However, it highly depends on sonographer’s experience. The objective of our study was to evaluate intra and inter-reader reliability of ultrasound assessment in rheumatoid arthritis (RA) using a Score named REUMA (Rapid Evaluation by US to Monitor Arthritis) among observers across Latin American using a web tool.

Methods: We conducted a cross-sectional study. Fifty-one Latin American ultrasonographers with different experience took part in a web- based US reading exercise evaluating static images from 20 RA patients. The 4 – joints US scores was calculated for each patient including bilateral radiocarpal, midcarpal and second metacarpophalangeal joints. Power Doppler (PD) and gray scale (GS) were graded from 0 to 3. US scores comes as the result of the addition of PD and GS score, with a total score ranged from 0 – 36, being 36 the highest disease activity. Five patients were evaluated twice in order to address intra – rater reliability. The inter and intra-rater reliability was assessed using a two-way random, absolute, individual and average-measures intra-class correlation coefficient (ICC), with reliability being poor for ICC <0.40, fair for 0.40 to 0.59, good for 0.60 to 0.74, and excellent for values between 0.75 and 1.0. Furthermore, we stratified sonographers according to US experience (defining High experience as: at least 5 years of experience and 80 US assessments/month), evaluating differences in intra – reader reliability, inter-reader reliability, and variation of observers means between patients. Statistical significance was assessed at a type I error rate of 0.05.

Results: A total of 1020 US image assessments were performed. Mean 4-joints US score was 17 ± 8 (Doppler subscale 10 ± 4; Synovitis subscale 7 ± 4). The ICC was in the excellent range for intra [(individual ICC = 0.945 (IC95% 0.905 – 0.965); average ICC = 0.972 (IC95% 0.950 – 0.982)] and inter- reader reliability [(individual ICC = 0.867 (IC95% 0.786 – 0.934); average ICC = 0.997 (IC95% 0.995 – 0.999)]. When comparing high with low experience sonographers, there was no significant differences in intra-class correlation coefficient. However, there was a greater variation between the means among low experience readers, ranging from 13 to 22, in comparison with 14 to 18 in higher experience sonographers (Figure 1), which could introduce a bias to inter – reader reliability estimates.

Conclusion: Ultrasonography represents an excellent complementary tool to evaluate disease activity in patients with rheumatoid arthritis. However, its reliability is related to sonographer expertise and experience. Low – experience readers exhibit a higher variation on disease activity estimates. It is necessary to develope US training programs in order to improve reliability. Figure 1. Agreement with the mean between multiple observers in total score, gray and power doppler subscale.

Disclosure: T. Cazenave, None; M. V. Martire, None; C. A. Waimann, None; E. Alarcón, None; L. Ventura, None; W. J. Spindler, None; C. Hernandez-Diaz, None; J. Rosa, None; S. Ruta, None; M. Guinsburg, None; G. Rodriguez Gil, None; C. Urquiola, None; G. Py, None; M. Alva, None; P. Tate, None; C. Cerón, None; L. Santiago, None; A. L. Alvarez del Castillo Araujo, None; M. J. Haye Salinas, None; E. Catay, None; M. Bravo, None; J. Zacariaz, None; C. Sandobal, None; G. Pacheco, None; M. Benegas, None; D. Navarta, None; V. Arturi, None; A. Bertoli, None; M. Audisio, None; C. Pineda, None; N. Estrella, None; C. Airoldi, None; P. Kohan, None; M. J. Santa Cruz, None; L. Saldarriaga Rivera, None; R. Wong, None; I. Carrillo, None; H. Najera, None; J. García, None; D. F. Pereira, None; F. Athayde Cardoso Linhares, None; J. A. Mendonça, None; M. Quintero, None; A. M. Reginato, None; E. N. Ayala Ledesma, None; L. Urioste, None; E. De Miguel, None; M. S. Gálvez Elkin, None; C. Saucedo, None; J. Marin, None; R. Arape, None; M. Gutierrez, None; M. Rosenffet, None.

To cite this abstract in AMA style:

Cazenave T, Martire MV, Waimann CA, Alarcón E, Ventura L, Spindler WJ, Hernandez-Diaz C, Rosa J, Ruta S, Guinsburg M, Rodriguez Gil G, Urquiola C, Py G, Alva M, Tate P, Cerón C, Santiago L, Alvarez del Castillo Araujo AL, Haye Salinas MJ, Catay E, Bravo M, Zacariaz J, Sandobal C, Pacheco G, Benegas M, Navarta D, Arturi V, Bertoli A, Audisio M, Pineda C, Estrella N, Airoldi C, Kohan P, Santa Cruz MJ, Saldarriaga Rivera L, Wong R, Carrillo I, Najera H, García J, Pereira DF, Athayde Cardoso Linhares F, Mendonça JA, Quintero M, Reginato AM, Ayala Ledesma EN, Urioste L, De Miguel E, Gálvez Elkin MS, Saucedo C, Marin J, Arape R, Gutierrez M, Rosenffet M. Measuring Agreement in the Ultrasonographic Evaluation of Disease Activity in Rheumatoid Arthritis Patients. a Latin-American Multicenter Exercise Assessing the Influence of Sonographer Experience and Expertise [abstract]. Arthritis Rheumatol. 2016; 68 (suppl 10). https://acrabstracts.org/abstract/measuring-agreement-in-the-ultrasonographic-evaluation-of-disease-activity-in-rheumatoid-arthritis-patients-a-latin-american-multicenter-exercise-assessing-the-influence-of-sonographer-experience-and/. Accessed .

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