Evaluating the Use of Patient Reported Outcome Measures to Assess Intra-Pandemic Psoriatic Arthritis Disease Activity and Comparing Them with Pre-Pandemic Clinical Assessments

Background/Aims In our department, patient reported outcome measures (PROMs), including RAPID-3 and PSAID12, were employed during the COVID-19 pandemic in asynchronous consultations for patients with psoriatic arthritis (PsA). We compared pre-pandemic DAS28-CRP with intrapandemic PROMs to assess changes in disease activity since the pandemic. Whilst previous studies have primarily compared PsA PROMs with clinician-assessed scores (e.g. PASDAS), we compare PsA PROMs with clinicians' overall assessment of disease activity;this judgement considers PROMs, serology studies and individual patient feedback. Finally, we assess whether patients with PROMs indicating active disease were followed up appropriately. Methods Clinician-assessed scores were collected between 01/01/2019-01/03/ 2020 (''pre-pandemic''). Between 01/12/2020-31/03/2022 (''intrapandemic''), patient data from electronic surveys were analysed in a secure database for calculation of PROMs. These data, alongside blood results and patient comments, informed clinicians' triage decisions. Clinical outcome data were collected from electronic patient records;>=3 months follow-up appointment allocation was the target for patients with active disease (moderate/high disease activity). Data analysis was performed using r (version 4.2.2). Results In our pre-pandemic cohort (n=393), 79.8% of patients were in remission (per DAS28-CRP). Conversely, the intra-pandemic cohort (n=231) showed remission rates of 14.3% (per PSAID12) and 0% (RAPID-3). Indeed, 33.7% (based on PSAID12) vs 75.8% (RAPID-3) had moderate/ high disease activity. These results were validated in a paired cohort (n=38, score recorded in both windows). Disease activity worsened during the pandemic for 63.2% (PSAID12) and 97.4% (RAPID-3) of patients. PSAID-12 correlated positively with RAPID-3 (r=0.52, p<0.001), especially when RAPID-3 >=6.5 (r=0.75, p<0.001). When comparing PROMs with clinicians' assessment of PsA activity in our paired cohort, PSAID12 and RAPID-3 accurately reflected disease status in 70.6% and 58.8% of patients respectively. 3/9 and 9/27 patients with active disease, based on PSAID12 and RAPID-3 respectively, were seen within three months. Conversely, 7/10 patients who clinicians had deemed to have active disease were seen within three months. Conclusion Despite approximately 80% of patients being in pre-pandemic remission, the majority reported active intra-pandemic PsA. Whilst RAPID-3 skewed patients towards active disease, PSAID12 skewed patients towards remission/low disease activity. PSAID-12 and RAPID- 3 have been previously correlated;however, here we suggest that they could be used interchangeably in patients with high disease activity. PSAID-12 was a better predictor of clinicians' assessment of disease activity, although neither PROM correlated well with >=3 months followup appointment allocation. Although RAPID-3 and PSAID12 helped inform clinicians' decisions, neither alone sufficiently reflects patients' disease states. Remote management is practicable, but future studies should validate these findings across a larger cohort and assess the utility of different PROMs across PsA disease activity categories. Furthermore, multivariate analysis is warranted to ascertain which (combination of) variable(s) (e.g., PROMs, serology results, tender/ swollen joint count) best correlates with clinician judgement.

Comparison of disease activity outcome virtually (tele-rheumatology) and face-to- face disease activity scores for patients with rheumatoid arthritis: A prospective study

Background and Aim: Since the emergence of COVID-19, tele-rheumatology care has presented as an appealing alternative way for accessing health care. The efficacy of tele-care needs to be evaluated in our setting. This study aimed at assessing the agreement between the tele-visit and the face-to- face clinic-based visit. Methodology: We prospectively recruited patients with rheumatoid arthritis;who were following up in the out-patient department clinics between December 2021 and May 2022. Each patient underwent disease activity assessment by means of disease activity score 28-c- reactive protein (DAS28-CRP) and disease activity score28-erythrocyte sedimentation rate (DAS28-ESR). Within two weeks from the face-to- face visit, we virtually assessed their disease activity, through a telephone-based interview, by applying Routine Assessment of Patient Index Data 3 (RAPID3) score, collecting data on demographics and inquiring about satisfaction with the tele-visit. Disease activity scores were categorized into remission or low disease activity, and moderate to high disease activity. Result(s): In our study, 78 patients were recruited and completed the two-points interview. A total of 62(79.49%) of the participants were female;mean age of 54.73 +/- 13.71 years. Seropositivity for rheumatoid factor and/or anti-citrullinated peptide was found in 51(83.61%) participants. 27% of patients with RAPID3 had remission or low disease activity. While this was 71% and 33% for DAS28-CRP and DAS28-ESR, respectively. Moderate to high disease activity percentage of 73%, 29% and 67% were found in RAPID3, DAS28-CRP and DAS28-ESR, respectively. Furthermore, the correlations of RAPID 3 were relatively moderate but significant with DAS28-CRP (r = 0.6, P-value < 0.001) and DAS28-ESR (r = 0.4, P-value = 0.001), respectively. Satisfaction rates with the tele-visit were at odds with other reported publications. Conclusion(s): Tele-rheumatology assessment of disease activity for patients with rheumatoid arthritis appears to be feasible in our setting. Further studies should aim at assessing patients' satisfaction and the recently implemented video-based tele-clinics.

ANALYSIS of the ACCEPTANCE and USEFULNESS of A NON-PRESENTIAL CONSULTATION, in PATIENTS with CHRONIC INFLAMMATORY JOINT DISEASES USING A DIGITAL PLATFORM

Background: The Covid-19 pandemic has meant a modifcation of the patterns of the doctor-patient relationship, favoring online visits and reducing face-to-face visits. Likewise, the implementation of Patient-Reported Outcomes (PROs) that do not require the intervention of the doctor in our clinical practice and that given their close relationship with the clinical activity of chronic infammatory joint diseases (CIJD) has favored an empowerment of patients and can allow the development of the online visit. Objectives: Know the use and acceptance of patients with CIJD: rheumatoid arthritis (RA), psoriatic arthritis (PsA) and spondyloarthropathies (SpA) of a non-face-to-face online visit, through a digital environment. Methods: Patients were included in a platform called Rheumanet for access by username and passwords (https://www.laconsultacercadetI.com/). At the time of inclusion, demographic variables were collected: date of birth, sex, level of education (primary education, secondary education, vocational training, further education and higher education), distance from the hospital to the patient's home, and clinical variables such as diagnosis: RA, PsA or SpA, as well as the duration of the disease. Prior to the appointment, patients were encouraged to complete a PRO survey to assess their clinical situation: Routine Assessment of Patient Index Data 3 (RAPID3) for RA, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) for SpA and RAPID3 and/or BASDAI for the PsA. Both the RAPID3 and BASDAI were scored for the patient's knowledge and assigned to a color scale based on disease activity in green (remission or low activity), orange (moderate activity) or red (severe activity). Likewise, they were ordered to express through a free text what they would tell us as if they were in a face-to-face consultation. Complementary tests (analytical, radiological studies and others) are obtained simultaneously from the medical records and a joint assessment of the visit is carried out. Results: Between September 1, 2020 and January 31, 2022, a total of 248 patients (113 RA, 53 SpA and 82 PsA) were included in the platform. 172 (69.3%) patients used the digital platform and made at least one non-face-to-face visit during follow-up. The number of online visits made by each patient ranged from 1 to a maximum of 13 visits. 80 patients (70.7%) suffered from RA, 40 (75.4%) from SpA and 52 (63.4%) from PsA. The number of patients who made non-face-to-face visits was 38 (72.3%) for a disease duration of <5 years and 137 (64.5%) for >5 years. When the ages of the patients were analyzed, the number of patients who made visits was 75 (73.5%) between 18 and 30 years old, 50 (67.7%) between 30 and 50 and 47 (66.4 %) from 50 years. According to the degree of activity of the disease, 75 patients were in remission or low activity at some point during the visits, 63 patients with moderate activity and 34 with severe activity. The distribution according to level of education was: 11 (6.3%) primary education, 21 (12.2%) secondary education, 37 (21.5%) vocational training, 63 (36.6%) further education and 40 (23.2%)higher education. The number of online visits was higher in patients who lived at a distance of 50 km or more from the hospital, reaching 100% of the visits in this subgroup of patients. Conclusion: The online visit through a digital platform through PROs is well accepted by our population with CIJD, especially in the young population, with a higher cultural level and whose home is far from the hospital. The online visit was made by patients regardless of the severity of their disease activity. Speed and ease of use using PROs already known to the patient and clinician is an important consideration for rheumatolo-gists working in healthcare systems where patient contact time is limited. It would be interesting to obtain this information in non-pandemic situations such as COVID-19, which would make it possible to assess actual acceptance and its use in this type of patient in circumstances in which fear of contagion is not a variabl to consider.

STRESS-ASSOCIATED INCREASES in RHEUMATOID ARTHRITIS DISEASE ACTIVITY and FLARES during the COVID-19 PANDEMIC

Background: The novel coronavirus disease 2019 (COVID-19) pandemic has spurred global action. Beginning in March of 2020, the Southern California COVID-19 pandemic response to limit virus transmission was characterized by mandated lockdowns and quarantines, resulting in signifcant stressors for rheumatology patients and potentially threatening their disease. Objectives: To examine factors associated with changes in rheumatoid arthritis (RA) disease activity and fares in the COVID-19 pandemic. Methods: RA patients identifed by ICD-9/10 codes and active email addresses within a University of California, Los Angeles (UCLA) Rheumatology database were sent surveys via email in July and November of 2020. The survey was UCLA Institutional Review Board approved and included electronic consent and questions related to: perceptions of disease activity/remission via Routine Assessment of Patient Index Data 3 (RAPID3), fare frequency, RA fare questionnaire (RA-FQ), Perceived Stress Scale (PSS-4), and pandemic impact on stress (I.e. emotional state, apprehension, panic, helplessness, work, home, fnancial, and social distancing stress). Demographics were extracted from electronic medical records. Results were examined via descriptive analyses, Pearson correlations, and chi-square test for comparisons plus linear stepwise regressions where appropriate to evaluate the relationship between stress measures, RA disease activity, and fare frequency and severity. Results: Among 5037 patients surveyed, 361 in July and 4676 in Novem-ber,1128 (22.4%) responded. The study population demographics were: mean age of 57.5 ± 15.1 years, 79.4% female, racially diverse (69.6% Caucasian, 13.7 % LatinX, 9.5 % Asian, and 4.9% Black), and 62% seropositive (CCP and/or RF). Perceived disease activity and remission remained stable in most patients with 719 reporting no fares, and 409 in current fares at the time of the survey (Table 1). A minority reported perceived increases in disease activity which were associated with multiple aspects of perceived stress. At survey completion, 346 had not experienced fares, 290 had experienced one fare, and 492 had experienced multiple fares. Use of DMARDs was associated with lack of fare versus current fare (77.8% versus 71.6%, p = 0.02). The use of conventional synthetic, biologic, or targeted synthetic DMARDs were not associated with fare while current corticosteroid use was associated with fare (9.3% without fare and 20.8% with fare, p < 0.0001). Current fare was associated with increased PSS-4 scores (odds ratio (OR): 1.17 (95% confdence interval: 1.12-1.22, p < 0.0001). Figure 1 describes the odds ratio of experiencing aspects of stress with the presence of RA fare. Conclusion: In a large survey population of RA patients during the COVID-19 pandemic, multiple aspects of stress were found to correlate with RA disease activity and fare.

DMARD DISRUPTION, INCREASED DISEASE ACTIVITY, and PROLONGED SYMPTOM DURATION after ACUTE COVID-19 among PATIENTS with RHEUMATIC DISEASE: A PROSPECTIVE STUDY

Background: Systemic autoimmune rheumatic disease (SARD) patients may be at risk for disease fare and prolonged symptom duration after COVID-19, perhaps related to DMARD disruption and immune activation. Objectives: To describe DMARD disruption and identify differences in SARD activity among patients with and without prolonged COVID-19 symptom duration. Methods: We identifed all SARD patients with confrmed COVID-19 at the Mass General Brigham healthcare system in Boston, USA;prospective recruitment is ongoing. Surveys were used to collect demographics, clinical characteristics, DMARD disruption, COVID-19 course, and SARD disease activity before and after COVID-19. The survey included validated instruments measuring disease activity, pain, fatigue, functional status, and respiratory quality of life. Prolonged symptom duration was defned as COVID-19 symptoms lasting ≥28 days. We compared differences in patient-reported measures between those with and without prolonged symptoms. Results: We analyzed survey responses from 174 COVID-19 survivors with SARDs (mean age 52±16 years, 81% female, 80% White). The most common SARDs were RA (40%) and SLE (14%). Fifty-one percent of the 127 respondents on any DMARD reported a disruption to their regimen at COVID-19 onset (Figure 1). Among individual DMARDs, 56-77% were reported to have any change, except for hydroxychloroquine (23%) and rituximab (46%). SARD fare after COVID-19 was reported by 41% of respondents (Table 1). Patient global assessment of SARD activity was worse after COVID-19 (mean 7.6±2.3 before vs. 6.6±2.9 after COVID-19, p<0.001). Prolonged symptom duration was reported by 45% of participants. Those with prolonged symptoms had a higher initial COVID-19 symptom count (median 7 vs. 4, p<0.001) and were more likely to be hospitalized for COVID-19 (28% vs. 17%, p=0.001). Respondents experiencing prolonged symptom duration had higher disease activity on RAPID3 (p=0.007) as well as more pain (p<0.001) and fatigue (p=0.03) compared to those without prolonged symptoms. Conclusion: DMARD disruption, SARD fare, and prolonged symptoms were common in this prospective study of COVID-19 survivors with SARDs. Those with prolonged COVID-19 symptom duration, defned as ≥28 days, had higher SARD activity, more pain, and more fatigue compared to those without prolonged symptoms. These fndings suggest that post-acute sequelae of COVID-19 may have a large impact on underlying SARD activity and quality of life.

SAFETY and IMMUNOGENICITY of COVID-19 VACCINES in PATIENTS with IMMUNE MEDIATED INFLAMMATORY DISEASE

Background: COVID-19 vaccination strategies have evolved with increasing vaccine availability and emerging vaccine safety data. While data on immuno-genicity and safety of COVID vaccination strategies exists, there is limited data for people with immune mediated infammatory diseases (IMIDs) such as infam-matory arthritis (IA), systemic autoimmune rheumatic disease (SARD), infam-matory bowel disease (IBD) and multiple sclerosis (MS). Objectives: In IMID patients treated with homologous or heterogeneous COVID vaccines, to compare post vaccine IMID disease activity and COVID antibody responses. Methods: Between March 2021 and Dec 2021, patients with IA (n= 70;77% rheumatoid arthritis), SARD (n=82;70% lupus), IBD (n= 92;40% crohn's), and MS (n= 71;77% RRMS) self-reported COVID illness and exposure risks, and disease activity prior to and 1 month post both COVID-19 vaccinations (V1 and V2). Disease activity was assessed by the Systemic Lupus Activity Questionnaire (SLAQ) for SARDs, the RAPID-3 and RA fate index for IA, the IBD Symptoms Inventory-short form (IBDSI) and IBD fare index for IBD and the 25 meter walk and 9 hole peg test and Expanded Disability Status Scale (EDSS) for MS. Patient reported fare state was assessed using the relevant questions these indices (SLAQ 'Have you had a fare?';RA Flare index 'Are you in a fare?';IBD fare 'My IBD is sometimes to continously active'). Disease activity and serum anti-spike, anti-receptor binding domain (RBD) and anti-nucleocapsid (NC) IgG antibody titers at 30 days post V2 were compared across vaccine courses and to age-sex matched vaccinated blood donor controls (CNTS). Results: Patients were predominantly female (79.7%), with a mean (standard deviation-sd) age of 56 (15) years;8% had suspected or diagnosed COVID-19 illness;1.2% positive anti-NC (Table 1). For all IMIDS, the majority received mRNA vaccines-BNT162b2 (BNT) or mRNA1273 (V1 74%;V2 97%;) the rest received ChAdOx1 viral vector vaccines;71% received homologogous vaccines (ChAdOx1-ChAdOx n=6;BNT-BNT n=174;mRNA1271-mRNA1273 n=21;ChAdOx1-BNT n=36;ChAdOx1-mRNA1273 n=30;BNT-mRNA1273 n=15;mRNA1273-BNT n=3;other n=4). For most IMIDs, disease activity was similar before and after each vaccination. Post V2 disease activity did not differ between homologous versus heterologous vaccines nor by vaccine type (RAPID3;SLAQ, 25 meter walk and 9 hole peg test and EDSS overall and subscales, IBDSI overall and subscales all p=NS). In 254 IMIDs, most seroconverted (anti-spike 86%;anti-RBD 96%). Seroconversion rates for CNTS were 98.1% for anti-Spike and 3.5% for anti-NC. Antibody titers were higher following homologous mRNA (BNT or mRNA12723) than homologous vector vaccine (Figure 1). For IMIDs primed with ChAdOx vector vaccine, boosting with BNT or mRNA1273 generated similarly increased anti-Spike and anti-RBD titers. Conclusion: Heterologous COVID vaccination improves seroconversion rates following a viral vector vaccine and does not lead to disease fare in most IMID patients. While data is needed to assess vaccine effectiveness, duration of immu-nogenicity and effects of subsequent vaccination, this work supports mixing COVID vaccines for IMID patients.

PSYCHOSOCIAL IMPACTS of the COVID-19 PANDEMIC on ETHIOPIAN and CANADIAN RHEUMATOLOGY PATIENTS

Background: The Coronavirus-2019 (COVID-19) pandemic increased psychosocial distress in the general population and in patients with rheumatic disease. Limited data exists on the impact of COVID-19 in rheumatology patients living in Africa. Objectives: To describe COVID-19 related illness and psychosocial impact in Ethiopian (ET) rheumatology patients attending the only public rheumatology clinic in Ethiopia (Tikur Anbessa Specialized Hospital (TAH) in Addis Ababa). To compare fndings in ET with fndings in Canadian (CA) rheumatology patients. Methods: Between May 1 and Oct 31 2021, 130 patients attending the TAH rheumatology clinic answered questions related to COVID-19 infection, symptoms and testing, and psychosocial impacts of the COVID-19 pandemic. We assessed depression (Patient Health Questionnaire-9), anxiety (General Anxiety Disorder-7;GAD7), COVID-19 stress factors and coping measures, Resilience (Brief Resilience Scale-BRS) and medication compliance (Morisky medication adherence scale-4 item;MAS4). Rheumatic disease severity was assessed with the Routine Assessment of Patient Index Data-3 (RAPID-3). Questionnaires were translated to Amharic. Descriptive statistics are reported [mean (standard deviation), median (25%, 75%) number and percent.)] and compared to data of 97 CA patients with rheumatoid arthritis (RA) and lupus patients from Quebec1. Results: ET patients were mainly female (71%) with a mean (SD) age of 47 (16), and resided in the capital city (Addis Ababa) (72%). Half had RA or lupus. A quarter of patients had moderate to severe rheumatic disease severity desite good medication adherence [MAS4 score of 3(2,4)]. Most (89%) reported no COVID-19 symptoms since the beginning of the pandemic, were not tested for COVID-19 and reported few risk factors for COVID-19 exposure. Eight (6%) ETs were diagnosed with COVID-19;2 required hospitalization. Diagnosed patients reported a median of 2 COVID-19 symptoms (range 0-8;mainly cough, fever and malaise). Within the entire cohort, depression (PHQ9= 10 or above) and anxiety (GAD7=10 or above) were more frequent in ETs than CAs (depression 30% vs 3%;anxiety 16% vs 1%) yet nearly half (47%) of ETs had normal or high resilience levels. The most common COVID-19 stressors were risk of contracting COVID illness personally [ETs vs CAs risk ratio(95% confdence limits-CL);0.67 (0.5, 0.99)] or of loved one [0.56 (0.36, 0.86)]. More ETs reported COVID-19 related stress related to difficulty obtaining food, medicine or other essentials [1.74, (1.00-3.0)], and getting needed supports [1.97 (1.03, 3.77)] (Table 1). CAs and ETs used similar levels of problem solving [median (25%,75%) CA 3.3 (2.8, 3.3), ET 3.5 (3.0, 3.7)] and emotion-focus [CA 2.5 (2.2, 3.1);ET 3.3 (2.8, 3.7)] coping strategies. Conclusion: During the COVID-19 pandemic, depression was more common in ETs compared to CAs with rheumatic disease. COVID-19-related stressors due to insecurity in obtaining the basic essentials and support were more pronounced in ETs. Differences between ETs and CA in these stressors may refect local public health and economic supports. There were no differences in coping strategies.