109outcomes and results of care. An earlier report [ 70 ] highlighted that pain, function,
and RAPID scores should be considered as vital signs in chronic diseases, analo-
gous to pulse and temperature in acute disease and blood pressure and cholesterol
in long-term health conditions. However, whilst more attention has been paid to the
long-term value of PROMs (functional disability is the most signifi cant predictor of
mortality in RA), its short-term value in routine clinical care, role in enhancing the
patient-centered care approach, as well as improving patients’ experience, came to
light recently. This was supported by the results of a recent report [ 71 ] that empha-
sized the expansion of PROMs from the static phase of capturing and measuring
outcomes at a single point of time to a more dynamic role over a long period.
Another study [ 24 ], which looked into sharing the patients’ previous PROMs
records with them either in a paper or electronic format (visual feedback), revealed
that viewing previous PROMs records had a signifi cant positive impact on their
disease activity control as well as compliance to therapy. This was achieved by
helping the patients to be more adherent to their medications and less likely to stop
due to intolerance.
The Biomarker Concept in Rheumatoid Arthritis
Better understanding of the disease pathology and the implementation of recent
radiographic tools (such as ultrasound [US] and magnetic resonance imaging
[MRI]) lead to the concept that RA is a syndrome with different clinical stages.
During the course of the disease (Table 4.2 ), there are four major time points when
crucial decisions are required. First, the stage of early infl ammatory arthritis, in
particular before the diagnostic criteria are fulfi lled where markers for prognosis are
especially needed at this stage. Second, once the diagnosis is established, markers
of disease activity and severity are needed. Third, screening tests for prediction of
response to therapy and progression of the disease, and fi nally, later in the disease
course, markers/predictors of comorbidities and mortality are required to establish
rules to increase treatment success and reduce safety concerns. Therefore, the pro-
posed biomarker(s) should be able to identify these new subsets at the different
critical time points [ 72 ]. The proper timing at this stage creates the so-called “win-
dow of opportunity.”
Table 4.2 The biomark er concept in RA: patient-reported outcome (PRO) parameters in relation
to the 4 major time points in the disease process
Stage Disease process Relevant PRO parameter
First stage Early infl ammatory arthritis Functional disability, morning stiffness,
quality of life
Second stage Established disease activity Patient global assessment, pain score,
patient self-reported joint tenderness
Third stage Prediction of response Functional disability, quality of life
Fourth stage Predictor of co-morbidity Co-morbidity screen, functional disability4 PROMs for Rheumatoid Arthritis