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Long-term predictors of health-related quality of life in spondyloarthritis

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Resumo:	Introduction Spondyloarthritis (SpA) is a group of inflammatory rheumatic diseases that share common clinical features, genetic susceptibility, and pathophysiological mechanisms. It includes ankylosing spondylitis, psoriatic arthritis, reactive arthritis, arthritis associated with inflammatory bowel disease, and undifferentiated SpA. Recently, SpA has also been classified into axial SpA (axSpA) and peripheral SpA (pSpA), according to the cardinal manifestations of the disease. SpA is a chronic condition with multi-dimensional burden on physical, mental, social, and economic wellbeing, affecting global functioning and health (GH) and health-related quality of life (HRQoL). Different SpA phenotypes may variably influence GH and the physical, social, and mental HRQoL domains. Factors such as sociodemographic, lifestyle, clinical aspects, and treatments have been associated to GH and HRQoL in patients with SpA but exhibit contradictory findings, making integration challenging. Comparative HRQoL research, especially against chronic low back pain (CLBP), is vital for evidence-based decision-making and patient-centered care. Longitudinal studies are needed to understand the long-term effects on patients’ lives and the fluctuating nature of HRQoL tied to lifestyle factors and therapy. Understanding the SpA phenotypes’ distinct impacts on HRQoL domains is crucial for comprehensive management approaches and improved wellbeing. Objectives The primary objective of this research project was to address the burden of SpA, focusing on HRQoL and physical function, and identify factors associated with these health outcomes, along with their long-term predictors. We aimed to (1) assess the burden of SpA on HRQoL and physical function as compared to the general population; (2) compare HRQoL and physical function between individuals with SpA and individuals with CLBP at a population level; (3) identify factors associated with HRQoL and physical function in individuals with SpA, and CLBP, including sociodemographic characteristics, modifiable lifestyle factors and disease and health characteristics; (4) evaluate long-term HRQoL, and to identify and compare factors associated with HRQoL and GH within the spectrum of spondyloarthritis, including sociodemographic characteristics, modifiable lifestyle factors, clinical characteristics, and treatment-related factors; and (5) estimate the relationship between disease activity and quality of life utilities for economic evaluation in individuals with axial spondyloarthritis. Methodology Data were analyzed from four cohorts: the Epidemiology of Chronic Diseases (EpiDoC) cohort, the Assessment of Spondyloarthritis International Society (ASAS) peripheral involvement in SpA (perSpA) cohort, the Rheumatic Diseases Portuguese Register (Reuma.pt) cohort, and the SPondyloArthritis Caught Early (SPACE) cohort. The main studied outcomes were HRQoL, assessed with the EuroQuality of life five dimensions (EQ-5D) score, the Medical Outcomes Study Short-Form 36 Health Survey (SF-36) questionnaire, or the Ankylosing Spondylitis Quality of Life (ASQoL) score, depending on the cohort; GH, assessed with the Assessment of SpondyloArthritis international Society Health Index (ASAS-HI); and physical function, assessed with the Health Assessment Questionnaire Disability Index (HAQ-DI). Sociodemographic, lifestyle, clinical, and treatment-related variables were collected across the studied cohorts. Results In the EpiDoC cohort, we analyzed 92 patients with SpA, 1,376 individuals suffering from CLBP, and 679 subjects without rheumatic diseases. Our study highlights the considerable impact of SpA on the mental, physical, and social domains of HRQoL in Portugal, providing valuable insights from a population-based perspective. By comparing SpA to CLBP, we shed light on their similar burden on HRQoL. Additionally, we investigated the factors associated with HRQoL in both conditions. In SpA patients, we found that multimorbidity and higher active disease were associated with worse HRQoL. Among CLBP patients, multimorbidity, obesity, and low back pain intensity were associated with worse HRQoL. Notably, regular physical exercise was significantly associated with better HRQoL in both conditions. Furthermore, we confirmed the substantial impact of SpA on physical functioning, assessed by the HAQ-DI. In comparison to CLBP, SpA patients reported higher levels of disability. Factors associated with physical disability were also explored. For SpA patients, higher levels of physical disability were associated with retirement and multimorbidity. Conversely, in CLBP patients, higher physical disability was associated with low back pain intensity, increasing age, obesity, multimorbidity, and retirement. Interestingly, lower physical disability in CLBP was associated with alcohol consumption and being male. Notably, regular physical exercise was associated with reduced physical disability in both conditions. These two studies, collectively underscore the significant impact of SpA and CLBP on various domains of HRQoL and physical functioning when compared to the general population. Furthermore, while SpA and CLBP patients reported similar HRQoL, SpA patients exhibited higher levels of physical disability. The identification of factors associated with HRQoL and physical disability by clinicians, may facilitate more targeted interventions to enhance HRQoL and physical functioning. Given that SpA phenotypes may impact HRQoL domains and GH in distinct ways, we conducted an analysis of associated factors within the perSpA cohort comprising 4,185 SpA patients: 2,719 with axSpA, 433 with pSpA, and 1,033 with psoriatic arthritis. In axSpA, we found that higher disease activity, lower physical function, female sex, and the presence of fibromyalgia were all associated with worse HRQoL. Conversely, older age and having university education were associated with a better outcome. For pSpA patients, higher disease activity and lower physical function were associated with worse HRQoL. In the context of psoriatic arthritis, higher disease activity, lower physical function, axial involvement, and female sex were all associated with worse HRQoL. Meanwhile, with regards to GH assessments for axSpA patients, we observed that higher disease activity, lower physical function, peripheral involvement, female sex, and the presence of fibromyalgia were all associated with worse GH. Conversely, older age and university education were associated with better GH outcomes. For pSpA patients, lower physical function, and female sex were associated with worse GH, while a university education was associated with better GH. Lastly, among psoriatic arthritis patients, higher disease activity, lower physical function, axial involvement, female sex, and the presence of fibromyalgia were associated with worse GH, while older age and university education were associated with a better outcome. This study shows the critical role of disease activity and physical function as major determinants of HRQoL and GH across the different SpA phenotypes. However, it’s important to recognize that clinical characteristics and sociodemographic factors also play an important role, highlighting the need for personalized, patient-centered approaches. In the Reuma.pt cohort, we conducted an analysis of HRQoL in 342 patients with psoriatic arthritis. After a 3-year follow-up, notable improvements were observed in both the EQ-5D score and general perception of health. Predictors of poorer HRQoL encompassed older age, female sex, higher disease activity, exposure to several biologic disease-modifying anti-rheumatic drugs (bDMARDs), and switching between bDMARDs. This study provides valuable insights into the long-term HRQoL in patients of psoriatic arthritis patients, shedding light on determinants of unfavorable outcomes, such as sociodemographic factors and exposure to multiple biologic therapies, which is often indicative of more challenging-to-treat disease. Furthermore, we evaluated long-term HRQoL in axSpA patients, and identified key factors influencing HRQoL. We analyzed 709 patients from the Reuma.pt cohort. Among patients who had never undergone biologic therapy, HRQoL remained stable throughout the entire follow-up period. Conversely, patients already on biologic therapy at baseline, experienced progressive improvement in HRQoL over the 3-year study duration. Predictors of poorer HRQoL included advancing age, active disease, lower physical function, and symptoms of anxiety or depression. Interestingly, patients with blue-collar jobs, but not those with white-collar jobs, reported worse HRQoL compared to non-employed patients. Married patients exhibited better HRQoL. This study provides insights into the long-term HRQoL of axSpA patients, shedding light on factors contributing to poor outcomes, such as increasing age, blue-collar job type, and the presence of anxiety and depressive symptoms. In the study to estimate the relationship (“mapping”) between the Ankylosing Spondylitis Disease Activity Index (ASDAS) instrument and the EQ-5D, we analyzed 5,000 observations from axSpA patients in the Reuma.pt cohort. Subsequently, we tested the proposed model using 400 observations from the SPACE cohort. This study demonstrates the suitability of ASDAS as a reliable tool for estimating quality of life, measured by the EQ-5D utility score, in clinical studies involving individuals with axSpA. Conclusions Our analysis highlights the cumulative impact of CLBP on HRQoL and physical functioning, as well as the influence of SpA on HRQoL, GH, and physical functioning. This research, enhances our understanding of the disease burden across diverse HRQoL domains, as well as its impact on GH, throughout the entire spectrum of SpA. This knowledge offers valuable guidance for development of more targeted interventions (political, clinical) addressing modifiable factors. Through the management of these factors, clinicians can improve wellbeing and enhance overall HRQoL and GH by tailoring interventions applied to the various SpA phenotypes. Lastly, grounded in the data we have gathered in our research, we present a stratified model for health outcomes applicable to the entire spectrum of SpA, which can be subject to validation in future studies.
Autores principais:	Santos, Helena
Assunto:	Spondyloarhritis Quality-of-life Predictors Determinants Outcomes
Ano:	2024
País:	Portugal
Tipo de documento:	tese de doutoramento
Tipo de acesso:	acesso embargado
Instituição associada:	Universidade Nova de Lisboa
Idioma:	inglês
Origem:	Repositório Institucional da UNL