Updated 2019 ACR Recommendations for Rheumatoid Arthritis Disease Activity Measures

The 2019 update of the American College of Rheumatology recommendations on disease activity measurements in rheumatoid arthritis was recently released.

A working group of rheumatologists and rheumatology professionals convened to update the American College of Rheumatology (ACR) recommendations for rheumatoid arthritis (RA) disease activity measures by identifying 11 measures that met the minimum standard and 5 that were preferred for regular use in clinical settings, according to a systematic literature review published in Arthritis Care & Research.1

Researchers examined articles published between January 2009 and January 2017 on the Ovid Medline, EMBASE, and Cochrane databases. Study details and psychometric properties were abstracted, and study quality was assessed by the Consensus-Based Standards for the Selection of Health Measurement Instruments 4-point scoring template. Psychometric properties for each RA disease activity measure were classified as strong, moderate, limited, conflicting, or unknown level of evidence. Researchers also considered prior literature performed as part of the 2012 ACR RA Disease Activity Recommendations.2 They scored feasibility of RA disease activity measures on a scale of 0 to 4, with scores ≥1 indicating measures feasible for regular use and scores of 4 indicating the most feasible measures.

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During the selection process, researchers identified 2 recommendations on RA disease activity measures for use in clinical settings: measures that met a minimum standard for regular use and measures with the most favorable psychometric properties and feasibility for preferred use.

Of the 5199 articles identified, 110 met the study inclusion criteria. Data included in these studies indicated that patients were mostly women with a mean age ≥60 years.

The search resulted in 47 disease activity measures, based on patient-reported, provider assessment, laboratory, and imaging data. Clinical Disease Activity Index (CDAI), Disease Activity Score (DAS) 28, Multibiomarker Disease Activity (MBDA) score, Routine Assessment of Patient Index Data (RAPID) 3, and Simplified Disease Activity Index (SDAI) were the most frequently studied RA disease activity measures, with a strong level of evidence. Among 25 measures scored for feasibility of regular use, 11 (44%) received the highest grading score of 4, 6 measures (24%) received a score of 3, 5 (20%) received a score of 2, and 3 (12%) received a score of 1.

Researchers found that 11 measures, including CDAI, DAS, DAS28-erythrocyte sedimentation rate/C-reactive protein (ESR/CRP), Patient Derived DAS28, Hospital Universitario La Princesa Index, MBDA (MBDA score, VECTRA), Rheumatoid Arthritis Disease Activity Index (RADAI), RADAI-5, RAPID3, RAPID5, and SDAI, met the minimum criteria for RA disease activity measures for regular use. Among these, CDAI, DAS28-ESR/CRP, RAPID3, and SDAI were part of the prior ACR recommendations for RA disease activity measures.

According to results from the modified Delphi voting process, 4 measures, including CDAI, DAS28, RAPID3, and SDAI (mean scores, 8.8, 7.6, 7.6, 7.6 [range, 2.6-5.6], respectively), met the criteria for RA disease activity measures for preferred use. The ACR Quality Measures Subcommittee added another recommendation to these measures, based on its feasibility, current use, and strength of inclusion in previous ACR recommendations: Patient Activity Scale-II.

“These recommendations can assist clinicians with adhering to a treat-to-target approach for the management of RA but should not be interpreted as dictating the ‘proper’ measure to be used in individual circumstances or clinical practices. As additional measures are developed and performance of measures is further characterized, these recommendations should again be evaluated,” the researchers concluded.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


1. England BR, Tiong BK, Bergman MJ, et al. 2019 update of the American College of Rheumatology recommended rheumatoid arthritis disease activity measures [published online November 11, 2019]. Arthritis Care Res. doi:10.1002/acr.24042

2. Anderson JK, Zimmerman L, Caplan L, Michaud K. Measures of rheumatoid arthritis disease activity: Patient (PtGA) and Provider (PrGA) Global Assessment of Disease Activity, Disease Activity Score (DAS) and Disease Activity Score With 28‐Joint Counts (DAS28), Simplified Disease Activity Index (SDAI), Clinical Disease Activity Index (CDAI), Patient Activity Score (PAS) and Patient Activity Score‐II (PASII), Routine Assessment of Patient Index Data (RAPID), Rheumatoid Arthritis Disease Activity Index (RADAI) and Rheumatoid Arthritis Disease Activity Index‐5 (RADAI‐5), Chronic Arthritis Systemic Index (CASI), Patient‐Based Disease Activity Score With ESR (PDAS1) and Patient‐Based Disease Activity Score Without ESR (PDAS2), and Mean Overall Index for Rheumatoid Arthritis (MOIRA) [published online November 7, 2019]. Arthritis Care Res. doi:10.1002/acr.20621