Reliability of joint count assessment in rheumatoid arthritis: A systematic literature review

BackgroundJoint counts are central to the assessment of rheumatoid arthritis (RA) but reliability is an issue.ObjectivesTo evaluate the reliability and agreement of joint counts (intra-observer and inter-observer) by health care professionals (physicians, nurses, and metrologists) and patients in RA, and the impact of training and standardization on joint count reliability through a systematic literature review.MethodsArticles reporting joint count reliability or agreement in RA in PubMed, EMBase, and the Cochrane library between 1960 and 2012 were selected. Data were extracted regarding tender joint counts (TJCs) and swollen joint counts (SJCs) derived by physicians, metrologists, or patients for intra-observer and inter-observer reliability. In addition, methods and effects of training or standardization were extracted. Statistics expressing reliability such as intraclass correlation coefficients (ICCs) were extracted. Data analysis was primarily descriptive due to high heterogeneity.ResultsTwenty-eight studies on health care professionals (HCP) and 20 studies on patients were included. Intra-observer reliability for TJCs and SJCs was good for HCPs and patients (range of ICC: 0.49–0.98). Inter-observer reliability between HCPs for TJCs was higher than for SJCs (range of ICC: 0.64–0.88 vs. 0.29–0.98). Patient inter-observer reliability with HCPs as comparators was better for TJCs (range of ICC: 0.31–0.91) compared to SJCs (0.16–0.64). Nine studies (7 with HCPs and 2 with patients) evaluated consensus or training, with improvement in reliability of TJCs but conflicting evidence for SJCs.ConclusionIntra- and inter-observer reliability was high for TJCs for HCPs and patients: among all groups, reliability was better for TJCs than SJCs. Inter-observer reliability of SJCs was poorer for patients than HCPs. Data were inconclusive regarding the potential for training to improve SJC reliability. Overall, the results support further evaluation for patient-reported joint counts as an outcome measure.