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ZusammenfassungQualitätsstandards (QS) sind messbare Konstrukte, die helfen sollen, Versorgungslücken quantitativ zu erfassen, um langfristig die Versorgungsqualität zu verbessern. Die Assessment of SpondyloArthritis International Society (ASAS) hat kürzlich erstmals internationale QS für das Management von Patient*innen mit axialer Spondyloarthritis (axSpA) konsentiert und veröffentlicht. Die Deutsche Gesellschaft für Rheumatologie (DGRh) hat daraufhin beschlossen, diese Standards durch eine Gruppe von Expert*innen aus unterschiedlichen Versorgungsbereichen zu übersetzen, zu prüfen und ggf. zu übernehmen. Vor diesem Hintergrund wurden erstmals nationale QS für das Management von Patient*innen mit axSpA für Deutschland entwickelt. Hierbei wurde v. a. auf Machbarkeit und Praxisrelevanz geachtet. Letztlich wurden 9 QS definiert, mit denen die Qualität der Versorgung in Deutschland gemessen und verbessert werden kann bzw. soll.

Even in the era of modern guidelines, the treatment of rheumatic diseases is only as good as the framework of rheumatological care within which the treatment is carried out. The access to high-quality medical treatment for all patients is therefore essentially decisive for the prognosis of the patients. This article describes the current state of outpatient treatment in rheumatology and demonstrates which quality projects, such as treatment contracts, outpatient specialized medical treatment (ASV), digitalization and training as specialized rheumatological assistant (RFA), have been created in order to ensure the treatment of our patients. Furthermore, standards are defined that can guarantee a contemporary and guideline-conform treatment in outpatient rheumatological units. As an example it is an affirmation of the Professional Association of German Rheumatologists (BDRh) for ensuring optimal care for all rheumatology patients through early or emergency rheumatology clinics, treat to target, appropriate delegation of medical duties and diversification of treatment, thus an assurance of the quality and comprehensive treatment in rheumatology. The important topic of safeguarding the next generation of rheumatologists, which is indispensable for this, is also discussed.

Systemic vaccination against SARS-CoV-2 elicited high titers of specific antibodies in the blood and in the oral cavity. Preexisting autoimmune diseases, such as rheumatoid arthritis, and biological treatments, like B cell depletion, are known to exhibit higher risk of severe COVID-19 manifestation and increased frequency of breakthrough infections after vaccination. We hypothesized that such increased risk is associated with an aberrant induction of secreted antibodies in the oral cavity. Here we evaluated the levels of secreted antibodies in the oral cavity against the SARS-CoV-2 Spike protein during the course of vaccination in RA patients with or without B cell depletion. We found that total salivary IgG levels were correlated with number of B cells in the blood. Anti-Spike IgG responses 7 days after second vaccination were induced in the oral cavity of all healthy individuals, while only 6 out 23 RA patients exhibited anti-Spike IgG in their saliva regardless of B cell depleting therapy. Importantly, both salivary and serologic anti-Spike IgG and IgA responses towards WT and omicron Spike variants were efficiently induced by third vaccination in RA patients with or without B cell depletion to the levels that were similar to healthy individuals. Altogether, these data advocate for the necessity of three dose vaccination for RA patients to mount anti-Spike antibody responses at the mucosal surfaces and annotate the reduction of secreted salivary IgG by B cell depletion.

BackgroundThe rheumatoid arthritis impact of disease score (RAID) is a patient-reported outcome measure to evaluate the impact of rheumatoid arthritis (RA) on patients’ quality of life (1). While an adapted instrument has been developed for psoriatic arthritis (2), there are no comparable instruments for other inflammatory rheumatic diseases. Since the RAID includes generic questions on pain, functional capacity, fatigue, physical and emotional well-being, sleep disturbances and coping, it could be an informative instrument beyond RA.ObjectivesTo analyse the performance of the RAID in ankylosing spondylitis (AS), systemic lupus erythematosus (SLE), polymyalgia rheumatica (PMR), primary Sjögren’s syndrome (pSS), idiopathic inflammatory myositis (IIM), and systemic sclerosis (SSc) compared to RA.MethodsFrom 2015 to 2019, a total of 12,398 patients reported the RAID in the National Database of the German Collaborative Arthritis Centres. We calculated the age- and sex-adjusted partial correlation (0.3-0.5 weak, 0.5-0.7 moderate, > 0.7 strong correlation) between the RAID score and five other patient- or physician-reported outcomes, namely patient global (PtGl) health status, PtGl disease activity, physician global (PhGl) disease activity, the World Health Organisation Well-Being Index (WHO-5) and the EuroQoL-5 Dimensions (EQ-5D). Furthermore, for each of the diagnoses the mean difference between the RAID and the other outcomes was compared with the respective differences for RA. The EQ-5D and WHO-5 were rescaled to match the scale of the RAID (range 0-10). General linear regression was used to assess the age- and sex-adjusted effect of each diagnosis on the difference between the RAID and the five other scores with RA as the referent diagnosis. We defined the effect of a diagnosis as clinically relevant if the mean change of difference was at least one unit.ResultsThe mean RAID score in RA (3.6) was lower than in AS (4.0) and SSc (3.8) and higher than in SLE, PMR, pSS or IIM (Table 1). Across all diagnoses, the RAID correlated strongly with PtGl health status (0.72 to 0.83), moderately to strongly with PtGl disease activity (0.55 to 0.78) and WHO-5 (0.67 to 0.83), moderately with the EQ-5D (0.61 to 0.68), and weakly with PhGl disease activity (0.25 to 0.41). Small mean differences were found between the RAID and either PtGl disease activity (0 to -0.6), PtGl health status (-0.4 to -0.9) or WHO-5 (-0.7 to -1.3). A higher deviation was observed for EQ-5D (1.1 to 1.7) and PhGl disease activity (1.4 to 2.2). However, the discrepancies between the five outcomes and the RAID turned out to be similar across all diagnoses and, more importantly, comparable to RA. Linear regression revealed no clinically relevant effect of any of the diagnoses on the difference between RAID and the other outcomes (Figure 1).Table 1.Characteristics and patient- and physician-reported outcomes in patients with inflammatory rheumatic diseases.RAASSLEPMRpSSIIMSScNumber of cases7826153211421105301106386Female (%)74428964895876Age, in years (mean±SD)63±1451±1447±1573±853±1658±1458±14Disease duration, in years (mean±SD)13±1118±1315±105±612±911±812±10RAID (mean±SD)3.6±2.34.0±2.33.0±2.43.2±2.33.4±2.43.5±2.53.8±2.3PtGl health status (mean±SD)4.2±2.34.4±2.23.6±2.44.1±2.34.1±2.34.2±2.54.6±2.1PtGl disease activity (mean±SD)3.7±2.44.0±2.42.7±2.53.8±2.73.5±2.63.7±2.54.1±2.3PhGl disease activity (mean±SD)1.8±1.92.2±1.91.6±1.31.0±1.41.8±1.31.8±1.62.2±1.6EQ-5D (mean±SD)0.8±0.20.8±0.20.8±0.20.8±0.20.8±0.20.8±0.20.8±0.2WHO-5 (mean±SD)57±2553±2358±2556±2657±2560±2653±24SD, Standard Deviation; PtGl, Patient Global; PhGl, Physician Global; EuroQoL-5 Dimensions (EQ-5D); World Health Organisation Well-Being Index (WHO-5)Figure 1.ConclusionThe RAID score performed comparably well across all diagnoses investigated. These findings support the use of the RAID for measuring the impact of disease not only in RA, but also in AS, SLE, PMR, pSS, IIM and SSc.References[1]PMID: 21540201[2]PMID: 24790067AcknowledgementsWe thank all participating rheumatologists and patients for their valuable contributions.The National Database of the German Collaborative Arthritis centers is supported by the Association of Regional Cooperative Rheumatology Centres, the German Society for Rheumatology and joint contributions to the Rheumatological Training Academy and the German Rheumatism Research Centre by the following members of the Working Group of Corporate Members of the German Society for Rheumatology: AbbVie, AstraZeneca, BMS, GALAPAGOS, GSK, Lilly, Medac, MSD, Pfizer, Sanofi-Aventis and UCB.Disclosure of InterestsKatja Thiele: None declared, Katinka Albrecht: None declared, Angela Zink: None declared, Martin Aringer: None declared, Kirsten Karberg: None declared, Susanna Spaethling-Mestekemper Speakers bureau: BMS, Gilead, GSK, Janssen, Lilly, Novartis, Pfizer, Sanofi, UCB, Consultant of: Abbvie, Gilead, GSK, UCB, Novartis, Ulrich von Hinueber: None declared, Johanna Callhoff Paid instructor for: Rheumatologische Fortbildungsakademie GmbH, Grant/research support from: Abbvie, AstraZeneca, BMS, GALAPAGOS, GSK, Lilly, Medac, MSD, Pfizer, Sanofi, UCB

Background The vast majority of patients with rheumatoid arthritis (RA) included in the national database of the German Collaborative Arthritis Centers are treated with disease-modifying antirheumatic drugs (DMARD). The clinical and patient-related characteristics of patients who did not have DMARD treatment in the longer term were investigated. Methodology Between 2012 and 2016 a total of 10,289 patients with RA were documented. Patient characteristics, disease activity and severity, comorbidities and concomitant treatment were descriptively evaluated. Patients who were without DMARDs for more than 1 year and not in remission (disease activity score 28, simple disease activity index or Boolean remission) were analyzed separately. Logistic regression was used to investigate which variables were associated with DMARD treatment. Results A total of 426 patients were ≤1 year without DMARDs, 1090 > 1 year without DMARDs and 8773 (85%) currently had DMARD treatment. Of the patients who were without DMARDs for more than 1 year, 51% were in remission. Even if no remission criteria were met, the rheumatologists nevertheless found the strived for RA situation in the majority of patients. Of the patients who were without DMARDs for more than 1 year, 13% received glucocorticoid treatment >5 mg/day. In patients with a high degree of severity (odds ratio, OR severe vs. asymptomatic/mild 2.33, 95% confidence interval, CI 1.80;3.02) or positive rheumatoid factor (OR 2.24, CI 1.96;2.56) the chance of receiving DMARD treatment was twice as high. Existing comorbidities did not reduce the chance of receiving DMARD treatment. Conclusion The RA patients in the national database who had no DMARDs for more than 1 year were mostly in remission or with low disease activity. Signs of inadequate disease control were found in only 11% of all patients without DMARD treatment.

Mit der ambulanten spezialfacharztlichen Versorgung (ASV) nach § 116b SGB (Sozialgesetzbuch) V besteht seit April 2018 eine dritte Versorgungsebene, in der Patienten mit chronisch entzundlichen Rheumaerkrankungen behandelt werden konnen. Die Kooperation von verschiedenen Facharztgruppen, die an der Rheumaversorgung beteiligt sind, wird gefordert, auch die sektorenubergreifende Kooperation zwischen Rheumatologen wie auch anderen Facharzten in der Praxis und im Krankenhaus. Durch den Wegfall der Budgetierung von Fallzahl und Leistungen in dieser Versorgungsebene wird eine deutliche Verbesserung der Versorgungssituation der Menschen mit Rheuma durch zusatzliche Behandlungsressourcen erwartet. Bis Ende Mai 2019 waren 72 internistische Rheumatologen in den ersten 9 neu zugelassenen ASV-Teams tatig. Wegen burokratischer Erschwernisse verzogert sich bisher die Umsetzung der ASV fur rheumatische Erkrankungen. Die Hurden bestehen bei der Teambildung und dem aufwendigen burokratischen Anmeldeprozess und bei der Bewilligung des Antrags durch einzelne erweitere Landesausschusse (ELAs). Die Verbande der Rheumatologen, der BDRh (Berufsverband Deutscher Rheumatologen e. V.), der VRA (Verband der Rheumatologischen Akutkliniken e. V.) und die DGRh (Deutsche Gesellschaft fur Rheumatologie e. V.) setzen sich dafur ein, den Zugang zur ASV Rheumatologische Erkrankungen einfacher zu gestalten, auch mit dem Ziel einer sachgerechten Vergutung der anderen Facharztgruppen. Die Chance, mit dieser sektorenubergreifenden Versorgung eine bundesweit flachendeckende Versorgung fur Menschen mit Rheuma mit kurzen Wartezeiten und einer besseren interdisziplinaren Kooperation zwischen den Fachgruppen zu erreichen, sollte genutzt werden.

Quality standards (QS) are measurable constructs designed to quantify gaps in care and subsequently to improve quality of care. The Assessment of SpondyloArthritis International Society (ASAS) recently generated and published international QS for the management of patients with axial spondyloarthritis (axSpA) for the first time. The German Society of Rheumatology (DGRh) then decided to translate, review and possibly adopt these standards by a group of experts from different care settings. Against this background, national QS for the management of patients with axSpA for Germany were developed for the first time. The main focus was on feasibility and practical relevance. Ultimately, nine QS were defined with which the quality of care in Germany can and should be measured and improved.Qualitätsstandards (QS) sind messbare Konstrukte, die helfen sollen, Versorgungslücken quantitativ zu erfassen, um langfristig die Versorgungsqualität zu verbessern. Die Assessment of SpondyloArthritis International Society (ASAS) hat kürzlich erstmals internationale QS für das Management von Patient*innen mit axialer Spondyloarthritis (axSpA) konsentiert und veröffentlicht. Die Deutsche Gesellschaft für Rheumatologie (DGRh) hat daraufhin beschlossen, diese Standards durch eine Gruppe von Expert*innen aus unterschiedlichen Versorgungsbereichen zu übersetzen, zu prüfen und ggf. zu übernehmen. Vor diesem Hintergrund wurden erstmals nationale QS für das Management von Patient*innen mit axSpA für Deutschland entwickelt. Hierbei wurde v. a. auf Machbarkeit und Praxisrelevanz geachtet. Letztlich wurden 9 QS definiert, mit denen die Qualität der Versorgung in Deutschland gemessen und verbessert werden kann bzw. soll.

Real-world data are crucial to continuously improve the management of patients with rheumatic and musculoskeletal diseases (RMDs). The German RheumaDatenRhePort (RHADAR) registry encompasses a network of rheumatologists and researchers in Germany providing pseudonymized real-world patient data and allowing timely and continuous improvement in the care of RMD patients. The RHADAR modules allow automated anamnesis and adaptive coordination of appointments regarding individual urgency levels. Further modules focus on the collection and integration of electronic patient-reported outcomes in between consultations. The digital RHADAR modules ultimately allow a patient-centered adaptive approach to integrated medical care starting as early as possible in the disease course. Such a closed-loop system consisting of various modules along the whole patient pathway enables comprehensive and timely patient management in an unprecedented manner.

BackgroundThe development of RA is described by a preclinical phase of autoimmunity, that precedes clinical disease. This autoimmune phase is characterized by the presence of anti-modified protein antibodies that recognize citrullinated proteins (ACPA). A subset of individuals with ACPA develops RA, i.e. those with imaging signs of subclinical inflammation in the joints. As T cell mediated B cell activation is a key step in developing autoimmunity and RA, interventions that target this process may be useful for preventing the onset of RA. In this context, abatacept seems being an attractive therapeutic tool as it interrupts the activation of T cells and has a favourable safety profile in the treatment of RA.ObjectivesTo test whether treatment of abatacept, as compared to placebo, delays the onset of RA in ACPA positive individuals with a high risk to develop RA.MethodsARIAA is an international, randomized double-blinded placebo-controlled multi-center study in RA-at risk individuals, being ACPA positive and showing MRI signs of inflammation. The study was composed of a 6 months treatment phase with either abatacept s.c. 125 mg weekly or placebo and a 12 months observation phase with no treatment. Primary endpoint was the improvement of MRI inflammation after 6 months, secondary endpoints were the progression to RA after 6 and 18 months. The primary analysis was done on the ITT population and missing values were classified as treatment failures.ResultsBetween November 2014 and December 2019 139 RA-at risk individuals were included into ARIAA by 14 study sites (11 in Germany, 1 in the Czech Republic and 2 in Spain). Of them, 100 patients were randomized to receive either abatacept or placebo. Two patients were excluded and 98 patients could be evaluated for efficacy and safety. The primary endpoint was met: 61% of abatacept and 31% of placebo treated individuals (p=0.0043) improved in MRI inflammation. Furthermore, only 4 patients (8.2%) in the abatacept group but 17 patients in the placebo group (34.7%) progressed to RA after 6 months (p= 0.0025). Even 1 year after cessation of treatment (18 months after inclusion) the number of patients progressing to RA was lower in the abatacept group (35%) than in the placebo group (57%; p=0.0421). With respect to safety, 12 serious adverse events (each one gastritis, cellulitis, pneumonia, tendinitis calcificans, rotator cuff syndrome, cholelithiasis, peripheral artery disease, idiopathic pain syndrome, prostate cancer, penile neoplasm; trabeculectomy, cataract surgery) were reported, with only one (pneumonia) being considered to be related to treatment.ConclusionAbatacept significantly reduces subclinical joint inflammation and delays the development of RA in at-risk individuals.Table 1.ABAPBOAllN494998Females, N (%)31 (63.3)39 (79.6)70 (71.4)Age (ys); mean (±SD)51.3 (±10.8)48.5 (±12.6)49.9 (±11.7)SJC (N); mean (±SD)000TJC (N); mean (±SD)3.06 (± 3.75)3.51 (± 4.42)3.29 (±4.08)VAS Pain (mm) mean (±SD)42.2 (± 27.1)42.8 (± 33.2)42.5 (± 30.2)VAS PG (mm) mean (±SD42.2 (±28.7)43.0 (± 33.8)42.6 (± 31.2)MRI improvement, N (%)30 (61.2)15 (30.6)45 (45.9)RA at 6 months, N (%)4 (8.2)17 (34.7)21 (21.4)RA at 18 months, N (%)17 (34.7)28 (57.1)45 (45.9)AcknowledgementsThe study was supported by BMS according to the items outlined in the IIS contract and the IMI funded project RTCure.Disclosure of InterestsJürgen Rech Consultant of: Abbvie, Biogen, BMS, Chugai, GSK, Lilly, MSD; Novartis, Roche, Sanofi, Sobi, UCB, Consultancy: Biogen, BMS, Chugai, GSK, Lilly, MSD, Novartis, Roche, Sanofi, Sobi, UCB, Grant/research support from: Sobi, Novartis, Arnd Kleyer Consultant of: BMS, Pfizer, Sanofi, Abbvie, Janssen, Medac, Novartis, Lilly Deutschland GmbH, Gilead, Amgen, Grant/research support from: Novartis, Lilly Deutschland GmbH, Mikkel Østergaard: None declared, Melanie Hagen: None declared, Larissa Valor: None declared, Koray Tascilar: None declared, Gerhard Krönke: None declared, Verena Schönau: None declared, Stefan Kleinert: None declared, Xenofon Baraliakos: None declared, Juergen Braun: None declared, Martin Fleck: None declared, Andrea Rubbert-Roth: None declared, Frank Behrens: None declared, Martin Feuchtenberger: None declared, Michael Zaenker: None declared, David M Kofler: None declared, Reinhard Voll: None declared, Cornelia Glaser: None declared, Axel Hueber: None declared, Eugen Feist: None declared, Gerd Rüdiger Burmester: None declared, Kirsten Karberg: None declared, Johannes Strunk: None declared, Juan de Dios Cañete: None declared, Ladislav Šenolt: None declared, Esperanza Naredo: None declared, Georg Schett: None declared.

BackgroundVaccination is considered efficient in controlling infections incl. SARS-CoV-2. Prior studies showed that patients receiving rituximab (RTX) with low B cell counts are at increased infectious risk (1) and risk of inadequate vaccination responses (2, 3). Thus, the ability to further define and predict vaccination responses in these patients may guide their optimal protection.ObjectivesTo assess predictive biomarkers of vaccination responses upon SARS-CoV-2 vaccination in RTX treated patients.MethodsB cell characteristics before vaccination were evaluated to predict responses in 15 patients with autoimmune inflammatory rheumatic diseases receiving RTX. 11 patients with rheumatoid arthritis on other therapies (RA), 11 kidney transplant recipients (KTR) and 15 healthy volunteers (HC) served as controls. A multidimensional analysis of B cell subsets and a correlation matrix were performed to identify predictive biomarkers.ResultsSignificant differences regarding absolute B cell counts and specific subset distribution pattern between the groups were validated at baseline. Here, the majority of B cells from vaccination responders of the RTX group (RTX IgG+) comprised naïve and transitional B cells, whereas vaccination non-responders (RTX IgG-) carried preferentially plasmablasts and double negative (CD27-IgD-) B cells (Figure 1). Moreover, there was a positive correlation between neutralizing antibodies and absolute B cell numbers with B cells expressing HLA-DR and CXCR5 (involved in antigen presentation and germinal center formation) as well as an inverse correlation with CD95 expression and CD21low expression (marker for activation and exhaustion) on B cells.ConclusionSubstantial repopulation of naïve B cells upon RTX therapy appears to be essential for an adequate vaccination response requiring germinal center formation. In contrast, expression of exhaustion markers (CD21low, CXCR5-, CD95+) indicate negative predictors of vaccination responses. These results may guide optimized vaccination strategies in RTX treated patients clearly requiring antigen-inexperienced B cells for appropriate protection.References[1]Sparks JA, Wallace ZS, Seet AM, Gianfrancesco MA, Izadi Z, Hyrich KL, et al. Associations of baseline use of biologic or targeted synthetic DMARDs with COVID-19 severity in rheumatoid arthritis: Results from the COVID-19 Global Rheumatology Alliance physician registry. Annals of the Rheumatic Diseases. 2021;80(9):1137-46.[2]Stefanski AL, Rincon-Arevalo H, Schrezenmeier E, Karberg K, Szelinski F, Ritter J, et al. B cell numbers predict humoral and cellular response upon SARS-CoV-2 vaccination among patients treated with rituximab. Arthritis & Rheumatology. Accepted Author Manuscript.[3]Mrak D, Tobudic S, Koblischke M, Graninger M, Radner H, Sieghart D, et al. SARS-CoV-2 vaccination in rituximab-treated patients: B cells promote humoral immune responses in the presence of T-cell-mediated immunity. Annals of the rheumatic diseases. 2021;80(10):1345-50.Disclosure of InterestsNone declared

Even in the era of modern guidelines, the treatment of rheumatic diseases is only as good as the framework of rheumatological care within which the treatment is carried out. The access to high-quality medical treatment for all patients is therefore essentially decisive for the prognosis of the patients. This article describes the current state of outpatient treatment in rheumatology and demonstrates which quality projects, such as treatment contracts, outpatient specialized medical treatment (ASV), digitalization and training as specialized rheumatological assistant (RFA), have been created in order to ensure the treatment of our patients. Furthermore, standards are defined that can guarantee a contemporary and guideline-conform treatment in outpatient rheumatological units. As an example it is an affirmation of the Professional Association of German Rheumatologists (BDRh) for ensuring optimal care for all rheumatology patients through early or emergency rheumatology clinics, treat to target, appropriate delegation of medical duties and diversification of treatment, thus an assurance of the quality and comprehensive treatment in rheumatology. The important topic of safeguarding the next generation of rheumatologists, which is indispensable for this, is also discussed.Auch im Zeitalter moderner Leitlinien ist die Behandlung rheumatischer Erkrankungen nur so gut wie die rheumatologische Versorgung, in deren Rahmen die Behandlung erfolgt. Der Zugang zu einer qualitativ hochwertigen Medizin für alle Patienten entscheidet daher wesentlich über die Prognose der Patienten. Die vorliegende Arbeit beschreibt den aktuellen Stand der ambulanten Versorgung in der Rheumatologie und zeigt auf, welche Qualitätsprojekte, wie z. B. Versorgungsverträge, ambulante spezialärztliche Versorgung (ASV), Digitalisierung, Ausbildung zur rheumatologischen Fachassistentin (RFA) u. a., geschaffen wurden, um die Versorgung unserer Patienten zu sichern. Darüber hinaus definiert sie Standards, welche in ambulanten rheumatologischen Einheiten eine zeitgemäße und leitliniengerechte Behandlung sicherstellen können. Als Leitbild ist sie ein Bekenntnis des BDRh zur Versorgungssicherheit aller rheumatologischer Patienten durch Früh- bzw. Notfallsprechstunden, Treat-to-Target, angemessener Delegation ärztlicher Leistungen und Verbreiterung der Versorgung, also einer Sicherung der Qualität und umfassenden Versorgung in der Rheumatologie. Auch auf das wichtige Thema der Sicherung des rheumatologischen Nachwuchses, welches dafür unabdingbar ist, wird eingegangen.

New treatment strategies and treatment possibilities as well as undertreatment due to the lack of medical specialists especially in rheumatology, necessitate a qualified further training of rheumatological assistant personnel. The increasing independent work of medical and rheumatological assistants expected by physicians with respect to patient management and practice organization, necessitates an intensive cooperation between the two professional groups. The aim is to guarantee the competent treatment of chronically ill patients with rheumatism. Finally, this concept offers the chance of additional professional qualifications for the rheumatological assistant profession and support for rheumatologists in the daily routine. This particularly applies to the engagement at several levels supported by the results of various studies, which indicate tasks that can be delegated to rheumatological assistants and confirm an improvement in the quality of patient care.

Background:Psoriatic arthritis (PsA) is a heterogeneous disease with multiple musculoskeletal and dermatological manifestations. Due to this multifaceted clinical appearance, international guidelines do not provide a clear recommendation for one specific score to assess disease activity in PsA [1]. The Disease Activity Index for Psoriatic Arthritis (DAPSA), a validated, unidimensional score focusing on joint involvement, is one of the recommended options [1]. However, routine determination of C-reactive protein (CRP) to calculate DAPSA values takes hours to days. In contrast, quick quantitative CRP (qCRP) tests require only a few minutes and might facilitate regular assessment of the DAPSA (as Q-DAPSA) in clinical routine.Objectives:To validate the Q-DAPSA in a prospective, multicenter study of PsA patients. Since the Disease Activity Score 28 (DAS28) is not only used in rheumatoid arthritis, but also in PsA patients, the study also investigated the performance of a qCRP based DAS28 (DAS28-qCRP) in a PsA cohort.Methods:The study was conducted in five centers in Berlin, Germany. Consecutive adult (≥ 18 years) PsA patients were included. In addition to a rheumatological assessment, including patient reported outcomes (PROs), routine CRP and erythrocyte sedimentation rate (ESR) were measured in the local labs. Additionally, a qCRP testing with the „QuikRead go instrument“ (Aidian Oy, Finland) was performed locally at the study center (measurement range 0.5 - 200 mg/l for hematocrit concentrations of 40 – 45%). Statistical analysis included descriptive statistics, cross tabulation and weighted Cohen´s kappa comparing disease activity categories, Bland-Altman plots and intraclass correlation coefficient (ICC) for DAPSA, Q-DAPSA, DAS28-CRP and DAS28-qCRP.Results:In this study 104 patients were included between January and October 2020 (mean age: 51.2 years, mean disease duration: 7.1 years, 49 patients (47.1%) were male). 53 patients (51.0%) were treated with a bDMARD and 37 patients (35.6%) with csDMARDs. CRP and qCRP showed mean values of 5.20 and 6.17 mg/l, respectively. With the Q-DAPSA, 103 patients (99.0%) were assigned to the same disease activity category when compared to DAPSA (Table 1). Weighted Cohen´s kappa was 0.990 (95%CI 0.970; 1.000). ICC for numerical values of DAPSA and Q-DAPSA was 1.000 (95%CI 0.999; 1.000). The agreement of Q-DAPSA and DAPSA is shown in a Bland-Altman plot (Figure 1). DAS28-CRP and -qCRP were available for 103 patients; 101 patients (98.1%) showed the same disease activity category in the DAS28-qCRP and weighted Cohen´s kappa was 0.951 (95%CI 0.886; 1.000).Conclusion:The Q-DAPSA and DAPSA showed an almost perfect agreement on the assignment to disease activity categories (99%) with the important advantage of time. With Q-DAPSA, rheumatologists could base their clinical decision-making on a disease activity measurement by using a composite score immediately. Consequently, Q-DAPSA can be integrated in clinical routine and clinical trials and could be implemented into the treat-to-target concept in PsA patients. For rheumatologists who prefer DAS28-CRP for assessing disease activity in PsA patients, DAS28-qCRP may serve as a suitable alternative.References:[1]Smolen JS, et al. Ann Rheum Dis. 2018 Jan; 77(1):3-17.Table 1.Disease activity categories by Q-DAPSA vs. DAPASQ-DAPSA (n = 104)Remission (≤ 4)Low Disease Activity (> 4 and ≤ 14)High Disease Activity (> 14 and≤ 28)Very high Disease Activity (> 28)DAPSARemission (≤ 4)36 (34.6%)1 (1.0%)Low Disease Activity (> 4 and ≤ 14)39 (37.5%)High Disease Activity (> 14 and ≤ 28)22 (21.2%)Very high Disease Activity (> 28)6 (5.8%)The fields highlighted in red indicate that disease activity categories do not match. DAPSA = Disease activity index for Psoriatic Arthritis, Q-DAPSA = DAPSA calculated based on a quick quantitative CRPFigure 1.Bland-Altman plot for Q-DAPSA and DAPSAAcknowledgements:The authors would like to deeply thank Braun T, Doerwald C, Deter N, Höppner C, Lackinger J, Lorenz C, Lunkwitz K, Mandt B, Sron S and Zernicke J for their practical support and coordinating the study.Funding statement:The AQUA study was supported by an unrestricted research grant from Novartis. Testing kits were provided free of charge from Aidian Oy, Finland.Disclosure of Interests:None declared.

Background:There is some evidence that neuropsychiatric changes occur in systemic lupus(1) and rheumatoid arthritis(2). However, little is known regarding a possible disease-related impairment of cognitive abilities in axial spondyloarthritis (axSpA).Objectives:To evaluate patients with axSpA regarding cognitive impairments.Methods:Patients with axSpA attending two rheumatology practices were routinely evaluated by rheumatologists and underwent a computer-based memory and attention test (MAT) (3, 4) with subscale scores ranging from 0 (worst) to 15 (best). The results of short-term memory and working memory were compared to an age-, sex- and education-matched control group of healthy subjects. Descriptive results are presented as median (IQR) for interval data and n (%) for nominal data if not stated otherwise. Two-tailed Wilcoxon signed-rank tests including Bonferroni-Holm adjustment for multiple tests were conducted to investigate the magnitude of potential differences in cognitive abilities.Results:101 consecutive patients were tested (Table 1). After multiple testing adjustment for two subscales, Wilcoxon signed-rank tests returned significant findings for working memory (V = 539.5, p = 0.006, |r| = 0.204) but not for short-term memory (V = 1075, p = 0.351, |r| = 0.078). Regarding the scales’ anchors, descriptive results on pairwise differences suggested axSpA patients to have working memory scores that are on average 10.7% lower compared to control participants (mean Δ= -1.64, SD Δ= 5.95).Table 1.Patients and disease characteristicsn%MeanSDMedian25% Quantile75% QuantileAge10110051.111.6524260Age (female)4847.552.611.75444.561Age (male)5352.549.811.5514157< 13 years formal education4746.5≥ 13 years formal education5453.5HLA B27 positive n/N64/9263.4Disease duration (years)10110013.711.712421Disease duration (female, years)4847.511.69.99417.2Disease duration (male, years)5352.515.512.915523BASDAI9291.13.71.73.82.45BASFI9190.132.42.31.24.5BASMI7574.31.92.3103ASDAS98972.30.82.31.82.8Conclusion:The MAT computerized testing is a feasible test and was well accepted by patients. Results regarding working memory suggest that cognitive abilities needed to accomplish everyday tasks may be impaired in axSpA patients. Further work is needed to characterise possible causes of or associations with this cognitive impairment.References:[1]Zabala A, Salgueiro M, Saez-Atxukarro O, Ballesteros J, Ruiz-Irastorza G, Segarra R. Cognitive Impairment in Patients With Neuropsychiatric and Non-neuropsychiatric Systemic Lupus Erythematosus: A Systematic Review and Meta-analysis. J Int Neuropsychol Soc. 2018:1-11.[2]Vitturi BK, Nascimento BAC, Alves BR, de Campos FSC, Torigoe DY. Cognitive impairment in patients with rheumatoid arthritis. J Clin Neurosci. 2019;69:81-7.[3]Adler G, Bektas M, Feger M, Lembach Y. [Computer-based assessment of memory and attention: evaluation of the memory and attention test (MAT)]. Psychiatr Prax. 2012;39(2):79-83.[4]Adler G, Lembach Y. Memory and selective attention in multiple sclerosis: cross-sectional computer-based assessment in a large outpatient sample. Eur Arch Psychiatry Clin Neurosci. 2015;265(5):439-43.Acknowledgements:This study was funded by the RHADAR GbR (A Network of Rheumatologists), Bahnhofstr. 32, 82152 Planegg, Germany. RHADAR GbR has received a grant for this study from Novartis Pharma GmbH.Disclosure of Interests:Stefan Kleinert Consultant of: Novartis, Abbvie, Grant/research support from: Novartis, Praxedis Rapp: None declared., Florian Schuch Speakers bureau: Novartis, Abbvie, Gilead, Consultant of: Novartis, Abbvie, Gilead, Monika Ronneberger: None declared., Joerg Wendler Speakers bureau: Roche, Pharma, JanssenCilag, Novartis, Abbvie, Consultant of: JanssenCilag, Patrizia Sternad: None declared., Florian Popp: None declared., Peter Bartz-Bazzanella: None declared., Cay-Benedict von der Decken: None declared., Kirsten Karberg Speakers bureau: Roche, Sanofi, Abbvie, Lilly, Georg Gauler Speakers bureau: Abbvie, Gilead, Novartis, Lilly, Consultant of: Lilly, Gilead, Abbvie, Patrick Wurth Speakers bureau: Abbvie, Lilly, UCB, Medac, Susanna Spaethling-Mestekemper Speakers bureau: Abbvie, BMS, Celgene, Gilead, GSK, Hexal, Lilly, MSD, Novartis, Pfizer, Sanofi, UCB, Christoph Kuhn: None declared., Matthias Englbrecht Speakers bureau: AbbVie, Chugai, Eli Lilly, Novartis, Roche, Sanofi, Mundipharma, Paid instructor for: AbbVie, Chugai, Roche, Consultant of: AbbVie, Novartis, Roche, Sanofi, Grant/research support from: Roche, Chugai, Wolfgang Vorbrüggen: None declared., Georg Adler: None declared., Martin Welcker Speakers bureau: Abbvie, Actelion, Amgen, Biogen,BMS, Berlin Chemie, Celgene, Galapagos, Gilead, GSK, Hexal, Janssen, Medac, MSD, Mundipharma, Mylan, Novartis, Pfizer, Roche, Sanofi, SOBI, UCB, Grant/research support from: Novartis, Abbvie.

The vast majority of patients with rheumatoid arthritis (RA) included in the national database of the German Collaborative Arthritis Centers are treated with disease-modifying antirheumatic drugs (DMARD). The clinical and patient-related characteristics of patients who did not have DMARD treatment in the longer term were investigated.Between 2012 and 2016 a total of 10,289 patients with RA were documented. Patient characteristics, disease activity and severity, comorbidities and concomitant treatment were descriptively evaluated. Patients who were without DMARDs for more than 1 year and not in remission (disease activity score 28, simple disease activity index or Boolean remission) were analyzed separately. Logistic regression was used to investigate which variables were associated with DMARD treatment.A total of 426 patients were ≤1 year without DMARDs, 1090 1 year without DMARDs and 8773 (85%) currently had DMARD treatment. Of the patients who were without DMARDs for more than 1 year, 51% were in remission. Even if no remission criteria were met, the rheumatologists nevertheless found the strived for RA situation in the majority of patients. Of the patients who were without DMARDs for more than 1 year, 13% received glucocorticoid treatment5 mg/day. In patients with a high degree of severity (odds ratio, OR severe vs. asymptomatic/mild 2.33, 95% confidence interval, CI 1.80;3.02) or positive rheumatoid factor (OR 2.24, CI 1.96;2.56) the chance of receiving DMARD treatment was twice as high. Existing comorbidities did not reduce the chance of receiving DMARD treatment.The RA patients in the national database who had no DMARDs for more than 1 year were mostly in remission or with low disease activity. Signs of inadequate disease control were found in only 11% of all patients without DMARD treatment.HINTERGRUND: Die große Mehrheit der in der Kerndokumentation erfassten Patienten mit rheumatoider Arthritis (RA) wird mit krankheitsmodifizierenden Antirheumatika (DMARDs) behandelt. Wir haben klinische und patientenbezogene Merkmale der Patienten untersucht, die längerfristig keine DMARD-Therapie haben.Zwischen 2012 und 2016 wurden 10.289 Patienten mit RA dokumentiert. Patientencharakteristika, Krankheitsaktivität und -schweregrad, Komorbidität und Begleittherapie wurden deskriptiv ausgewertet. Patienten, die über 1 Jahr ohne DMARDs und nicht in Remission (nach disease activity score 28, simple disease activity index oder Boolean Remission) waren, wurden gesondert analysiert. Mit logistischer Regression wurde untersucht, welche Variablen mit einer DMARD-Therapie assoziiert sind.Es waren 426 Patienten ≤1 Jahr ohne DMARD, 1090 1 Jahr ohne DMARDs, und 8773 (85 %) hatten aktuell eine DMARD-Therapie. Patienten, die über 1 Jahr ohne DMARDs waren, befanden sich zu 51 % in Remission. Wurde kein Remissionskriterium erfüllt, so befanden die Rheumatologen trotzdem mehrheitlich einen angestrebten Zustand der RA. Es erhielten 13 % aller Patienten, die über 1 Jahr ohne DMARDs waren, eine Glukokortikoidtherapie5 mg/Tag. Eine doppelt so hohe Chance, eine DMARD-Therapie zu bekommen, hatten Patienten mit einem hohen Schweregrad (Odds Ratio [OR] [sehr] schwer vs. asymptomatisch/leicht 2,33 [95 %-KI: 1,80;3,02]) bzw. positivem Rheumafaktor (OR 2,24 [1,96;2,56]). Vorhandene Komorbiditäten verringerten nicht die Chance, ein DMARD zu erhalten.RA-Patienten der Kerndokumentation, die über 1 Jahr kein DMARD haben, sind mehrheitlich in Remission oder befinden sich in niedriger Krankheitsaktivität. Anzeichen für eine unzureichende Krankheitskontrolle finden sich nur bei 11 % aller Patienten ohne DMARD-Therapie.

Since April 2018, the new third level care model of outpatient specialist care (ASV) according to §116b of the Social Code Book V (SGBV) has been available for patients with chronic inflammatory rheumatic diseases in Germany. Not only is a multiprofessional cooperation between the disciplines involved in treating rheumatic diseases promoted but also the cooperation between specialized rheumatologists and other specialists in private practice and in hospitals is encouraged. As budget capping limiting services and number of cases do not apply in ASV, a significant improvement of patient care in rheumatology is expected due to an increase in provider capacity. At the end of May 2019, 72 rheumatologists in the first 9 newly approved ASV teams had qualified for this new care concept. Bureaucratic obstacles have so far delayed the implementation of ASV. Difficulties arose in building a team with different specialties, in the process of registration of the teams and the assessment of the registration by certain regional boards responsible for access control. The national associations of rheumatologists, the Professional Association of German Rheumatologists (BDRh), the VRA (Verband der Rheumatologischen Akutkliniken e. V.) and the German Society of Rheumatology (DGRh) campaign for an easier admission of providers to the ASV and for adequate financing of all specialties involved in the ASV. The aim is to realize the chance of the ASV for better rheumatological care nationwide with shorter waiting times for a medical appointment and a better cooperation between specialists.

Background:According to international recommendations, the Ankylosing Spondylitis Disease Activity Score (ASDAS) is the preferred score for assessing disease activity in axial spondyloarthritis (axSpA) [1]. However, routine determination of C-reactive protein (CRP) to calculate ASDAS values takes hours to days. This limits the use of ASDAS in clinical routine and clinical trials and hinders the implementation of treat-to-target approaches in axSpA. Whereas quick quantitative CRP (qCRP) tests allow CRP assessment within a few minutes. In a pilot project the performance of qCRP-based ASDAS assessment (ASDAS-qCRP) was already investigated in a single center study of 50 newly diagnosed, bDMARD-naïve axSpA patients with promising results [2].Objectives:To validate the ASDAS-qCRP in a prospective, multicenter study of axSpA patients in a typical axSpA cohort with an appropriate sample size.Methods:The study was conducted in five centers in Germany. Consecutive adult (≥ 18 years) axSpA patients were included. In addition to a rheumatological assessment, including patient reported outcomes (PROs), routine CRP and erythrocyte sedimentation rate (ESR) were measured in the local labs. Additionally, a qCRP testing with the „QuikRead go instrument“ (Aidian Oy, Finland) was performed at the study center (measurement range 0.5 - 200 mg/l for hematocrit concentrations of 40 – 45%). Statistical analysis included descriptive statistics, cross tabulation and weighted Cohen´s kappa comparing disease activity categories, Bland-Altman plots and intraclass correlation coefficient (ICC) for ASDAS-CRP and ASDAS-qCRP.Results:In this study 251 axSpA patients were included between January and September 2020 (mean age: 38.4 years; mean disease duration: 6.2 years, 159 patients (63.3%) were male, 211 (84.1%) HLA-B27 positive and 195 (77.7%) were classified as radiographic axSpA). 143 patients (57.0%) were treated with bDMARDs. CRP and qCRP showed mean values of 2.12 and 2.17 mg/l, respectively. With the ASDAS-qCRP, 242 patients (96.4%) were assigned to the same disease activity category as compared to the ASDAS based on the conventional lab CRP measurement (Table 1). Weighted Cohen´s kappa was 0.966 (95%CI: 0.943; 0.988). ICC for ASDAS-CRP- and ASDAS-qCRP-values was 0.997 (95%CI: 0.994; 0.999). The agreement of ASDAS-qCRP and ASDAS-CRP is shown in a Bland-Altman plot (Figure 1).Table 1.Disease activity categories by ASDAS-qCRP vs. ASDAS-CRPASDAS-qCRP (n = 251)Inactive Disease(< 1.3)Low Disease Activity (1.3 - < 2.1)High Disease Activity (2.1 - 3.5)Very high Disease Activity (> 3.5)ASDAS-CRPInactive Disease(< 1.3)56 (22.3%)2 (0.8%)Low Disease Activity (1.3 - < 2.1)62 (24.7%)7 (2.8%)High Disease Activity (2.1 - 3.5)97 (38.6%)Very high Disease Activity (> 3.5)27 (10.8%)The fields highlighted in red indicate that disease activity categories do not match.ASDAS = Ankylosing Spondylitis Disease Activity Score, CRP = C-reactive protein, qCRP = quick quantitative CRPConclusion:The ASDAS-qCRP and ASDAS-CRP showed an almost perfect agreement on the assignment to disease activity categories (96%) with the important advantage of time. With ASDAS-qCRP, rheumatologists could base their clinical decision-making on a disease activity measurement by using a composite score immediately. ASDAS-qCRP, therefore, can be integrated in clinical routine and clinical trials in the future and may facilitate implementation of the treat-to-target concept in axial SpA.References:[1]Smolen JS, et al. Ann Rheum Dis. 2018 Jan; 77(1):3-17.[2]Proft F, et al. Joint Bone Spine. 2019 Jul 29.Figure 1.Bland-Altman plot for ASDAS-qCRP and ASDAS-CRPAcknowledgements:The authors would like to deeply thank Braun T, Doerwald C, Deter N, Höppner C, Lackinger J, Lorenz C, Lunkwitz K, Mandt B, Sron S and Zernicke J for their practical support and coordinating the study.Funding statement: The AQUA study was supported by an unrestricted research grant from Novartis. Testing kits were provided free of charge from Aidian Oy, Finland.Disclosure of Interests:None declared

Background:Therapeutic decisions in RA patients should be based on regular disease activity assessment using scores like the Simplified Disease Activity Index (SDAI) or the Clinical Disease Activity Index (CDAI) [1]. The CDAI has the benefit of being immediately available, while the SDAI encompasses with the C-reactive protein (CRP) an acute phase reactant and therefore is the recommended score for the use in clinical trials. However, CRP determination takes hours to days, thus hindering the treat-to-target concept using the SDAI. Quick quantitative CRP (qCRP) tests allow CRP measurement within a few minutes. Therefore, qCRP based SDAI (SDAI-Q) could combine the advantages of both scores.Objectives:To validate the SDAI-Q in a prospective, multicenter study of RA patients.Methods:The study was conducted in five centers in Berlin, Germany. Consecutive adult (≥ 18 years) RA patients were included. In addition to a rheumatological assessment, including patient reported outcomes, routine CRP was measured in the local labs. Additionally, a qCRP testing with the „QuikRead go instrument“ (Aidian Oy, Finland) was performed locally (measurement range 0.5 - 200 mg/l). Statistical analysis included descriptive statistics, cross tabulation and weighted Cohen´s kappa comparing disease activity categories, Bland-Altman plots and intraclass correlation coefficient (ICC) for CRP, qCRP, SDAI, SDAI-Q and CDAI.Results:In this study 100 RA patients were included (mean age: 60.9 years, mean disease duration: 11.4 years, 73.0% were female, 63.0% RF positive, 57.0% ACPA positive, 49.0% positive and 29% negative for both parameters). 75.0% were treated with csDMARD, 15% with tsDMARDs, 39.0% with bDMARDs and 40% with glucocorticoids (mean prednisolone equivalent: 5.4 mg prednisolone/d). Mean CRP and qCRP-levels were 6.97 and 7.89 mg/l, respectively (ICC 0.992; 95%CI: 0.987; 0.995). Comparing SDAI-Q and SDAI, all patients (100%) achieved the same disease activity status (Table 1A); weighted Cohen´s kappa was 1.000 (95%CI: 1.000; 1.000). ICC for SDAI-Q- and SDAI-values was 1.000 (95%CI: 1.000; 1.000). The agreement of SDAI-Q and SDAI is shown in a Bland-Altman plot (Figure 1). When comparing the CDAI with the SDAI-Q 93 patients (93%) were assigned to the same disease activity category (Table 1B); weighted Cohen´s kappa was 0.929 (95%CI: 0.878; 0.981). ICC for numerical values of SDAI-Q and CDAI was 0.989 (95%CI: 0.978; 0.994).Conclusion:SDAI-Q showed an absolute agreement with SDAI on the assignment to disease activity categories with the important advantage of time. With SDAI-Q, rheumatologists could base their clinical decision-making immediately on an index-based disease activity measurement by using a composite score considering acute phase reactants. Consequently, SDAI-Q can be integrated in clinical routine and clinical trials and could be implemented into the treat-to-target concept in RA patients.References:[1]Smolen JS, et al. Ann Rheum Dis. 2016 Jan; 75(1):3-15.Table 1.A) Disease activity categories by SDAI-Q vs. SDAI; B) Disease activity categories by SDAI-Q vs. CDAIASDAI-Q (n = 100)Remission (≤ 3.3)Low Disease Activity (> 3.3 and ≤ 11)Moderate Disease Activity (> 11 and ≤ 26)High Disease Activity (> 26)SDAIRemission (≤ 3.3)28 (28.0%)Low Disease Activity (> 3.3 and ≤ 11)31 (31.0%)Moderate Disease Activity (> 11 and ≤ 26)35 (35.0%)High Disease Activity (> 26)6 (6.0%)BSDAI-Q (n = 100)Remission (≤ 3.3)Low Disease Activity (> 3.3 and ≤ 11)Moderate Disease Activity (> 11 and ≤ 26)High Disease Activity (> 26)CDAIRemission (≤ 2.8)26 (26.0%)Low Disease Activity (> 2.8 and ≤ 10)2 (2.0%)28 (28.0%)2 (2.0%)Moderate Disease Activity (> 10 and ≤ 22)3 (3.0%)33 (33.0%)High Disease Activity (> 22)6 (6.0%)Fields highlighted in red indicate that disease activity categories do not match.SDAI = Simplified Disease Activity Index;SDAI-Q = SDAI calculated with a quick quantitative CRP assay;CDAI = Clinical Disease Activity Index.Figure 1.Bland-Altman plot for SDAI and SDAI-Q AcknowledgementsThe authors would like to deeply thank Braun T, Doerwald C, Deter N, Höppner C, Lackinger J, Lorenz C, Lunkwitz K, Mandt B, Sron S and Zernicke J for their practical support and coordinating the study.Funding statement:The AQUA study was supported by an unrestricted research grant from Novartis. Testing kits were provided free of charge from Aidian Oy, Finland.Disclosure of Interests:None declared

The management of patients with spondyloarthritis (SpA) has experienced a paradigm shift in recent years. This is true for the treatment of axial as well as peripheral manifestations. International treat to target (T2T) recommendations for SpA based on the T2T strategy have now also been published, which contain 5 higher level principles (A-E) in addition to the 15 recommendations. In order to make the recommendations known and to promote national distribution, German experts have now issued a translation of the T2T recommendations for SpA into German.

Background Early stages of rheumatic diseases are still difficult to diagnose and treatment is delayed often due to the lack of practicing rheumatologists. Therefore, novel ways of diagnostic strategies are urgently needed. Objectives Evaluation of a structured screening system for selecting and treating patients (pts) with rheumatoid arthritis (RA) or rheumatic and musculoskeletal diseases (RMD) with health professional assistants (HPA, trained specialist nurses). Methods 177 pts visited a screening appointment for early arthritis (EA) between February 2015 and July 2016 in a specialised EA clinic. Inclusion criterion was arthritis in ≥one joint for less than one year. Pts had three options for accessing the screening: phone call with qualified HPAs, online questionnaire or attending a walk in clinic (figure 1). Upon screening, all pts filled in a digital questionnaire about their symptoms and comorbidities. In group 1 an HPA performed the joint count and analysed the questionnaire for 116 pts before giving a suspected diagnosis. Subsequently, a rheumatologist saw these pts and also made a suspected diagnosis. 61 pts in group 2 were examined directly by a rheumatologist. In case of a suspected RMD or abnormal laboratory parameters, pts received a new appointment for completing diagnostics, or in acute cases, treatment was started immediately. All pts had the opportunity of a new appointment in case of persistency or worsening of the symptoms. Results Pts had a mean age of 50.9±15.2 years and 135 (76.3%) pts were female. 160 (90.4%) pts had access to the screening by phone call. 10 (5.7%) pts used the online questionnaire, and 7 (3.9%) pts used the walk-in consultation. Pts waited 3.1±1.8 weeks for a screening appointment. According to the digital questionnaire pts had symptoms for 58.1±90.5 weeks at the screening appointment. 34 (56.7%) pts with RMD visited the screening clinic within six months after symptom onset. 2 (1.7%) pts had an RMD that had not been suspected by the HPA upon screening in group 1 and subsequently received conventional disease modifying antirheumatic drugs (cDMARDs) and glucocorticoids (GC). In group 2, 3 (4.9%) pts received cDMARDs although in the screening an RMD had not been initially suspected by the rheumatologist. In total 69 (39.0%) pts finally had an RMD, whereof 43 (24.3%) pts had an RA. 44 (24.9%) pts received therapy with a cDMARDs and 6 (3.4%) had the recommendation for a therapy with cDMARDs but refused treatment. Therapy with cDMARDs started 44.8±41.9 days after screening. 21 (11.9%) pts could already start with GC at the screening appointment. 27 (15.2%) pts without a diagnosed RMD visited the rheumatologist at least twice. Conclusions HPAs can select pts with RMDs efficiently in a structured screening system which leads to treating RMDs at an early stage in times of limited resources. Acknowledgements Abbvie supported the project within the T2T Initiative Germany. Disclosure of Interest None declared

The management of patients with spondyloarthritis (SpA) has experienced a paradigm shift in recent years. This is true for the treatment of axial as well as peripheral manifestations. International treat to target (T2T) recommendations for SpA based on the T2T strategy have now also been published, which contain 5 higher level principles (A-E) in addition to the 15 recommendations. In order to make the recommendations known and to promote national distribution, German experts have now issued a translation of the T2T recommendations for SpA into German.

The development of evidence-based treat-to-target (T2T) recommendations alleviates decision-making for the rheumatologist and simultaneously promises substantial improvement of outcome for rheumatoid arthritis (RA) patients. For the office-based rheumatologist in Germany, however, implementation of T2T recommendations contains several difficulties. Limitations arise as a result of an insufficient number of rheumatologists as well as a lack of adequate remuneration both resulting in a lack of time for the individual RA patient. Furthermore budget limitations hinder the appropriate use of antirheumatic drugs and insofar counteract treating to the target of remission. Establishment of selective contracts for rheumatologists by health insurance funds might reduce many of these problems in future for the office-based rheumatologist in Germany.

Neue Therapieprinzipien und Fortschritte in der Diagnostik haben es ermoglicht, bei Erkrankungen des rheumatischen Formenkreises und hier besonders bei der rheumatoiden Arthritis (RA) ein Krankheitsbild fruh zu definieren und durch eine fruhzeitig begonnene Medikation bei einem betrachtlichem Anteil der Patienten eine niedrige Krankheitsaktivitat oder Remission zu erzielen. Mit der zusatzlichen Entwicklung neuer Parameter zur Analyse der Krankheitsaktivitat stellte sich eine internationale Arbeitsgruppe von Rheumatologen und Rheumapatienten – in Anlehnung an die Optimierung der Therapie von Patienten mit einem Hypertonus oder Diabetes – die Aufgabe, einen Behandlungsplan fur die RA zu entwickeln mit dem Ziel, so haufig wie moglich eine Remission zu erzielen. Diese Treat-To-Target-Empfehlungen wurden von nationalen Arbeitsgruppen, so auch in Deutschland, hinsichtlich ihrer Umsetzbarkeit in die Infrastruktur des deutschen Gesundheitswesens diskutiert und Moglichkeiten zur Implementierung erortert. Am Modell der RA wurden wichtige Aktionselemente und Postulate fur eine verbesserte Versorgung von Menschen mit der Volkskrankheit Rheuma aufgestellt, die in dem vorliegenden Manuskript im Einzelnen diskutiert werden.

Background Making the diagnosis of axial spondyloarthritis (axSpA) may be difficult. Antibodies against CD74 have been shown to be present in 2/3 of patients with long established axial SpA. Objectives InterSpA is an international multicenter study, conducted to compare the sensitivity and specificity of anti-CD74 and HLA-B27 in patients with axSpA of recent onset. Methods Patients between 18 and 45 years suffering from inflammatory back pain (IBP) for maximally 2 years were recruited. The presence of ankylosing spondylitis, additional inflammatory rheumatic disorders and biologic therapy were exclusion criteria. MRI of sacroiliac joint was performed in all patients; HLA-B27 was detected by genotyping and anti-CD74 using a CE certified kit of Aesku Diagnostics (Wendelsheim, Germany). The sensitivity of anti-CD74 and HLA-B27 were calculated in patients fulfilling the imaging arm of ASAS criteria, in all patients fulfilling ASAS criteria and in 100 blood donors. Both the MRI reading as well as the laboratory procedures were performed blinded. Results 205 patients suffering from IBP were recruited. There were 40 recruiting failures. The remaining 165 patients had a mean age of 29.4 years, a mean duration of IBP of 12.6 months, 50% of the patients were female. Sacroiliitis was diagnosed by the local and an independent expert reader in 71/123 (57.7%). So far complete data sets are available of 91 patients. Of these, 16 fulfilled the ASAS criteria of axSpA by a pathologic MRI only, 40 by both MRI and presence of HLA-B27 and 20 by HLA-B27 only. The sensitivities of IgA anti-CD74, IgG anti-CD74 and HLA-B27 were 71.4%, 26.8% and 75% in the 56 axSpA patients with a pathologic MRI, 73.7%, 23.7% and 81.6% in all 76 patients fulfilling ASAS criteria, and 3%, 5% and 8% in the blood donors. The likelihood ratios are 23.8 (IgA anti-CD74), 5.4 (IgG anti-CD74) and 9.4 (HLA-B27) when considering the patients with a pathologic MRI only, and 24.6 (IgA anti-CD74), 4.7 (IgG anti-CD74) and 10.2 (HLA-B27) when considering all patients fulfilling ASAS criteria. Conclusions Considering their specificity and sensitivity, IgA anti-CD74 is a useful addition to our diagnostic tools for axSpA. Acknowledgement This study is funded by AbbVie Deutschland GmbH & Co. KG. AbbVie contributes to study logistics and site management. The authors determined study design, conduct of the study and the content of the publication. No payments were made to the authors for writing this manuscript. Disclosure of Interest E. Riechers Grant/research support from: AbbVie GmbH, N. T. Baerlecken Grant/research support from: AbbVie GmbH, X. Baraliakos: None declared, K. Achilles-Mehr Bakhsh: None declared, P. M. Aries: None declared, B. Bannert: None declared, K. Becker: None declared, J. F. Brandt-Jurgens: None declared, J. Braun: None declared, B. Ehrenstein: None declared, H. Euler: None declared, M. Fleck: None declared, R. Hein: None declared, K. Karberg: None declared, L. Kohler: None declared, T. Matthias: None declared, R. Max: None declared, A. Melzer: None declared, D. Meyer-Olson: None declared, J. Rech: None declared, K. Rockwitz: None declared, M. Rudwaleit: None declared, E. Schweikhard Employee of: Aesku GmbH, J. Sieper: None declared, C. Stille: None declared, U. von Hinuber: None declared, P. Wagener: None declared, H. Weidemann: None declared, S. Zinke: None declared, T. Witte Grant/research support from: AbbVie GmbH

Background Early stages of rheumatic diseases (0–12 weeks) including rheumatoid arthritis (RA) are still difficult to diagnose. For this reason, incorrect referrals to a rheumatologist result in a high use of resources in outpatient clinics. Objectives Implementation of a structured screening system for selecting and treating patients (pts) with RA or other rheumatic and musculoskeletal diseases (RMD). Methods 98 pts visited a screening appointment for early arthritis (EA) between February 2015 and September 2015 in special EA departments. Inclusion criterion was arthritis ≥ one joint for less than one year recorded by phone. Qualified health professional assistants (HPA) conducted the phone call. Upon screening, all pts filled in a tablet based questionnaire to be developed for future online use about their symptoms. Subsequently, 53 pts (group 1) were seen first by an HPA who analysed the questionnaire and performed the joint count. Based on these findings, the HPA made a suspected diagnosis. Afterwards, also a rheumatologist saw these pts and made a suspected diagnosis. In comparison, the rheumatologist directly examined 45 pts without an HPA (group 2). In both groups, typical clinical findings led to a new appointment, or in acute cases, treatment was started immediately. If an RMD was suspected or laboratory parameters were abnormal, pts received a second appointment as well. The documentation of the real-life data was carried out by the Medpath © system based on medical and flexible adaptable paths. Results Mean duration between phone call and screening was 19.6±12.8 days. Pts had an age of 18–80 years (mean 51.1±15.5 years), and 73 pts (74.5%) were female. Although all pts had reported symptoms of less than one year over the phone, only 70 pts (71.4%) fulfilled this criterion when asked in the questionnaire. In group 1, according to the HPA 22 of 53 (41.5%) pts had an RMD upon screening. The suspected diagnoses of HPA and rheumatologist corresponded in 43 of 53 (81.1%) pts in the screening. In group 2, the rheumatologist suspected 14 of 45 (31.1%) pts having an RMD in the first visit. 59 (60.2%) pts had no RMD. 23 (23.5%) pts had RA that was seropositive in 14 (14.3%) pts. All RA pts were recommended a therapy with conventional disease modifying antirheumatic drugs (cDMARDs) and glucocorticoids (GC), which 21 (21.4%) pts started 17.2±27.6 days after screening. 3 (3%) pts initially had a preclinical seropositive RA, which changed into definite RA in need for treatment with cDMARDs after 191 days in one patient. 3 (3%) pts received inpatient treatment and systemic lupus erythematosus was diagnosed in one case. Conclusions The structured screening system efficiently selects pts with RMDs and leads to treating RMD at an early stage in times of limited resources. Acknowledgement Abbvie supports the project within the T2T Initiative Germany. Disclosure of Interest None declared

The development of evidence-based treat-to-target (T2T) recommendations alleviates decision-making for the rheumatologist and simultaneously promises substantial improvement of outcome for rheumatoid arthritis (RA) patients. For the office-based rheumatologist in Germany, however, implementation of T2T recommendations contains several difficulties. Limitations arise as a result of an insufficient number of rheumatologists as well as a lack of adequate remuneration both resulting in a lack of time for the individual RA patient. Furthermore budget limitations hinder the appropriate use of antirheumatic drugs and insofar counteract treating to the target of remission. Establishment of selective contracts for rheumatologists by health insurance funds might reduce many of these problems in future for the office-based rheumatologist in Germany.

New therapeutic principles and considerable diagnostic advances have made it possible to define different rheumatic diseases and especially rheumatoid arthritis (RA) at an early stage and by starting an early and aggressive medication a considerable proportion of patients with RA will reach the status of low disease activity or even remission. With the additional development of composite measures to estimate the disease activity of RA, it was the goal of an international working group consisting of rheumatologists and patients to develop recommendations for treating rheumatoid arthritis in a similar way as for patients with hypertension or diabetes, with the aim to achieve remission as often as possible. This treat-to-target initiative has taken off in quite a number of different countries including Germany leading to discussions on how this initiative can be integrated into the specific national healthcare systems and what possibilities would exist for its implementation. To develop strategies for an improved healthcare of people suffering from rheumatic diseases and using RA as an example, action elements and postulates were developed which will be discussed in more detail in the present manuscript.

Objective. Antibody subclasses reflect specific immunological processes and may be indicative of the underlying pathological pattern in an autoimmune disease like RA. We therefore quantified anti-cyclic citrullinated peptides (CCP) and anti- citrullinated vimentin (MCV) IgG subclass titres in RA patients and compared them with the respective titres of antibodies directed against the varicella zoster virus (VZV) and to total serum titres. Methods. Sera of 77 patients fulfilling the ACR criteria for RA were collected. An IgG subclass-specific ELISA system was then established and combined with commercially available MCV, CCP and VZV pre-coated microtitre plates. Results. Even though IgG1 is the predominant subclass among antibodies against CCP and MCV in RA patients, IgG4 is second with respect to titres and frequencies. This increase in IgG4 among RA-specific antibodies is independent of disease duration and does not reflect a general skewing of the immune response in these patients as overall serum titres and antibodies directed against VZV show a normal distribution of IgG1, IgG2, IgG3 and IgG4. Conclusion. Elevated IgG4 titres are specific for auto-antibodies against citrullinated antigens in RA and are indicative of a Th2-biased environment during the generation of auto-reactive plasma cells. We discuss here an indirect role for IgG4 auto-antibodies in hindering the elimination of auto-reactive B and plasma cells and thus driving the autoimmune process.