Development, Sensibility and Reliability of a New Case-finding Questionnaire: the Toronto Axial Spondyloarthritis Questionnaire (TASQ) in Inflammatory Bowel Disease by Khalid Abdalla Ali Bin Yarouf Alnaqbi MBBS, CCD, FRCPC, FACP, FACR A thesis submitted in conformity with the requirements for the degree of Master of Science Graduate Department of The Institute of Medical Science University of Toronto ©Copyright by Khalid Abdalla Ali Bin Yarouf Alnaqbi, 2012 ii Development, Sensibility and Reliability of a New Case- finding Questionnaire: the Toronto Axial Spondyloarthritis Questionnaire (TASQ) in Inflammatory Bowel Disease Khalid Abdalla Ali Bin Yarouf Alnaqbi Master of Science Institute of Medical Science University of Toronto 2012 Abstract Background: There is an unacceptable delay in diagnosis of axial Spondyloarthritis (axSpA) especially in its early stages among patients with inflammatory bowel disease (IBD). Objective: to develop a sensible and reliable questionnaire to identify undetected axSpA among IBD patients. Methods: Candidate items for the questionnaire were selected on 3 domains (IBD, inflammatory back symptoms, and extra-axial features). Sensibility of the Toronto axSpA Questionnaire (TASQ) was assessed leading to drafting 18 items. Test-retest reliability study was conducted among 77 patients with established IBD and axSpA and kappa agreement coefficients were calculated for items. Results: The TASQ was developed using multiple steps of sensibility assessment resulting in 16 items. Kappa coefficients ranged from 0.81 to 1.00 for all items indicating almost perfect agreement. ii iii Conclusion: TASQ is a newly developed, sensible and reliable questionnaire that should facilitate identification and referral of IBD patients to rheumatologists and should avoid delay in diagnosis of axSpA. iii iv Acknowledgments I am indebted to my parents, Mariam and Abdalla Alnaqbi, for their love and support since I was born. I am also deeply indebted to my wife, Tamador Alnaqbi, for her continuous support especially during the completion of this thesis. Caring for our lovely 3 children (Mahra, Mayed, and Bader) in a faraway country from home is a great testimony that behind every great work is a woman! I would like to express my sincere gratitude to my supervisor, Prof. Robert Inman, whose enthusiasm and commitment made a great impact in the achievement of this project. I am blessed to have him as a world expert and a mentor who takes pride in the achievements of his co- workers. This was partly why I pursued a Clinical Research Fellowship in the Spondyloarthritis Program at the University of Toronto. A debt of my gratitude must go to the members of my thesis committee, Profs. Dafna Gladman, and Brian Feldman. They kindly guided me while my knowledge in research was growing. Thank you for being proud of me. Special thanks go to Dr. George Tomlinson for his guidance on statistical analysis of this project. I am grateful for the Spondyloarthritis team for their valuable feedback including Laura Passalent (advanced physiotherapist), Joan Blair (clinical trial manager), Donna Young (infusion nurse coordinator), Phyllis McGee (biologic nurse coordinator), and Adele Carty (research analyst). I am also grateful for Drs. Zahi Touma and Sindhu Johnson for their valuable contributions. A great appreciation must be given to my oral defense examiners, Drs. Muhammad Asim Khan and Cheryl Rosen for their insightful comments. Last but not least, I would like to thank the patients of the Spondylitis Clinic who took time to participate in this project and provided their constructive feedback. iv v Table of Contents Acknowledgments .......................................................................................................................... iv Table of Contents ............................................................................................................................ v List of Abbreviations ..................................................................................................................... ix List of Tables .................................................................................................................................. x List of Figures ................................................................................................................................ xi Chapter 1 Introduction and Literature Review ............................................................................... 1 1 Spondyloarthritis ...................................................................................................................... 2 1.1 Epidemiology and Classification Criteria for AS .............................................................. 2 1.2 Clinical Manifestations of AS ........................................................................................... 4 1.3 Outcome Measures in AS .................................................................................................. 6 1.3.1 Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) .............................. 6 1.3.2 Bath Ankylosing Spondylitis Functional Index (BASFI) ........................................... 7 1.3.3 Patient Global Assessment of Disease Activity .......................................................... 7 1.3.4 Ankylosing Spondylitis Disease Activity Score (ASDAS) ......................................... 7 1.3.5 Total Back Pain Score ................................................................................................. 8 1.3.6 Nocturnal Back Pain Score.......................................................................................... 8 1.3.7 Ankylosing Spondylitis Quality of Life (ASQoL) ...................................................... 8 1.3.8 Duration of Morning Stiffness of the Back over Last Week ....................................... 8 1.3.9 Fatigue ......................................................................................................................... 8 1.3.10 Outcome Measures Requiring Physical Examination ............................................... 9 1.3.11 Acute Phase Reactants (ESR or CRP) ....................................................................... 9 1.4 Primary AS and secondary AS .......................................................................................... 9 1.5 Axial Spondyloarthritis (axSpA) ....................................................................................... 9 1.6 Management of axSpA .................................................................................................... 10 2 axSpA in Inflammatory Bowel Disease (IBD) ...................................................................... 11 2.1 Epidemiology of IBD ...................................................................................................... 11 2.2 History and Epidemiology of IBD-Associated Arthritis ................................................. 12 2.3 Clinical Manifestations of IBD-Associated Arthritis ...................................................... 13 2.4 Management of IBD-Associated Arthritis ....................................................................... 16 v vi 3 Literature Review about Previous Attempts for Earlier Detection of axSpA ........................ 17 3.1 Early Descriptive Studies of Inflammatory Back pain .................................................... 17 3.2 Development of Rome Classification Criteria of AS (1961) ........................................... 18 3.3 New York Criteria (1966) ................................................................................................ 20 3.4 Studies of Calin and Colleagues (1977) .......................................................................... 22 3.5 Modification of New York Criteria (1984) ..................................................................... 23 3.6 Mau Criteria for Early AS (1985) .................................................................................... 25 3.7 Proposal for Diagnosis of AS by Cats and Colleagues (1987) ........................................ 27 3.8 Amor Criteria and ESSG Criteria for Classification of SpA (1990-1991) ...................... 28 3.9 Studies of Rudwaleit and Colleagues (2004-2006) ......................................................... 32 3.10 Development of the ASAS Criteria for axSpA (2009) .................................................. 36 3.11 Development of Case Ascertainment Questionnaire (2010) ......................................... 39 3.12 Summary ........................................................................................................................ 41 Chapter 2 Rationale, Hypothesis and Aims .................................................................................. 42 1 Rationale ................................................................................................................................ 43 2 Hypothesis .............................................................................................................................. 43 3 Aims ....................................................................................................................................... 43 Chapter 3 Methods ........................................................................................................................ 44 1 Development of Questionnaire Items .................................................................................... 45 1.1 Phase 1: Conceptualization .............................................................................................. 47 1.2 Phase 2: Item Pool Generation ........................................................................................ 47 1.3 Phase 3: Scaling Responses and Instrument Format ....................................................... 48 1.4 Phase 4: Selection of Items .............................................................................................. 48 1.4.1 Sensibility Assessment of Questionnaire Items ........................................................ 49 1.5 Phase 5: Pilot Study ......................................................................................................... 54 1.6 Phase 6: Sensibility Assessment of Post-Piloted TASQ Completed by the Committee Members ................................................................................................................................... 55 2 Reliability study ..................................................................................................................... 55 2.1 Concept ............................................................................................................................ 55 2.2 Population of Interest and Sampling Method .................................................................. 56 2.3 Sample Size Calculations for Test-Retest Reliability Study ........................................... 57 3 Statistical Analyses ................................................................................................................ 58 vi vii 3.1 Statistical Analysis for the Sensibility Assessment ......................................................... 58 3.2 Statistical Analysis for Patients in the Pilot Study .......................................................... 58 3.3 Statistical Analyses for Responders and Non-Responders .............................................. 59 3.4 Coding the Questionnaire’s Responses ........................................................................... 59 3.5 Statistical Analysis for Test-Retest Reliability ................................................................ 60 Chapter 4 Results .......................................................................................................................... 61 1 Selection of Items Using Sensibility Assessment .................................................................. 62 2 Pilot study .............................................................................................................................. 65 2.1 Stage 1 ............................................................................................................................. 67 2.2 Stage 2 ............................................................................................................................. 68 2.3 Stage 3 ............................................................................................................................. 70 3 Second Sensibility Assessment Completed by the Committee Members ............................. 70 4 Version 4 of the Questionnaire .............................................................................................. 72 5 Description of the Items in the Final Questionnaire .............................................................. 72 5.1 Inflammatory Bowel Disease (IBD) ................................................................................ 74 5.2 Inflammatory Back Symptoms ........................................................................................ 74 5.3 Extra-axial manifestations ............................................................................................... 77 6 Reliability study ..................................................................................................................... 78 6.1 Response Rate of Reliability Questionnaires .................................................................. 78 6.2 Missing Answers on the Questionnaire ........................................................................... 78 6.3 Comparison between Responders and Non-Responders ................................................. 79 6.4 Descriptive Statistics of the Items ................................................................................... 81 6.5 Test-Retest (Intra-rater) Reliability ................................................................................. 86 Chapter 5 Discussion .................................................................................................................... 88 1 Questionnaire Development ................................................................................................... 89 2 Clinimetric Measures in the Literature .................................................................................. 90 3 Sensibility Assessment of TASQ ........................................................................................... 92 3.1 Comprehensibility (Transparency) .................................................................................. 92 3.2 Content Validity ............................................................................................................... 93 3.3 Feasibility ........................................................................................................................ 94 3.3.1 Acceptability ............................................................................................................. 94 3.3.2 Readability................................................................................................................. 94 vii viii 4 Reliability ............................................................................................................................... 97 4.1 Rating Responses of the Questionnaire Items ................................................................. 97 4.2 Test-Retest Reliability ..................................................................................................... 98 5 Recent Questionnaire for Back Pain (April 2012) ................................................................. 99 Chapter 6 Conclusions ................................................................................................................ 101 Chapter 7 Limitations and Future Directions .............................................................................. 103 1 Development ........................................................................................................................ 104 2 Future Validation Studies .................................................................................................... 105 Bibliography ............................................................................................................................... 107 Appendix A: Consent to participate in a research study ............................................................. 117 viii ix List of Abbreviations AS: Ankylosing Spondylitis ASAS: Assessment of SpondyloArthritis international Society axSpA: axial SpondyloArthritis BASDAI: Bath Ankylosing Spondylitis Disease Activity Index BASFI: Bath Ankylosing Spondylitis Disease Functional Index CI: Confidence Interval CRP: C-Reactive Protein ESR: Erythrocyte Sedimentation rate ESSG: European Spondyloarthropathy Study Group IBD: Inflammatory Bowel Disease IBP: Inflammatory Back Pain LR: Likelihood Ratio MLBP: Mechanical Low Back Pain MRI: Magnetic Resonance Imaging NSAIDs: Non-Steroidal Anti-Inflammatory Drugs OR: Odds Ratio SpA: Spondyloarthritis SPARCC: Spondyloarthritis Research Consortium of Canada Registry for Spondyloarthritis TASQ: Toronto Axial Spondyloarthritis Questionnaire TNF: Tumor Necrosis Factor TWH: Toronto Western Hospital ix x List of Tables Table 1. Summary of the characteristics of articular involvement in IBD patients ...................... 15 Table 2. Mau criteria for early diagnosis of AS (1985). ............................................................... 26 Table 3. Proposal for diagnostic criteria of AS (1987) ................................................................. 27 Table 4. Summary of diagnostic tests for individual parameters used for the diagnosis of early axSpA in patients with chronic back pain lasting ≥ 3 months ........................................ 33 Table 5. Frequencies and positive likelihood ratios of IBP features in AS and MLBP patients .. 35 Table 6. Checklist of sensibility assessment with definitions ....................................................... 51 Table 7. Questionnaire for sensibility assessment ........................................................................ 53 Table 8. Sensibility assessment for the pre-piloted TASQ completed by the committee members ........................................................................................................................................ 63 Table 9. Stages of sensibility assessment of TASQ by patients ................................................... 66 Table 10. Comparison of sensibility assessments completed by the committee members for the pre-piloted and post-piloted TASQ .............................................................................. 71 Table 11. Demographic and clinical characteristics of responders and non-responders. Values are means (SD) unless otherwise indicated ........................................................................ 80 Table 12. Summary of the responses for features of axSpA among patients with axSpA and IBD ...................................................................................................................................... 82 Table 13. Results of the test-retest reliability analysis ................................................................. 87 x