# Variability of Psoriatic Arthritis Impact of Disease questionnaire (PsAID12) thresholds in psoriatic arthritis: insights from the observational ReFlaP study

Clementina López-Medina, Clémence Gorlier, Ana-Maria Orbai, Laura Coates, Uta Kiltz, Ying-Ying Leung, Penelope Palominos, Juan Cañete, Rossana Scrivo, Andra Balanescu, et al.

► To cite this version:

Clementina López-Medina, Clémence Gorlier, Ana-Maria Orbai, Laura Coates, Uta Kiltz, et al. Variability of Psoriatic Arthritis Impact of Disease questionnaire (PsAID12) thresholds in psoriatic arthritis: insights from the observational ReFlaP study. Rheumatology, 2025, 64 (5), pp.3090-3094. 10.1093/rheumatology/keaf002. hal-05441011

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## Concise report – Rheumatology (Oxford)

### Variability of Psoriatic Arthritis Impact of Disease questionnaire (PsAID12) thresholds in psoriatic arthritis: insights from the observational ReFlaP study.

Clementina López-Medina, Clémence Gorlier, Ana-Maria Orbai, Laura C Coates, Uta Kiltz, Ying-Ying Leung, Penelope Palominos, Juan D Cañete, Rossana Scrivo, Andra Balanescu, Emmanuelle Dernis, Sandra Meisalu, Adeline Ruyssen-Witrand, Martin Soubrier, Sibel Zehra Aydin, Lihi Eder, Inna Gaydukova, Ennio Lubrano, Umut Kalyoncu, Pascal Richette, M. Elaine Husni, Josef S. Smolen, Maarten de Wit, Laure Gossec

## Affiliations

**Clementina López-Medina:** University of Cordoba, Reina Sofía Hospital, IMIBIC, Cordoba, Spain

**Clémence Gorlier, Laure Gossec:**
1 Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France

2 AP-HP, Pitié-Salpêtrière hospital, Rheumatology department, Paris, France.

ORCID Gossec 0000-0002-4528-310X

**Laura C Coates,** Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK

**Uta Kiltz,** Rheumazentrum Ruhrgebiet, Herne and Ruhr-Universität Bochum, Germany

**Ying-Ying Leung,** Singapore General Hospital, Duke-NUS Medical School, Singapore

**Penelope Palominos,** Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil

**Juan D Cañete,** Hospital Clínic and IDIBAPS, Barcelona, Spain

**Rossana Scrivo,** Rheumatology Unit, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza Università di Roma, Rome, Italy

**Andra Balanescu,** Sf. Maria Hospital, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania

**Emmanuelle Dernis,** Le Mans Central Hospital, Le Mans, France

**Sandra Meisalu,** East-Tallinn Central Hospital, Tallinn, Estonia

**Adeline Ruyssen-Witrand,** Rheumatology Unit, Toulouse university Hospital, CIC1463, Inserm, Université Paul Sabatier Toulouse III, Toulouse, France

**Martin Soubrier,** Gabriel Montpied Hospital, Clermont Ferrand, France

**Sibel Zehra Aydin,** University of Ottawa, the Ottawa Hospital Research Institute, Ottawa, Canada

**Lihi Eder,** Women's College Hospital, University of Toronto, Toronto, ON, Canada

**Inna Gaydukova,** North-western State medical university, St. Petersburg, Russia, Russia

**Ennio Lubrano,** Academic Rheumatology Unit, Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio", University of Molise, Campobasso, Italy.

**Umut Kalyoncu,** Hacettepe University Faculty of Medicine, Department of Internal Medicine, Division of Rheumatology, Ankara, Turkey

**Pascal Richette,** Hopital Lariboisière Centre Viggo Petersen, service de rhumatologie, Paris, France; Université Paris Diderot UFR de Médecine, Inserm UMR1132 Bioscar, Paris, France

**M. Elaine Husni,** Cleveland Clinic, Department of Rheumatic and Immunologic Diseases, Cleveland, USA

**Maarten de Wit,** Patient research partner, Amsterdam, Netherlands
**Josef Smolen**, Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria

**Ana-Maria Orbai**, MD MHS, Johns Hopkins University School of Medicine, Division of Rheumatology, Baltimore, MD, USA

**Key Indexing Terms:** PsAID, patient-reported outcomes, remission, disease activity, psoriatic arthritis

**Corresponding author:**

Clementina Lopez-Medina, MD, PhD
University of Cordoba, Reina Sofia University Hospital, Cordoba, Spain
Menendez Pidal Avenue, 14004, Cordoba, Spain
Email: h72lomee@uco.es

Word count: 2096 words, 18 references

**Funding:** The ReFlaP study received financial support from Pfizer through an unrestricted research grant.

**Key messages:**

1. Thresholds for the Psoriatic Arthritis (PsA) Impact of Disease questionnaire (PsAID12) have been defined.

2. These thresholds varied depending on the external anchor used.

3. The proposed cutoffs are 1.7 for remission, 3.1 for moderate disease activity and 4.8 for high disease activity.
# ABSTRACT

## Objectives

To explore thresholds for the Psoriatic Arthritis (PsA) Impact of Disease questionnaire (PsAID12) score against disease activity measures in an observational setting, in patients with PsA.

## Methods

The baseline data from the ReFlaP observational, prospective, multicenter and international study was used (NCT03119805). Cutoffs for PsAID12 were determined against disease activity scores, defining disease impact states (i.e. remission, low impact, moderate impact and high impact). Statistics used to assess the optimal cutoff point included the Youden's index and the 75th percentile method, with external anchors (i.e., DAPSA, VDLA/MDA and single questions for both patients and physicians) serving as gold standards. The diagnostic performance of these cutoffs was evaluated using Receiver Operating Characteristic (ROC) curve analyses.

## Results

A total of 410 patients were analyzed. Mean (standard deviation, SD) PsAID12 score was 3.4 (SD 2.5). The prevalence of remission varied between 12.4% and 36.1%, while low disease activity ranged from 37.8% to 59.8%. PsAID12 performed well against external anchors, with high areas under the ROC curves ranging from 0.75 to 0.94. Thresholds varied depending on the external anchor used: PsAID12 cutoffs ranged 1.4-3.0 for remission, 1.9-4.2 for low disease impact, and 4.5-4.8 for moderate disease impact. Compared to composite scores, patient and physician opinions performed less stringent.

## Conclusion

This study established cutoffs for PsAID12 in a clinical practice observational population, corresponding to remission and varying levels of disease activity. However, these proposed cutoffs need further validation, and an expert consensus is essential to confirm the most accurate thresholds for future use.
# INTRODUCTION

Psoriatic arthritis (PsA) is a multifaceted inflammatory disease characterized by significant heterogeneity, contributing to a wide spectrum of alterations in health-related quality of life [1]. The Psoriatic Arthritis (PsA) Impact of Disease questionnaire (PsAID12) is a robust instrument designed to evaluate patient-important symptoms and the overall impact of PsA [2]. Encompassing 12 distinct health domains, the PsAID12 score effectively measures the multifaceted repercussion of PsA, ranging from physical to psychological aspects. It has been provisionally recommended as a core outcome measure for health-related quality of life domain of PsA by OMERACT [3,4].

Thresholds for continuous scores help clinicians interpret the degree of symptoms. A more precise understanding by quantifying impact levels that may correlate with different disease states is crucial. However, thresholds depend on the gold standard or reference measure (anchor) being used.

To date, various threshold proposals have been established for the PsAID12. The first established a value below 4, representing a patient acceptable symptom state (PASS)[5]. Using disease activity as external anchor, two studies proposed to establish PsAID12 thresholds based on the clinical Disease Activity index for Psoriatic Arthritis (DAPSA). Di Carlo et al. published cut-off values for the PsAID12 corresponding to different levels of disease impact [6], although the sample size was limited. Recently, new thresholds for the PsAID12 have been calculated in a randomized control trial (RCT) population [7]. The suitability of using a different external anchor such as the patient's or physician's opinion remains uncertain [8].

The objective of this study was to identify thresholds for PsAID12 in an observational setting, corresponding to degrees (states) of disease impact (i.e. remission, low, moderate, and high impact) in PsA, using different reference measures. This was achieved through an anchor-driven approach using several reference definitions of disease activity including composite scores and both patient and physician perceptions.
# METHODS

## Study population and study design

The ReFlaP (Remission/Flare in PsA) study has been described elsewhere [9]. Briefly, this was an observational, prospective, multicenter and international (14 countries) study conducted between June 2017 and August 2018 (NCT03119805). Patients were evaluated twice, but only baseline data are used here.

Consecutive adults with a definite diagnosis of PsA according to their rheumatologists, and with greater than 2 years of disease duration were included. All patients provided informed consent, with ethical committee approval at each site.

## Data collection

- **General data:** Patient demographic variables (age, gender, work status, level of education), disease characteristics (disease duration, predominant type of PsA: peripheral, axial or enthesal), and current treatment (conventional synthetic or biologic disease-modifying anti-rheumatic drugs (cs- or bDMARDs)) were collected. All elements necessary to calculate the Very Low Disease Activity (VLDA) / Minimal Disease Activity (MDA) [10] and DAPSA scores were also collected [11].

- **PsAID12:** The PsAID12 assesses the impact of PsA across 12 domains using numerical rating scales (ranging from 0 to 10, where higher results indicate higher impact). Domains include pain, physical function, fatigue, coping and depression among others. The final PsAID12 score is calculated by combining these domains, yielding a score between 0 and 10 (higher scores indicate worse condition) [7]. This questionnaire is known for its readability, simplicity, reliability and validity [6].

- **Definitions used as external anchors for disease activity levels:**

a) Remission was defined using VLDA (which requires the presence of these seven items: tender joint count ≤1, swollen joint count ≤1, enthesitis count ≤1, patient's global assessment ≤2/10, pain ≤1.5/10, skin psoriasis (Psoriasis Area Severity Index (PASI) ≤1 or Body Surface Area (BSA) ≤3% and HAQ-DI ≤0.5) and DAPSA ≤4, along with single questions for both patients and physicians. For patients: "At this time, is your psoriatic arthritis in remission, if this means: you feel your disease is as good as gone?". For physicians: "At this time, is the psoriatic arthritis in remission, if this means: the absence of
clinical and laboratory evidence of significant inflammatory disease activity?" [9];

* b) Low impact was defined using MDA (which requires the presence of at least five of the items previously described for VLDA), DAPSA ≤14 and single questions for both patients and physicians. For patients: "At this time, are you in low disease activity, if this means: your disease is in low activity but it's not as good as gone?", and for physicians: "At this time, is the psoriatic arthritis in low or minimal disease activity?".

* c) Moderate disease impact anchor was based on DAPSA cut-offs of moderate (>14 and ≤28) disease activity [11]; and

* d) high disease impact anchor was also based on DAPSA cut-offs of high (>28) disease activity [11].

## Statistical analysis

All patients with complete data for calculating remission and low impact according to all definitions were included in the analysis. Missing data were not imputed, and only complete cases were analysed. Descriptive statistics were used to summarize baseline demographic and clinical characteristics of the patients. Similarly, to the approach used in previous cut-off development [7], cutoffs for PsAID12 were determined using Youden's index on Receiver Operating Characteristic (ROC) curve analyses and the 75th percentile method, with the external anchors serving as gold standards.

All statistical analyses were conducted with R version 3.4.0 (http://r-project.org).

## RESULTS

### Population

Out of 466 patients, 410 complete cases were analyzed (Table 1). Overall, 208 (50.7%) patients were male, with a mean age of 52.8 (standard deviation [SD] 12.4) years. The mean (SD) disease duration was 10.2 (8.3) years, indicating a long-standing disease history. A majority of patients were receiving DMARDs, with 73.6% on csDMARDs and 72.8% on bDMARDs. Disease activity levels were moderate: the mean (SD) tender joint count (TJC) was 4.9 (9.8), mean swollen joint count (SJC) was 2.4 (7.3), mean physician global assessment (PhGA) was 3.1 (2.5) and mean patient global assessment (PGA) was 4.1 (2.8). Mean PsAID12
score was 3.4 (2.5).

## Disease activity levels

Frequencies of disease activity states varies by definitions used (Supplementary Table 1). The prevalence of remission varied between 12.4 and 36.1%, while low disease activity ranged from 37.8% to 59.8% (Supplementary Figure 1). Moderate and high disease activity (defined solely on DAPSA cutoffs) were observed in 108 (26.3%) and 73 (17.8%) patients, respectively.

## Cutoffs for PsAID12

PsAID12 performed well against the external anchors, based on high areas under the ROC curves ranging from 0.75 to 0.94 (Table 2). As expected, PsAID12 thresholds varied depending on the external anchor used. PsAID12 cut-offs were more stringent (lower) for achieving the VLDA and MDA criteria compared to DAPSA remission and low disease activity (Table 2).

a) For defining remission, PsAID12 cutoffs found using the Youden Index methodology varied depending on the anchor: from 1.4 using the VLDA as the anchor, to 1.8 using the physician's question. Using the DAPSA, this cut-off was established on 1.7. However, when using the 75th percentile methodology, PsAID12 cutoffs for remission ranged from 0.8 to 3.0 using VLDA and physician's question as anchors, respectively.

b) PsAID12 cutoffs for defining low disease impact, were found to be 2.0 and 4.2, using the MDA and physician's question, respectively, according to the Youden Index methodology, with very similar results when using the 75th percentile technique. Considering the DAPSA as external anchor, this threshold for low impact was established on 3.1. Nevertheless, the Area Under the Curve (AUC) were greater using the DAPSA and MDA as anchors in comparison with patients' and physicians' questions.

c) Cutoffs for moderate disease impact could only be calculated using the DAPSA as the anchor, with a result of 4.5 and 4.8 according to the 75th percentile and ROC techniques, respectively. (Supplementary Table 2).

In general, compared to composite scores, patient and physician' opinions performed less stringent (i.e., <1.8 and 1.8 to 4.2 for remission and low impact, according to the physicians' opinion, and <1.7 and <2.4 according to patient's opinion).
Discussion

This study has enabled us to propose thresholds for the PsAID12 score in an observational
setting, corresponding to different levels of disease impact. Thresholds were more stringent
when using the DAPSA and VLDA/MDA as external anchors compared to patient and
physician opinions, and these thresholds also demonstrated a higher AUC. Compared to the
previous PsAID12 thresholds proposed in an RCT setting where DAPSA was established as
the external anchor, the thresholds developed in the ReFlaP cohort were less stringent. This
difference possibly reflects variations in patient status and expectations in clinical practice.

Remission is a complex concept. From the patients' perspective, little is known about their perception of remission and about which level of symptoms would be acceptable for them [12]. In Rheumatoid Arthritis, studies have shown that the three most important domains of patients' perceived remission are the absence or reduction of pain and fatigue and the improvement or maintenance of independence [13]. In PsA, there are little qualitative data on patients' assessments of remission, but an international qualitative study is ongoing to answer these questions. Patients with PsA have to deal with both symptoms related to their joint involvement, skin and nail psoriasis and its burden, as well as other manifestations such as axial disease and/or enthesitis. This leads to a multi-faceted disease from the patients' perspective, which may lead to heterogeneity in what patients would consider to be remission.

For composite scores, we know the prevalence of remission is much lower defined by the
VLDA due its stringiness explained by the inclusion of joints, enthesitis and psoriasis, and due
to Boolean scoring [14]. In fact, our results showed that thresholds for the PsAID12 using
the VLDA as external anchors were the most stringent in comparison with patients' and
physicians' opinion. Consequently, the remission rates observed using VLDA thresholds were
lower, indicating that this method sets a higher standard for what is considered remission.
This highlights the importance of chosen external anchor in defining and measuring
treatment outcomes.

LDA status in our population showed a wider range of variation (from 59.8% to 37.8%
defined by the patient's perception or MDA, respectively), probably reflecting the inaccuracy
and uncertainty around this concept or the inclusion of remission in the LDA status.

In our study, moderate and high impact in the PsAID12 were defined using DAPSA as an
external anchor, as no other comparator was available. Di Carlo et al. also established cutoffs for moderate (between 4.1 and 6.7) and high impact (above 6.7), being less stringent than our findings, probably due to the lower sample size and patients' characteristics.

This study had strengths and weaknesses. Recruitment occurred at tertiary care centers, leading to a high percentage of patients on biologics, which may limit external validity. However, representativeness was ensured through an international large-scale selection of consecutive patients with PsA. Due to the absence of consensus on defining disease activity in PsA, both commonly used scores and recommended by the Treat-to-Target task force [15], VLDA/MDA and DAPSA, were employed as external anchors. Furthermore, cutoffs corresponding to patient and physician-perceived remission/low impact were identified using innovative questions. Notably, considerable effort was invested in developing these patient questions, involving patient research partners to ensure face and content validity. The involvement of patient research partners in this process is crucial, as it provide insights directly from the patient perspective, enhancing the relevance and accuracy of the questions. It should be acknowledged, however, that these questions may emphasize musculoskeletal concepts more than skin psoriasis concepts. By involving patient research partners, some of the these limitations could be mitigated, although a balance between different disease aspects remains challenge.

There is no consensus on the optimal approach for calculating cutoffs for disease impact. These anchors are meaningful, easy to interpret and closely related to the measured concept, which strengthens the study. Moreover, the obtained cutoffs were reasonably close to those from a previous pilot study by Di Carlo et al [6]. Selecting appropriate external anchors for patient-reported outcomes is challenging due to the risk of circular reasoning. PsA composite measures incorporate patient-reported outcomes such as pain and patient global assessment [10]. However, these measures were developed with limited patient involvement, and cutoffs for remission/low impact were not driven by patient input [16]. The specific single questions developed for the present study are not expected to introduce more circularity with PsAID12 than what is typical for patient-reported outcomes. This is important because discrepancies in disease activity assessment can impact on treatment decisions and shared decision-making, highlighting the need for stablishing accurate thresholds to ensure that treatment decisions are based on reliable assessment [17,18].
In conclusion, this study has explored cutoffs for PsAID12 in an observational, clinical practice population, corresponding to different levels of disease impact. However, these proposed cutoffs require validation and comparison with recently proposed thresholds from RCT. Subsequently, expert consensus is needed to determine the most accurate thresholds for future use.

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<table><caption>Table 1. Clinical characteristics of the included population.</caption><thead><tr><th></th><th>All<br>N = 410</th><th>REM/LDA by<br>DAPSA<br>N=229</th><th>REM/LDA by<br>MDA/VLDA<br>N = 155</th><th>REM/LDA by<br>patient<br>question<br>N = 245</th></tr></thead><tbody><tr><td>Male, n (%)</td><td>208 (50.7%)</td><td>137 (60.6%)</td><td>105 (69.1%)</td><td>68 (42.2%)</td></tr><tr><td>Mean age, years (SD)</td><td>52.8 (12.4)</td><td>52.8 (12.7)</td><td>52.2 (12.1)</td><td>53.6 (12.2)</td></tr><tr><td>Mean PsA duration, years (SD)</td><td>10.2 (8.3)</td><td>10.9 (8.2)</td><td>11.4 (8.4)</td><td>10.7 (8.6)</td></tr><tr><td>Current smoking, n (%)</td><td>68 (18.1%)</td><td>33 (15.7%)</td><td>19 (13.2%)</td><td>31 (14.2%)</td></tr><tr><td>Current conventional DMARDs, n (%)</td><td>243 (73.6%)</td><td>142 (76.3%)</td><td>85 (70.8%)</td><td>156 (77.6%)</td></tr><tr><td>Current biological DMARDs, n (%)</td><td>233 (72.8%)</td><td>145 (79.7%)</td><td>96 (82.1%)</td><td>87 (67.4%)</td></tr><tr><td>Oral glucocorticoids, n (%)</td><td>67 (18.6%)</td><td>26 (12.9%)</td><td>10 (7.5%)</td><td>34 (15.7%)</td></tr></tbody></table>
<table><tr><td>BSA of psoriasis ≥5%, n (%)</td><td>37 (9.2%)</td><td>13 (5.7%)</td><td>2 (1.3%)</td><td>21 (12.9%)</td></tr><tr><td>Tender enthesal points, LEI, mean (SD)</td><td>0.6 (1.4)</td><td>0.1 (0.4)</td><td>0.1 (0.3)</td><td>0.3 (0.9)</td></tr><tr><td>Tender joints count (0-68), mean (SD)</td><td>4.9 (9.8)</td><td>0.7 (1.1)</td><td>0.3 (0.7)</td><td>2.9 (7.2)</td></tr><tr><td>Swollen joints count (0-66), mean (SD)</td><td>2.4 (7.3)</td><td>0.4 (1.0)</td><td>0.4 (0.9)</td><td>1.4 (5.2)</td></tr><tr><td>Physician's global assessment of PsA, mean (SD)</td><td>3.1 (2.5)</td><td>1.8 (1.7)</td><td>1.3 (1.4)</td><td>2.4 (2.1)</td></tr><tr><td>Patient's global assessment of pain (0-10), mean (SD)</td><td>4.1 (2.8)</td><td>2.3 (1.8)</td><td>1.9 (1.9)</td><td>3.2 (2.4)</td></tr><tr><td>Patient's global assessment of PsA (0-10), mean (SD)</td><td>4.2 (2.8)</td><td>2.5 (1.9)</td><td>2.1 (2.0)</td><td>3.3 (2.3)</td></tr><tr><td>DAPSA, mean (SD)</td><td>17.0 (17.7)</td><td>6.2 (3.9)</td><td>5.2 (4.4)</td><td>11.8 (14.7)</td></tr><tr><td>HAQ (0-3), mean (SD)</td><td>0.68 (0.68)</td><td>0.38 (0.49)</td><td>0.16 (0.28)</td><td>0.50 (0.57)</td></tr><tr><td>PsAID12 (0-10), mean (SD)</td><td>3.4 (2.5)</td><td>2.0 (1.7)</td><td>1.4 (1.3)</td><td>2.5 (2.1)</td></tr></table>

PsA: psoriatic arthritis; DMARDs: disease-modifying antirheumatic drugs; BSA: Body Surface Area; LEI: Leeds enthesitis index; DAPSA: Disease Activity Index for Psoriatic Arthritis; HAQ: Health Assessment Questionnaire; LDA: Low Disease Activity; PsAID12: Psoriatic Arthritis (PsA) Impact of Disease questionnaire; REM: remission; VLDA: Very Low Disease Activity

<table><caption>Table 2. Calculated cutoffs for PsAID12 for different disease impact levels in PsA using different external anchors.</caption><thead><tr><th rowspan="2"></th><th colspan="3">Remission</th><th colspan="3">Low impact</th><th colspan="3">Moderate impact</th></tr><tr><th>AUC</th><th>ROC Youden index</th><th>75<sup>th</sup> percentile</th><th>AUC</th><th>ROC Youden index</th><th>75<sup>th</sup></th><th>AUC</th><th>ROC Youden index</th><th>75<sup>th</sup></th></tr></thead><tbody><tr><th>DAPSA</th><td>0.94</td><td>1.7</td><td>1.4</td><td>0.89</td><td>3.1</td><td>3.1</td><td>0.85</td><td>4.8</td><td>4.5</td></tr><tr><th>VLDA / MDA</th><td>0.94</td><td>1.4</td><td>0.8</td><td>0.91</td><td>2.0</td><td>1.9</td><td>-</td><td>-</td><td>-</td></tr><tr><th>Patient's question</th><td>0.77</td><td>1.7</td><td>2.4</td><td>0.83</td><td>3.7</td><td>3.7</td><td>-</td><td>-</td><td>-</td></tr><tr><th>Physician's question</th><td>0.75</td><td>1.8</td><td>3.0</td><td>0.77</td><td>4.2</td><td>4.1</td><td>-</td><td>-</td><td>-</td></tr></tbody></table>

PsAID12: Psoriatic Arthritis (PsA) Impact of Disease questionnaire; ROC: Receiver Operating Characteristic; AUC: area under curve; DAPSA: Disease Activity Index for Psoriatic Arthritis; VLDA: Very Low Disease Activity; MDA: minimal disease activity.

Supplementary Figure 1. Prevalence of remission and low disease activity according to different definitions.
<figure><img src="image_2.png" /></figure>

DAPSA: Disease Activity index for Psoriatic Arthritis; MDA: Minimal Disease Activity; VLDA: Very low disease activity.

<table><caption>**Supplementary Table 1. Frequency of disease activity states according to different definitions**</caption><thead><tr><th></th><th>DAPSA</th><th>VLDA/MDA</th><th>Physician-perceived status</th><th>Patient-perceived status</th></tr></thead><tbody><tr><th>Remission</th><td>78 (19.0%)</td><td>51 (12.4%)</td><td>148 (36.1%)</td><td>88 (21.5%)</td></tr><tr><th>LDA (including remission)</th><td>229 (55.9%)</td><td>155 (37.8%)</td><td>175 (42.7%)</td><td>245 (59.8%)</td></tr><tr><th>Moderate disease activity</th><td>108 (26.3%)</td><td>-</td><td>-</td><td>-</td></tr><tr><th>High disease activity</th><td>73 (17.8%)</td><td>-</td><td>-</td><td>-</td></tr></tbody></table>

DAPSA: Disease Activity Index for Psoriatic Arthritis; VLDA: Very Low Disease Activity; MDA: minimal disease activity; Patient perceived, and physician perceived statuses are based on the single questions for each status.