Beeldvorming – Erosies

Publicatiedatum: 13-04-2026

Beoordeeld op geldigheid: 13-04-2026

Uitgangsvraag

Welke beeldvormende modaliteiten (conventionele radiografie, echo, CT, MRI) kunnen worden ingezet bij patiënten die zich presenteren met artritis om RA-typische erosieve afwijkingen aan te tonen danwel uit te sluiten?

Aanbeveling

Verricht niet routinematig beeldvormend onderzoek (conventionele radiografie, echografie, CT of MRI) van gewrichten bij patiënten die zich presenteren met artritis verdacht voor RA om RA te diagnosticeren, aangezien dit geen aanvullende meerwaarde heeft naast anamnese, lichamelijk onderzoek en laboratoriumonderzoek.

Wanneer de differentiaaldiagnose breder is dan RA, kan het wel nuttig zijn om additionele beeldvorming te verrichten. In dat geval verwijzen we naar de daarvoor betreffende richtlijnen.

Overwegingen

Balans tussen gewenste en ongewenste effecten

In totaal zijn er twee systematische reviews (SRs) en drie observationele studies beschreven die de plaats van verschillende beeldvormende modaliteiten (focus op detectie van erosies) voor het stellen van de diagnose reumatoïde artritis rapporteren.

De beschreven resultaten zijn gebaseerd op zowel retrospectieve als prospectieve cohort- studies en zijn uitgevoerd in heterogene studiepopulaties (d.w.z. de inclusie-criteria variëren sterk). Daarnaast varieerde de grootte van studiepopulatie per individuele studie, met veelal kleine studies, varieerde de prevalentie van RA (of was deze onduidelijk) en was het niet altijd mogelijk om data te poolen of te extraheren uit de systematisch reviews. Ook is er onduidelijkheid over mogelijke verschillen tussen personen die de beeldvormende diagnostiek uitvoeren. Daarnaast zijn er meestal niet meerdere modaliteiten in 1 studie meegenomen (bijvoorbeeld om de meerwaarde van MRI over conventionele röntgenfoto’s (CR) te kunnen beoordelen). Ten slotte is er enige circulariteit met de RA classificatie criteria van 1987 en de CR, omdat aanwezigheid van 3 of meer typische RA erosies als pathognomisch (specificiteit 100%) wordt gezien voor RA.

De bewijskracht voor de beschreven uitkomstmaten wordt gegradeerd met GRADE ‘Low’ voor de modaliteit echografie, met GRADE ‘Very low’ voor de modaliteit MRI en röntgen.

Naast de bevindingen op basis van de PICO beschrijft de studie van Ulijn (2024) dat erosies geassocieerd met RA werden vastgesteld bij 32/724 (4.4%) patiënten die zich presenteerden met artritis en verdenking op RA. Bij slechts twee van 724 personen (0.3%) leidde het vinden van erosies tot verandering van classificatie van geen naar wel RA volgens de classificatiecriteria.

Er zijn geen studies gevonden m.b.t. CT. Deze beeldvorming wordt in de praktijk niet of nauwelijks gebruikt m.b.t. het stellen van de diagnose reumatoïde artritis. Dit komt onder andere door de hoge stralingsbelasting. Er zijn echter ontwikkelingen in het aanpassen van de scantechniek waardoor de hoeveelheid straling gereduceerd wordt en CT in de toekomst mogelijk wel een plek kan innemen. Met de huidige vorm van CT, en het ontbreken van (positief) bewijs voor een toegevoegde waarde, wordt dit type beeldvorming echter niet geadviseerd (Diekhoff, 2025).

Het is belangrijk om te benoemen dat erosies op een conventionele foto pas laat in het ziekteproces zichtbaar zijn. Op basis van dit punt is er niet direct een aanvullende meerwaarde voor deze beeldvorming.

Literatuur voormalige richtlijn RA diagnostiek

Röntgenfoto’s

De conclusies uit de voormalige richtlijn geven aan dat de aanwezigheid van erosies op CR bij een patiënt met ongedifferentieerde artritis de kans op het ontwikkelen van RA vergroot. Er wordt geadviseerd om, ondanks de lage sensitiviteit, CR van handen en voeten te maken bij patiënten met verdenking op RA. Nu de sensitiviteit in de huidige tijd veel lager blijkt, is de waarde nog verder afgenomen.

Echografie

De diagnostische waardes voor het vaststellen van erosies gerelateerd aan RA bij gebruik van echografie is buiten beschouwing gelaten in de voormalige richtlijn.

MRI

De diagnostische waardes voor het vaststellen van erosies gerelateerd aan RA bij gebruik van MRI is buiten beschouwing gelaten in de voormalige richtlijn.

Waarden en voorkeuren van patiënten (en eventueel hun naasten/verzorgers)

Het maken van CR is voor patiënten weinig belastend. Het maken van een echo of MRI kost wat tijd, maar is eveneens niet erg belastend.

Deze drie diagnostische modaliteiten gaan weinig gepaard met relevante kans op fout positieve of toevallige nevenbevindingen. Omgekeerd is het achterwege laten van het uitvoeren van beeldvormend onderzoek in deze context voor patiënten acceptabel, aangezien er geen duidelijk concept bestaat welke testen moeten worden uitgevoerd.

Een negatieve röntgenfoto sluit een erosie nog niet uit (NPV 45%) en draagt derhalve niet reeel voldoende bij aan geruststelling van een patiënt. Het is belangrijk om patiënten goed te informeren over het te verrichten onderzoek.

Kostenaspecten

De benoemde studies bespreken alleen diagnostische waardes van beeldvorming en niet de eventuele verbetering in klinische uitkomsten voor patiënten, of de kosteneffectiviteit van deze diagnostiek. De interventie (het uitvoeren van beeldvormend onderzoek naar erosies bij presentatie met artritis verdacht voor RA) levert meer kosten op ten opzichte van de controle behandeling, het achterwege laten van routine beeldvorming in deze. Dit weegt niet op tegen het verschil in effectiviteit. Gezien de lage prevalentie van erosieve afwijkingen passend bij RA, de diagnostische waarde die al aanwezig is van de RA classificatie criteria, en de beperkte testkarakteristieken van deze testen zal routinematige inzet van deze diagnostiek de uitkomsten voor patiënten met artritis hoogstwaarschijnlijk niet veranderen.

Deze richtlijn gaat over diagnostiek met één test. Als een teststrategie wordt gebruikt met meerdere testen achter elkaar (bijvoorbeeld CR nadat op echo een erosie is gevonden), zullen de belasting en kosten toenemen, en zal de additionele waarde per test afnemen en de kans op fout positieve bevindingen toenemen. Dit wordt dus niet geadviseerd.

Gelijkheid ((health) equity/equitable)

De interventie leidt niet tot verschil in van gezondheidsgelijkheid, want deze vormen van diagnostiek zijn met name in de tweede lijn bij de reumatoloog vrijelijk en geheel vergoed beschikbaar.

Aanvaardbaarheid:

Ethische aanvaardbaarheid

De interventie / diagnostiek of het weglaten daarvan lijkt aanvaardbaar voor de betrokkenen. Er zijn geen ethische bezwaren gezien de lage patiënt belasting en de vrijwel afwezige meerwaarde.

Duurzaamheid

Bij de interventie spelen de volgende duurzaamheidsaspecten een rol. Het doen van diagnostiek leidt tot wat meer milieubelasting vanwege reizen, stroomverbruik, en gebruik van disposables. Bij de controle spelen de geen duurzaamheidsaspecten een rol.

Haalbaarheid

De interventie / diagnostiek (zowel het uitvoeren of laten van beeldvormende testen bij presentatie met artritis verdacht voor RA) lijkt haalbaar. De interventie / diagnostiek was wat betreft CR, en in mindere mate echo in sommige ziekenhuizen standaardzorg in de praktijk.

De-implementatie van gebruik van deze diagnostiek is in principe eenvoudig te doen.

Rationale van de aanbeveling: weging van argumenten voor en tegen de diagnostische procedure

De volgende overwegingen hebben geleid tot de aanbeveling. Erosieve afwijkingen typisch voor RA hebben een hoge specificiteit/positief voorspellende waarde voor de diagnose RA, maar een lage sensitiviteit/negatief voorspellende waarde. Het is niet zinvol om routinematig onderzoek te doen naar erosieve afwijkingen middels het maken van CR, US, CT of MRI van handen en/of voeten bij presentatie met artritis verdacht voor RA vanwege:

De prevalentie van erosieve afwijkingen is erg laag in de huidige tijd in Nederland, waar de patiënt- en arts delay beperkt is, en de toegankelijkheid van zorg goed.
Deze afwijkingen komen met name voor bij patiënten waar de diagnose RA al evident is (op basis van kliniek, CRP, RF, CCP), en resulteren dus maar zeer zelden in verandering van de diagnose.
Behandeling van artritis met een DMARD zal onafhankelijk van erosiviteit of niet plaatsvinden. Prognostisch ongunstige RA wordt iets anders behandeld (sneller door naar bDMARD). Maar erosiviteit is maar één van de prognostisch ongunstige factoren (zoals vrouwelijk geslacht, hoge CRP, hoge DAS28, hoge HAQ, RF/CCP +, etc. (EULAR RA treatment recommendations 2022), en hangt daar ook mee samen, en erosiviteit of niet leidt dus vrijwel niet tot andere classificatie van prognose (Ulijn, 2024).

Eindbeoordeling:

Sterke aanbeveling voor niet doen.

Onderbouwing

Achtergrond

In patients with clinically present arthritis without a clear diagnosis, rheumatoid arthritis may be developing. Based on the characteristics of the arthritis in anamnesis and physical examination (including number of joints, symmetry, number of joint groups, large or small joints) and simple additional laboratory tests (CRP and ESR, rheumatoid factor (RF), anti-cyclic citrullinated peptide (CCP)), the diagnosis of RA can be made or made unlikely. Sometimes erosive abnormalities may be found in the joints, where an erosion is defined as: “A bone erosion is a peri-inflammatory destructive bone lesion that radiologically refers to a break in cortical bone with destruction of the natural barrier between the extraskeletal tissue and the bone marrow compartment.” (Geusens, 2016). An erosion can be visible as a lucency with a cortical break, but the cortical break is not always visible in all directions of the X ray image.

Finding characteristic erosions consistent with RA on conventional X ray imaging (at least three erosions of wrists, MCP, PIP or MTP joints) may have additional value in doubtful cases, because they are considered pathognomonic for RA. This will be particularly important when the presence of erosive lesions changes the final diagnosis and subsequent treatment.

One point that needs to be highlighted is the fact that erosions have often not yet developed at presentation of the patient with arthritis, since patients with arthritis have been presenting to secondary care earlier in recent decades, which means that, in contrast to the past (before the year 2000), only a very limited percentage of patients have erosive disease at presentation.

Because the presence of this type of erosion on conventional radiography can be considered pathognomonic, the specificity is by definition 100%. The search question is therefore focused on the sensitivity, and in particular to what extent the sensitivity of the classification criteria is increased by adding X-rays of hands and feet.

The specificity for erosive lesions on other modalities (ultrasound, CT, MRI) is not yet known; for these modalities, the RA classification criteria are used as the reference standard. Furthermore, it has been assumed that both clinical practice and scientific evidence show that nuclear imaging (bone scan, FDG-PET CT) has no added value for finding erosive abnormalities, this has not been formally investigated in this guideline.

Conclusies / Summary of Findings

Conventional radiography

Very low GRADE

The evidence is very uncertain about the sensitivity, specificity, positive predictive value and negative predictive value of the presence of erosions on conventional radiography, in patients with suspected RA to diagnose RA.

Sources: (Koevoets, 2011; Ulijn, 2024; Filer, 2011)

Ultrasound

Low GRADE

The sensitivity of US (focus on erosions) for RA diagnosis in patients with suspected RA was 38%, using the RA classification criteria as reference.

The specificity of US (focus on erosions) for RA diagnosis in patients with suspected RA, ranges from 93% to 100%, using the RA classification criteria as reference.

The positive predictive value of US (focus on erosions) for RA diagnosis in patients with suspected RA, ranges from 85% to 100%, using the RA classification criteria as reference.

The negative predictive value of US (focus on erosions) for RA diagnosis in patients with suspected RA, ranges from 48% to 60%, using the RA classification criteria as reference.

Sources: (Machado, 2011; Broll, 2012; Filer, 2011)

MRI

Very low GRADE

The evidence is very uncertain about the sensitivity, specificity, positive predictive value and negative predictive value of the presence of erosions on MRI, in patients with clinically suspected RA, to diagnose RA.

Sources: (Machado, 2011; Broll, 2012)

Samenvatting literatuur

Description of studies

Description of systematic reviews

Machado (2011) performed a systematic literature review to assess the diagnostic and prognostic value in diagnosis of rheumatoid arthritis (RA) of magnetic resonance imaging (MRI) and ultrasound (US) in patients with undifferentiated peripheral inflammatory arthritis (UPIA). Medline, Embase, the Cochrane Library, and abstracts presented at the 2007 and 2008 meetings of the American College of Rheumatology and European League Against Rheumatism meetings were searched until February 2009.

Included were cohort studies, retrospective case-control studies and randomized controlled trials in which each arm of a trial can be seen as a cohort study. More details are available in the evidence table. In total, 11 studies (N=624) were included that evaluated MRI, of which 2 studies (N=170) included truly undifferentiated populations while the other 9 included mixed populations at baseline. These mixed populations included patients with UPIA, as well as patients with arthralgia or those with an established diagnosis at baseline. Further, two studies (N=156) were included that evaluated US. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio and negative likelihood ratio were calculated.

The mean age ranged from 44 to 58 years, and the participants were often females (range 68% to 92%). Due to heterogeneity, it was difficult to pool outcomes. The overall risk of bias was high.

Koevoets (2011) performed a systematic literature review to assess the diagnostic and predictive value of conventional radiography (CR) in patients with undifferentiated arthritis (UA) for the diagnosis of RA. Medline, Embase, and the Cochrane Library were searched for articles published between 1950 and February 2009. Included were cohort studies, retrospective case-control studies and randomized controlled trials in which each arm of a trial can be seen as a separate cohort study. More details are available in the evidence table. In total, 25 studies were included, of which five studies with a pure UA population. Four of these five studies were diagnostic studies and one assessed prognosis. Three of these five studies were performed using the same cohort (the Leiden Early Arthritis Cohort) but with different numbers of patients included. Positive and negative likelihood ratios were presented for only two studies (N=367), the other two diagnostic studies did not show associations between erosions and diagnosis of RA or had included conventional radiographs in a prediction model with anti-CCP.

Of these two studies, the mean age of included patients was 51 and 55 years, of whom 54% and 85% female. Due to heterogeneity, it was difficult to pool outcomes. The overall risk of bias was high.

Description of observational studies

Ulijn (2024) performed a retrospective cohort study to investigate the prevalence, diagnostic, and prognostic value of RA-associated erosions seen on CR in patients with newly presenting arthritis, using the RA classification criteria as reference standard.

Patients with newly presenting arthritis who were suspected of RA, visiting the rheumatology department were included. More details are described in the evidence tables.

In total 724 patients were included. The prevalence of final (after >1 year) clinical diagnosis classification of RA was 41% (299/724). The mean age was 57 (SD 15) years and 449/724 (62%) were female. Outcomes of interest were the prevalence of erosions and the proportion of patients in whom the presence of erosions changed the classification of the diagnosis to RA. The overall risk of bias was low.

Broll (2012) performed a prospective cohort study to investigate the diagnostic values of US and MRI for the diagnosis of RA in patients with suspected arthritis, using the classification criteria as reference standard.

Patients with suspected arthritis of the wrist or finger joints visiting the rheumatology department were included. More details are described in the evidence tables.

In total 50 patients were included. The prevalence of RA was 52% (26/50). The mean age was 57 (SD 11.4) years and 33/50 (66%) were female. Outcomes of interest were the prevalence of erosions, and the diagnostic values of US and MRI for erosions using de RA classification criteria as reference. The study is limited by the fact of the strict inclusion criteria which limited the generalizability. The overall risk of bias was high.

Filer (2011) performed a prospective cohort study to investigate the diagnostic values of US and CR for the diagnosis of RA in patients with suspected arthritis, using the classification criteria as reference standard.

Patients with clinically apparent synovitis of at least one joint and inflammatory joint symptoms (inflammatory joint pain, and/or swelling and/or morning stiffness) of 3 months or less duration were included. More details are described in the evidence tables.

In total 58 patients were included. The prevalence of RA was 50% (29/58). The median age was 63 (range 19-82) years and 13/29 (45%) were female in the group with RA patients (N=29). Outcomes of interest were the prevalence of erosions, and the diagnostic values of US and conventional radiography for erosions using de RA classification criteria as reference. The study is limited by the fact of the strict inclusion criteria which limited the generalizability. The overall risk of bias was high.

Results

Outcomes for diagnostic values are summarized per intervention (i.e., CR, US, MRI) and outcome measure.

There were no studies found which analyzed CT according to the PICO, therefore these could not be discussed.

1. Conventional radiography (CR)

In the systematic review of Koevoets (2011), 25 studies (n ranges from 32 to 590 patients) evaluated CR. Individual study results of interest are presented below and could not be pooled due to heterogeneity in study population and different methods to assess erosions.

The study of Van Aken (2005) showed that ‘erosive disease (based on Sharp-van der Heijde score (SvdH) hands or feet CR)’ was a prognostic factor for the development of RA at 1 year:

Positive likelihood ratio: 3.5 (95%CI 2.1-6.0)
Negative likelihood ratio: 0.8 (95%CI 0.7-0.9)

The study of Duer (2008) showed that ‘Larsen grade 1 hand or feet CR’ was a prognostic factor for the development of RA at 2 years:

Positive likelihood ratio: 10.9 (95%CI 1.4-87.3)
Negative likelihood ratio: 0.7 (95%CI 0.4-1.0)

Ulijn (2024) studied 724 patients with newly presenting arthritis who were suspected of RA. Of them 299 (41%) were diagnosed with RA. Erosions, based on CR of hand and feet, were detected in 107/724 (14.8%, 95%CI 12.3-17.6) patients. Of them 32/724 (4.4%, 95%CI 3.1-6.2) were typical RA-associated erosions, the others mainly due to erosive osteoarthritis. The presence of at least one RA-associated erosion on the routine X-HF resulted in a classification diagnosis changed to RA in 2/724 (0.3%, 95%CI 0.0-1.0%) patients leading to a number needed to screen (NNS) of 362 (95%CI 335 - 389). This contributory value was not influenced by duration of complaints at presentation, or RF and CCP status.

Filer (2011) studied 58 patients with clinically apparent synovitis of at least one joint. Of them 29 (50%) were diagnosed with RA. Erosions, based on radiographs of hand and foot, were detected in 1/58 (1.7%) patient (within the RA group; 1/29 (3.5%)).

This resulted in the following values for the prediction of RA, based on the presence of erosions on CR:

Sensitivity: 3.5%
Specificity: 100%
Positive predictive value: 100%
Negative predictive value: 45%
Area under the curve: 0.52
Positive likelihood ratio: -
Negative likelihood ratio: 0.97

2. Ultrasound (US)

In the systematic review of Machado (2011), two studies evaluated US. Individual study results are not presented as the reported outcomes (i.e., predictive values for progression to persistent inflammatory arthritis and relapse) were not of interest for the current question.

Broll (2012) studied 50 patients with suspected arthritis of the wrist or finger joints. Of them 26 (52%) were diagnosed with RA.

The diagnostic value of erosions (US) to diagnose RA based on the classification criteria are as followed:

Sensitivity: 37.5%
Specificity: 100%
Positive predictive value: 100%
Negative predictive value: 47.7%

Filer (2011) studied 58 patients with clinically apparent synovitis of at least one joint. Of them 29 (50%) were diagnosed with RA. Erosions, based on US hand and foot, were detected in 14/58 (24%) patients (within the RA group; 11/29 (38%); within the non-RA group 2/13 (15%); within the resolving group 1/16 (6%)).

This resulted in the following values for the prediction of RA, based on the presence of erosions on US:

Sensitivity: 38%
Specificity: 93%
Positive predictive value: 85%
Negative predictive value: 60%
Area under the curve: 0.66
Positive likelihood ratio: 5.5
Negative likelihood ratio: 0.67

3. Magnetic resonance imaging (MRI)

In the systematic review of Machado (2011), eleven studies (n ranges from 13 to 129 patients) evaluated MRI. Individual study results are presented below and could not be pooled due to heterogeneity in selection criteria.

Since two studies reported data relevant for the current question, only these data are presented:

Duer (2008) studied 41 patients with undifferentiated peripheral inflammatory arthritis. Of them 11 (27%) were diagnosed with RA.

Results regarding the performance of ‘MRI erosion pattern of RA’ for prediction of progression to RA are descripted below:

Sensitivity: 64%
Specificity: 77%
Positive predictive value: 50%
Negative predictive value: 85%
Positive likelihood ratio: 4.8 (95%CI 1.7-13.2)
Negative likelihood ratio: 0.4 (95%CI 0.2-0.9)

Tamai (2009) studied 129 patients with undifferentiated peripheral inflammatory arthritis. Of them 75 (58%) were diagnosed with RA.

Results regarding the performance of ‘MRI bone erosion’ for prediction of progression to RA are descripted below:

Sensitivity: 29%
Specificity: 91%
Positive predictive value: 81%
Negative predictive value: 48%
Positive likelihood ratio: 3.2 (95%CI 1.3-7.8)
Negative likelihood ratio: 0.8 (95%CI 0.7-0.9)

Broll (2012) studied 50 patients with suspected arthritis of the wrist or finger joints. Of them 26 (52%) were diagnosed with RA.

The diagnostic value of erosions (low-field MRI) to diagnose RA based on the classification criteria are as followed:

Sensitivity: 58.1%
Specificity: 83.3%
Positive predictive value: 85.7%
Negative predictive value: 53.5%

Level of evidence of the literature

The level of evidence (GRADE method) is determined per comparison and diagnostic outcome measure and is based on results from diagnostic accuracy studies and therefore starts at level “high”. Subsequently, the level of evidence was downgraded if there were relevant shortcomings in one of the several GRADE domains: risk of bias, inconsistency, indirectness, imprecision, and publication bias.

Conventional radiography

The level of evidence regarding the outcome measures started as high, because results were from diagnostic accuracy studies. The level of evidence was downgraded by three levels because of risk of bias (i.e., limitations in publications regarding selection of patients, heterogeneity between study results; -2), and imprecision (not meeting optimal information size; -1). The level of evidence for the outcomes ‘sensitivity, specificity, positive predictive value, negative predictive value, area under the curve, positive likelihood ratio, negative likelihood ratio’ is very low.

The level of evidence regarding the outcome measures started as high, because results were from diagnostic accuracy studies. The level of evidence was downgraded by two levels because of risk of bias (i.e., limitations in publications regarding selection of patients; -1), and imprecision (not meeting optimal information size; -1). The level of evidence for the outcomes ‘sensitivity, specificity, positive predictive value, negative predictive value’ is low.

MRI
The level of evidence regarding the outcome measures started as high, because results were from diagnostic accuracy studies. The level of evidence was downgraded by three levels because of risk of bias (i.e., limitations in publications regarding selection of patients, additional information definitions; -2), and imprecision (not meeting optimal information size; -1). The level of evidence for the outcomes ‘sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio’ is very low.

Zoeken en selecteren

A systematic review of the literature was performed to answer the following question:

What is the diagnostic value of performing imaging techniques (conventional radiography (CR), ultrasound (US), CT, MRI) compared to the reference standard (classification criteria) in patients with clinical arthritis suspected of rheumatoid arthritis to assess rheumatoid arthritis?

For CR of hands and feet

P:	Patients with clinical arthritis suspected of rheumatoid arthritis
I:	CR (focus on detection of erosions typical for RA)
R:	N.v.t.
O:	The sensitivity of erosions typical for RA in patients with undifferentiated clinical arthritis, and the increase in sensitivity when the results are added to the classification criteria for RA or the clinical diagnosis
T/S:	Within 2 years, secondary care

For US, CT, MRI

P:	Patients with clinical arthritis suspected of rheumatoid arthritis
I:	US, CT, MRI
R:	Classification criteria for RA
O:	Sensitivity and specificity for classification of RA. Sensitivity and specificity for future erosions on conventional radiographs of hands and feet
T/S:	Within 2 years, secondary care

Relevant outcome measures

The guideline development group considered the following two as critical outcome measures for decision making

The sensitivity (=prevalence in patients with final diagnosis of RA) of erosions typical for RA.
The increase in sensitivity when adding the test to the classification criteria: The proportion of patients in whom the presence of erosions typical for RA result in the diagnosis / classification being changed from undifferentiated arthritis to RA.

The working group did not define a priori outcome measures, but used the definition as defined in the studies.

1. The working group defined a MCID of 10% in sensitivity, specificity, PPV and NPV as a minimal clinically (patient) important difference.

2. The working group defined an area under the ROC of 0.80 (10 patients to screen for 1 confirmed diagnosis) as a MCID.

Outcome	Consequence	Consequence relevant for patient	Importance (1-10)
TP	Confirmation of diagnosis	Start treatment	8
TN	Ruling out diagnosis	Continuing diagnostic proces	10
FP	Wrong diagnosis	Possibly incorrect treatment	8
FN	Missing diagnosis	Delayed start of treatment	10
Inconclusive to interpret results	Diagnosis remains unclear	Possibly incorrect or delayed treatment	7
_{TP= true positives, TN= true negatives, FP= false positives, FN= false negatives}

Search and select (Methods)

The databases Medline (via OVID) and Embase (via Embase.com) were searched with relevant search terms from 2010 until June 2024. The detailed search strategy is depicted under the tab Methods. The systematic literature search resulted in 83 systematic reviews (SR) and 1,124 observational studies. Studies were selected based on the following criteria: PICO, adult patients, articles in English, no animal research. Five systematic reviews were selected based on title and abstract. After reading the full text, three studies were excluded (see the table with reasons for exclusion under the tab Methods), and two SR were included. Further, three additional observational studies were included because of their added value in focusing specifically on erosions.

Results

Two systematic reviews and three additional observational studies were included in the analysis of the literature. Important study characteristics and results are summarized in the evidence tables. The assessment of the risk of bias is summarized in the risk of bias tables.

Referenties

Broll M, Albrecht K, Tarner I, Müller-Ladner U, Strunk J. Sensitivity and specificity of ultrasonography and low-field magnetic resonance imaging for diagnosing arthritis. Clin Exp Rheumatol. 2012 Jul-Aug;30(4):543-7. Epub 2012 Aug 29. PMID: 22703848.
Filer A, de Pablo P, Allen G, Nightingale P, Jordan A, Jobanputra P, Bowman S, Buckley CD, Raza K. Utility of ultrasound joint counts in the prediction of rheumatoid arthritis in patients with very early synovitis. Ann Rheum Dis. 2011 Mar;70(3):500-7. doi: 10.1136/ard.2010.131573. Epub 2010 Nov 29. PMID: 21115552; PMCID: PMC3033529.
Geusens, P., Goldring, S. R., Briot, K., & Roux, C. (2016). The role of the immune system in the development of osteoporosis and fracture risk. In Osteoimmunology (pp. 187-214). Academic Press.
Koevoets R, Machado P, Bombardier C, van der Heijde DM. The value of conventional radiographs in undifferentiated arthritis: a systematic review. J Rheumatol Suppl. 2011 Mar;87:26-30. doi: 10.3899/jrheum.101071. PMID: 21364053.
Machado PM, Koevoets R, Bombardier C, van der Heijde DM. The value of magnetic resonance imaging and ultrasound in undifferentiated arthritis: a systematic review. J Rheumatol Suppl. 2011 Mar;87:31-7. doi: 10.3899/jrheum.101072. PMID: 21364054.
van Ravesteijn H, van Dijk I, Darmon D, van de Laar F, Lucassen P, Olde Hartman T, van Weel C, Speckens A. The reassuring value of diagnostic tests: a systematic review. Patient Educ Couns. 2012 Jan;86(1):3-8. doi: 10.1016/j.pec.2011.02.003. Epub 2011 Mar 6. PMID: 21382687.
Rolfe A, Burton C. Reassurance after diagnostic testing with a low pretest probability of serious disease: systematic review and meta-analysis. JAMA Intern Med. 2013 Mar 25;173(6):407-16. doi: 10.1001/jamainternmed.2013.2762. PMID: 23440131.
Ulijn E, den Broeder N, Ten Cate D, van Overdijk K, Demirel H, Landewé R, van Herwaarden N, den Broeder A. Limited Diagnostic and Prognostic Value of Routine Radiographs in Newly Presenting Arthritis Suspected of Rheumatoid Arthritis: A Retrospective Study. Arthritis Care Res (Hoboken). 2024 Apr;76(4):497-502. doi: 10.1002/acr.25271. Epub 2024 Jan 25. PMID: 37933435.

Evidence tabellen

Evidence table for systematic reviews of diagnostic test accuracy studies

Study reference

Study characteristics

Patient characteristics

Index test

(test of interest)

Reference test

Follow-up

Outcome measures and effect size

Comments

Machado, 2011

PS., study characteristics and results are extracted from the SR (unless stated otherwise)

Systematic review

Literature search date: until February 2009

MRI; n=11

A: Duer, 2008

B: Tamai, 2009

C: Mori, 2008

D: Narváez, 2008

E: Zampogna, 2008

F: Tamai, 2006

G: Solau-Gervais, 2006

H: Boutry, 2005

I: Klarlund, 2000

J: Sugimoto, 2000

K: Sugimoto, 1996

Ultrasound, n=2

L: Freeston, 2010

M: Sciré, 2009

Study design: Three types of studies were considered for inclusion: (1) cohort studies; (2) retrospective case-control studies; and (3) randomized controlled trials.

Setting and Country:

No details described in publication.

Source of funding and conflicts of interest:

Supported by an unrestricted educational grant from Abbott. Abbott had no role in the design, literature search, data collection, data analysis, data interpretation, or writing of this report. Dr. Bombardier holds a Pfizer Chair and Canada Research Chair in Knowledge Transfer for Musculoskeletal Care

Inclusion criteria SR:

During the 2008-2009 3e Initiative kickoff meeting, experts decided that only patients in whom clinically apparent joint swelling (synovial proliferation or synovial effusion) was observed by the rheumatologist should be included.

For the current systematic review, participants were to be patients that, after initial visits and diagnostic investigations, did not fulfill the diagnostic/ classification

criteria for any rheumatologic disorder. Because we anticipated that very few studies would have included truly undifferentiated populations at baseline, we also kept a record of results from studies in mixed populations (e.g., UPIA + arthralgia, UPIA + early RA), as these could be useful for extrapolating results.

13 studies included

Important patient characteristics:

N, mean age

A: 41, 55y

B: 129, 16-80y

C: 17, 58y

D: 40, 54y

E: 39, 51y

F: 113, unkown

G: 30, 47y

H: 56, 46y

I: 13, 13-68y

J: 50, 44y

K: 96, 47y

L: 50, 21-80y

M: 106, 60y

Sex: Female (n, %)

A: 35, 85%

B: 100, 78%

C: 14, 82%

D: 28, 70%

E: 29, 74%

F: unknown

G: unknown

H: 38, 68%

I: 12, 92%

J: 41, 82%

K: 24, 89%

L: 38, 76%

M: 75, 71%

Describe index and interpretation

MRI; n=11

MRI synovitis and erosion pattern of RA
MRI synovitis pattern of RA
MRI erosion pattern of RA
MRI synovitis or erosion pattern of RA
MRI synovitis and erosion and scintigraphy patterns of RA (several joints, but not distal interphalangeal joints and CMC1)

MRI synovitis
MRI symmetric synovitis
MRI bone edema
MRI bone erosion
MRI bone edema and/or erosion

MRI criterion (MIP) plus CARF+ and/or anti-CCP+
Symmetrical hand synovitis with MRI (MIP)

MRI synovitis with BME or erosions

MRI rate of early enhancement ratio (REE)**, MRI relative enhancement (RE)**, morning stiffness, SJC, TJC, patient global, Ritchie index, DAS, HAQ, ESR, IgM RF, anti-CCP

Respectively ≥: 1, 2, or 3 of: anti-CCP+, MRI

MRI OMERACT MCP erosion score > 15

MRI MCP BME
MRI MCP synovitis
MRI MCP bone erosions
MRI MCP bone defects
MRI MCP tenosynovitis
MRI wrist BME
MRI wrist synovitis
MRI wrist bone erosions
MRI wrist bone defects
MRI wrist tenosynovitis

MRI erosions
MRI tenosynovitis

Bilateral MRI synovitis of the same joint area (wrist, MCP, or PIP)

US, n=2

US GS ≥ 1
US GS ≥ 2
US GS = 3
US PD ≥ 2
US PD ≥ 1
US FT in any finger
Erosive on US

Ultrasound (44 joints): US-JC, US PD, US GS

Describe reference test and cut-off point(s):

Diagnosis of RA after 1 to 2 years according to ACR

Prevalence (%)

Not mentioned.

For how many participants were no complete outcome data available?

Not mentioned.

Reasons for incomplete outcome data described?

Not mentioned.

A: 24 mo

B: 12 mo

C: 27.4 mo

D: 20 mo

E: 38.4 mo

F: 12 mo

G: 30.6 mo

H: 29 mo

I: 12 mo

J: 26 mo

K: 9.7 mo

L: 12 mo

M: 24 mo

Outcome measures and effect size (include 95%CI and p-value if available):

Outcome measure-MRI- erosion

- Sensitivity (%)

UPIA populations:

A: 64

B: 77

Mixed populations:

G: 63

H (MCP): 61

H (wrist): 100

I: 20

- Specificity (%)

UPIA populations:

A: 77

B: 91

Mixed populations:

G: 71

H (MCP): 53

H (wrist): 16

I: 100

- PPV (%)

UPIA populations:

A: 50

B: 81

Mixed populations:

G: 71

H (MCP): 65

H (wrist): 64

I: 100

- NPV (%)

UPIA populations:

A: 85

B: 48

Mixed populations:

G: 63

H (MCP): 48

H (wrist): 100

I: 67

- Positive likelihood ratio (%)

UPIA populations:

A: 2.7 (1.2-6.0)

B: 3.2 (1.3-7.8)

Mixed populations:

G: 2.2 (0.9-5.4)

H (MCP): 1.3 (0.7-2.2)

H (wrist): 1.2 (1.0-1.4)

I: inf

- Negative likelihood ratio (%)

UPIA populations:

A: 0.5 (0.2-1.1)

B: 0.8 (0.7-0.9)

Mixed populations:

G: 0.5 (0.1-1.1)

H (MCP): 0.7 (0.4-1.4)

H (wrist): 0 (NA)

I: 0.8 (0.5-1.2)

Outcome measure-US-erosive in >=1 joint

- Sensitivity

L: 53

- Specificity

L: 73

- PPV

L: 87

- NPV:

L: 31

- Positive likelihood ratio (%)

L: 1.9 (0.7-5.3)

- Negative likelihood ratio (%)

L: 0.7 (0.4-1.1)

Study quality (ROB):

Levels of Evidence were assigned according to the Oxford Centre for Evidence-based Medicine, for all studies = 2b

Place of the index test in the clinical pathway: replacement, triage, add-on

Choice of cut-off point: influences test characteristics (sens, spec); important in relation to the clinical question (e.g. if a disease is to be ruled out, sensitivity is the critical outcome measure and more important than specificity: high sensitivity comes at the expense of low specificity and high rates of false postives, and usually those testing positive are subjected to further diagnostic tests for final diagnosis)

* depends on observer

Brief description of author’s conclusion:
MRI bone edema and combined synovitis and erosion pattern seem useful in predicting development of RA from UPIA. The value of US in UPIA remains to be determined. The absence of MRI synovitis seems useful in excluding development of RA. No data were found about the value of repeating MRI/US. Studies evaluating MRI/US in UPIA are scarce, but current knowledge strongly encourages further testing in UA.

Personal remarks on study quality, conclusions, and other issues (potentially) relevant to the research question:
- mixed populations (only 2 studies included truly UPIA) of patients with UPIA, as well as patients with arthralgia or those with an established diagnosis at baseline
- index test varies
- reference standard unclear
- observational data

- information about conflict of interest /funding not reported.

Results based on MRI studies in mixed populations must be viewed with caution due to

the heterogeneity of the study populations and the different

measurements and outcomes that were used and that made

the pooling of data impossible.

Koevoets, 2011

PS., study characteristics and results are extracted from the SR (unless stated otherwise)

Literature search up to February 2009

A: van Aken, 2005

B: van der Helm, 2007

C: van Gallen, 2004

D: Jansen, 2002

E: Duer, 2007

F: Devauchelle, 2001

G: Devauchelle, 2004

H: Devauchelle, 2006

I:Sareux, 2001

J: Jansen, 2004

K; Jansen, 2003

L: Nielen, 2005

M: Bukhari, 2003

N: Bukhari, 2002

O : Jensen, 2004

P: Knudsen, 2008

Q: Klarund, 2000

R: Cunnae, 2001

S: Daragon, 2001
T: Isomaki, 1987

U: Isomaki, 1984

V: Visser, 2002

W: Gough, 1994

X: Boire, 2005

Y: Kuriya, 2008

.....

Study design: cohort, case-control

[prospective / retrospective]

Setting and Country:

Source of funding and conflicts of interest:

[commercial / non-commercial funding/ industrial co-authorship / potential conflicts of interest ]

Inclusion criteria SR:

(1) cohort studies

in which patients from a given UA population had CR at baseline and in

whom the outcome after a period of followup was recorded;

(2) retrospective

case-control studies in which patients had CR at baseline and who were

known to have had UA when the baseline investigation was performed; and

(3) randomized controlled trials of UA patients that implicitly addressed the

question of diagnostic or prognostic value, as each arm of a trial can be seen

as a separate cohort study.

Exclusion criteria SR:

See selection criteria

25 studies included
5 with a pure UA population and 20 with a mixed

population

Important patient characteristics:

N, mean age

A: : 326; 51

B: 590; 53

C: 318; 49

D: 77; 49

E: 41; 55

F: 258; 50

G: 149; 50

H: 258; 50

I:270; NR

J: 279; 56

K; 362; 57

L: 379; 56

M: 335; 55

N: 439; 55

O : 75; 50

P: 75; 50

Q: 55; 50

R: 206; 46

S: 32; 46
T: 105; NR

U: 275; 37

V: 524; 49

W: 177; NR

X: 165; 59

Y: 105; 44

Sex:

See table 1 of original article

Describe index and comparator tests* and

cut-off point(s):

in all studies: Conventional radiographs

method voor assessing erosions differs; which method per study is not descripted in detail.

Describe reference test and cut-off point(s):

Diagnosis of RA after 1 to 2 years according to criteria

Prevalence (%)

Not mentioned.

For how many participants were no complete outcome data available?

Not mentioned.

Reasons for incomplete outcome data described?

Not mentioned.

Endpoint of follow-up:

Varies between 6 months to 3 years; although not mentioned in detail for all studies;

Outcome measures and effect size (include 95%CI and p-value if available):

LR + (95%CI) for erosions with outcome RA diagnose

A: 3.5 (2.1-6.0)

E: 10.9 (1.4-87.3)

F[only hands]: 4.1 (1.7-9.5)

G: 6.2 (2.4-15.6)

H: 1.8 (1.03.1)

I: 9.7 (3.4-27.2)

W: 6.0 (1.9-18.7)

Study quality (ROB): as assessed by the authors, varies between moderate to good.

Place of the index test in the clinical pathway: replacement, triage, add-on

Choice of cut-off point: different methods are used to assess erosions.

Facultative:

Brief description of author’s conclusion
In conclusion, radiographs can be a valuable test in

patients with UA and in mixed populations for predicting

diagnosis and prognosis.

Personal remarks on study quality, conclusions, and other issues (potentially) relevant to the research question

Year of publication of SR and included articles.

Sensitivity analyses:

Stratified for UA and mixed population.

Heterogeneity: NA as outcomes were not pooled.

_{*comparator test equals the C of the PICO; two or more index/ comparator tests may be compared; note that a comparator test is not the same as a reference test}

Table of quality assessment for systematic reviews of diagnostic studies

Based on AMSTAR checklist (Shea et al.; 2007, BMC Methodol 7: 10; doi:10.1186/1471-2288-7-10) and PRISMA checklist (Moher et al 2009, PLoS Med 6: e1000097; doi:10.1371/journal.pmed1000097)

Study First author, year	Appropriate and clearly focused question?¹ Yes/no/unclear	Comprehensive and systematic literature search?² Yes/no/unclear	Description of included and excluded studies?³ Yes/no/unclear	Description of relevant characteristics of included studies?⁴ Yes/no/unclear	Assessment of scientific quality of included studies?⁵ Yes/no/unclear	Enough similarities between studies to make combining them reasonable?⁶ Yes/no/unclear	Potential risk of publication bias taken into account?⁷ Yes/no/unclear	Potential conflicts of interest reported?⁸ Yes/no/unclear
Machado, 2011	No, no clear reference test.	Unclear, in Appendix although this document is not available	Unclear, in Appendix although this document is not available	Yes, table 1	Unclear, in Appendix although this document is not available	Yes, stratified analyses are performed	Unclear, not mentioned	Yes, is descripted.
Koevoets, 2011	No, no clear reference test.	Unclear, in Appendix although this document is not available	Unclear, in Appendix although this document is not available	Yes, table 1	Unclear, in Appendix although this document is not available	Yes, stratified analyses are performed	Unclear, not mentioned	Yes, is descripted.

Study

First author, year

Appropriate and clearly focused question?¹

Yes/no/unclear

Comprehensive and systematic literature search?²

Yes/no/unclear

Description of included and excluded studies?³

Yes/no/unclear

Description of relevant characteristics of included studies?⁴

Yes/no/unclear

Assessment of scientific quality of included studies?⁵

Yes/no/unclear

Enough similarities between studies to make combining them reasonable?⁶

Yes/no/unclear

Potential risk of publication bias taken into account?⁷

Yes/no/unclear

Potential conflicts of interest reported?⁸

Yes/no/unclear

Machado, 2011

No, no clear reference test.

Unclear, in Appendix although this document is not available

Yes, table 1

Unclear, in Appendix although this document is not available

Yes, stratified analyses are performed

Unclear, not mentioned

Yes, is descripted.

Koevoets, 2011

No, no clear reference test.

Unclear, in Appendix although this document is not available

Yes, table 1

Unclear, in Appendix although this document is not available

Yes, stratified analyses are performed

Unclear, not mentioned

Yes, is descripted.

_{^1. Research question (PICO) and inclusion criteria should be appropriate (in relation to the research question to be answered in the clinical guideline) and predefined}

_{^2. Search period and strategy should be described; at least Medline searched}

_{^3. Potentially relevant studies that are excluded at final selection (after reading the full text) should be referenced with reasons}

_{^4. Characteristics of individual studies relevant to the research question (PICO) should be reported}

_{^5. Quality of individual studies should be assessed using a quality scoring tool or checklist (preferably QUADAS-2; COSMIN checklist for measuring instruments) and taken into account in the evidence synthesis}

_{^6. Clinical and statistical heterogeneity should be assessed; clinical: enough similarities in patient characteristics, diagnostic tests (strategy) to allow pooling? For pooled data: at least 5 studies available for pooling; assessment of statistical heterogeneity and, more importantly (see Note), assessment of the reasons for heterogeneity (if present)? Note: sensitivity and specificity depend on the situation in which the test is being used and the thresholds that have been set, and sensitivity and specificity are correlated; therefore, the use of heterogeneity statistics (p-values; I2) is problematic, and rather than testing whether heterogeneity is present, heterogeneity should be assessed by eye-balling (degree of overlap of confidence intervals in Forest plot), and the reasons for heterogeneity should be examined.}

_{^7. There is no clear evidence for publication bias in diagnostic studies, and an ongoing discussion on which statistical method should be used. Tests to identify publication bias are likely to give false-positive results, among available tests, Deeks’ test is most valid. Irrespective of the use of statistical methods, you may score “Yes” if the authors discuss the potential risk of publication bias.}

_{^8. Sources of support (including commercial co-authorship) should be reported in both the systematic review and the included studies. Note: To get a “yes,” source of funding or support must be indicated for the systematic review AND for each of the included studies.}

Evidence table for diagnostic test accuracy studies

Study reference	Study characteristics	Patient characteristics	Index test (test of interest)	Reference test	Follow-up	Outcome measures and effect size	Comments
Ulijn, 2024	Type of study: retrospective cohort study Setting and country: rheumatology department of the Sint Maartenskliniek, a large tertiary referral center specialized in rheumatology in the Netherlands Funding and conflicts of interest: none	Inclusion criteria: All new patients >16y who visited the outpatient clinic between Jan 2016 and Jan 2019 were considered for inclusion. We aimed to include all patients with newly presenting arthritis who were suspected of RA. This was operationalized by including patients who met four entry criteria. Firstly, arthritis should have been present at the first consultation (judged by a rheumatologist). Secondly, RF and ACPA were measured within 6 months before or within 4 days after the first consultation. Thirdly, RA should have been noted in the differential diagnosis and/or in the order of the radiograph. Lastly, only a set of radiographs of hands and feet were considered for inclusion, as an Xhand or feet alone is more likely to be performed on indication rather than routinely. Exclusion criteria: Patients were excluded if they had a preexisting RA diagnosis, another diagnosis of inflammatory arthritis, or if a different indication was noted for the radiograph. N=724 Prevalence: 299 Mean age ± SD: 57 ± 15.0 y Sex: 38% M / 62% F Other important characteristics:	Describe index test: conventional radiography (routine radiographs) of hands and feet in which at least one typical RA-associated erosion was found. Cut-off point(s):	Describe reference test: The final clinical diagnosis by a rheumatologist was cross-referenced with the reimbursement code (Diagnosis Treatment Combination 101), or International Classification of Diseases (ICD) codes for RA (ICD 9 714.x, ICD 10 M06.9), to ensure the clinical diagnosis that was used was accurate and up-to-date. Cut-off point(s):	Time between the index test and reference test: Unknown, but at inclusion patients had to have newly presenting arthritis who were suspected of RA. For how many participants were no complete outcome data available? N.A., this is retrospective cohort study. Reasons for incomplete outcome data described? N.A.	Outcome measures and effect size (include 95%CI and p-value if available): Diagnostic value for diagnosis of RA: NNS: 362 (724/2)	Selection bias might have occurred as the entry criteria included mandatory testing of RF/ACPA. However, patients in whom these tests had not been performed but still had arthritis were likely to have a lower chance of having RA. In conclusion, the recommendation of conducting routine X-HF with newly presenting arthritis suspected of RA might be reconsidered because of low prevalence of early erosive disease and lack of diagnostic and prognostic value of RA-associated erosions.
Broll, 2012	Type of study: Prospective cohort study Setting and country: Secondary care, Germany Funding and conflicts of interest: Not mentioned.	Inclusion criteria: arthralgia, tenderness, soft tissue swelling and/or morning stiffness >1 hour in at least one wrist or finger joint, no prior diagnosis of arthritis and no prior treatment with steroids or disease-modifying antirheumatic drugs (DMARDs). Concomitant non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics were allowed Exclusion criteria: Not mentioned. N=50 Prevalence: 26/50 (52%) Mean age ± SD: 57 (11.4) Sex: 17M / 33 F Other important characteristics: 5/50 (10%) had radiographic erosions	Describe index test 1: US Cut-off point(s): See method part Describe index test 2: MRI Cut-off point(s): See method part	Describe reference test: Diagnosis of RA according to ACR classification criteria.	Time between the index test en reference test: Not mentioned. For how many participants were no complete outcome data available? Not mentioned Reasons for incomplete outcome data described? N.a.	Outcome measures and effect size (include 95%CI and p-value if available): Diagnostic value of erosions (US) with reference standard the clinical diagnosis Sensi= 37.5% Speci = 100% PPV= 100% NPV= 47.4% Diagnostic value of erosions (MRI) with reference standard the clinical diagnosis Sensi= 58.1% Speci= 83.3% PPV= 85.7% NPV= 53.5%	Conclusion of article: Both grey-scale ultrasonography including PDUS and low-field MRI are suitable imaging methods for diagnosing arthritis at an early stage. However, PDUS displays a higher specificity and almost the same sensitivity as compared to contrast-enhanced MRI, while being a much simpler and less costly procedure. Conclusions for erosions are in line. Limitations: Sample size prevalence op RA/erosions *fact that erosion occurs later in disease
Filer, 2011	Type of study: Prospective cohort study Setting and country: Secondary Care, UK Funding and conflicts of interest: Funding The ultrasound equipment used in this study was funded by Arthritis Research UK, and the Rheumatology Research Group is a member of the EU AutoCure Consortium. Competing interests CDB and KR have received grants and honoraria from Wyeth, Cellzome, UCB and Pfi zer. AF has received grant support from Cellzome and Pfi zer. SB has received honoraria or grant support from Roche, Genentech, UCB,	Inclusion criteria: clinically apparent synovitis of at least one joint and inflammatory joint symptoms (infl ammatory joint pain, and/or swelling and/or morning stiffness) of 3 months or less duration underwent baseline assessment and 18-month follow-up to determine diagnosis of RA. Exclusion criteria: Not mentioned. N=58 Prevalence RA:29/58 (50%) VERA=29 VENRA=13 Resolving:=16 Mean age ± SD: VERA: 63 (19-82) VENRA: 45 (18-83) Resolving: 40 (23-75) Sex: n/N (%)F VERA: 13/29 (45) VENRA: 9/13 (69) Resolving: 10/16 (63) Other important characteristics: Presence of erosions US VERA: 11/29 (38) VENRA: 2/13 (26) Resolving: 1/16 (6) xrays VERA: 1/29 (3.5) VENRA: 0/13 (0) Resolving: 0/16 (0)	Describe index test 1: US Cut-off point(s): See method part Describe index test 2: Xray	Describe reference test: Diagnosis of RA according to ACR of ACR/EULAR classification criteria.	Time between the index test en reference test: Within 24h US. For how many participants were no complete outcome data available? Not mentioned Reasons for incomplete outcome data described? N.a.	Outcome measures and effect size (include 95%CI and p-value if available): Diagnostic value of erosions (US – hand/foot) with reference standard the clinical diagnosis Sensi= 38% Speci = 93% PPV= 85% NPV= 60% AUC- 0.655 LR+ = 5.5 LR- = 0.67 Diagnostic value of erosions (xray – hand/foot) with reference standard the clinical diagnosis Sensi= 3.5% Speci = 100% PPV= 100% NPV= 45% AUC- 0.517 LR+ = - LR- = 0.97	Conclusion of article: In a longitudinal study, extended ultrasound joint evaluation significantly increased detection of joint involvement in all regions and outcome groups. Greyscale and power Doppler scanning of metacarpophalangeal joints, wrists and metatarsophalangeal joints provides the optimum minimal ultrasound data to improve on clinical predictive models for RA. Conclusions for erosions US is more sensitive and less specific compared to Xrays to detect erosions. Limitations: Low proportion of females Sample size prevalence op RA/erosions *fact that erosion occurs later in disease

Study reference

Study characteristics

Patient characteristics

Index test

(test of interest)

Reference test

Follow-up

Outcome measures and effect size

Comments

Ulijn, 2024

Type of study:

retrospective cohort study

Setting and country:

rheumatology department of the Sint Maartenskliniek, a large tertiary referral center specialized in rheumatology in the Netherlands

Funding and conflicts of interest:

none

Inclusion criteria:

All new patients >16y who visited the outpatient clinic between Jan 2016 and Jan 2019 were considered for inclusion. We aimed to include all patients with newly presenting arthritis who were suspected of RA. This was operationalized by including patients who met four entry criteria. Firstly, arthritis should have been present at the first consultation (judged by a rheumatologist). Secondly, RF and ACPA were measured within 6 months before or within 4 days after the first consultation. Thirdly, RA should have been noted in the differential diagnosis and/or in the order of the radiograph. Lastly, only a set of radiographs of hands and feet were considered for inclusion, as an Xhand or feet alone is more likely to be performed on indication rather than routinely.

Exclusion criteria:

Patients were excluded if they had a preexisting RA diagnosis, another diagnosis of inflammatory arthritis, or if a different indication was noted for the radiograph.

N=724

Prevalence: 299

Mean age ± SD: 57 ± 15.0 y

Sex: 38% M / 62% F

Other important characteristics:

Describe index test:

conventional radiography (routine radiographs) of hands and feet in which at least one typical RA-associated erosion was found.

Cut-off point(s):

Describe reference test:

The final clinical diagnosis by a rheumatologist was cross-referenced with the reimbursement code (Diagnosis Treatment Combination 101), or International Classification of Diseases (ICD) codes for RA (ICD 9 714.x, ICD 10 M06.9), to ensure the clinical diagnosis that was used was accurate and up-to-date.

Cut-off point(s):

Time between the index test and reference test:

Unknown, but at inclusion patients had to have newly presenting arthritis who were suspected of RA.

For how many participants were no complete outcome data available?

N.A., this is retrospective cohort study.

Reasons for incomplete outcome data described?

N.A.

Outcome measures and effect size (include 95%CI and p-value if available):

Diagnostic value for diagnosis of RA:

NNS: 362 (724/2)

Selection bias might have occurred as the entry criteria included mandatory testing of RF/ACPA. However, patients in whom these tests had not been performed but still had arthritis were likely to have a lower chance of having RA.

In conclusion, the recommendation of conducting routine X-HF with newly presenting arthritis suspected of RA might be reconsidered because of low prevalence of early erosive disease and lack of diagnostic and prognostic value of RA-associated erosions.

Broll, 2012

Type of study:

Prospective cohort study

Setting and country:

Secondary care, Germany

Funding and conflicts of interest:

Not mentioned.

Inclusion criteria:
arthralgia, tenderness, soft tissue swelling and/or morning stiffness >1 hour in at least one wrist or finger joint, no prior diagnosis of arthritis and no prior treatment with steroids or disease-modifying antirheumatic drugs (DMARDs). Concomitant non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics were allowed

Exclusion criteria:

Not mentioned.

N=50

Prevalence: 26/50 (52%)

Mean age ± SD: 57 (11.4)

Sex: 17M / 33 F

Other important characteristics:

5/50 (10%) had radiographic erosions

Describe index test 1:

Cut-off point(s):

See method part

Describe index test 2:

MRI

Cut-off point(s):

See method part

Describe reference test:

Diagnosis of RA according to ACR classification criteria.

Time between the index test en reference test:

Not mentioned.

For how many participants were no complete outcome data available?

Not mentioned

Reasons for incomplete outcome data described?

N.a.

Outcome measures and effect size (include 95%CI and p-value if available):

Diagnostic value of erosions (US) with reference standard the clinical diagnosis
Sensi= 37.5%
Speci = 100%

PPV= 100%

NPV= 47.4%

Diagnostic value of erosions (MRI) with reference standard the clinical diagnosis

Sensi= 58.1%
Speci= 83.3%

PPV= 85.7%

NPV= 53.5%

Conclusion of article:

Both grey-scale ultrasonography including PDUS and low-field MRI are suitable imaging methods for diagnosing

arthritis at an early stage. However, PDUS displays a higher specificity and almost the same sensitivity as compared to

contrast-enhanced MRI, while being a much simpler and less costly procedure.

Conclusions for erosions are in line.

Limitations:

Sample size
prevalence op RA/erosions
*fact that erosion occurs later in disease

Filer, 2011

Type of study:

Prospective cohort study

Setting and country:
Secondary Care, UK

Funding and conflicts of interest:
Funding The ultrasound equipment used in this study was funded by Arthritis

Research UK, and the Rheumatology Research Group is a member of the EU AutoCure

Consortium.

Competing interests CDB and KR have received grants and honoraria from

Wyeth, Cellzome, UCB and Pfi zer. AF has received grant support from Cellzome and

Pfi zer. SB has received honoraria or grant support from Roche, Genentech, UCB,

Inclusion criteria:
clinically apparent synovitis

of at least one joint and inflammatory joint symptoms (infl ammatory joint pain, and/or swelling

and/or morning stiffness) of 3 months or less

duration underwent baseline assessment and

18-month follow-up to determine diagnosis of RA.

Exclusion criteria:

Not mentioned.

N=58

Prevalence RA:29/58 (50%)
VERA=29

VENRA=13

Resolving:=16

Mean age ± SD:
VERA: 63 (19-82)

VENRA: 45 (18-83)

Resolving: 40 (23-75)

Sex: n/N (%)F

VERA: 13/29 (45)

VENRA: 9/13 (69)

Resolving: 10/16 (63)

Other important characteristics:

Presence of erosions

US
VERA: 11/29 (38)

VENRA: 2/13 (26)

Resolving: 1/16 (6)

xrays

VERA: 1/29 (3.5)

VENRA: 0/13 (0)

Resolving: 0/16 (0)

Describe index test 1:

Cut-off point(s):

See method part

Describe index test 2:

Xray

Describe reference test:

Diagnosis of RA according to ACR of ACR/EULAR classification criteria.

Time between the index test en reference test:

Within 24h US.

For how many participants were no complete outcome data available?

Not mentioned

Reasons for incomplete outcome data described?

N.a.

Outcome measures and effect size (include 95%CI and p-value if available):

Diagnostic value of erosions (US – hand/foot) with reference standard the clinical diagnosis
Sensi= 38%
Speci = 93%

PPV= 85%

NPV= 60%

AUC- 0.655

LR+ = 5.5

LR- = 0.67

Diagnostic value of erosions (xray – hand/foot) with reference standard the clinical diagnosis
Sensi= 3.5%
Speci = 100%

PPV= 100%

NPV= 45%

AUC- 0.517

LR+ = -

LR- = 0.97

Conclusion of article:

In a longitudinal study, extended ultrasound

joint evaluation significantly increased detection of joint

involvement in all regions and outcome groups. Greyscale and power Doppler scanning of metacarpophalangeal

joints, wrists and metatarsophalangeal joints provides the optimum minimal ultrasound data to improve on clinical predictive models for RA.

Conclusions for erosions US is more sensitive and less specific compared to Xrays to detect erosions.

Limitations:

Low proportion of females

Sample size
prevalence op RA/erosions
*fact that erosion occurs later in disease

Risk of bias assessment diagnostic accuracy studies (QUADAS II, 2011)

Study reference	Patient selection	Index test	Reference standard	Flow and timing	Comments with respect to applicability
Ulijn, 2024	Was a consecutive or random sample of patients enrolled? Yes, retrospective cohort study Was a case-control design avoided? Yes, retrospective cohort study Did the study avoid inappropriate exclusions? Yes, only one exclusion criteria.	Were the index test results interpreted without knowledge of the results of the reference standard? Yes If a threshold was used, was it pre-specified? N.a.	Is the reference standard likely to correctly classify the target condition? Yes Were the reference standard results interpreted without knowledge of the results of the index test? No, first xray thereafter reference standard, but this will not influence the outcome.	Was there an appropriate interval between index test(s) and reference standard? Yes, see results part Did all patients receive a reference standard? Yes, see results part Did patients receive the same reference standard? Yes, see results part Were all patients included in the analysis? Yes, see results part	Are there concerns that the included patients do not match the review question? No Are there concerns that the index test, its conduct, or interpretation differ from the review question? No Are there concerns that the target condition as defined by the reference standard does not match the review question? No
CONCLUSION: Could the selection of patients have introduced bias? RISK: LOW	CONCLUSION: Could the conduct or interpretation of the index test have introduced bias? RISK: LOW	CONCLUSION: Could the reference standard, its conduct, or its interpretation have introduced bias? RISK: LOW	CONCLUSION Could the patient flow have introduced bias? RISK: LOW
Broll, 2012	Was a consecutive or random sample of patients enrolled? No Was a case-control design avoided? Yes Did the study avoid inappropriate exclusions? Yes	Were the index test results interpreted without knowledge of the results of the reference standard? Unclear If a threshold was used, was it pre-specified? Unclear	Is the reference standard likely to correctly classify the target condition? Yes, classification criteria Were the reference standard results interpreted without knowledge of the results of the index test? Unclear	Was there an appropriate interval between index test(s) and reference standard? Unclear Did all patients receive a reference standard? Yes Did patients receive the same reference standard? Yes Were all patients included in the analysis? Yes	Are there concerns that the included patients do not match the review question? Yes, only wrist and finger joints Are there concerns that the index test, its conduct, or interpretation differ from the review question? No Are there concerns that the target condition as defined by the reference standard does not match the review question? No
	CONCLUSION: Could the selection of patients have introduced bias? RISK: HIGH, only patients with suspected arthritis of wrist or finger joints.	CONCLUSION: Could the conduct or interpretation of the index test have introduced bias? RISK: UNCLEAR, no detailed information	CONCLUSION: Could the reference standard, its conduct, or its interpretation have introduced bias? RISK: LOW	CONCLUSION Could the patient flow have introduced bias? RISK: LOW
Filer, 2011	Was a consecutive or random sample of patients enrolled? No Was a case-control design avoided? Yes Did the study avoid inappropriate exclusions? Yes	Were the index test results interpreted without knowledge of the results of the reference standard? Yes If a threshold was used, was it pre-specified? Yes	Is the reference standard likely to correctly classify the target condition? Yes Were the reference standard results interpreted without knowledge of the results of the index test? Yes	Was there an appropriate interval between index test(s) and reference standard? Yes Did all patients receive a reference standard? Yes Did patients receive the same reference standard? Yes Were all patients included in the analysis? Ye	Are there concerns that the included patients do not match the review question? Yes, as only patients were included with clinically apparent synovitis of at least one joint and inflammatory joint symptoms Are there concerns that the index test, its conduct, or interpretation differ from the review question? No Are there concerns that the target condition as defined by the reference standard does not match the review question? No
	CONCLUSION: Could the selection of patients have introduced bias? RISK: HIGH, only patients with clinically apparent synovitis of at least one joint and inflammatory joint symptoms	CONCLUSION: Could the conduct or interpretation of the index test have introduced bias? RISK: LOW	CONCLUSION: Could the reference standard, its conduct, or its interpretation have introduced bias? RISK: LOW/HIGH/UNCLEAR	CONCLUSION Could the patient flow have introduced bias? RISK: LOW

Study reference

Patient selection

Index test

Reference standard

Flow and timing

Comments with respect to applicability

Ulijn, 2024

Was a consecutive or random sample of patients enrolled?

Yes, retrospective cohort study

Was a case-control design avoided?

Yes, retrospective cohort study

Did the study avoid inappropriate exclusions?

Yes, only one exclusion criteria.

Were the index test results interpreted without knowledge of the results of the reference standard?

Yes

If a threshold was used, was it pre-specified?

N.a.

Is the reference standard likely to correctly classify the target condition?

Yes

Were the reference standard results interpreted without knowledge of the results of the index test?

No, first xray thereafter reference standard, but this will not influence the outcome.

Was there an appropriate interval between index test(s) and reference standard?

Yes, see results part

Did all patients receive a reference standard?

Yes, see results part

Did patients receive the same reference standard?

Yes, see results part

Were all patients included in the analysis?

Yes, see results part

Are there concerns that the included patients do not match the review question?

Are there concerns that the index test, its conduct, or interpretation differ from the review question?

Are there concerns that the target condition as defined by the reference standard does not match the review question?

CONCLUSION:

Could the selection of patients have introduced bias?

RISK: LOW

CONCLUSION:

Could the conduct or interpretation of the index test have introduced bias?

RISK: LOW

CONCLUSION:

Could the reference standard, its conduct, or its interpretation have introduced bias?

RISK: LOW

CONCLUSION

Could the patient flow have introduced bias?

RISK: LOW

Broll, 2012

Was a consecutive or random sample of patients enrolled?

Was a case-control design avoided?

Yes

Did the study avoid inappropriate exclusions?

Yes

Were the index test results interpreted without knowledge of the results of the reference standard?

Unclear

If a threshold was used, was it pre-specified?

Unclear

Is the reference standard likely to correctly classify the target condition?

Yes, classification criteria

Were the reference standard results interpreted without knowledge of the results of the index test?

Unclear

Was there an appropriate interval between index test(s) and reference standard?

Unclear

Did all patients receive a reference standard?

Yes

Did patients receive the same reference standard?

Yes

Were all patients included in the analysis?

Yes

Are there concerns that the included patients do not match the review question?

Yes, only wrist and finger joints

Are there concerns that the index test, its conduct, or interpretation differ from the review question?

Are there concerns that the target condition as defined by the reference standard does not match the review question?

CONCLUSION:

Could the selection of patients have introduced bias?

RISK: HIGH, only patients with suspected arthritis of wrist or finger joints.

CONCLUSION:

Could the conduct or interpretation of the index test have introduced bias?

RISK: UNCLEAR, no detailed information

CONCLUSION:

Could the reference standard, its conduct, or its interpretation have introduced bias?

RISK: LOW

CONCLUSION

Could the patient flow have introduced bias?

RISK: LOW

Filer, 2011

Was a consecutive or random sample of patients enrolled?

Was a case-control design avoided?

Yes

Did the study avoid inappropriate exclusions?

Yes

Were the index test results interpreted without knowledge of the results of the reference standard?

Yes

If a threshold was used, was it pre-specified?

Yes

Is the reference standard likely to correctly classify the target condition?

Yes

Were the reference standard results interpreted without knowledge of the results of the index test?

Yes

Was there an appropriate interval between index test(s) and reference standard?

Yes

Did all patients receive a reference standard?

Yes

Did patients receive the same reference standard?

Yes

Were all patients included in the analysis?

Are there concerns that the included patients do not match the review question?

Yes, as only patients were included with clinically apparent synovitis of at least one joint and inflammatory joint symptoms

Are there concerns that the index test, its conduct, or interpretation differ from the review question?

Are there concerns that the target condition as defined by the reference standard does not match the review question?

CONCLUSION:

Could the selection of patients have introduced bias?

RISK: HIGH, only patients with clinically apparent synovitis of at least one joint and inflammatory joint symptoms

CONCLUSION:

Could the conduct or interpretation of the index test have introduced bias?

RISK: LOW

CONCLUSION:

Could the reference standard, its conduct, or its interpretation have introduced bias?

RISK: LOW/HIGH/UNCLEAR

CONCLUSION

Could the patient flow have introduced bias?

RISK: LOW

_{Judgments on risk of bias are dependent on the research question: some items are more likely to introduce bias than others, and may be given more weight in the final conclusion on the overall risk of bias per domain:}

_{Patient selection:}

_{Consecutive or random sample has a low risk to introduce bias.}
_{A case control design is very likely to overestimate accuracy and thus introduce bias.}
_{Inappropriate exclusion is likely to introduce bias.}

_{Index test:}

_{This item is similar to “blinding” in intervention studies. The potential for bias is related to the subjectivity of index test interpretation and the order of testing.}
_{Selecting the test threshold to optimise sensitivity and/or specificity may lead to overoptimistic estimates of test performance and introduce bias.}

_{Reference standard:}

_{When the reference standard is not 100% sensitive and 100% specific, disagreements between the index test and reference standard may be incorrect, which increases the risk of bias.}
_{This item is similar to “blinding” in intervention studies. The potential for bias is related to the subjectivity of index test interpretation and the order of testing.}

_{Flow and timing:}

_{If there is a delay or if treatment is started between index test and reference standard, misclassification may occur due to recovery or deterioration of the condition, which increases the risk of bias.}
_{If the results of the index test influence the decision on whether to perform the reference standard or which reference standard is used, estimated diagnostic accuracy may be biased.}
_{All patients who were recruited into the study should be included in the analysis, if not, the risk of bias is increased.}

_{Judgement on applicability:}

_{Patient selection: there may be concerns regarding applicability if patients included in the study differ from those targeted by the review question, in terms of severity of the target condition, demographic features, presence of differential diagnosis or co-morbidity, setting of the study and previous testing protocols.}

_{Index test: if index tests methods differ from those specified in the review question there may be concerns regarding applicability.}

_{Reference standard: the reference standard may be free of bias but the target condition that it defines may differ from the target condition specified in the review question.}

Table of excluded studies

Reference	Reason for exclusion
Tang H, Qu X, Yue B. Diagnostic test accuracy of magnetic resonance imaging and ultrasound for detecting bone erosion in patients with rheumatoid arthritis. Clin Rheumatol. 2020 Apr;39(4):1283-1293. doi: 10.1007/s10067-019-04825-6. Epub 2019 Nov 12. PMID: 31713730.	Population is patients with positive RA diagnosis or diagnosis during follow-up. Results are not presented seperately for these two groups.
Sakellariou G, Scirè CA, Adinolfi A, Batticciotto A, Bortoluzzi A, Delle Sedie A, De Lucia O, Dejaco C, Epis OM, Filippucci E, Idolazzi L, Picchianti Diamanti A, Zabotti A, Iagnocco A, Filippou G. Differential Diagnosis of Inflammatory Arthropathies by Musculoskeletal Ultrasonography: A Systematic Literature Review. Front Med (Lausanne). 2020 May 7;7:141. doi: 10.3389/fmed.2020.00141. PMID: 32457913; PMCID: PMC7221062.	No individual diagnostic study results are presented in this systematic review.
Boylan M. Should ultrasound be used routinely in the diagnosis of rheumatoid arthritis? Ir J Med Sci. 2020 May;189(2):735-748. doi: 10.1007/s11845-019-02096-3. Epub 2019 Oct 23. PMID: 31646431.	No individual diagnostic study results are presented in this systematic review.

Verantwoording

Beoordelingsdatum en geldigheid

Publicatiedatum : 13-04-2026

Beoordeeld op geldigheid : 13-04-2026

Initiatief en autorisatie

Initiatief:

Nederlandse Vereniging voor Reumatologie

Geautoriseerd door:

Nederlandse Vereniging voor Nucleaire geneeskunde
Nederlandse Vereniging voor Pathologie
Nederlandse Vereniging voor Radiologie
Nederlandse Vereniging voor Reumatologie
Verpleegkundigen en Verzorgenden Nederland
Nederlandse Vereniging voor Klinische Chemie en Laboratoriumgeneeskunde
ReumaNederland
Nationale Vereniging ReumaZorg Nederland

Algemene gegevens

De ontwikkeling/herziening van deze richtlijnmodule werd ondersteund door het Kennisinstituut van de Federatie Medisch Specialisten (www.demedischspecialist.nl/kennisinstituut) en werd gefinancierd door de Stichting Kwaliteitsgelden Medisch Specialisten (SKMS). Patiëntenparticipatie bij deze richtlijn werd medegefinancierd uit de Kwaliteitsgelden Patiënten Consumenten (SKPC) binnen het programma Kwaliteit, Inzicht en Doelmatigheid in de medisch specialistische Zorg (KIDZ). De financier heeft geen enkele invloed gehad op de inhoud van de richtlijnmodule.

Samenstelling werkgroep

Voor het ontwikkelen van de richtlijnmodule is in 2023 een multidisciplinaire werkgroep ingesteld, bestaande uit vertegenwoordigers van alle relevante specialismen (zie hiervoor de Samenstelling van de werkgroep) die betrokken zijn bij de zorg voor patiënten met een inflammatoire (reumatische) aandoening.

Werkgroep

Dr. S.M. van der Kooij (voorzitter), reumatoloog, werkzaam in HagaZiekenhuis, NVR.
Dr. A.A. den Broeder, reumatoloog en klinisch epidemioloog, werkzaam in Sint Maartensklinkiek en Radboud Universitair Medische Centrum, NVR.
Prof. Dr. D. van der Woude, reumatoloog, werkzaam in Leids Universitair Medisch Centrum, NVR.
Drs. T. de Mooij, AIOS reumatologie, werkzaam in Erasmus Medisch Centrum, NVR.
Drs. Z. Kerami, reumatoloog, werkzaam in Dijklander Ziekenhuis, NVR (tot december 2024, vanaf mei 2025 werkzaam als reumatoloog bij NHS Lothian).
Dr. M.A. Korteweg, radioloog, Reade, NVvR.
Dr. W. van der Bruggen, nucleair geneeskundige, werkzaam in Slingeland Ziekenhuis en Streekziekenhuis Koningin Beatrix, NVNG.
Dr. M.C.F.J. de Rotte, klinisch chemicus, werkzaam in Amsterdam Universitair Medisch Centrum, NVKC.
MSc. J. Postma, verpleegkundig specialist reumatologie, werkzaam in Martini Ziekenhuis, V&VN.
Drs. H. Koning, patiëntvertegenwoordiger, Nationale Vereniging ReumaZorg Nederland.

Klankbordgroep

P. Borsje, ervaringsdeskundige en beleidsmedewerker Patiëntenparticipatie en Communicatie, Nationale Vereniging ReumaZorg Nederland, Nationale Vereniging ReumaZorg Nederland.

Met ondersteuning van

Dr. L. Küpers , adviseur, Kennisinstituut van de Federatie Medisch Specialisten.
Dr. M.M.A. Verhoeven, adviseur, Kennisinstituut van de Federatie Medisch Specialisten tot april 2025.
Drs. J.M.H. van der Hart MSc, adviseur, Kennisinstituut van de Federatie Medisch Specialisten vanaf april 2025.
Drs. F.A. Pepping MSc, junior adviseur, Kennisinstituut van de Federatie Medisch Specialisten.

Belangenverklaringen

Een overzicht van de belangen van werkgroepleden en het oordeel over het omgaan met eventuele belangen vindt u in onderstaande tabel. De ondertekende belangenverklaringen zijn op te vragen bij het secretariaat van het Kennisinstituut van de Federatie Medisch Specialisten via secretariaat@kennisinstituut.nl.

Tabel Gemelde (neven)functies en belangen werkgroep

Werkgroeplid	Functie	Nevenfuncties	Gemelde belangen	Ondernomen actie
Dr S.M. van der Klooij (voorzitter), NVR	Reumatoloog	-	-	Geen
Dr. A.A. den Broeder, NVR	Reumatoloog en epidemioloog	- Expert advisering ZIN - WAR ReumaNederland - Associate editor Rheumatology	Extern gefinancierd onderzoek door o.a. ZonMw, Abbvie, Galapagos en Novartis. Geen raakvlakken met richtlijnmodules.	Geen
Prof. Dr. D. van der Woude, NVR	Reumatoloog	- Docent Antonius Academy Nieuwegein - Lid Scientific Committee FOREUM - Hoofdredacteur Nederlands Tijdschrift voor Reumatologie - Sectie-redacteur reumatologie Nederlands Tijdschrift voor Geneeskunde - Advisory board Galapagos (gebruik van JAK-remmers, 2019 en 2020)	Onderzoek gefinancierd door ZonMw, NWO en FOREUM. Geen raakvlakken met richtlijnmodules.	Geen
Drs. T. de Mooij, NVR	AIOS reumatologie	-	-	Geen
Drs. Z. Kerami, NVR	Reumatoloog	-	-	Geen
Dr. M.A. Korteweg, NVvR	Radioloog	- Radioloog waarnemer Bovenij ziekenhuis, Acibadem,in Kralendijk Bonaire - Docent Schola medica en Neac - Annotator Quantitas Solutions -PI ESSR uniform grading CT scans of SIjoints -reviewer ECR	-	Geen
Dr. W. van der Bruggen, NVNG	Nucleair geneeskundige	-	-	Geen
Dr. M.C.F.J. de Rotte, NVKC	Klinisch chemicus	Vakspecialist-auditor Raad voor accredatie	Meerdere onderzoeksproejcten in personalized medicine of methotrexaat bij RA (niet extern gefinancierd, geen raakvlakken met richtlijn).	Geen
MSc. J. Postma, V&VN	Verpleegkundig specialist reumatologie	Deelname ontwikkeling ‘ziektekaarten in beeld’ ReumaZorg Nederland	Online sessie ‘patient journey’ reumapatienten Pfizer (eenmalig, geen raakvlakken met richtlijn)	Geen
Drs. H. Koning, ReumaZorg Nederland	Patiëntvertegenwoordiger	- Referent Patientenfederatie Nederland - Projectmanager, Julius Centrum UMCU (tot 1 december 2025)	-	Geen

Inbreng patiëntenperspectief

De werkgroep besteedde aandacht aan het patiëntenperspectief door een afgevaardigde van de patiëntenvereniging Nationale Vereniging ReumaZorg Nederland. De conceptrichtlijn is tevens voor commentaar voorgelegd aan deze patiëntenvereniging en de eventueel aangeleverde commentaren zijn bekeken en verwerkt.

Kwalitatieve raming van mogelijke financiële gevolgen in het kader van de Wkkgz

Bij de richtlijnmodule voerde de werkgroep conform de Wet kwaliteit, klachten en geschillen zorg (Wkkgz) een kwalitatieve raming uit om te beoordelen of de aanbevelingen mogelijk leiden tot substantiële financiële gevolgen. Bij het uitvoeren van deze beoordeling is de richtlijnmodule op verschillende domeinen getoetst (zie het stroomschema bij Werkwijze).

Module	Uitkomst raming	Toelichting
Beeldvorming - Erosies	Geen financiële gevolgen	Hoewel uit de toetsing volgt dat de aanbeveling(en) breed toepasbaar zijn (5.000-40.000 patiënten per jaar), volgt ook uit de toetsing dat het overgrote deel van de zorgaanbieders en zorgverleners al aan de norm voldoet. Er worden daarom geen substantiële financiële gevolgen verwacht.

Werkwijze

Voor meer details over de gebruikte richtlijnmethodologie verwijzen wij u naar de Werkwijze. Relevante informatie voor de ontwikkeling/herziening van deze richtlijnmodule is hieronder weergegeven.

Zoekverantwoording

Zoekstrategie - 27 juni 2024

Embase.com

No.	Query	Results
#1	'rheumatoid arthritis'/exp OR 'arthralgia'/exp OR (((rheuma* OR reuma* OR revma) NEAR/3 (arthrit OR artrit* OR diseas* OR condition* OR nodule)):ti,ab,kw) OR ((inflammat NEAR/3 (arthrit* OR artrit* OR joint)):ti,ab,kw) OR ((('auto immun' OR autoimmun* OR deform* OR persistent) NEAR/3 (arthrit* OR artrit)):ti,ab,kw) OR ((felty NEAR/2 syndrome):ti,ab,kw) OR ((caplan NEAR/2 syndrome):ti,ab,kw) OR (((ach OR pain) NEAR/3 (joint OR articular)):ti,ab,kw) OR arthralgia:ti,ab,kw OR arthrodynia:ti,ab,kw OR polyarthralgia:ti,ab,kw OR 'acpa positive':ti,ab,kw OR 'positive acpa':ti,ab,kw	441885
#2	'nuclear magnetic resonance imaging'/exp OR 'mri scanner'/exp OR ('magnetic resonance':ab,ti AND (image:ab,ti OR images:ab,ti OR imaging:ab,ti)) OR mri:ab,ti OR mris:ab,ti OR nmr:ab,ti OR mra:ab,ti OR mras:ab,ti OR zeugmatograph:ab,ti OR 'mr tomography':ab,ti OR 'mr tomographies':ab,ti OR 'mr tomographic':ab,ti OR 'mr imag':ti,ab,kw OR 'proton spin':ab,ti OR ((magneti*:ab,ti OR 'chemical shift':ab,ti) AND imaging:ab,ti) OR fmri:ab,ti OR fmris:ab,ti OR rsfmri:ti,ab,kw	1648307
#3	'computer assisted tomography'/exp OR 'cat scan':ti,ab,kw OR ((compute NEAR/3 tomograph*):ti,ab,kw) OR ct:ti,ab,kw	1817278
#4	'ultrasound'/exp OR 'ultrasound scanner'/exp OR 'echography'/exp OR 'endoscopic ultrasonography'/exp OR ultraso:ti,ab,kw OR sonograph:ti,ab,kw OR echograph:ti,ab,kw OR sonogram:ti,ab,kw	1509346
#5	'x ray':ti,ab,kw OR 'x rad':ti,ab,kw OR radiograph:ti,ab,kw OR 'radiogram':ti,ab,kw OR 'radioimag':ti,ab,kw OR 'radiophotograph':ti,ab,kw OR 'roentgen photograph':ti,ab,kw OR 'roentgen':ti,ab,kw OR 'rontgen':ti,ab,kw	886738
#6	#2 OR #3 OR #4 OR #5	4719114
#7	'erosion'/exp OR 'bone erosion'/exp OR 'joint erosion'/exp OR 'bone malformation'/exp OR (((bone* OR osteoarticular) NEAR/3 (anomal* OR deform* OR malformat)):ti,ab,kw) OR 'ossificat':ti,ab,kw OR erosi*:ti,ab,kw	235626
#8	#1 AND #6 AND #7	8683
#9	'sensitivity and specificity'/de OR sensitivity:ab,ti OR specificity:ab,ti OR predict*:ab,ti OR 'roc curve':ab,ti OR 'receiver operator':ab,ti OR 'receiver operators':ab,ti OR likelihood:ab,ti OR 'diagnostic error'/exp OR 'diagnostic accuracy'/exp OR 'diagnostic test accuracy study'/exp OR 'inter observer':ab,ti OR 'intra observer':ab,ti OR interobserver:ab,ti OR intraobserver:ab,ti OR validity:ab,ti OR kappa:ab,ti OR reliability:ab,ti OR reproducibility:ab,ti OR ((test NEAR/2 're-test'):ab,ti) OR ((test NEAR/2 'retest'):ab,ti) OR 'reproducibility'/exp OR accuracy:ab,ti OR 'differential diagnosis'/exp OR 'validation study'/de OR 'measurement precision'/exp OR 'diagnostic value'/exp OR 'reliability'/exp OR 'predictive value'/exp OR ppv:ti,ab,kw OR npv:ti,ab,kw OR (((false OR true) NEAR/3 (negative OR positive)):ti,ab)	6487959
#10	#8 AND #9	3118
#11	#10 AND [2000-2024]/py NOT ('conference abstract'/it OR 'editorial'/it OR 'letter'/it OR 'note'/it) NOT (('animal'/exp OR 'animal experiment'/exp OR 'animal model'/exp OR 'nonhuman'/exp) NOT 'human'/exp)	1557
#12	'meta analysis'/exp OR 'meta analysis (topic)'/exp OR metaanaly:ti,ab OR 'meta analy':ti,ab OR metanaly:ti,ab OR 'systematic review'/de OR 'cochrane database of systematic reviews'/jt OR prisma:ti,ab OR prospero:ti,ab OR (((systemati OR scoping OR umbrella OR 'structured literature') NEAR/3 (review* OR overview)):ti,ab) OR ((systemic NEAR/1 review):ti,ab) OR (((systemati OR literature OR database* OR 'data base') NEAR/10 search):ti,ab) OR (((structured OR comprehensive* OR systemic) NEAR/3 search):ti,ab) OR (((literature NEAR/3 review):ti,ab) AND (search:ti,ab OR database:ti,ab OR 'data base':ti,ab)) OR (('data extraction':ti,ab OR 'data source':ti,ab) AND 'study selection':ti,ab) OR ('search strategy':ti,ab AND 'selection criteria':ti,ab) OR ('data source':ti,ab AND 'data synthesis':ti,ab) OR medline:ab OR pubmed:ab OR embase:ab OR cochrane:ab OR (((critical OR rapid) NEAR/2 (review* OR overview* OR synthes)):ti) OR ((((critical OR rapid) NEAR/3 (review OR overview* OR synthes)):ab) AND (search:ab OR database:ab OR 'data base':ab)) OR metasynthes:ti,ab OR 'meta synthes':ti,ab	1040876
#13	'major clinical study'/de OR 'clinical study'/de OR 'case control study'/de OR 'family study'/de OR 'longitudinal study'/de OR 'retrospective study'/de OR 'prospective study'/de OR 'comparative study'/de OR 'cohort analysis'/de OR ((cohort NEAR/1 (study OR studies)):ab,ti) OR (('case control' NEAR/1 (study OR studies)):ab,ti) OR (('follow up' NEAR/1 (study OR studies)):ab,ti) OR (observational NEAR/1 (study OR studies)) OR ((epidemiologic NEAR/1 (study OR studies)):ab,ti) OR (('cross sectional' NEAR/1 (study OR studies)):ab,ti)	8295928
#14	'case control study'/de OR 'comparative study'/exp OR 'control group'/de OR 'controlled study'/de OR 'controlled clinical trial'/de OR 'crossover procedure'/de OR 'double blind procedure'/de OR 'phase 2 clinical trial'/de OR 'phase 3 clinical trial'/de OR 'phase 4 clinical trial'/de OR 'pretest posttest design'/de OR 'pretest posttest control group design'/de OR 'quasi experimental study'/de OR 'single blind procedure'/de OR 'triple blind procedure'/de OR (((control OR controlled) NEAR/6 trial):ti,ab,kw) OR (((control OR controlled) NEAR/6 (study OR studies)):ti,ab,kw) OR (((control OR controlled) NEAR/1 active):ti,ab,kw) OR 'open label':ti,ab,kw OR (((double OR two OR three OR multi OR trial) NEAR/1 (arm OR arms)):ti,ab,kw) OR ((allocat NEAR/10 (arm OR arms)):ti,ab,kw) OR placebo:ti,ab,kw OR 'sham-control':ti,ab,kw OR (((single OR double OR triple OR assessor) NEAR/1 (blind* OR masked)):ti,ab,kw) OR nonrandom:ti,ab,kw OR 'non-random':ti,ab,kw OR 'quasi-experiment':ti,ab,kw OR crossover:ti,ab,kw OR 'cross over':ti,ab,kw OR 'parallel group':ti,ab,kw OR 'factorial trial':ti,ab,kw OR ((phase NEAR/5 (study OR trial)):ti,ab,kw) OR ((case* NEAR/6 (matched OR control)):ti,ab,kw) OR ((match NEAR/6 (pair OR pairs OR cohort* OR control* OR group* OR healthy OR age OR sex OR gender OR patient* OR subject* OR participant)):ti,ab,kw) OR ((propensity NEAR/6 (scor OR match)):ti,ab,kw) OR versus:ti OR vs:ti OR compar:ti OR ((compar* NEAR/1 study):ti,ab,kw) OR (('major clinical study'/de OR 'clinical study'/de OR 'cohort analysis'/de OR 'observational study'/de OR 'cross-sectional study'/de OR 'multicenter study'/de OR 'correlational study'/de OR 'follow up'/de OR cohort:ti,ab,kw OR 'follow up':ti,ab,kw OR followup:ti,ab,kw OR longitudinal:ti,ab,kw OR prospective:ti,ab,kw OR retrospective:ti,ab,kw OR observational:ti,ab,kw OR 'cross sectional':ti,ab,kw OR cross?ectional:ti,ab,kw OR multicent:ti,ab,kw OR 'multi-cent':ti,ab,kw OR consecutive:ti,ab,kw) AND (group:ti,ab,kw OR groups:ti,ab,kw OR subgroup:ti,ab,kw OR versus:ti,ab,kw OR vs:ti,ab,kw OR compar:ti,ab,kw OR 'odds ratio':ab OR 'relative odds':ab OR 'risk ratio':ab OR 'relative risk*':ab OR 'rate ratio':ab OR aor:ab OR arr:ab OR rrr:ab OR ((('or' OR 'rr') NEAR/6 ci):ab)))	15201230
#15	#11 AND #12 – SR’s	76
#16	#11 AND (#13 OR #14) NOT #15 – Observationele studies	973
#17	#15 OR #16	1049

Ovid/Medline

#	Searches	Results
1	exp Arthritis, Rheumatoid/ or exp Arthralgia/ or ((rheuma* or reuma* or revma) adj3 (arthrit or artrit* or diseas* or condition* or nodule)).ti,ab,kf. or (inflammat adj3 (arthrit* or artrit* or joint)).ti,ab,kf. or ((auto immun or autoimmun* or deform* or persistent) adj3 (arthrit* or artrit)).ti,ab,kf. or (felty adj2 syndrome).ti,ab,kf. or (caplan adj2 syndrome).ti,ab,kf. or ((ach or pain) adj3 (joint or articular)).ti,ab,kf. or arthralgia.ti,ab,kf. or arthrodynia.ti,ab,kf. or polyarthralgia.ti,ab,kf. or acpa positive.ti,ab,kf. or positive acpa.ti,ab,kf.	251453
2	exp magnetic resonance imaging/ or ("magnetic resonance" and (image or images or imaging)).ti,ab,kf. or mri.ti,ab,kf. or mris.ti,ab,kf. or nmr.ti,ab,kf. or mra.ti,ab,kf. or mras.ti,ab,kf. or zeugmatograph.ti,ab,kf. or "mr tomography".ti,ab,kf. or "mr tomographies".ti,ab,kf. or "mr tomographic".ti,ab,kf. or 'mr imag'.ti,ab,kf. or "proton spin".ti,ab,kf. or ((magneti* or "chemical shift") and imaging).ti,ab,kf. or fmri.ti,ab,kf. or fmris.ti,ab,kf. or rsfmri.ti,ab,kf.	1001627
3	exp Tomography, X-Ray Computed/ or computed tomograph.ti,ab,kf. or ct.ti,ab,kf. or cts.ti,ab,kf. or cat scan.ti,ab,kf. or computer assisted tomograph.ti,ab,kf. or computerized tomograph.ti,ab,kf. or computerised tomograph.ti,ab,kf. or computed x ray tomograph.ti,ab,kf. or computed xray tomograph*.ti,ab,kf.	888935
4	exp Ultrasonography/ or exp Ultrasonics/ or exp Endosonography/ or ultraso.ti,ab,kf. or sonograph.ti,ab,kf. or echograph.ti,ab,kf. or sonogram.ti,ab,kf.	780079
5	exp X-Rays/ or exp Radiography/ or x ray.ti,ab,kf. or x rad.ti,ab,kf. or radiograph.ti,ab,kf. or radiogram.ti,ab,kf. or radioimag.ti,ab,kf. or radiophotograph.ti,ab,kf. or roentgen photograph.ti,ab,kf. or roentgen.ti,ab,kf. or rontgen.ti,ab,kf.	1758339
6	2 or 3 or 4 or 5	3395558
7	(erosi* or ((bone* or osteoarticular) adj3 (anomal* or deform* or malformat* or ossificat)) or ossificat).ti,ab,kf.	88060
8	1 and 6 and 7	3649
9	exp "Sensitivity and Specificity"/ or (sensitivity or specificity).ti,ab. or (predict* or ROC-curve or receiver-operator).ti,ab. or (likelihood or LR).ti,ab. or exp Diagnostic Errors/ or (inter-observer or intra-observer or interobserver or intraobserver or validity or kappa or reliability).ti,ab. or reproducibility.ti,ab. or (test adj2 (re-test or retest)).ti,ab. or "Reproducibility of Results"/ or accuracy.ti,ab. or Diagnosis, Differential/ or Validation Study/ or ((false or true) adj3 (negative or positive)).ti,ab.	5122304
10	8 and 9	1306
11	limit 10 to yr="2000 -Current"	1137
12	11 not (comment/ or editorial/ or letter/) not ((exp animals/ or exp models, animal/) not humans/)	1101
13	meta-analysis/ or meta-analysis as topic/ or (metaanaly* or meta-analy* or metanaly).ti,ab,kf. or systematic review/ or cochrane.jw. or (prisma or prospero).ti,ab,kf. or ((systemati or scoping or umbrella or "structured literature") adj3 (review* or overview)).ti,ab,kf. or (systemic adj1 review).ti,ab,kf. or ((systemati or literature or database* or data-base) adj10 search).ti,ab,kf. or ((structured or comprehensive* or systemic) adj3 search).ti,ab,kf. or ((literature adj3 review) and (search or database* or data-base)).ti,ab,kf. or (("data extraction" or "data source") and "study selection").ti,ab,kf. or ("search strategy" and "selection criteria").ti,ab,kf. or ("data source" and "data synthesis").ti,ab,kf. or (medline or pubmed or embase or cochrane).ab. or ((critical or rapid) adj2 (review or overview* or synthes)).ti. or (((critical or rapid) adj3 (review or overview* or synthes)) and (search or database* or data-base)).ab. or (metasynthes or meta-synthes*).ti,ab,kf.	755458
14	Epidemiologic studies/ or case control studies/ or exp cohort studies/ or Controlled Before-After Studies/ or Case control.tw. or cohort.tw. or Cohort analy$.tw. or (Follow up adj (study or studies)).tw. or (observational adj (study or studies)).tw. or Longitudinal.tw. or Retrospective.tw. or prospective.tw. or consecutive*.tw. or Cross sectional.tw. or Cross-sectional studies/ or historically controlled study/ or interrupted time series analysis/ [Onder exp cohort studies vallen ook longitudinale, prospectieve en retrospectieve studies]	4759686
15	Case-control Studies/ or clinical trial, phase ii/ or clinical trial, phase iii/ or clinical trial, phase iv/ or comparative study/ or control groups/ or controlled before-after studies/ or controlled clinical trial/ or double-blind method/ or historically controlled study/ or matched-pair analysis/ or single-blind method/ or (((control or controlled) adj6 (study or studies or trial)) or (compar* adj (study or studies)) or ((control or controlled) adj1 active) or "open label" or ((double or two or three or multi or trial) adj (arm or arms)) or (allocat adj10 (arm or arms)) or placebo* or "sham-control" or ((single or double or triple or assessor) adj1 (blind or masked)) or nonrandom* or "non-random" or "quasi-experiment" or "parallel group" or "factorial trial" or "pretest posttest" or (phase adj5 (study or trial)) or (case adj6 (matched or control)) or (match adj6 (pair or pairs or cohort* or control* or group* or healthy or age or sex or gender or patient* or subject* or participant)) or (propensity adj6 (scor or match))).ti,ab,kf. or (confounding adj6 adjust).ti,ab. or (versus or vs or compar).ti. or ((exp cohort studies/ or epidemiologic studies/ or multicenter study/ or observational study/ or seroepidemiologic studies/ or (cohort or 'follow up' or followup or longitudinal* or prospective* or retrospective* or observational* or multicent* or 'multi-cent' or consecutive).ti,ab,kf.) and ((group or groups or subgroup* or versus or vs or compar).ti,ab,kf. or ('odds ratio' or 'relative odds' or 'risk ratio' or 'relative risk' or aor or arr or rrr).ab. or (("OR" or "RR") adj6 CI).ab.))	5721457
16	12 and 13 – SR’s	51
17	(12 and (14 or 15)) not 16 – Observationele studies	692
18	16 or 17	743

Richtlijnendatabase

Reumatoïde Artritis (RA)

Reumatoïde Artritis (RA)

Beeldvorming – Erosies

Uitgangsvraag

Aanbeveling

Overwegingen

Onderbouwing

Achtergrond

Conclusies / Summary of Findings

Samenvatting literatuur

Zoeken en selecteren

Referenties

Evidence tabellen

Verantwoording

Beoordelingsdatum en geldigheid

Initiatief en autorisatie

Algemene gegevens

Samenstelling werkgroep

Belangenverklaringen

Inbreng patiëntenperspectief

Werkwijze

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