NEW YORK — Despite clinical advances, most rheumatology patient encounters are conducted much as they were 40 years ago, according to Dr. Theodore Pincus, who spoke at both the New York University Hospital for Joint Diseases meeting on Evidence-Based RA Therapy and the Fifth Annual Clinical Research Methodology Course.
And the patient loses out as a result.
Laboratory tests that are usually performed are not necessarily diagnostic, as 30%-40% of patients with rheumatoid arthritis have normal values of many measures (erythrocyte-sedimentation rate, C-reactive protein, and presence of rheumatoid factor and/or anti–cyclic citrullinated peptide antibodies). In addition, radiography and formal joint counts have significant clinical limitations, said Dr Pincus.
There is underuse of patient self-assessment tools such as the HAQ (Health Assessment Questionnaire) or MDHAQ (Multidimensional Health Assessment Questionnaire), both of which predict work disability, costs, and death from RA more precisely than do radiographs or laboratory tests, he said.
“I believe the MDHAQ-RAPID3 [Routine Assessment of Patient Index Data 3] should be incorporated into your infrastructure of care,” said Dr. Pincus, a clinical professor of medicine at New York University.
He described a 10-point checklist for all visits with patients who have rheumatic disease that is based on evidence and that relies more upon patient self-assessment and physician global assessment than it does on findings from joint counts, laboratory tests, or radiography.
Dr. Pincus proposed that physicians follow the 10-measure checklist during every clinical encounter to document patient status and quantify patient progress. (See box.) The checklist includes six self-report measures from the MDHAQ self-report questionnaire, including evaluation of function, pain, fatigue, and other symptoms; a patient global estimate of status; and the RAPID3 score. The four physician global measures include assessment of inflammation, damage, and changes that are noninflammatory, as well as a physician global estimate of status.
The MDHAQ is a version of the HAQ, which was the only patient self-assessment tool actually developed in the clinic, said Dr. Pincus. The MDHAQ has been modified to reflect escalating standards of rheumatology care, so currently patients are asked if they can walk 2 miles or participate in recreational activities or sports. Queries about sleep, anxiety, and depression have also been added. In addition, the MDHAQ provides a review of systems and recent medical history information.
According to Dr. Pincus, the HAQ and MDHAQ are better predictors than are joint count, laboratory tests, or radiographs of functional status, work disability, joint replacement surgery, or cost.
Dr. Pincus reported having no relevant financial disclosures.
Visit Checklist
In the 10-point checklist, the patient MDHAQ self-report questionnaire measures include the following:
▸ Function.
▸ Pain.
▸ Patient global estimate of status.
▸ RAPID3.
▸ Fatigue.
The physician global measures include the following:
▸ Physician global estimate of status.
▸ Inflammation.
▸ Damage.
▸ Noninflammatory/nondamage.
Source: Dr. Pincus