NEW YORK — The soft data that can be gathered from self-administered patient questionnaires are more telling about how a patient with rheumatoid arthritis is faring than are x-rays or some lab tests that are wrongly considered to be prognostic.
Dr. Theodore Pincus recently told a group of rheumatologists at a course sponsored by New York University that “patient questionnaire scores are the most valuable data we collect in taking care of patients.”
“The rheumatologist should be leading the world in recognizing these matters, rather than trying to say that we can be like cardiologists and look at images,” said Dr. Pincus of the department of medicine at the university.
That's why he encourages physicians to make patient questionnaires a standard part of the assessment of RA patients and then document those numerical measurements for easy reference.
Questionnaires like the Routine Assessment of Patient Index Data 3 (RAPID3) can be administered cheaply—for just the cost of pencils and photocopies—and scored by physicians in 5–10 seconds, he said.
These types of patient-oriented measures are especially important in rheumatology where there is no single standard measure when it comes to diagnosis or predicting functionality, said Dr. Pincus.
Functional disability, patient global estimate, socioeconomic status, and age are better predictors of cost, work disability, and death in RA than are rheumatoid factor and radiographs, he noted.
Although the conventional measures that make up the American College of Rheumatology core data set have served the specialty well, they all have their limitations, said Dr. Pincus.
Joint counts are the most specific measure to assess patients with RA, but the measure is not necessarily the most significant when it comes to prognosis and management, he said. Joint counts may improve over time, even while joint damage and functional disability continue to progress.
It also takes physicians significantly longer to perform a joint count than to score a patient self-assessment (about 1.5 minutes vs. about 5–10 seconds).
And many rheumatologists don't actually perform formal tender and swollen joint counts on the patients they examine, he said.
Radiographs also have drawbacks, Dr. Pincus said. Although clinical trials have shown statistically significant data from radiographs, it's still unclear how important they are clinically in individual patients, he said.
The usefulness of x-rays is also limited because treatment is often initiated prior to the emergence of erosions.
Laboratory tests, which are often seen by physicians and patients as the most important measures, also fall short in rheumatology. For example, medical textbooks have said for years that the erythrocyte sedimentation rate is increased in nearly all patients with active RA, but today the data show that many patients with active RA do not have an increased ESR, Dr. Pincus said.
Studies from around the world have shown that as many as 37%–45% of RA patients have an ESR value less than 28 mm/hour, which is within normal limits (J. Rheumatol. 1994;21:1227–37).
While a complete blood count test is often of great value, generally laboratory tests tend to be overrated in rheumatology, he said.
Disclosures: Dr. Pincus disclosed a financial relationship with a number of pharmaceutical companies including Amgen Inc., Bristol-Myers Squibb Co., Abbott Laboratories, Wyeth Pharmaceuticals, Genentech, and UCB.
Rheumatologists should be leading the way in recognizing the validity of patient-completed questionnaires.
Source DR. PINCUS