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Can a Multi-Dimensional Health Assessment Questionnaire (MDHAQ) and Routine Assessment of Patient Index Data (RAPID) scores be informative in patients with all rheumatic diseases?

https://doi.org/10.1016/j.berh.2007.02.006Get rights and content

A multidimensional health assessment questionnaire (MDHAQ) is useful in standard care of patients with all rheumatic diseases in a busy clinical setting. The MDHAQ was adapted from the classical health assessment questionnaire (HAQ) for feasibility in standard clinical care, with reduction of the number of activities from 20 to 10, visual analog scales (VAS) as 21 circles rather than 10 cm lines, availability of all core data set patient self-report measures and scoring templates on the front side, and a review of systems symptom checklist and review of recent medical history on the reverse side of a single page. Scoring templates are also available for routine assessment of patient index data (RAPID) scores, based on a composite of the three patient reported outcome (PRO) measures from the core data set included on the HAQ and MDHAQ, physical function pain, and patient estimate of global status. Flow sheets illustrating use of the MDHAQ in standard clinical care of patients with various rheumatic diseases, including psoriatic arthritis, systemic lupus erythematosus, ankylosing spondylitis, gout, scleroderma, vasculitis, fibromyalgia, inflammatory bowel disease arthritis, Behcet's syndrome, and familial Mediterranean fever, are presented to illustrate use of this simple questionnaire to add to clinical decisions and document patient courses and outcomes in standard clinical care of patients with all rheumatic diseases.

Introduction

The science of clinical measurement in rheumatic diseases has seen great progress over the last three decades. Nonetheless, most standard rheumatology care outside of clinical trials and other clinical research studies is conducted largely according to ‘Gestalt’ impressions of the treating rheumatologist, without quantitative measures – other than laboratory tests, which often are not informative and even give false-positive and false-negative results.1, 2, *3 Therefore, any possible benefits of extensive advances in measurement of clinical status by experts in clinical research are available to only a very small fraction of patients with rheumatic diseases.

A primary reason why measurement is not a component of standard rheumatology care involves the difficulty of collecting, scoring, and managing complex measures and indices in a busy clinical setting, particularly prior to seeing the patient, so that the quantitative data might be used to contribute to patient care. Most visits in a rheumatology setting involve less than 30 minutes, and attention to patient concerns appears a higher priority than measurement. Nonetheless, it would appear desirable to include some quantitative measurement in standard rheumatology care, as quantitative measures ranging from blood pressure to serum creatinine have greatly advanced patient care in many domains.

One approach to introducing clinical measurement into standard rheumatology care involves provision of incentives to a rheumatologist for collection of measures, such as a monetary reimbursement or as a direct requirement to prescribe a certain therapy for a particular patient. A second approach might involve simplification of a measure so that it could be scored and reviewed in a few seconds, and would be regarded as adding to, rather than interfering with, completion of a standard clinical visit. Such a measure might be analogous to an acute-phase reactant, such as the erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), which are not nearly as specific as antineutrophil cytoplasmic antibodies in vasculitis or anti-DNA antibodies in Systemic Lupus Erythematosus (SLE), but are of considerable value in standard care.

Disease-specific questionnaires and indices provide more comprehensive and specific information than more general questionnaires concerning patients with these conditions. Examples of disease-specific questionnaires include, the Western Ontario McMaster Osteoarthritis Scale (WOMAC)4, Fibromyalgia Impact Questionnaire (FIQ)5, Bath Ankylosing Spondylitis Functional Index (BASFI).6 Examples of disease-specific indices include:

  • In rheumatoid arthritis (RA): the American College of Rheumatology (ACR) Core Data Set7, 8, 9, and Disease Activity Score (DAS).10, 11

  • In SLE: the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI)12, British Isles Lupus Activity Score (BILAG)13, Systemic Lupus Activities Measurement (SLAM)14, Lupus Activity Index (LAI)15, and European Consensus Lupus Activity Measurement (ECLAM).16, 17

  • In ankylosing spondylitis (AS): the BATH Ankylosing Spondylitis Disease Activity Index (BASDAI)18, Modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS)19, Bath Ankylosing Spondylitis Metrology Index20, and Dougados Functional Index (DFI).21

  • In vasculitis: the Birmingham Vasculitis Activity Score (BVAS)22, Vasculitis Activity Index23, and BVAS-derived Wegener's Granulomatosis Activity Index.24

Each of these measures is more informative in the specific disease than any general measure. However, few patients with osteoarthritis, fibromyalgia, RA, SLE, AS, or vasculitis – outside of research studies – are monitored according to any of these measures and indices.

It has been suggested that ‘80% of the data in 100% of the patients may be preferable to 100% of the data in 5% of the patients’ (or fewer) who might be included in clinical research.25 Therefore, a less comprehensive measure, which is feasible and applicable in standard clinical care, appears preferable to no quantitative measure at all.

The Health Assessment Questionnaire (HAQ)26 is classified as ‘disease specific’ because it was developed initially for use in patients with RA, in contrast to questionnaires such as the Short Form 36 (SF36)27, a protoype ‘generic’ questionnaire developed to be applicable to patients with many diseases or no disease at all.28, 29 However, the HAQ might function effectively as a ‘generic’ questionnaire, as people with all rheumatic diseases, and indeed all diseases, are affected by limitations of functional status, pain and poor global status.28

Similarly, derivatives of the HAQ, such as the multidimensional HAQ (MDHAQ)30, *31, appear useful in all rheumatic diseases.32 For example, in osteoarthritis clinical trials, the physical function scale was found to be more sensitive to changes than traditional physical measures.33 Furthermore, the pain visual analog scale (VAS) on the MDHAQ is more sensitive than the WOMAC an osteoarthritis – specific questionnaire to distinguish diclofenac/misoprotol from acetaminophen (paracetamol)34 or celecoxib from acetaminophen (paracetamol).35 In fibromyalgia, ratios of pain or fatigue to physical function scores, as well as the number of symptoms reported on a review-of-systems symptom checklist, distinguish these patients from those with RA as effectively as ESR.*36, 37

The MDHAQ was adapted from the HAQ for feasibility in standard clinical care, with reduction of the number of activities from 20 to 10, VAS as 21 circles rather than a 10-cm line, availability of all American College of Rheumatology (ACR) Core Data Set patient self-report measures and scoring templates on the front page, with a review of systems symptom checklist and review of recent medical history on the reverse side of a single page. Scoring templates are also available for Routine Assessment of Patient Index Data (RAPID) scores, based on a composite of the three patient-reported outcome (PRO) measures from the Core Data Set included on the HAQ and MDHAQ. RAPID 3 – a composite of physical function, pain, and global status (derived from the Core Data Set) – can be calculated without a ruler, calculator, computer or website in about 10 seconds. RAPID 3 distinguishes active from control treatment in RA clinical trials involving leflunomide38, 39, methotrexate38, 39, adalimumab40, and abatacept41 at levels similar to ACR or DAS-28 criteria, and are correlated significantly with DAS-28 in these trials and in standard clinical care.42 A preliminary proposed classification of RAPID scores includes four categories: 0–1 = near remission, 1.01–2 = low severity, 2.01–4 = moderate severity, 4.01–10 = high severity. These categories can be useful to guide ‘tight control’43 of inflammation in RA and other diseases.

Routine completion of an MDHAQ by every patient at every visit in the infrastructure of standard rheumatology care44 might allow effective quantitative monitoring of clinical status with minimal work on the part of the physician and the staff. The author have empirically collected MDHAQ scores to monitor clinical status in patients with all rheumatic diseases for many years. In this report, data are presented concerning the MDHAQ and RAPID 3 in patients with rheumatic diseases other than RA, including examples of flow sheets to illustrate the courses of individual patients monitored in standard clinical care.

Section snippets

MDHAQ scores in 1107 patients with various rheumatic diseases

Mean and median scores for physical function, pain, global status, as well as fatigue and RAPID 3 are illustrated in Table 1 for 1107 patients at their first visit between September 1996 (when a patient global score and RAPID 3 score became available in the clinic) and December 2005. Scores for patients with fibromyalgia are higher for all three components of RAPID 3, as well as for the index. Lowest scores on all three scales are seen in patients with vasculitis. A high score for pain with

Flow sheets to illustrate patient monitoring of MDHAQ and RAPID scores

Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9, Figure 10, Figure 11 illustrate courses over periods varying from a few months to 15 years in patients with different diagnoses other than RA, to illustrate the value of monitoring scores on the MDHAQ for the three Core Data Set PRO measures and RAPID 3 over time in all patients seen in standard rheumatology clinical care.

These flow sheets of 11 patients who did not have RA have been selected to illustrate

Acknowledgement

Supported in part by grants from the U.S. Arthritis Foundation and the Jack Massey Foundation.

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