Measures in RA: Joint counts,
radiographs, laboratory tests,
patient questionnaires advantages and disadvantages
[email protected]
It’s all about
measurement

“When you can measure what
you are speaking about, and
express it in numbers, you
know something about it; but
when you cannot measure it
[and] express it in numbers,
your knowledge is of a meager
and unsatisfactory kind.”
Lord Kelvin – quoted by:
Buchanan W, Smythe H.
J Rheumatol. 1982:9;653–4.
Complexities in assessment of
patients with rheumatic diseases:
1.
2.
3.
No single “gold standard” (eg, blood
pressure, cholesterol) for clinical trials
or standard care: therefore, indices of 37 measures.
Laboratory tests limited in both
diagnosis and treatment - primary
criteria are clinical.
Patient questionnaires to assess
physical function, pain, global status,
often best quantitative measures.
American College of Rheumatology (ACR)
Core Data Set & Disease Activity Score (DAS)
3 Physician/Assessor measures
1. Tender joint count (also in DAS)
2. Swollen joint count (also in DAS)
3. Assessor Global status
3 Patient self-report measures
4. Physical Function - HAQ, HAQ II, MDHAQ
5. Pain
6. Patient Global status (also in DAS)
1 Laboratory Measure
7. Acute phase reactant –ESR, CRP–also in DAS
(8. Radiograph – longer than 1 year)
Felson et al, Arth Rheum 36:729, 1993. van Riel, Br J Rheumatol 31:793, 1994.
RA Measures for
clinical research vs clinical care
Clinical research
Joint count
68/70 joints -tender,
swollen, limited motion,
pain on motion, deformed
X-ray
Detailed Larsen, Sharpe/
van der Heijde scores
Lab
ESR, CRP, anti-CCP, RF
Patient questionnaires
Complete, long
Takes time
Complex scoring
Results to data center
Results unknown in care
Clinical care
28 joints – tender, swollen
?Erosions
?Joint space narrowing
ESR, CRP, anti-CCP, RF
Patient friendly,<10 min
Saves time for MD
“Eyeball” results
Results on clinical flowsheet
Adds to clinical care
Formal Joint Counts in
Management of Patients With RA
 Most specific measure to assess RA
 Most important measure in clinical
trials
 28-joint count as useful in clinical
trials as 68–70 joint counts
Joints included in various standard joint counts
66/68
Joints
Ritchie
Index
Temporomandibular
+
+
Sternoclavicular
+
+
+
Acromioclavicular
+
+
+
Shoulder
+
+
+
Elbow
+
+
+
Wrist
+
+
MCP
+
Hand PIP
+
DIP
+
Hip
+
+
Knee
+
+
+
+
Ankle
+
+
+
+
+
+
+
+
Joint
Talocalcaneal
44
Joints
36
Joints
28
Joints
42
Joints
+
+
+
+
+
+
+
+
+
+
+
+ (-1)
+
+
+
+
+
+
+
+
+
+
+
Tarsus
+
+
MTP
+
+
Foot DIP
+
A simplified twenty-eightjoint quantitative articular
index in rheumatoid
arthritis
HA Fuchs, RH Brooks,
LF Callahan, T Pincus
Arthritis Rheum 32:531-537, 1989
Question for Rheumatologists
For patients with RA under your care (not including
patients in clinical trials), how often do you perform
formal tender and swollen joint counts?
Never
13%
1–24% of visits
25–49% of visits
50–74% of visits
75–99% of visits
Always
32%
11%
14%
16%
14%
Median number of seconds to score various RA measures
120
100
Seconds
80
60
40
20
0
Rheum #1
Rheum #2
Rheum #3
Mean
28 JT
CT
DAS28
84
113
71
90
12.9
16.8
14.6
14.6
HAQ MDHAQ
RAPID
FN +
+ PN, RAPID2 RAPID 3
4MD
PN, GL
GL
41.5
42.2
41.9
6.4
8.5
7.5
7.5
4.3
4.4
4
4.3
9.2
12.1
9.1
9.6
11.8
16.1
12
12.2
RAPID
RAPID 5
4JC
19
22.8
15.3
19
19.4
27.3
17.5
19.4
Relative efficiencies of 7 ACR Core Data Set
measures in 4 adalimumab clinical trials a.
Arithmetic change
3.00
2.72
2.65
2.50
2.14
2.12
2.00
1.86
1.48
1.50
1.10
1.00
1.00
2.06
1.55
1.60
1.42
1.52
1.48
1.36
1.30
1.12
1.00
0.92
0.94
1.00
1.66
1.00
1.43
1.27
1.17
0.60
0.50
0.22
0.00
ARMADA
DE011
DE019
STAR
Tender Joint Count
Swollen Joint Coun
Assessor Global
CRP
Function (HAQ)
Pain
Patient Global
Some Problems With Joint Counts in RA
1. Joint counts have lower relative
efficiencies than MD global and patient
measures
2. Formal studies indicate poor
reproducibility
3. Tedious to perform – interrupt visit
4. Most visits to a rheumatologist include
a careful joint examination, but do not
include a formal joint count
3. Please place a check (√) in the appropriate spot to indicate the amount of pain you
are having today in each of the joint areas listed below:
None
Mild Moderate Severe
None
Mild Moderate Severe
a.LEFT FINGERS
b.LEFT WRIST
c.LEFT ELBOW
d.LEFT SHOULDER
e.LEFT HIP
f.LEFT KNEE
g.LEFT ANKLE
h.LEFT TOES
i.RIGHT FINGERS
j.RIGHT WRIST
k.RIGHT ELBOW
l.RIGHT SHOULDER
m.RIGHT HIP
n.RIGHT KNEE
o.RIGHT ANKLE
p.RIGHT TOES
q.NECK
r.BACK
Should contemporary
rheumatoid arthritis clinical
trials be more like standard
patient care and vice versa?
T Pincus, T Sokka
Ann Rheum Dis 63(Suppl II):ii32-ii39, 2004
Radiographs in Diagnosis and
Management of Patients With RA
 Excellent quantitative scoring
systems - Sharp, van der Heijde,
Larsen, Genant
 Erosions are closest to
pathognomonic sign in RA
 Reflect cumulative damage of
disease
Radiographic and joint
count findings of the hand
in rheumatoid arthritis:
related and unrelated
findings
HA Fuchs, LF Callahan, JJ Kaye,
RH Brooks, EP Nance, T Pincus
Arthritis Rheum 31:44-51, 1988
Radiographs and joint counts in RA:
Related and unrelated findings
Fuchs, Callahan, Kaye, Brooks, Nance, Pincus Arthritis Rheum 31:44, 1988
Associations of HLA-DR4 with
rheumatoid factor and
radiographic severity in
rheumatoid arthritis.
NJ Olsen, LF Callahan, RH Brooks,
EP Nance, JJ Kaye, P Stastny, T Pincus
Am J Med 84:257-264, 1988
Strongly and Weakly Related
Measures to Assess RA
Radiographs
ESR, CRP
Shared epitope
Rheumatoid factor
Joint deformity
Duration of disease
Functional disability
Pain
Patient global
Joint swelling
Joint tenderness
Age
Predicting Mortality in RA: Most Baseline
Measures Are Worse in Patients Who Will
Die Over a 5-Year Period
Mean Baseline Values
P Value
Alive
Dead
Age (years)
ARA functional class
Number of comorbidities
Walking time
ESR
mHAQ score
Learned helplessness
Global self-report
Number of extra-articular features
Duration of disease
Years of education
Joint count
55.1
2.2
1.1
10.8
33.8
1.98
2.41
2.6
0.2
9.1
10.8
12.8
65.5
2.6
2.1
16.8
48.3
2.32
2.55
3.0
0.5
12.7
9.4
15.9
< 0.001
< 0.001
< 0.001
< 0.001
0.004
0.005
0.007
0.01
0.02
0.03
0.03
0.04
Radiograph score
RF titer
Pain
1.2
2.7
5.40
1.4
2.9
5.19
0.20
0.28
0.68
Callahan LF, et al. Arthritis Care Res. 1997;10:381–394.
RA Cohort #2- Cox Proportional Hazards Model
Analyses Including Demographic, Functional, SelfReport, Joint Count, X-ray, Laboratory and Disease
Variables in 206 patients
Age
Univariate
RR
P
(95% CL) Value
1.07
<0.001
Stepwise Model
RR
P
(95% CL) Value
1.06
<0.001
Comorbidity
MHAQ ADL Score
Disease duration
Education
ESR
Joint count
1.63
2.00
1.04
0.89
1.01
1.02
<0.001
0.003
0.02
0.007
0.005
0.10
1.40
1.76
-----
Walking time
X-ray
1.03
1.40
0.04
0.17
---
Arthritis Care Res 10:381,1997
0.02
0.02
-------
5-Year Survival in 206 Patients
with RA: 1985-1990
Rheumatoid Factor
MHAQ Score
80
80
Survival (%)
100
Survival (%)
100
60
60
40
Absent (29)
Present
20
(175)
1.00 (12)
1.01–1.99
2.00–2.99
(91)
3.00
(86) (21)
40
20
0
0
0
12
24
36
48
Months After Baseline
60
0
12
24
36
48
Months After Baseline
Arthritis Care Res. 1997;10:381.
60
Predictors of mortality in RA n=1922
Odds Ratio
HAQ
2.93
Pt Global severity
1.28
Pain
1.25
Depression
1.34
Anxiety
1.28
Grip strength
1.01
ESR
1.01
RF, titer
1.13
Hematocrit
1.06
Larsen X-ray score 1.04
Duration
1.01
Joint count
1.01
Age
Comorbidities
Male
1.09
1.19
2.10
z score p value
11.1
<0.001
8.5
<0.001
8.3
<0.001
8.8
<0.001
7.2
<0.001
6.2
<0.001
5.7
<0.001
4.6
<0.001
3.8
<0.001
4.7
0.002
2.1
0.036
0.76
0.445
11.9
4.69
5.28
<0.001
<0.001
<0.001
Wolfe et al Arth Rheum 48:1530, 2003
The HAQ or MDHAQ, not a joint count, lab
test or X-ray, is Best Predictor in RA of…





Functional status (Pincus et al. Arthritis Rheum. 1984,
Wolfe et al. J Rheumatol. 1991)
Work disability (Borg et al. J Rheumatol 1991, Callahan
et al. J Clin Epidemiol. 1992, Wolfe and Hawley. J
Rheumatol. 1998, Fex et al. J Rheumatol 1998, Sokka et
al. J Rheumatol 1999, Barrett et al. Rheumatology 2000,
Puolakka et al. Ann Rheum Dis 64:130-133, 2005 )
Costs (Lubeck et al. Arthritis Rheum. 1986)
Joint replacement surgery (Wolfe and Zwillich. Arthritis
Rheum. 1998)
Death (Pincus et al. Arthritis Rheum. 1984, Ann Intern
Med.1994, Wolfe et al. J Rheumatol 1988, Leigh&Fries J
Rheumatol 1991, Wolfe et al. Arthritis Rheum. 1994,
Callahan et al. Arthrits Care Res 1996, 1997, Soderlin et
al. J Rheumatol 1998, Maiden et al. Ann Rheum Dis 1999,
Sokka et al. Ann Rheum Dis 2004)
Some Problems With
Radiographs in RA
1. Quantitative score tedious to
perform
2. Treatment initiated prior to erosions
– MRI, ultrasound are more
sensitive
3. Radiographic damage has poor
prognostic value for work disability,
death and even joint replacement
Laboratory Tests in Diagnosis and
Management of Patients With RA
1. Most important measure in most
clinical situations, e.g.,
cholesterol, hemoglobin,
creatinine, glucose, etc.
2. Many tests may be of value –
CBC, ESR, CRP, RF, anti-CCP
3. No work for the rheumatologist
ESR Values in Patients With RA
ESR ≥ 28
mm/h
ESR < 28
mm/h
Females
63%
37%
Males
55%
45%
Wolfe F, Michaud K, J Rheumatol. 1994;21:1227–1237.
ESR and CRP at 1st Visit
a. Jyvaskyla, FIN
CRP
ESR
≥28 mm/hr <28 mm/hr
>10 mg/L
<10 mg/L
Total
775 (44%)
199 (11%)
974 (55%)
202 (12%)
568 (33%)
770 (45%)
b. Nashville, TN, USA
CRP
ESR
≥28 mm/hr <28 mm/hr
>10 mg/L
<10 mg/L
Total
48 (28%)
29 (17%)
77 (45%)
22 (13%)
71 (42%)
93 (55%)
Total
977 (56%)
767 (44%)
1744 (100%)
Total
70 (41%)
100 (59%)
170 (100%)
The level of inflammation in
rheumatoid arthritis is
determined early and remains
stable over the longterm course
of the illness
F Wolfe, T Pincus
J Rheumatol 28:1817-1824, 2001
Some Problems With Laboratory Tests in
Diagnosis and Management of RA
1. ESR & CRP - normal in 40% at
presentation
2. Anti-CCP & RF - negative in 20–50% of
patients
3. Treatment decisions are based primarily
on clinical criteria
4. Lab tests have good prognostic value for
radiographic damage but poor prognostic
value for work disability or death
CRP = C-reactive protein; CCP = cyclic citrullinated protein
Why should rheumatologists collect patient
self-report data in routine clinical care?
1. Significant correlation with joint counts, ESR, X-ray
2. More reproducible than joint counts, lab, X-ray score
3. As informative as ACR20/50/70 or DAS in clinical trials
4. Predict work disability, costs, TJR, and premature
death more significantly than traditional measures
5. Data most relevant to patient and family
6. Saves time for patient and MD to focus on major
patient matters including under-appreciated concerns
7. Record quantitative data to document status from one
visit to the next, particularly over long periods
8. Doctor does not measure but interprets measures
9. MDHAQ- all key data and indices one side of one page
10.Adds to the rheumatologist to be a better doctor
ACR Core Data Set Measure changes - 12 Months:
Leflunomide (LEF) vs Methotrexate (MTX)
vs Placebo (PBO)
Measure:
LEF
PBO MTX
Tender Jts
Swollen Jts
MD Global
ESR
FN- HAQ
FN-MHAQ
Pain
Pt Global
-7.7
-5.7
-2.8
-6.3
-0.45
-0.29
-2.2
-2.1
-3.0
-2.9
-1.0
+2.6
+0.03
+0.07
-0.4
+0.1
-6.6
-5.4
-2.4
-6.5
-0.26
-0.15
-1.7
-1.5
Effect Relative
Size Efficiency
-0.59
1.00
-0.44
0.56
-0.68
1.33
-0.41
0.48
-0.80
1.84
-0.69
1.37
-0.65
1.21
-0.81
1.88
Strand V, et al. Arch Intl Med. 1999; 159:2542-2550;
Tugwell P, et al. Arthritis Rheum. 2000; 43:506-514.
9- to 10-Year Survival According to
Quantitative Markers in Three Chronic
Diseases
A
Rheumatoid Arthritis – Activities of Daily Living
B
100
>90%
81%–90%
80
% Active “With Ease”
60
40
71%–80%
70%
20
Survival (%)
Survival (%)
100
Rheumatoid Arthritis – Formal Education Level
>12 Years
80
9–12 Years
60
8 Years
40
20
(Data from Pincus et al, 1987)
(Data from Pincus et al, 1987)
Months
0
40
60
80
100
Hodgkin’s Disease – Anatomic Stage
100
0
D
Stage I
80
60
Stage II
All Stages,
All Causes
Stage III
Stage IV
40
20
(Data from Kaplan, 1972)
0
2
4
6
Years
8
10
Survival (%)
Survival (%)
C
20
Months
20
40
60
80
100
Coronary Artery Disease – # of Involved Vessels
100
80
1 Artery
60
2 Arteries
40
3 Arteries
LCA
20
(Data from Proudfit et al, 1978)
0
2
4
6
8
Years
10
Relative Risk of Death Over 12-15 Years in
rheumatoid arthritis (RA) and
cardiovascular (CV) disease according to
baseline severity indicators
RA – 75 pts – 15 yrs - Pincus et al, Ann Int Med 120:26,1994
Functional status on
patient questionnaire
# of Involved Joints
< vs > 91.5% “with ease”
> vs < 18 joints
2.9:1
3.0:1
CV disease – 312,000 pts – 12 yrs –
Neaton et al, Arch Int Med 152:56,1992
Serum cholesterol
Systolic blood pressure
Diastolic blood pressure
Smoking
>245 vs <182 mg/Dl
>142 vs <118 mmHg
>92 vs <76 mmHg
>26 vs 0 cigarettes/day
2.9:1
3.0:1
2.9:1
2.9:1
Data adjusted for age, sex, education, disease duration
Treatment with TNF
blockers is associated
with reduced premature
mortality in patients with
rheumatoid arthritis
LTH Jacobsson, C Turesson, JA Nilsson,
IF Petersson, E Lindqvist, T Saxne, P Geborek
Arthritis Rheumatism 54:S330, 2006
A Practical System That (Almost) Works
For Routine Assessment of Functional
Status, Fatigue and Psychological
Distress
1. Patient given 2-page questionnaire by
receptionist: completed in waiting room
2. Nurse (or physician) reviews and/or
completes medication data
3. Physician does as little as possible:
completes brief data (may include joint
count)
4. Office staff enters flow sheet with
laboratory data
Patient questionnaires in
clinical research vs clinical care
Clinical research
Clinical care
Complete, long
Takes time
Complex scoring
No scoring at visit
Results unknown in care
Send to data center
Enter into computer
Patient friendly,<10 min
Saves time for MD
“Eyeball” results
Scoring templates for MD
Adds to clinical care
Review with patient
Enter unto flowsheet
add to care,
documentation
HAQ & multidimensional HAQ (MDHAQ)
HAQ
MDHAQ
1st report
1980
1999
Patient completion 5-10 min
5-10 min
# ADL
20
10
Pain VAS
10 cm line
21 circles
Pt Global VAS
10 cm line
21 circles
Psych, sleep
No
Sleep, anxiety
RADAI self-report
depression
joint count
No
Yes
Fatigue
No
VAS
Review of Systems
No
60 Symptoms
Medical history
No
Surgery, side effects
Demographic data
No
Yes
Social history
No
Yes
Scoring templates
No
Yes
Index
No
RAPID
MD scan (“eyeball”) 30 secs
5 secs
Time to score
41.8 secs7.5 secs
Multi-Dimensional Health Assessment Questionnaire (R771-NP2)
This questionnaire includes information not available from blood tests, X-rays, or any source other
than you. Please try to answer each question, even if you do not think it is related to you at this time.
Try to complete as much as you can yourself, but if you need help, please ask. There are no right or
FOR OFFICE
wrong answers. Please answer exactly as you think or feel. Thank you.
USE ONLY
MDHAQ
Page 1
1. Please check (√) the ONE best answer for your abilities at this time:
Without
With
With
OVER THE LAST WEEK, were you able to:
ANY
SOME
MUCH
Difficulty
Difficulty
Difficulty
a. Dress yourself, including tying shoelaces and
doing buttons?
_____0
_____1
_____2
b. Get in and out of bed?
_____0
_____1
_____2
c. Lift a full cup or glass to your mouth?
_____0
_____1
_____2
d. Walk outdoors on flat ground?
_____0
_____1
_____2
e. Wash and dry your entire body?
_____0
_____1
_____2
f. Bend down to pick up clothing from the floor?
_____0
_____1
_____2
g. Turn regular faucets on and off?
_____0
_____1
_____2
h. Get in and out of a car, bus, train, or airplane?
_____0
_____1
_____2
i. Walk two miles or three kilometers, if you wish?
_____0
_____1
_____2
j. Participate in recreational activities and sports
_____0
_____1
_____2
as you would like, if you wish?
k. Get a good night’s sleep?
_____0
_____1.1 _____2.2
l. Deal with feelings of anxiety or being nervous?
_____0
_____1.1 _____2.2
m.Deal with feelings of depression or feeling blue?
_____0
_____1.1 _____2.2
UNABLE
To Do
_____3
_____3
_____3
_____3
_____3
_____3
_____3
_____3
_____3
_____3.3
_____3.3
_____3.3
NO                      PAIN AS BAD AS
PAIN 0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10 IT COULD BE
3. Please place a check (√) in the appropriate spot to indicate the amount of pain you
are having today in each of the joint areas listed below:
None
Mild Moderate Severe
None
Mild Moderate Severe
i.RIGHT FINGERS
j.RIGHT WRIST
k.RIGHT ELBOW
l.RIGHT SHOULDER
m.RIGHT HIP
n.RIGHT KNEE
o.RIGHT ANKLE
p.RIGHT TOES
q.NECK
r.BACK
2
4. Considering all the ways in which illness and health conditions may affect you at this
time, please indicate below how you are doing:
VERY                     
WELL 0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10
For Office Use Only: RAPID 3
Please turn to the other side
RAPID 3 (0-10)
RAPID 4
VERY
POORLY
16=5.3
17=5.7
18=6.0
19=6.3
20=6.7
21=7.0
22=7.3
23=7.7
24=8.0
25=8.3
26=8.7
27=9.0
28=9.3
29=9.7
30=10
2.PN (0-10)
4.PTGL (0-10)
RAPID 3 (0-30)
3.a-pPTJT(0-10)
1=0.2
25=5.2
2=0.4
26=5.4
3=0.6
27=5.6
4=0.8
28=5.8
5=1.0
29=6.0
6=1.3
30=6.3
7=1.5
31=6.4
8=1.7
32=6.7
9=1.9
33=6.9
10=2.1 34=7.1
11=2.3 35=7.3
12=2.5 36=7.5
13=2.7 37=7.7
14=2.9 38=7.9
15=3.1 39=8.1
16=3.3 40=8.3
17=3.5 41=8.5
18=3.8 42=8.8
19=4.0 43=9.0
20=4.2 44=9.2
21=4.4 45=9.4
22=4.6 46=9.6
23=4.8 47=9.8
24=5.0 48=10
?
?
?
?
RAPID 4 (0-40)
RAPID 4 (0-10)
NR: 1=0.3, 2=0.7, 3=1.0 LS: 4=1.3, 5=1.7, 6=2.0
NR: 1=0.3, 2=0.5, 3=0.8, 4=1.0
LS: 5=1.3, 6=1.5, 7=1.8, 8=2.0
MS: 7=2.3, 8=2.7, 9=3.0, 10=3.3, 11=3.7, 12=4.0
MS: 9=2.3, 10=2.5, 11=2.8, 12=3.0, 13=3.3, 14=3.5, 15=3.8, 16=4.0
HS: 13=4.3, 14=4.7, 15=5.0, 16=5.3, 17=5.7,18=6.0,
HS: 17=4.3, 18=4.5, 19=4.8, 20=5.0, 21=5.3, 22=5.5, 23=5.8, 24=6.0,
19=6.3, 20=6.7, 21=7.0, 22=7.3, 23=7.7, 24=8.0,
25=6.3, 26=6.5, 27=6.8, 28=7.0, 29=7.3, 30=7.5, 31=7.8, 32=8.0,
25=8.3, 26=8.7, 27=9.0, 28=9.3, 29=9.7, 30=10.0
33=8.3, 34=8.5, 35=8.7, 36=9.0, 37=9.3, 38=9.5, 39=9.8, 40=10.0
NR: 1=0.2, 2=0.4, 3=0.6, 4=0.8 5=1.0 LS: 6=1.2, 7=1.4, 8=1.6, 9=1.8, 10=2.0,
RAPID 5
MS:11=2.2, 12=2.4, 13=2.6, 14=2.8, 15=3.0, 16=3.2, 17=3.4, 18=3.6, 19=3.8, 20=4.0
(0-10)
HS: 21=4.2, 22=4.4, 23=4.6, 24=4.8, 25=5.0, 26=5.2, 27=5.4, 28=5.6, 29=5.8, 30=6.0, 31=6.2, 32=6.4, 33=6.6, 34=6.8, 35=7.0,
36=7.2, 37=7.4, 38=7.6, 39=7.8, 40=8.0, 41=8.2, 42=8.4, 43=8.6, 44=8.8, 45=9.0, 46=9.2, 47=9.4, 48=9.6, 49=9.8, 50=10.0
Copyright: Health Report Services, Telephone 615-936-2151, E-mail [email protected]
1=0.3
2=0.7
3=1.0
4=1.3
5=1.7
6=2.0
7=2.3
8=2.7
9=3.0
10=3.3
11=3.7
12=4.0
13=4.3
14=4.7
15=5.0
_____3
2. How much pain have you had because of your condition OVER THE PAST WEEK? Please
indicate below how severe your pain has been:
a.LEFT FINGERS
b.LEFT WRIST
c.LEFT ELBOW
d.LEFT SHOULDER
e.LEFT HIP
f.LEFT KNEE
g.LEFT ANKLE
h.LEFT TOES
1.a-j FN (0-10)
\ \\
MDGLOBAL(0-10))
RAPID 5 (0-50)
43
Keep
It
Simple
Stupid
Considering all the ways in which illness and
health conditions may affect you at this time,
please indicate below how you are doing:
VERY                     
VERY
WELL 0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10 POORLY
VERY
WELL
______________________________________________
VERY
POORLY
RADAI vs Core Data Set measures (n=274)
RADAI
Swollen 28 JC
Tender 28 JC
MDGlobal VAS
ESR
CRP
FN MDHAQ
Pt Global VAS
Pain VAS
RADAI
--0.42
0.55
0.52
0.13*
0.08***
0.68
0.69
0.71
SJC 28
0.42
--0.55
0.74
0.23
0.18**
0.47
0.36
0.39
TJC 28
0.55
0.55
--0.57
0.32
0.21
0.52
0.53
0.56
ESR
0.13*
0.23
0.32
0.26
--0.50
0.25
0.21
0.21
Adjusted for age, disease duration, education and center, All p<0.0001,
except *p=0.035, **p=0.003, ***p>0.05
RA 35 yo F (#13) Onset: 02/2003 Visit 1
Visit Date
3/5/03
Function (0-10)
6.33
Pain (0-10)
7.8
Global (0-10)
9.1
ESR
-
Prednisone
N-10qd
Methotrexate
N15qw
Folic Acid
N-1qd
Ibuprofen
200prn
Hydrocodone
1q6h
N = new drug, C = change in dose, T = taper, D/C = discontinue
RA 35 yo F (#13) Onset: 02/2003 Visit 2
Visit Date
3/5/03
3/11/03
Function (0-10)
6.33
2.00
Pain (0-10)
7.8
5.6
Global (0-10)
9.1
5.6
-
17
Prednisone
N-10qd
C-5bid
Methotrexate
N15qw
15qw
ESR
n25biw
Etanercept
Folic Acid
N-1qd
1qd
Ibuprofen
200prn
200prn
1q6h
1q6h
Hydrocodone
N = new drug, C = change in dose, T = taper, D/C = discontinue
RA 35 yo F (#13) Onset: 02/2003 Visit 3
Visit Date
3/5/03
3/11/03
3/25/03
Function (0-10)
6.33
2.00
2.00
Pain (0-10)
7.8
5.6
1.8
Global (0-10)
9.1
5.6
2.8
-
17
11
Prednisone
N-10qd
C-5bid
T-5qd
Methotrexate
N15qw
15qw
15qw
n25biw
25biw
ESR
Etanercept
Folic Acid
N-1qd
1qd
1qd
Ibuprofen
200prn
200prn
200prn
1q6h
1q6h
1q6h
Hydrocodone
N = new drug, C = change in dose, T = taper, D/C = discontinue
RA 35 yo F (#13) Onset: 02/2003 Visit 4
Visit Date
3/5/03
3/11/03
3/25/03
5/20/03
Function (0-10)
6.33
2.00
2.00
1.67
Pain (0-10)
7.8
5.6
1.8
1.7
Global (0-10)
9.1
5.6
2.8
2.4
-
17
11
30
Prednisone
N-10qd
C-5bid
T-5qd
5qd
Methotrexate
N15qw
15qw
15qw
C20qw
n25biw
25biw
25biw
ESR
Etanercept
Folic Acid
N-1qd
1qd
1qd
1qd
Ibuprofen
200prn
200prn
200prn
200prn
1q6h
1q6h
1q6h
D/C
Hydrocodone
N = new drug, C = change in dose, T = taper, D/C = discontinue
RA 35 yo F (#13) Onset: 02/2003 Visit 5
Visit Date
3/5/03
3/11/03
3/25/03
5/20/03
8/19/03
Function (0-10)
6.33
2.00
2.00
1.67
1.00
Pain (0-10)
7.8
5.6
1.8
1.7
1.3
Global (0-10)
9.1
5.6
2.8
2.4
1.6
-
17
11
30
16
Prednisone
N-10qd
C-5bid
T-5qd
5qd
C-4qd
Methotrexate
N15qw
15qw
15qw
C20qw
20qw
n25biw
25biw
25biw
25biw
ESR
Etanercept
Folic Acid
N-1qd
1qd
1qd
1qd
1qd
Ibuprofen
200prn
200prn
200prn
200prn
200prn
1q6h
1q6h
1q6h
D/C
Hydrocodone
N = new drug, C = change in dose, T = taper, D/C = discontinue
RA 35 yo F (#13) Onset: 02/2003 Visit 10
Visit Date
3/5/03
3/11/03
3/25/03
5/20/03
8/19/03
1/24/06
Function (0-10)
6.33
2.00
2.00
1.67
1.00
0.67
Pain (0-10)
7.8
5.6
1.8
1.7
1.3
2.8
Global (0-10)
9.1
5.6
2.8
2.4
1.6
2.2
-
17
11
30
16
6
Prednisone
N-10qd
C-5bid
T-5qd
5qd
C-4qd
4qd
Methotrexate
N15qw
15qw
15qw
C20qw
20qw
20qw
n25biw
25biw
25biw
25biw
50qw
ESR
Etanercept
Folic Acid
N-1qd
1qd
1qd
1qd
1qd
1qd
Ibuprofen
200prn
200prn
200prn
200prn
200prn
200prn
1q6h
1q6h
1q6h
D/C
Hydrocodone
N = new drug, C = change in dose, T = taper, D/C = discontinue
The MDHAQ in Clinical Rheumatology
• In rheumatoid arthritis, the MDHAQ
distinguishes MTX or LEF from placebo in a
clinical trial as effectively as a joint count
or the ACR 20
• In osteoarthritis, the MDHAQ distinguishes
NSAID from acetaminophen as effectively
as the WOMAC
• In fibromyalgia, the MDHAQ distinguishes
patients from those with rheumatoid
arthritis as effectively as an ESR
Pain/MHAQ Ratio in RA and Fibromyalgia
P-VAS/D-ADL Ratio
10
9
2 Years
8
>2 Years
7
6
5
4
3
2
1
0
Rheumatoid
Arthritis
Non-Inflammatory Diffuse
Muskuloskeletal Pain
Callahan and Pincus. Arthritis and Rheumatism. 1990;33:1317.
DNA Binding of Serums- SLE and Control Patients
% DNA Bound
100
90
Other = Diseased controls
80
SS = Sjögren’s Syndrome
70
SLE = Unselected Patients
with SLE
60
50
40
30
Value of 20% indicates
abnormal binding activity
20
10
0
Normal (84)Other (57)SS (24) SLE (44)
Pincus et al.
NEJM. 1969;281:701.
Further clues to recognition of
patients with fibromyalgia from
a simple 2-page patient
multidimensional health
assessment questionnaire
(MDHAQ)
DA DeWalt, GW Reed, T Pincus
Clin Exp Rheumatol 22:453-461, 2004
Activities of Daily Living (ADL)
in prognosis of non- Rheumatic Diseases
• In congestive heart failure, ADL predict 36
month mortality as ejection fraction
Konstam, Am J Cardiology 78:890, 1996
• In AIDS, ADL predict 36 month mortality
as CD4/CD8 ratios, clinical AIDS
prognostic staging (CAPS), severity
classification for AIDS hospitalzations
(SCAH) Justice, J Clin Epidemiology
49:193, 1996
• In hospitalized elder patients, ADL
predict one year mortality beyond
physiologic data and comorbidities
Covinsky, J Gen Intern Med 12:203, 1997
Some limitations of patient self-report
questionnaires
1. Need for translation –language
issues
2. Cultural and linguistic issues
3. Possibility of “gaming” by patient,
health professional to provide
desired responses
4. Not specific to any disease
Multidimensional Health Assessment Questionnaire
AT THIS MOMENT, are you able to:
Dress yourself, including tying shoelaces and
doing buttons?
Get in and out of bed?
Lift a full cup or glass to your mouth?
Walk outdoors on flat ground?
Wash and dry your entire body?
Bend down to pick up clothing from the floor?
Turn regular faucets on and off?
Get in and out of a car, bus, train or airplane?
Walk 2 miles or 3 kilometers?
Participate in sports and games as you would like?
Get a good night’s sleep?
Deal with feelings of anxiety or being nervous?
Deal with feelings of depression or feeling blue?
Without ANY
Difficulty
With SOME
Difficulty
With MUCH
Difficult
UNABLE
To Do
----------------------------------------
----------------------------------------
----------------------------------------
----------------------------------------
How much pain have you had because of your condition IN THE PAST WEEK?
Place a mark on the line below to indicate how severe your pain has been:
NO PAIN
PAIN AS BAD AS
IT COULD BE
Considering all the ways in which your illness and and health conditions
may affect you at this time, place a mark to show how you are doing:
VERY
WELL
VERY
POORLY
5-Year Survival in 206 Patients
With RA: Cohort #2 – 19851990
Rheumatoid Factor
MHAQ Score
80
80
Survival (%)
100
Survival (%)
100
60
60
40
Absent (29)
Present
20
(175)
0.00 (12)
0.01–0.99 (91)
1.00–1.99 (86)
>2.00 (21)
40
20
0
0
0
12
24
36
48
Months After Baseline
Arthritis Care Res 10:381,1997
60
0
12
24
36
48
Months After Baseline
60
Evidence-Based Practice or
Practice-Based Evidence
T Pincus, T Sokka?
Nature Clinical Practice
Rheumatology
2:114-115, 2006
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