There is one additional benefit of using patient responses for monitoring and assessing patients. It does something novel and unique in modern medicine. It actually asks the patient to tell how he or she is doing. One has to ask: Whose perception is more accurate—the patient’s or the physician’s?
Like any other measure, RAPID is a clinical tool that helps rheumatologists make clinical decisions. It does not replace the physician, nor does it supersede common sense. An elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) will have a strong influence on DAS/SDAI, but one would never use that value alone in the decision-making process without first asking the patient about a recent infection or examining the patient for signs of disease activity. If that same patient had no tender or swollen joints but was feeling poorly (patient global=50) and had an ESR of 50 due to recent pneumonia, he or she would have a DAS28 of 4.4. No one would change a disease modifying antirheumatic drug (DMARD) or biologic based on that alone.
Technology is wonderful and a lot of fun, but you don’t need to be married to it (this from a solo practitioner with five computers in his office). Your “fancy” hand-held device didn’t make your life any easier; it made you spend more time to get the information. At the risk of being crude, for the average practicing rheumatologist, time is money. The paper questionnaire, at less than three cents per copy, is easy to read and easy to score. For those of us who are using computers, the results can be scanned into the EMR or quickly entered into the record manually.
As Drs. Smolen and Aletaha correctly point out, our treatment target should be remission. Having a tool that is easily completed, rapidly scored, and clinically useful will make this goal more likely to be embraced by all. The RAPID provides most if not all of these features.
Marty Bergman, MD
Arthritis and Rheumatology, Ridley Park, Pa.
Give PROs Another Go
I really enjoyed Dr. Pisetsky’s story about the HAQ in The Rheumatologist (“Twenty Questions”). It is so wonderful that one of the top-10 U.S. scientist-rheumatologists does not hesitate to reveal all his fatal mistakes in using the HAQ in the clinic. However, I could not resist pointing out some matters that such a prominent rheumatologist apparently never learned, with concern regarding what might be expected from an ordinary clinical rheumatologist.
- Deadly sin 1: You invaded and ruined the “Patient-reported outcomes” and turned them into “Pisetsky-reported outcomes;”
- Deadly sin 2: This patient will probably never see any value in PROs because of his traumatic experience the first time; and
- Deadly sin 3: Misunderstanding the scale of the HAQ: “As it turned out, the man’s HAQ was actually low, his perception of his functioning in fact worse than the reality.” Please note: low HAQ is good; high HAQ is bad!
My dear friend Dr. Pisetsky, you really messed up with your patient….Try again with the correct method and then write a new story, delighted of the value of PROs!
I did not reach the ceiling in learning about PROs and my experience is pale compared with the great geniuses Drs. Pincus and James Fries, MD; however, I would like to share with you what I have seen.