Patient Measures Are Worth the Work
Dr. Pisetsky’s foray into patient measures (“Twenty Questions” Parts 1 and 2, Feb. 2007, p. 6 and March 2007, p.6) along with Drs. Smolen and Aletaha’s article (“Target Remission,” March 2007, p. 1) are of considerable interest. Many of us in clinical practice are wrestling with the questions: “How are my patients doing?” and “Does my patient need better/more aggressive treatment?” You chose to go first with a calculator method, whereas Drs. Smolen and Aletaha have moved more to simple addition.
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My first attempt at patient measures was to use a Disease Activity Score (DAS) calculator. Like you, I found having a number helped me get a better idea of how my patient was doing, but to do this I needed to get the patient’s global response. Essentially, this requires the patient to fill out some form of a questionnaire, but my attitudes toward questionnaires were somewhat skeptical, to say the least. I had done clinical trials and had worked with the Health Assessment Questionnaire (HAQ) Disability Index, but had found it cumbersome. Not only did I need to review the two pages, I also needed to correct the domain scores to account for assistive devices. When that was done, it had to be added up and divided by eight. As a solo-practice rheumatologist, spending that amount of time on each patient would have put me out of practice.
At a meeting, I had the good fortune to talk with Ted Pincus, MD, who was kind enough to send me his adaptation of the HAQ, the multidimensional HAQ (MDHAQ), which he had developed to address HAQ’s limitations. It includes only activities that can be performed by all patients (eliminating questions like the one that perplexed you: Can you shampoo your hair?) and allows for a quick, visual review of the results. I would recommend that you consider using the MDHAQ to see if some of your concerns about questionnaires are addressed.
Using the MDHAQ, Dr. Pincus, Yusuf Yazici, MD, and I are developing of a user-friendly index, RAPID (rheumatology assessment of patient index data), a one-page questionnaire completed by patients while they sit in the waiting room prior to the actual office visit. Our work, presented at the 2006 ACR meeting, demonstrated that this form can be reviewed and scored in under 10 seconds. It is given to every patient—regardless of the diagnosis—at every visit. This simplifies my front-desk’s life because they don’t have to pick and choose (and explain) who does or does not get the questionnaire.