Outcomes measures are valuable tools for rheumatologists to assess the health status of patients with RA and they can improve clinical practice efficiency. However, deciding which measures to use – in addition to collecting and analyzing data – is a challenge. Fortunately, there are a number of strategies that can make the process worthwhile.
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Explore This IssueOctober 2007
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What Data to Gather?
What measures should be used in practice is “still an unsettled question,” says Timothy Harrington, MD, a rheumatologist at UW Health, the academic health system for the University of Wisconsin in Madison.
The Health Assessment Questionnaire (HAQ) is one candidate for evaluating RA in the clinic, says Dr. Harrington, who is also a professor of medicine at the University of Wisconsin School of Medicine and Public Health. This measure is simple and durable and can separate the physician’s assessment from the patient’s.
Other examples of outcomes measures that clinicians use include joint scores, X-rays, laboratory tests, and physician and patient global assessment status, says Eric Schned, MD, a rheumatologist at Park Nicollet Clinic in Minneapolis and a TR editorial board member. The Disease Activity Score (DAS), and its variants, are other measures that are increasingly used in addition to other activity scores, he adds.
Many comprehensive outcomes measures, such as DAS-28, were developed for clinical trials, says Dr. Harrington, and he notes that collecting the necessary data and calculating results of such measures in real time and then applying them to clinical decision making is complicated for physicians in an office setting.
When deciding which outcomes measures to employ in their practice, rheumatologists need to remember that more than one assessment is advisable, says Frederick Wolfe, MD, director of the National Data Bank for Rheumatic Diseases and clinical professor of medicine at the University of Kansas School of Medicine. Rheumatologists should also know the magnitude of change that is considered to be significant for each measure.
For example, an increase of 0.25 units in the HAQ Disability Index could be due to random variation or error, says Dr. Wolfe, who used outcomes measures in private practice for more than 25 years. If tools like the HAQ are used with other patient assessments, it is easier to interpret smaller changes.
Dr. Wolfe also advises using these outcomes measures over time because they can vary widely in an individual patient. They may also be influenced by various factors, such as other illnesses or pain not related to RA, he explains.
Collection and Analysis
No matter which outcomes measures are used, each practice must determine the best way to collect and analyze their data. Managing these logistics may be difficult. “Someone has to hand out forms to patients, collect them at the office visit, and enter data into the electronic or written record,” says Dr. Schned.
Martin Bergman, MD, a rheumatologist in private practice in Ridley Park, Penn., has office staff give patients a Routine Assessment of Patient Index Data (RAPID) questionnaire while they are in the waiting room. He then scores the questionnaire before meeting with the patient.
Computers facilitate data collection and analysis for some physicians. For example, David Fraser, MD, a rheumatologist at Coastal Arthritis and Rheumatism in Jacksonville, N.C., plans to have a computerized touch screen in the waiting room on which patients can complete a mini-HAQ. The computer will print out an assessment score, which Dr. Fraser or an administrator will record in the patient’s chart or manually input into the electronic medical record (EMR).
Dr. Fraser also finds computerized tools valuable in scoring and analyzing information. He uses an online calculator (www.das-score.nl) – developed by the Department of Rheumatology at the University Medicine Center of Nijmegen in the Netherlands – for scoring the DAS-28CRP.
For office use, he analyzes trends in DAS-28CRP and mini-HAQ data through his EMR. By using a spreadsheet program such as Excel, he can easily transfer EMR data to other software for statistical analysis when writing papers and abstracts or comparing one drug or patient subset with another.
One day, Dr. Fraser hopes to use a tablet PC to input and calculate DAS-28CRP data in the exam room. These data, in addition to mini-HAQ data captured by touch screen, would directly flow into the patient’s EMR.
While computers may help collect and analyze data, a paper-based system may be preferable, says Theodore Pincus, MD, professor of medicine in the rheumatology division at Vanderbilt University in Nashville, Tenn.
He keeps hard-copy records of patients’ multidimensional HAQ scores rather than entering data into an EMR. “If you have the patient’s chart, X-rays, lab reports, and outcomes measures all up on the computer, you have to scroll back and forth between four documents,” he explains. “Having a hard copy and spreading results out on a table is easier.”
Paper records can be as effective as electronic records if the practice uses standardized data forms and dictation templates, says Dr. Harrington, adding that switching to an EMR may not be realistic for many offices in the short term.
Whether the record is paper or computer based, Dr. Harrington advises that practices enter all their patient information into a registry built on diagnostic billing codes, organize clinical data in a standardized format, and monitor any quantitative measure that reflects active RA joint inflammation.
Effect on Patient Interaction and Treatment
Overall, outcomes measures appear to improve patient treatment, as well as the efficiency of clinical practice, according to experts.
Dr. Fraser says that assessing an individual’s DAS data helps him determine whether the patient is responding to a medication and if treatment should be altered.
“For [overall] trends, what I’ve seen using DAS is a general reduction in measurements when patients are taking biologics,” he says. Because data have indicated such an improvement, he adds biologics earlier to the treatment regimen.
Outcomes measures also make the patient visit more efficient, says Dr. Bergman. Specifically, the RAPID assessment enables him to quickly determine whether or not a patient is experiencing pain or having trouble with joint function.
Dr. Harrington notes that, by standardizing the data set and having the patient self-generate information that becomes part of clinical record, his practice saves about 40% of previous traditional patient visit time. “This is time that can be spent discussing important problems and treatment or doing other work,” he says. Additionally, having a standard data template saves about 40% of dictation time.
Despite some of the challenges inherent in collecting data, “the impacts on our practice and patient care are greater than we imagined,” concludes Dr. Harrington.
Heather Lindsey is a medical journalist based in New York City.