The March Rheuminations column, “Twenty Questions, Part 1” inspired many letters from TR readers. Here are just a few of those responses.
DAS in Clinical Practice—Not Ready For Prime Time
Joint counts, DAS [Disease Activity Score], and other numeric measures of RA disease activity are important tools for research, but as currently developed, are not appropriate for clinical practice. There are several reasons, so I’ll start with the most important one first. We live in a complex world where many seemingly good ideas can have unintended consequences. Unfortunately, out in community medicine, managed care companies are using joint counts, sed rates, and CRPs [c-reactive proteins] to restrict the use of biologics. For example, one of my RA patients on [methotrexate] with two very swollen wrists and erosive disease was recently denied an anti-TNF because the joint count was too low.
Dr. Theodore Pincus has data showing that 40% of patients on anti-TNFs at Vanderbilt have normal CRPs, yet another one of my patients had an anti-TNF denied because his CRP was <2.0. If we established the physician global score—the modified HAQ [Health Assessment Questionnaire] plus the [Visual Analog Scale] as the “gold standard”—we could circumvent these managed care manipulations.
There are also concerns about what we are really measuring. The burden of inflammation in a patient with two hot knees clearly exceeds that of a patient with several swollen [proximal interphalangeals], yet the joint count, and hence the DAS, is lower. DAS and joint counts amplify the significance of small joint disease and can be very misleading in terms of clinical reality. We know that sed rates are “falsely” elevated in patients with high RFs, monoclonal gammopathies, those with liver disease, and the elderly. CRPs are high in the overweight patient and in patients with infections. In populations of patients (i.e., a study), these issues cancel out, and markers of inflammation correlate well with disease activity, but in individuals, they do not. In clinical practice it is all about the individual patient.
I also have practice management concerns. Joint counts add to our already burdensome documentation requirements. A statement like “the [metacarpophalangeals] are slightly swollen and tender, but the left knee still has a large, warm effusion” is perfectly adequate and makes for better reading than a table of 0s and 1s. Let’s make the joint-count table and DAS calculation a separately reimbursable procedure and you’ll see a lot more enthusiasm for their use.
Finally, I’m put off by the implication that rheumatologists only perform joint exams if forced to do so by the exercise of deriving a DAS. Most of us look at and palpate almost every joint at every office visit; we just don’t record a tally.
Rheumatologists need to know what a DAS is and how to obtain one. We need to order CRPs and X-rays and MRIs when clinically appropriate. We need to assess our patients’ function and pain. We need to understand that a patient can feel well and look well, but still have synovitis and develop progressive erosions and loss of function over time. But forcing us to “objectify” an exceptionally complex scenario is not in the best interest of the patient or the clinician.
Barry Waters, MD, Coral Springs, Fla.
DAS, HAQ, and EMR
I greatly enjoyed your article on the use of the DAS and HAQ in RA. I am a rheumatologist in eastern North Carolina. For the past five years I have used the DAS-28 in my patients with RA. Although two companies have also given me the DAS calculator you referred to in your article, I have found the DAS Web site in the Netherlands, www.DAS-score.nl, very simple. My nurses input the data from my DAS data sheet and that number in my EMR [electronic medical record].
Monitoring serial DASs has benefited my patients a great deal. I have also had to use the scores a handful of times to petition insurance companies to pay for a BRM [biological response modifier] in certain patients.
My use of and experience with DAS, and now the HAQ, mirrors yours. In late 2005 I started using the Mini-HAQ in my practice. Currently I am trying to set up a touch-screen tablet PC for my patients to directly input their HAQ responses into my EMR. The learning curve has been far steeper for me with the HAQ than the DAS. I am hopeful that using the HAQ in RA and other [connective tissue diseases] will allow me greater flexibility in treating my patients.
Certainly the use of the DAS has allowed me to be more aggressive in the use of BRMs and aggressive combination therapies. In talking to patients about their disease, now “I have a number to throw at them.” At first patients were upset about “another piece of paper for me to fill out,” but now it is commonplace for them to start the forms and it takes me virtually no time to complete the data sheets.
Dave Fraser, MD, New Bern-Jacksonville, N.C.
DAS Forms
I am an office manager for Dr. Jeffrey Mathews. I read your article and am excited to re-implement using DAS in our office….I Googled DAS and didn’t have much luck, and I tried to find it online through ACR, and no luck. What I am looking for is forms that are easy to use at each visit….If you could direct me I would appreciate it very much.
Linda Webb, Provo, Utah
TR Responds: You can download DAS calculators in a variety of formats at www.das-score.nl/www.dasscore.nl/index.html. Good luck implementing the DAS!
And thank you to all of our readers who wrote in about “Twenty Questions.” We love to hear what you think about TR’s articles. Send us a letter via e-mail to [email protected] or [email protected].