Twenty Questions, Part 1

DAS and HAQ are acronyms for the two of the most important outcome measures in rheumatology. DAS stands for disease activity score while HAQ stands for health assessment questionnaire. Both are products of genius and have the potential to transform rheumatology care.

I mastered the DAS first and, a few weeks ago, tried the HAQ. Alas, my first foray with this instrument went awry after only the second question, when, as they say, I took my eye off the ball.

Treat by Numbers

My interest in adding the HAQ to my clinical repertoire should not be surprising. As a scientist, I believe that quantitation is the bedrock of medical practice as well as research. Furthermore, in my own practice, after incorporating the DAS into regular care, I learned an enormous amount. I have become a cheerleader for this outcome measure much to the amazement of many of my colleagues who do not share my enthusiasm. Indeed, after I extolled the virtues of the DAS at a conference, one of them said, “You should stick a fork in it.”

I started using the DAS in my clinic about two years ago. I had good reasons. First, I am convinced that, for the treatment of RA to advance, rheumatologists must learn to treat by the numbers. While one can debate whether the DAS is better than the DAS28 (and CDAI and SDAI are better than either), the point is that achieving the goal of remission will only happen when the metrics are there. If a clinician believes the patient is doing well, he or she should be able to translate this feeling into a number. Improvement in quality demands the same primacy for metrics.

In thinking about rheumatology today, I worry sometimes that there is too much reliance on intuition. I know that rheumatologists are skilled physicians, proud of their clinical acumen, but we are not seers or diviners and numbers count as well. I was dismayed recently to read an article saying that most rheumatologists “don’t have time to do a DAS.” For the life of me, I cannot figure out what is happening in offices where a simple count of 28 joints represents an unacceptable burden of time. How are providers making decisions if they are not making measurements?

The second reason for my using the DAS has to do with my research. For the past few years, I have been working on approaches to achieve remission in RA, using the DAS to determine this outcome. Unless I understood what a DAS28 of 2.6 really meant, I felt unable to design and conduct a study intelligently.