Maybe what my Rheumatoid patient reports is more useful than my tests?
By Dr Irwin Lim, Rheumatology
I listened to Theodore Pincus speak on the weekend. I found the professor of rheumatology very entertaining and his ideas made an impression.
The clinical approach to rheumatoid arthritis is very different from the approach to typical chronic diseases such as hypertension or diabetes.
With hypertension, there is a simple gold standard of blood pressure. With diabetes, it’s measuring the HbA1C. Patient history and physical examination don’t play a big role, and what the doctor decides to do is typically based on the gold standard measure.
With rheumatoid, there is no laboratory test or any other measure that can serve as a gold standard. Blood tests can be normal in the face of significant disease. Clinical examination can be variable and deciding which joint is swollen or tender is not a consistently easy thing to do. Our job is difficult!
Because of this, composite disease indexes have been developed to help us rheumatologists make our clinical decisions. The most widely used, and the one I use, is the DAS 28. This Disease Activity Score takes into account measures from a physical examination, laboratory tests and a patient self-report of how much the arthritis affects them.
Composite measurements like the DAS28 are not perfect ( as discussed here by Dr Philip Gardiner) and the DAS28 is used by only a minority of rheumatologists in Australia (probably the same worldwide). Often, the failings of the measure are given as reasons why it’s not used by those who choose to rely on “clinical” judgement. But, I think a perception that it takes a lot of time and a lack of exposure to using it in rheumatology training play a big part.
Professor Pincus developed the RAPID3 (Routine Assessment of Patient Index Data 3).
This measure includes only 3 patient self-report measures. It should take the patient less than a minute to complete and can be scored by the rheumatologist in less than 10 seconds!
This makes me very excited. I profess that I’ve previously heard about the RAPID3 but never really bothered investigating it further.
In rheumatoid, what the patient says is important and should feature prominently in management decisions, especially as we don’t have great “objective”, “scientific”, gold-standard measures.
The RAPID3 seems very simple, almost too simple but it’s been shown to correlate significantly with the DAS28. And that’s without formal joint counts or blood tests.
Professor Pincus made the point that patient questionnaires (like RAPID3) and scores of function actually predict mortality better than joint scores, laboratory tests and Xray changes! They also better predict long-term outcomes such as work disability, joint replacement surgery, functional status.
Now, I’m not likely to stop examining my patients and I’m sure I will still be ordering blood tests and imaging tests. And of course, patient questionnaires like RAPID3 have their own limitations.
But, it would seem to make sense for my patients to self complete this rather simple RAPID3 form before they come into my room.
It provides another piece of information to document how a patient is going, in a quantitative way, to compare from one visit to another. A measurement. A sort of rheumatology-blood-pressure substitute.
Have you had any experience with the RAPID3? If you have rheumatoid, do you think it’s worth filling?Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here. Arthritis requires an integrated approach. We call this, Connected Care. Contact us.