How to Collect an MDHAQ to Provide Rheumatology Vital Signs (Function, Pain, Global Status, and RAPID3 Scores) in the Infrastructure of Rheumatology Care, Including Some Misconceptions Regarding the MDHAQ

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Orient the staff regarding the importance of the MDHAQ in patient care

The use of patient questionnaires requires a change in office procedure, which can seem to add complexity and may engender resistance to change. However, the MDHAQ can streamline the flow of information from patient to physician with quantitative data, review of systems, and medical history, which saves time, supports management decisions, and improves documentation.

If office staff members see the rheumatologist reviewing a questionnaire in clinical care, they are likely to respond positively.

The MDHAQ should be distributed by the clinic receptionist as part of the office infrastructure to every patient with any diagnosis at every visit, as the most efficient distribution system

The best strategy to assure completion of an MDHAQ is for the receptionist to distribute a questionnaire at each visit of each patient on registration for a visit (Fig. 1). Many rheumatologists suggest that patient questionnaires should be used only for certain patients, such as those with RA, or at certain intervals, such as every 6 months. This approach generally fails in standard care, as any attempt to distribute questionnaires selectively adds considerably to staff time and complexity. An

The MDHAQ should be completed by the patient in the waiting area before the visit, rather than in the examination room or after the visit

Most patients spend at least 10 minutes in the waiting room before seeing a rheumatologist, and often longer. This is the time period in which it is most feasible and desirable for a patient to complete a questionnaire (Fig. 2). Completion before the encounter helps to focus patient concerns to prepare for the visit. Availability of the data to the physician at the time of the visit is helpful, analogous to availability of a radiograph to an orthopedist at the time a patient is seen,

Let the patient do as much of the work as possible; the health professional should do as little as possible

Health professionals have substantially more knowledge than the patient concerning disease pathogenesis, treatments, and outcomes, and may feel more qualified to complete a questionnaire than the patient herself or himself. Indeed, certain information that the patient may report, such as diagnosis and comorbidities, seems to be most accurately recorded by a health professional.15 However, the patient has superior knowledge to a health professional (or anyone else) concerning most items on the

The clinician should review the MDHAQ with the patient

Review of the MDHAQ by the physician with the patient (Fig. 3) is essential to the success of questionnaire completion in the infrastructure of usual care. Such a review improves the quality and efficiency of a patient visit. The 5 to 10 seconds involved provide information that often would require 2 to 5 minutes of query, particularly the recent medical history, and greater efficiency is inevitable.

It should be emphasized that lack of interest on the part of the physician leads to resistance

Flow sheets are desirable

Convenient entry onto a flow sheet (Fig. 4), along with laboratory tests and medications, organizes information to track scores serially on 1 page (see article 16). This information provides an overview at a glance of the patient's course, which is a cost-effective procedure. The senior author produces an electronically generated flow sheet from a Microsoft Access database on each patient at each visit, which includes MDHAQ scores, laboratory tests, and medications, to be available at the next

“I can tell whether my patient is doing well or not without an MDHAQ or RAPID3 score”

The treating clinician and patient have a sense of the patient's clinical status and change from a previous visit. It has been emphasized in many articles in this issue that patient history data are more prominent in clinical management of rheumatic diseases than in many other types of diseases. For example, when a patient sees a physician for management of hypertension, hyperlipidemia, osteoporosis, or many other conditions, the patient must learn from the doctor how well the condition is

“Patient questionnaires add extra time and interfere with patient flow”

Completion of an MDHAQ by each patient in usual clinical care adds almost no burden to patient flow, if the questionnaire is distributed when the patient registers for the visit, and is completed by the patient in the waiting room before being seen in the examination room. Scoring of a RAPID3 adds 5 to 10 seconds, which can be accomplished by a receptionist, office assistant, nurse, or physician. The review of systems and recent medical history on the MDHAQ saves time for the patient and

“Many patients object to completing a questionnaire”

Many people initially do not like to be asked to do anything that they have not done previously, such as asking a receptionist to present a questionnaire or asking a patient to complete the questionnaire in the waiting area. Furthermore, if the staff project an attitude that this is a “necessary evil” or “for research” or “to document for insurance,” and the physician does not review the questionnaire with the patient, everyone will lose interest. However, staff and patients are responsive to

“How can I monitor a patient who has RA quantitatively without a formal joint count?”

A formal joint count is the most specific measure to assess inflammation in patients with RA. However, the formal joint count has several limitations (see article 3). The greater specificity of a measure does not necessarily indicate greater sensitivity to change, compared with a less-specific measure. Relative efficiencies of all core data set measures to distinguish active from control treatments in clinical trials are similar.7, 19

“Patient questionnaire scores are influenced by irreversible damage, unlike joint counts, so they are not so sensitive to control of inflammation”

Patient questionnaire scores may reflect “irreversible” changes, analogous to radiographs, which might compromise their sensitivity to change with treatment.20 However, it seems that joint counts also may be influenced by irreversible changes, as the relative efficiencies of all core data set measures to distinguish active from control treatments in clinical trials are similar, as noted earlier.7, 19 Questionnaire scores, although affected by irreversible changes, vary as much as joint counts

“Patient questionnaire data do not give me so good information to guide clinical decisions and prognosis as traditional radiographic or laboratory measures”

The traditional biomedical model, the dominant paradigm of twentieth-century medicine,21, 22 values laboratory tests and radiographs as considerably more informative than patient questionnaires. However, patient-derived information is usually more prominent in clinical decisions than laboratory tests and radiographs in rheumatic diseases, compared with most other diseases. Patient questionnaires also are more significant to predict long-term work disability, costs, and premature mortality than

“RAPID3 scores may be increased in patients who have fibromyalgia and do not have an inflammatory disease”

It is recognized that RAPID3 scores may be increased in patients who have fibromyalgia (see article 20). These patients usually have scores for pain and global estimate of status greater than 6 (on a scale of 0–10), which alone would put them in the category of high severity, with RAPID3 score greater than 12 (see article 9). As noted earlier, it has never been suggested that RAPID3 scores alone should be used for diagnosis and management in the absence of further history, physical examination,

“The MDHAQ is useful only in RA and not in other rheumatic diseases”

Most patients who see a rheumatologist are likely to have problems concerning physical function, pain, global estimate of status, and fatigue (see article 15). Scores for these problems are regarded as “rheumatology vital signs,” of which all physicians should be aware (see article 10). All patients require a review of systems and recent medical history, which are available to the physician from the MDHAQ. The MDHAQ is useful in patients with all rheumatic diseases.12

“Does a patient questionnaire not eliminate the need to examine patients?”

A patient questionnaire is an adjunct to care, just like a radiograph or laboratory test. It has been suggested that a formal quantitative joint count may not be necessary, as a patient questionnaire provides quantitative data of similar value to monitor patients (see article 3). However, all visits of patients to a rheumatologist must include a careful further history and physical examination, including a careful joint examination, and laboratory tests and radiographs in many situations, for

“Does a patient questionnaire not replace conversation and interfere with doctor-patient communication?”

The patient questionnaire not only does not interfere with doctor-patient communication but it adds to it by directing the discussion to address patient concerns more directly. A careful history is always needed for diagnosis and management, and a patient questionnaire can provide factual information to save time for the doctor and patient.

Many patients with RA have such good clinical status that they do not require lengthy visits, but nonetheless require careful monitoring of therapy with

“MDHAQ and RAPID3 responses are used to trigger automatic therapeutic decisions”

The introduction of quantitative measures into clinical rheumatology may suggest essentially “automatic” responses, such as “anyone with a high RAPID3 score greater than 12, or a DAS28 greater than 5.1, or a CDAI score more than 22 must have a change in disease-modifying antirheumatic drug (DMARD) or biologic therapy.” A change in therapy should certainly be considered for patients with these values. However, RAPID3 or any measure should serve only as a guide to clinical judgment, although

“Patient questionnaires should be used only at certain intervals rather than at each visit”

Some rheumatologists suggest that they would like to administer the questionnaire only to people with RA, or only every 3 months. Such approaches generally fail, for several reasons. Asking the receptionist to recognize whether or not a patient should be given a questionnaire adds complexity, resulting in complaints from the staff, and a view of the questionnaire as a burden rather than a routine matter. Furthermore, the diagnosis is unknown in new patients (and sometimes in returning

“Electronic data capture is invariably more effective than pencil and paper”

Many suggest it is desirable for the patient to enter response data directly into an electronic database, to provide an accurate score. Direct entry into a computer eliminates the need for someone else to enter it into a database. However, programing and maintenance of computers for direct entry often add to costs, which may then be greater than costs of simple data entry. Furthermore, direct entry by patients seems too complex in most clinical settings, other than in specialized clinics with

“An MDHAQ cannot be completed by patients of low educational level”

About 20% of patients of low educational levels experience difficulty with completion of a questionnaire.27 Furthermore, patients of low educational levels generally have poorer status according to the MDHAQ and also have poorer status according to joint counts and ESR, reflecting poorer overall clinical status of patients with lower socioeconomic status.28 Illiterate patients may receive some help from a family member, but generally have a literacy partner to help them reach the clinic and

Summary

The MDHAQ is easily completed by patients, and a RAPID3 score gives results that are similar to the widely recognized indices DAS28 and CDAI, in less than 10% of the time. Simple strategies are available for distribution, collection, and management of the MDHAQ and RAPID3.14 It has been proposed that “80% of the data in 100% of the patients may be preferable to 100% of the data in 5% of the patients” (or fewer) who might be included in clinical research.30 An MDHAQ and RAPID3 score may provide

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  • Cited by (22)

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    A version of this article originally appeared in issue 21(4) of Best Practice & Research: Clinical Rheumatology.

    This research has been supported in part by grants from Bristol-Myers Squibb and Amgen.

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