OBJECTIVE: To survey physicians' opinions concerning the relative importance of 5 clinical encounter components - vital signs, patient history, physical examination, laboratory tests, and ancillary studies - in diagnosis and management of 8 chronic diseases. METHODS: A SurveyMonkey® internet survey was emailed to 7,265 U.S. physicians, including 3,542 rheumatologists and 3,723 non-rheumatologists, with a query:"Please indicate the relative importance of 5 sources of information - vital signs, patient history, physical examination, laboratory tests, and ancillary studies - in diagnosis of congestive heart failure (CHF), diabetes, hypercholesterolemia, hypertension, lymphoma, pulmonary fibrosis, rheumatoid arthritis (RA), and ulcerative colitis." Response options were 0-20%, 21-40%, 41-60%, 61-80%, and 81-100%. A second query with identical structure addressed management of the 8 diseases. The proportions of physicians who estimated each component as most (or tied for most) important in diagnosis or management were computed. RESULTS: The survey was completed by 313 physicians: 154 rheumatologists and 159 non-rheumatologists. More than 90% estimated vital signs as most important for hypertension, and laboratory tests for diabetes and hypercholesterolemia. More than 70% estimated ancillary studies as most important for lymphoma, pulmonary fibrosis and ulcerative colitis. Patient history and physical examination were estimated as most important for RA and CHF by >50% of non-rheumatologists. CONCLUSIONS: RA and CHF were the only 2 of 8 diseases studied for which >50% of non-rheumatologists estimated a patient history and physical examination as most important for diagnosis and management. Confirmation and extension of these observations in actual care may have implications for reimbursement and organization of clinical care. © 2012 by the American College of Rheumatology.

BACKGROUND An index is needed to assess the status of patients with rheumatoid arthritis (RA), as none of the existing measures are applicable to all individual patients. The 28-joint Disease Activity Score (DAS28) is the most specific and widely used index. Routine Assessment of Patient Index Data (RAPID3) is an index containing only the 3 patient self-report core dataset measures, without a laboratory test or formal joint count, and with simple scoring. RAPID3 is correlated significantly with DAS28, but calculated in 5-10 seconds on a Multidimensional Health Assessment Questionnaire (MDHAQ), compared to 114 seconds for DAS28. METHODS DAS28 (0-10 scale) categories for high, moderate, and low activity, and remission (≤ 2.6, 2.6-3.2, 3.21-5.1, and > 5.1, respectively) and proposed RAPID3 (0-30 scale) categories for severity (0 ≤ 3, 3.1-6, 6.1-12, and > 12) were compared in patients taking abatacept and control-treated patients at the endpoint of the Abatacept in Inadequate Response to Methotrexate (AIM) and the Abatacept Trial in Treatment of Anti-TNF INadequate Responders (ATTAIN) clinical trials, using cross-tabulations and kappa statistics. RESULTS Overall, 92%-99% of patients classified as having high DAS28 activity had high or moderate RAPID3 severity, while 64%-83% in DAS28 remission had RAPID3 low severity or remission; 50%-82% of patients with good or poor EULAR responses had good or poor RAPID3 responses. Kappa values ranged from 0.25 to 0.48, and weighted kappas from 0.32 to 0.52, indicating fair to moderate agreement for the 2 indices. CONCLUSION Proposed RAPID3 severity and response categories yield comparable results to DAS28 and EULAR criteria in AIM and ATTAIN. DAS28 is more specific for clinical trials. RAPID3 does not preclude also scoring DAS28, and may be informative in the infrastructure of routine care.

Research has demonstrated that health care practitioners' adherence to guidelines for managing low back pain (LBP) remain suboptimal in recommending work absence, but specific beliefs about their role in maintaining patients at work have not been adequately researched. We examined private musculoskeletal practitioners'(chiropractors, osteopaths, and physiotherapists) beliefs and reported clinical behaviours in reference to patients' work. A cross-sectional postal questionnaire of 900 musculoskeletal practitioners included the Attitudes to Back pain in musculoskeletal practitioners questionnaires, reported frequency of four work-related behaviours, and a new measure of practitioners' work-related beliefs. Data from 337 respondents (37%) were analysed. Eighty percent of respondents reported recommending work absence to patients with LBP sometimes, and 14% recommended a work absence often or always. Seventy percent of practitioners never visit the patient's workplace. Most practitioners report that they prescribe exercises that can be carried out at work. Physiotherapists visited the workplace more frequently and gave less sick leave certification than either of the other groups. They also regarded work as more beneficial and less of a threat to exacerbate patients' LBP. There were small but significant correlations between work-related beliefs and reported behaviours. Our study confirms that, in contrast to current guidelines, many practitioners believe that LBP necessitates work absence. Overall, practitioners perceived their role in returning patients to work as limited, and believed that direct contact with employers was beyond their remit. In the UK, physiotherapists appear to be better placed to liaise with work in terms of both their beliefs and activities.

Quantitative measurement according to a laboratory test such as hemoglobin A1c or creatinine provides a "gold standard" for care of every individual with a specific diagnosis. By contrast, no single "gold standard" quantitative measure is available in rheumatic diseases. Laboratory tests are limited, and clinical decisions are based more on patient history and physical examination than laboratory tests. A quantitative patient history is provided by a self-report questionnaire as standardized,"scientific" data to compare from one visit to the next. Patient questionnaires for usual clinical care emphasize feasibility, acceptability to patients and physicians, and clinical utility, which are not considered in research questionnaires. Development of a multidimensional health assessment questionnaire (MDHAQ) over 27 years is seen as a continuous quality improvement (CQI) rather than research activity, to account for all rather than a few selected patients for a research study. Both the traditional HAQ and MDHAQ are 2-page questionnaires, easily completed by patients in 5 to 10 minutes, although scoring a HAQ disability index (HAQ-DI) requires 42 seconds, compared to 5 seconds for an MDHAQ/RAPID3. The MDHAQ includes, within 2 pages: complex activities, psychological queries, visual analog scales (VAS) as 21 numbered circles rather than 10-cm lines, a fatigue VAS, RADAI (rheumatoid arthritis disease activity index) self-report joint count, traditional "medical" review of systems and recent medical history, and demographic data, as well as a data management system that incorporates medication data and laboratory tests, reports for physicians and patients, and flow sheets to compare a current visit with a previous visit.

"Treat-to-target" of rheumatoid arthritis (RA) is similar in many respects to hypertension and diabetes. All three diseases involve a dysregulation of normal physiologic functions, which results in long-term organ damage if not treated."Treat-to-target" strategies, based on values of specific quantitative measures, lead to improved outcomes, including longer survival. However, RA differs from hypertension and diabetes in at least fve important respects: 1. the absence of a single "gold standard" measure in RA for all individual patients necessitates indices; 2. the rarity of acute emergency situations in RA leads to underestimation of its natural history, which includes increased mortality rates similar to hypertension and diabetes; 3. the patient with hypertension or diabetes goes to the doctor to learn how she or he is doing, based on a "gold standard" quantitative measure, while the patient with RA goes to the doctor to tell the doctor how she or he is doing; 4. the history and physical examination in hypertension or diabetes may be recorded as narrative, nonquantitative information, as a vital sign or laboratory test provides the crucial information for clinical care but should be recorded as quantitative, standardized "scientifc" data on patient questionnaires and formal joint counts because of their importance in RA; and 5. patient mood or distress may impact directly RA indices used as quantitative measures in a "treat-to-target" strategy, which is not seen in hypertension or diabetes. These matters may be addressed through three global scales completed by health professionals concerning infammation, damage, or neither infammation nor damage as a basis for symptoms.

Objective To analyse poor physical function, pain, limited exercise and smoking, assessed in a patient-friendly self-report questionnaire format that has been completed by every patient at every visit over 20-30 years in the authors' and other usual care settings, to predict 5-year mortality in a general older population. Methods An extended version of a Multidimensional Health Assessment Questionnaire was mailed to 2000 subjects in Finland, identified as a randomly selected control cohort for a rheumatoid arthritis cohort. The questionnaire included queries concerning baseline physical function, pain, exercise and smoking status, identical to the clinic version, as well as age and 25 medical conditions. Five-year survival was analysed according to descriptive statistics, Kaplan-Meier curves and Cox regressions. Results The questionnaire was returned by 1523 subjects (76%). Five-year survival was 94% in all subjects, 98% in subjects with no disease or no acutely life-threatening disease, and 17% in subjects with an acutely life-threatening disease. Hazard ratios (HRs) for 5-year mortality were 3.5 for poor physical function, 2.2 for pain, 5.2 for limited exercise and 4.6 for smoking (p<0.01); 5-year survivals were 93%, 97%, 93% and 95%, respectively, compared with 91% for hypertension. Each of the four patient history variables predicted mortality at higher levels in subjects who reported no versus one or more acutely life-threatening conditions. Conclusions Poor physical function, pain, limited exercise and smoking can be assessed systematically on a simple standard Multidimensional Health Assessment Questionnaire, to identify potentially modifiable risk factors for premature mortality in the infrastructure of usual medical care and health maintenance.

This article summarises the experience of one academic rheumatologist in treatment of patients with rheumatoid arthritis (RA) over 25 years from 1980-2004 with low-dose prednisone, most with <5 mg/day over long periods. A database was available which included medications and multidimensional health assessment questionnaire (MDHAQ) scores for physical function, pain, and routine assessment of patient index data (RAPID3), completed by all patients at all visits in the infrastructure of care. Most patients were treated with long-term low-dose prednisone, often from the initial visit and indefinitely, and with methotrexate after 1990. The mean initial prednisone dose declined from 10.3 mg/day in 1980-1984 to 3.6 mg/day in 2000-2004. Although no formal criteria were used to determine the initial dose, prednisone doses were higher in patients who had more severe MDHAQ/RAPID3 scores, as expected, reflecting confounding by indication. Similar improvements were seen in clinical status over 12 months in patients treated with <5 vs. ≥ 5 mg/day prednisone, and maintained for >8 years. Adverse effects were primarily bruising and skin-thinning, with low levels of hypertension, diabetes, and cataracts, although this information was based only on self-report rather than systematic assessment by a health professional. These data reflect limitations of observational data. However, a consecutive patient database may provide long-term information not available from clinical trials. The data document that prednisone at doses <5 mg/day over long periods appears acceptable and effective for many patients with RA at this time. Further clinical trials and long-term observational studies are needed to develop optimal treatment strategies for patients with RA with low-dose prednisone.

A randomised, double-blind, placebo-controlled, withdrawal clinical trial was conducted of prednisone <5 mg/ day versus placebo in 31 patients with rheumatoid arthritis (RA). These patients had been treated with long-term 1-4 mg/day of prednisone, 22 with 3 mg/day, in usual clinical care at a single academic clinical setting. Stable clinical status over 12 weeks prior to screening for the trial was documented quantitatively by patient questionnaire scores. The protocol involved three phases: a)'equivalence'- 1-4 study prednisone 1-mg tablets taken for 12 weeks, to ascertain their efficacy versus the patient's usual prednisone tablets prior to randomisation; b)'transfer'- substitution of a 1-mg prednisone or identical placebo tablet at a rate of a single 1-mg tablet every 4 weeks (over 0-12 weeks) to the same number as baseline prednisone; c)'comparison'- observation over 24 subsequent weeks taking the same number of either placebo or prednisone tablets as at baseline. The primary outcome was withdrawal due to patient-reported lack of efficacy versus continuation in the trial for 24 weeks. Thirty-one patients were randomised, 15 to prednisone and 16 to placebo, with 3 administrative discontinuations. In 'intent-to-treat' analyses, 3/15 prednisone and 11/16 placebo participants withdrew (p=0.03). Among participants eligible for the primary outcome of withdrawal for lack of efficacy, 3/13 prednisone versus 11/15 placebo participants withdrew (p=0.02). No meaningful adverse events were reported, as anticipated. These data document statistically significant differences between the efficacy of 1-4 mg prednisone vs. placebo in only 31 patients, which may suggest a robust treatment effect.

OBJECTIVES:: The objective of the study was to report the evidence for effectiveness of different self-management course characteristics and components for chronic musculoskeletal pain. METHODS:: We searched 9 relevant electronic databases for randomized, controlled trials (RCTs). Two reviewers selected studies against inclusion criteria and assessed their quality. We classified RCTs according to type of course delivery (group, individual, mixed or remote), tutor (healthcare professional, lay or mixed), setting (medical, community or occupational), duration (more or less than 8 weeks), and the number and type of components (psychological, lifestyle, pain education, mind body therapies, and physical activity). We extracted data on pain intensity, physical function, self-efficacy, global health, and depression and compared these outcomes for self-management and usual care or waiting list control. We used random effects standardized mean difference meta-analysis. We looked for patterns of clinically important and statistically significant beneficial effects for courses with different delivery characteristics and the presence or absence of components across outcomes over 3 follow-up intervals. RESULTS:: We included 46 RCTs (N=8539). Group-delivered courses that had healthcare professional input showed more beneficial effects. Longer courses did not necessarily give better outcomes. There was mixed evidence of effectiveness for components of courses, but data for courses with a psychological component showed slightly more consistent beneficial effects over each follow-up period. DISCUSSION:: Serious consideration should be given to the development of short (<8 weeks) group and healthcare professional-delivered interventions but more research is required to establish the most effective and cost-effective course components.