Patient_Reported_Outcome_Measures_in_Rheumatic_Diseases

83

activity and a need for intensifi cation of therapy. Specifi c estimates for DOCSTR

might help to recognize this interpretation as not appropriate.

4. Many patients often have infl ammatory diseases may also have signifi cant dam-
   age, as well as distress, which often affects clinical management. A study of why
   a recommended treat-to-target strategy to intensify therapy in RA patients who
   have index scores indicating high disease activity [ 167 ] was not implemented by
   Australian rheumatologists indicated that 2 of the primary reasons were joint
   damage and fi bromyalgia, which caused elevated DAS28 scores that suggested
   moderate or high disease activity [ 42 ]. It appears that damage may be as much of
   a consideration in management of RA at this time as infl ammation (unpublished
   data).


5. It may be suggested that the expertise of a rheumatologist in both diagnosis and
   management involves not only quantitation of the level of pain, fatigue, or other
   problems in each patient, but also the extent to which the etiology of these prob-
   lems may result from infl ammation or reversible problems, damage or irrevers-
   ible problems, or distress. Availability of separate scales for infl ammation and
   distress provides an opportunity to clarify this matter.
   Analyses of new patients with many diagnoses by two rheumatologist (Table 3.11 )
   indicated that mean overall DOCGL scores were highest for patients with fi bromy-
   algia, followed by RA, spondyloarthropathies, osteoarthritis, gout, and systemic
   lupus erythematosus. Among the three subscales, mean DOCINF scores were high-
   est in RA, spondyloarthropathies, gout, and systemic lupus erythematosus, mean
   DOCDAM highest in osteoarthritis, and mean DOCSTR in fi bromyalgia [ 76 ]
   (Table 3.11 ). In patients with RA, mean DOCDAM and DOCSTR scores indicated
   coexistence of clinically important damage and/or fi bromyalgia in some patients
   [ 76 ]. These data indicate face validity of the three physician global estimates on
   subscales for infl ammation, damage, and symptoms due to neither infl ammation nor
   damage. Further analyses are ongoing—development of RheuMetric at this time

may be regarded as analogous to development of MDHAQ 15–25 years ago.

Table 3.10 Scores for three indices in two patients with fi bromyalgia, with no swollen joint and
normal ESR, illustrating high scores of DAS28 (disease activity score 28), CDAI (clinical disease
activity index), and RAPID3 (Routine Assessment of Patient Index Data) indices not due to
infl ammatory activity

TJC28 SJC28 DOC GL ESR FN PN PATGL Index score

Patient #1 28 0 0 20 1 10 10

DAS28 28 0 NI 20 NI NI 10 6.45H

CDAI 28 0 0 NI NI NI 10 38H

RAPID3 NI NI NI NI 1 10 10 21H

Patient #2 14 0 3 10 1 10 10

DAS28 14 0 NI 10 NI NI 10 5.11H

CDAI 14 0 3 NI NI NI 10 27H

RAPID3 NI NI NI NI 1 10 10 21H

3 PROMs (MDHAQ/RAPID3) and Physician RheuMetric Measures