67patients?” [ 57 ]. Much of this chapter is concerned with documenting the value of a
feasible “80 % measure” that will contribute to patient welfare, in contrast to a pos-
sibly preferable “100 % measure” that may be more informative in clinical research,
but generally not feasible in routine clinical care and therefore not used at all.
Development of MDHAQ as a Clinical Tool for Continuous
Quality Improvement in Usual Care, Rather
Than as a Research Tool
A major milestone for rheumatology was seen in 1980 with publication of the health
assessment questionnaire (HAQ) [ 50 ] and arthritis impact measurement scales
(AIMS) [ 58 ]. These reports introduced the concept that rheumatic diseases could be
viewed quantitatively from a patient’s perspective, consistent with a “biopsychoso-
cial model” that is complementary to a biomedical model [ 1 ]. Patient self-report
questionnaires can be used to record patient history information as quantitative,
standard scores, which meet criteria for “scientifi c” data, analogous to laboratory
tests, to supplement and substitute for narrative descriptions.
Over the ensuing 36 years, patient self-report questionnaires have advanced
knowledge concerning the prognosis, course, and outcomes of rheumatic diseases,
much of which was unavailable previously prior to availability of patient self-report
data.
Soon after publication in 1980, the HAQ and AIMS were introduced to usual
clinical care in one clinical setting at Vanderbilt University [ 59 , 60 ]. Although
the psychometric properties of the AIMS were well established, it became appar-
ent that the HAQ was more patient-friendly. Furthermore, it was far more feasi-
ble to ask each patient with any diagnosis to complete the same simple
questionnaire than to attempt to select different patients to compete different (or
no) questionnaires [ 60 ].
Experience over the years emphasizing feasibility and clinical relevance led to
many changes to facilitate the value of completion of questionnaire each at visit to
both patients and doctors in clinical care and outcomes research. These changes
over more than 25 years to develop an MDHAQ are viewed primarily as a continu-
ous quality improvement (CQI) activity with the primary aim of improving patient
care, rather than as a research activity [ 59 , 60 ], although quantitative data from the
MDHAQ have provided valuable clinical research results [ 39 , 61 – 66 ]. As noted, the
emphasis was on feasibility, clinical value, saving time for the physician, and rele-
vance to predict an outcome, as seen with a laboratory test, although it was also
regarded as necessary and important to meet psychometric criteria for validity and
reliability required in all questionnaires.
The CQI approach differs from traditional clinical research and clinical trials in
seeking to account for all patients rather than a few selected patients, as in most
clinical trials, and to implement fi ndings in actual care. CQI involves a series of
3 PROMs (MDHAQ/RAPID3) and Physician RheuMetric Measures