Leigh F. Callahan

Self-Report Questionnaire Scores in Rheumatoid Arthritis Compared with Traditional Physical, Radiographic, and Laboratory Measures

STUDY OBJECTIVEnTo assess whether scores on a simple self-report questionnaire to depict the clinical status of patients with rheumatoid arthritis are correlated with traditional measures of physical, radiographic, laboratory, functional, and global status.nnnDESIGNnThe self-report questionnaire was administered at the same time the following variables were assessed: American Rheumatism Association functional class, joint count, hand radiograph, erythrocyte sedimentation rate, rheumatoid factor titer, walking time, grip strength, button test, and global self-assessment.nnnSETTINGnUniversity rheumatology clinic, the rheumatology clinic of a Veterans Administration hospital, and a private rheumatology practice.nnnPATIENTSnThe study included 259 patients who met the criteria of the American Rheumatism Association for a diagnosis of definite or classic rheumatoid arthritis.nnnINTERVENTIONSnStandard rheumatologic care for patients with rheumatoid arthritis.nnnMEASUREMENTS AND MAIN RESULTSnSelf-report questionnaire scores were significantly correlated with the joint count, radiographic score, erythrocyte sedimentation rate, grip strength, button test, walking time, American Rheumatism Association functional class, and global self-assessment. Patients were categorized into five questionnaire score categories of 1.00, indicating no dysfunction, and 1.01 to 1.50, 1.51 to 2.00, 2.01 to 3.00, and 3.01 to 4.00, indicating progressive dysfunction. In these five categories, more than ten involved joints were seen in 11%, 37%, 67%, 79%, and 100% of patients, respectively, and erythrocyte sedimentation rates greater than 20 mm/h in 29%, 49%, 64%, 74%, and 85% of patients, respectively. Similar results were seen for other physical and radiographic measures. The questionnaire score was as effective in explaining other measures of clinical status as was any other available measure.nnnCONCLUSIONSnA simple self-report questionnaire provides information similar to many traditional measures in rheumatoid arthritis and appears to be an attractive, cost-effective approach to assessing and monitoring quantitatively the status of an individual patient.

Most chronic diseases are reported more frequently by individuals with fewer than 12 years of formal education in the age 18-64 United States population.

Data from the 1978 Social Security Survey of Disability and Work indicate that most chronic diseases in the age 18-64 population are reported significantly more frequently by individuals with fewer than 12 years of formal education. Of the 23 health conditions reported by more than 1% of the population, 19 differed significantly in reported frequencies according to formal educational level. The relative frequencies of any reported condition in individuals with 1-8, 9-11, 12 years, and more than 12 years of formal education, were 3.6, 2.3, 1.4 and 1.0 respectively. Significant trends according to formal educational level were seen for all types of chronic diseases, including cardiovascular, gastrointestinal, musculoskeletal, neoplastic, psychiatric, pulmonary and renal diseases. These trends remained significant for all categories except neoplastic disease when formal education was controlled for age, sex, race and smoking, suggesting that formal educational level may identify a marker in the pathobiology of disease of importance comparable to these other demographic variables.

Formal education as a marker for increased mortality and morbidity in rheumatoid arthritis

Increased mortality and morbidity was seen in association with lower formal educational levels in 75 rheumatoid arthritis (RA) patients over 9 years. Nine of the 20 patients with 8 or fewer years of education had died, compared to 10 of 34 with 9-12 years of education, and only one of 21 with more than 12 years of education. Among survivors with functional capacity data available from baseline and 9 year review, declines greater than 20% were seen in 8 of 10, 13 of 21, and 9 of 19 patients in the three education categories. Overall, 79% of grade-school educated, 43% of high-school educated, and 20% of college-educated patients had either died or declined more than 50% in functional capacity. Patients of different formal educational levels were similar at baseline in age, duration of disease, measures of functional capacity, number of involved hand joints, number of severe radiographic changes, use of gold, oral corticosteroids or other therapies, and associations between formal educational level and disease course are not explained by these variables. Formal educational level appears a simple quantitative marker which identifies a surrogate or composite variable associated with increased mortality and morbidity in RA.

HEALTH STATUS REPORTS IN THE CARE OF PATIENTS WITH RHEUMATOID ARTHRITIS

We examined the use of formal health status reports every 3 months over 1 year in the clinical care of patients with rheumatoid arthritis (RA). The reports consisted of single-page, computer-generated summaries of scores derived from either the AIMS (Arthritis Impact Measurement Scales) or the MHAQ (Modified Health Assessment Questionnaire) health status questionnaires. A total of 1920 subjects from 27 community practice sites were randomly assigned to three study groups in each practice: intervention, attention placebo and control. Results showed that 55% of the physicians found the reports to be at least moderately useful as an aid to patient management, primarily for improving the doctor-patient relationship. However, no detectable differences among the three groups were seen in terms of medication compliance, number of physician visits, number of referrals, frequency of major medication changes, attitudes towards the physician, patient satisfaction or change in health status over 1 year. The failure to demonstrate objective benefits of health status reports in this study may be due to physician unfamiliarity with health status scores, failure to link the report with an office visit, the relative stability of clinical status in the subjects over 1 year and the relatively short time-frame of the study.

Depression scales in rheumatoid arthritis: criterion contamination in interpretation of patient responses

Self-report depression scales include items concerning somatic symptoms, such as fatigue, pain, and inability to work, which may be symptoms of depression in individuals who do not have a chronic disease. However, in patients with somatic diseases such as rheumatoid arthritis, these symptoms may reflect disease rather than depression. Interpretation of responses to these items in patients with chronic disease as indicating depression is known as criterion contamination. Criterion contamination has been described in responses of patients with rheumatoid arthritis on many widely-used depression scales, including the Minnesota Multiphasic Personality Inventory (MMPI), the Beck Depression Inventory, and the Center for Epidemiologic Studies Depression Index (CES-D). Evidence for criterion contamination in responses of patients with rheumatoid arthritis on these depression scales is summarized in this essay.