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Measuring Signs and Symptoms in Rheumatoid Arthritis

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Measuring Signs and Symptoms in Rheumatoid Arthritis Powered By Docstoc
					  Measuring Signs and
Symptoms in Rheumatoid
       Arthritis
    David R. Karp, MD, PhD
  Chief, Rheumatic Diseases
UT Southwestern Medical Center
                                       Data Warehouse


        Clinical                            Clinical
         Care                              Research




Electronic                                  Administrative
Health Record                               Databases

                         Billing
                   Quality Assurance
          Rheumatoid Arthritis

   “Common” autoimmune disease -
    Prevalence ~1% of population
   Joint inflammation, swelling, pain,
    dysfunction, and disability
   Cartilage and bone destruction
   Significant co-morbidities
             Diagnosis of RA

   Characteristic clinical features
   Presence of characteristic autoantibodies
    (but only in ~80% of patients)
   Presence of characteristic radiographic
    findings (x-ray, MRI, or ultrasound)
                Treatment of RA

   Synthetic Disease Modifying Anti-
    Rheumatic Drugs
       Methotrexate, leflunomide, sulfasalazine
   Biological agents (anti-cytokine)
       Anti-TNF, anti-B cell, anti-IL-6
   Combinations
   Placebo (in research)
      Immunopathology of RA



  Unaffected       Pre-Clinical         Clinical

Normal (?)       Auto-Antibodies    Inflammation
Immune           Altered Cellular   Tissue Damage
System           Immunity           Disability


               Genetics - Environment
     Why we Measure RA
Determines How (Unfortunately)
   In the office
       Document to support a diagnosis and response to
        therapy
       (Usually) the minimum necessary to support a given
        level of billing - more detail = more $
   In research
       Standardized exams, lab tests, symptoms
       But, too many standards
   Efforts to use research standards in practice
             Billable Interactions

   History (symptoms)
       Location, severity, timing, duration, quality,
        context, modifying factors, and associated
        “signs and symptoms”
       E.g., Complains of severe (9/10), aching pain
        in both hands and feet, worse in the morning,
        relieved with warm water, present daily for
        two weeks
                 Billable Interactions
   Physical Examination (signs)
       Vital Signs
            BP, pulse, respiration, temperature, height
            General appearance
       Inspection and palpation of the skin
       Examination of the bones, joints, muscles, and
        tendons for
            Alignment, tenderness, masses, effusions, etc.
            Range of motion
            Stability
            Strength
                Billable Interactions

   Data (findings)
       Laboratory tests
            Rheumatoid factor, anti-citrullinated peptide
             antibodies
       Radiographs
          Joint space narrowing (loss of cartilage)
          Bony erosions

       Decision-making
        Measuring RA in Research
   Pre-Clinical
       Auto-Antibodies (Rheumatoid Factor, anti-CCP,
        others)
       Genetics (HLA-DR4, others)
       Biomarkers, MRI
   Clinical
       Acute Phase Reactants (CRP, ESR)
       Tender/Swollen Joints
       Patient-Derived Measures (HAQ/Pain/Global)
       MD Impression
       Combined data
       Safety and co-morbidity
        Measures of RA Activity or
         Response to Therapy
   ACR 20/50/70
       FDA mandated binary measure to differentiate
        placebo from active treatment
       Misses partial response
       May not be clinically meaningful
   DAS 28
       Empiric, continuous measure
       Can identify clinical remission
   Health Assessment Questionnaire
                ACR 20/50/70
   20 - 50 - 70% improvement in tender and
    swollen joint counts, and:
   Indicated percent improvement in 3 of 5:
       ESR or CRP
       Pain scale
       Patient global
       Physician global
       Health Assessment Questionnaire
                          DAS 28

   Tender Joints - 0-28
   Swollen Joints - 0-28
   ESR or CRP
   Global Health VAS (0-100)

DAS  0.56  TJC  0.28  SJC  0.36  ln(CRP 1)  0.014  GH  0.96
Taking Research Metrics to the
       Clinic and Back
   Good evidence that tight control directed by
    standardized measures achieves a better
    functional outcome
   While DAS 28 works, other scales have been
    developed for “real time” assessment
   How much time does it take the patient,
    receptionist/RN, and physician?
   Consent/HIPAA
   Lack of EMR support
   Not (yet) required for billing or credentialling
     How do you Monitor Response/Safety in Practice?
      FREQUENTLY DONE                     SELDOM DONE
   96% Vital Signs                  27% 28 Joint count TJC,SJC
   81% CBC, ESR                     20% 66 Joint count
   88% AM Stiffness                 23% Yearly Feet X-rays
   83% MD Overall assessment        21% Yearly Chest Xray
   75% Joint Exam (Pt focused)      21% Hepatitis panel
       OFTEN DONE                    15% HAQ (some version)
68% CRP                              16% Rheumatoid factor
59% PPD                              12% CCP antibody
54% LFTs                             23% Urinalysis
51% Yearly Hand X-rays               5% MRI
39,51% Pt Global, Pt Pain            1% Ultrasound
39% Symptom survey                   6% DAS (some version)
33% MD Global Assessment             2.8% ACR20 (some version)
                  Conclusions
   Rheumatology encounters are a combination of
    patient-, physician-, and test-derived information
   Data collected in real life for diagnosis and
    therapy, billing, and research may be different
   Likely drivers for standardized data collection
    will be EMR development, billing, and pay for
    performance issues (“quality measures”).

				
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posted:7/25/2012
language:English
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