To the Editor:
We thank Dr. Leeb for his comments, and agree entirely with most of his points, including that speakers at educational events should present their views independently rather than a “canned” message, discuss their own experience, and address the clinical needs of the majority of rheumatologists. Topics such as the Disease Activity Score (DAS), patient questionnaires, magnetic resonance imaging, or other measures, should be presented only by speakers who have experience with these measures.
We also agree that clinical decisions require physician judgment and should not be based on a rote implementation of a certain numerical value of the index. However, we do feel that quantitative monitoring of patients in usual clinical care enhances judgment and clinical decisions, documented in clinical trials and clinical experience.
We have attempted over the years to simplify quantitative measures for usual clinical care, including reduction of a 68-joint count to 28 joints1, and a 20-item Health Assessment Questionnaire (HAQ) to an 8-item modified HAQ (MHAQ)2 or a 10-item multidimensional HAQ (MDHAQ)3. By about 1995, we found that quantitative data from a patient questionnaire along with a careful clinical joint examination, without quantitation of the exact number of swollen and tender joints, were sufficient for informed clinical decisions and documentation of changes. We also have discussed some limitations of the DAS4.
Routine Assessment of Patient Index Data 3 (RAPID3) scores, based only on patient questionnaire data for the 3 RA Core Data Set measures— patient functional status, pain, and global estimate — are correlated with DAS28 and Clinical Disease Activity Index at highly significant levels, considerably greater than correlations of erythrocyte sedimentation rate with C-reactive protein5.We suggest that RAPID3 scores greater than 6 on a 0–30 scale or 2 on a 0–10 scale indicate a need to consider strongly a change in therapy, while levels below 6 on a 0–30 scale or 2 on a 0–10 scale indicate low activity, and below 3 on a 0–30 scale or 1 on a 0–10 scale indicate near-remission5. RAPID3 scores and other MDHAQ medical history information save time for patients and clinicians, document changes in status, enhance clinical decisions, and result in better outcomes6.
We also agree with Dr. Greenwald, who points out another aspect of “hotel-based medicine”—large expenditures for attractive technology that adds nothing to an educational program. Indeed, it could be suggested that if doctors in the same room were viewing each other by videocasting rather than in person, part of the pedagogical value is undoubtedly lost. The idea of a movie star might actually perk up the programmed talk.
If most rheumatologists receive 4–6 dinner invitations a month, the annual expenditures could be easily used to support a formal clinical trial of RAPID3 in enhancing patient outcomes and documentation, analogous to studies using American College of Rheumatology criteria and DAS28 to maintain “tight control” of patients with RA7, such as FIN-RACo8, TICORA9, BeSt10, and CIMESTRA11. Such a clinical trial might be considerably more valuable to the sponsors, not to mention patients and rheumatologists, than further “hotel-based medicine.”
We appreciate these comments and welcome continuing dialogue, particularly toward elimination of the canned talk.
