Complexities in Assessment of Rheumatoid Arthritis: Absence of a Single Gold Standard Measure

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Absence of a gold standard in rheumatic diseases

Quantitative assessment and monitoring of typical chronic diseases, such as hypertension, diabetes, and osteoporosis, is characterized by a gold standard measure, such as blood pressure, hemoglobin A1c, and bone density, to provide the primary information for diagnosis, assessment, prognosis, and monitoring for clinical decisions. Tight control according to this gold standard measure has been documented to result in better patient outcomes, including improved survival, largely, in many

Sensitivity and specificity of laboratory tests in inflammatory rheumatic diseases

Laboratory tests are abnormal in most patients who have RA or SLE, and are helpful in many patients. More than one third of patients with RA have at presentation, however, a normal erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, and anti–cyclic citrullinated peptide antibodies (Table 1).4, 5, 6, 7 More than one third of patients with SLE have normal levels of anti-DNA antibodies, and ANA subset tests anti-Smith (anti-Sm) and antiribonucleoprotein (anti-RNP) (Table 2,

Diagnosis, classification, and management of rheumatic diseases

In the absence of a single gold standard measure, the clinical approach to patients with inflammatory rheumatic diseases is guided by patterns of the four types of information used in standard clinical assessment: (1) patient history, (2) physical examination, (3) laboratory tests, and (4) imaging studies. These four types of measures are incorporated into formal classification criteria established to standardize patient enrollment in clinical trials and other clinical research studies for RA,12

Patient history in management decisions in rheumatic diseases

In most diseases a patient history and symptoms are regarded as “subjective,” “unscientific” information, the primary purpose of which generally is to identify an “objective” gold standard “scientific” measure, which provides the primary information to diagnose, assess, monitor, and guide clinical decisions. By contrast, in rheumatic diseases, information from a patient history is considerably more prominent in management decisions compared with typical chronic diseases.

A patient history can be

Diagnosis based on a physician's judgment

A final important difference between rheumatic diseases and typical chronic diseases is that rheumatic disease diagnoses are based on the judgment of an individual physician, rather than a pathognomonic marker from a physical examination, laboratory test, biopsy, imaging study, or other measure, as is the case in most typical chronic diseases. For example, in compiling information concerning the prevalence of various autoantibodies in patients with RA, SLE, and other rheumatic diseases (see

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    A version of this article originally appeared in the 21:4 issue of Best Practice & Research Clinical Rheumatology.

    Supported in part by grants from the Arthritis Foundation, the Jack C. Massey Foundation, Bristol-Myers Squibb, and Amgen.

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    Copyright © 2009 Elsevier Inc. All rights reserved.