An A Multi-Dimensional Health Assessment Questionnaire (MDHAQ) and Routine Assessment of Patient Index Data (RAPID) Scores Be Informative in Patients With All Rheumatic Diseases

Best Practice & Research Clinical Rheumatology
Vol. 21, No. 4, pp. 733753, 2007

doi:10.1016/j.berh.2007.02.006
available online at http://www.sciencedirect.com
11
Can a Multi-Dimensional Health Assessment
Questionnaire (MDHAQ) and Routine
Assessment of Patient Index Data (RAPID)
scores be informative in patients
with all rheumatic diseases?
Theodore Pincus *
MD
Director of Outcomes Research

NYUHospital for Joint Diseases, 301 East 17 Street, New York, NY 10003, USA
Tuulikki Sokka
PhD
Consultant Rheumatologist
Jyvaskyla Central Hospital, Jyvaskyla, Finland
Medcare Oy, Aanekoski, Finland
A multidimensional health assessment questionnaire (MDHAQ) is useful in standard care of

patients with all rheumatic diseases in a busy clinical setting. The MDHAQ was adapted from
the classical health assessment questionnaire (HAQ) for feasibility in standard clinical care,
with reduction of the number of activities from 20 to 10, visual analog scales (VAS) as 21 circles
rather than 10 cm lines, availability of all core data set patient self-report measures and scoring
templates on the front side, and a review of systems symptom checklist and review of recent
medical history on the reverse side of a single page. Scoring templates are also available for routine assessment of patient index data (RAPID) scores, based on a composite of the three patient
reported outcome (PRO) measures from the core data set included on the HAQ and MDHAQ,
physical function pain, and patient estimate of global status. Flow sheets illustrating use of the
MDHAQ in standard clinical care of patients with various rheumatic diseases, including psoriatic
arthritis, systemic lupus erythematosus, ankylosing spondylitis, gout, scleroderma, vasculitis, fibromyalgia, inflammatory bowel disease arthritis, Behcets syndrome, and familial Mediterranean
fever, are presented to illustrate use of this simple questionnaire to add to clinical decisions and
document patient courses and outcomes in standard clinical care of patients with all rheumatic
diseases.
* Tel.: 1 615 936 2152; Fax: 1 615 936 2159.

E-mail address: tedpincus@gmail.com (T. Pincus).
1521-6942/$ - see front matter 2007 Published by Elsevier Ltd.
734 T. Pincus and T. Sokka
Key words: Multidimensional Health Assessment Questionnaire (MDHAQ); Routine Assessment of Patient Index Data (RAPID); rheumatic diseases.
INTRODUCTION
The science of clinical measurement in rheumatic diseases has seen great progress
over the last three decades. Nonetheless, most standard rheumatology care outside
of clinical trials and other clinical research studies is conducted largely according to
Gestalt impressions of the treating rheumatologist, without quantitative measures
other than laboratory tests, which often are not informative and even give false-positive
and false-negative results.13 Therefore, any possible benefits of extensive advances in
measurement of clinical status by experts in clinical research are available to only
a very small fraction of patients with rheumatic diseases.
A primary reason why measurement is not a component of standard rheumatology
care involves the difficulty of collecting, scoring, and managing complex measures and
indices in a busy clinical setting, particularly prior to seeing the patient, so that the
quantitative data might be used to contribute to patient care. Most visits in a rheumatology setting involve less than 30 minutes, and attention to patient concerns appears
a higher priority than measurement. Nonetheless, it would appear desirable to include
some quantitative measurement in standard rheumatology care, as quantitative measures ranging from blood pressure to serum creatinine have greatly advanced
patient care in many domains.
One approach to introducing clinical measurement into standard rheumatology
care involves provision of incentives to a rheumatologist for collection of measures,
such as a monetary reimbursement or as a direct requirement to prescribe a certain
therapy for a particular patient. A second approach might involve simplification of
a measure so that it could be scored and reviewed in a few seconds, and would be
regarded as adding to, rather than interfering with, completion of a standard clinical
visit. Such a measure might be analogous to an acute-phase reactant, such as the erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), which are not nearly as
specific as antineutrophil cytoplasmic antibodies in vasculitis or anti-DNA antibodies in
Systemic Lupus Erythematosus (SLE), but are of considerable value in standard care.
Disease-specific questionnaires and indices provide more comprehensive and specific information than more general questionnaires concerning patients with these
conditions. Examples of disease-specific questionnaires include, the Western Ontario
McMaster Osteoarthritis Scale (WOMAC)4, Fibromyalgia Impact Questionnaire
(FIQ)5, Bath Ankylosing Spondylitis Functional Index (BASFI).6 Examples of diseasespecific indices include:
In rheumatoid arthritis (RA): the American College of Rheumatology (ACR) Core
Data Set79, and Disease Activity Score (DAS).10,11
In SLE: the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI)12, British
Isles Lupus Activity Score (BILAG)13, Systemic Lupus Activities Measurement
(SLAM)14, Lupus Activity Index (LAI)15, and European Consensus Lupus Activity
Measurement (ECLAM).16,17
In ankylosing spondylitis (AS): the BATH Ankylosing Spondylitis Disease Activity
Index (BASDAI)18, Modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS)19,
Bath Ankylosing Spondylitis Metrology Index20, and Dougados Functional Index
(DFI).21
MDHAQ and RAPID scores be informative in patients with all rheumatic diseases 735
In vasculitis: the Birmingham Vasculitis Activity Score (BVAS)22, Vasculitis Activity

Index23, and BVAS-derived Wegeners Granulomatosis Activity Index.24
Each of these measures is more informative in the specific disease than any general
measure. However, few patients with osteoarthritis, fibromyalgia, RA, SLE, AS, or vasculitis outside of research studies are monitored according to any of these measures and indices.
It has been suggested that 80% of the data in 100% of the patients may be preferable
to 100% of the data in 5% of the patients (or fewer) who might be included in clinical
research.25 Therefore, a less comprehensive measure, which is feasible and applicable in
standard clinical care, appears preferable to no quantitative measure at all.
The Health Assessment Questionnaire (HAQ)26 is classified as disease specific because it was developed initially for use in patients with RA, in contrast to questionnaires such as the Short Form 36 (SF36)27, a protoype generic questionnaire
developed to be applicable to patients with many diseases or no disease at all.28,29
However, the HAQ might function effectively as a generic questionnaire, as people
with all rheumatic diseases, and indeed all diseases, are affected by limitations of functional status, pain and poor global status.28
Similarly, derivatives of the HAQ, such as the multidimensional HAQ
(MDHAQ)30,31, appear useful in all rheumatic diseases.32 For example, in osteoarthritis clinical trials, the physical function scale was found to be more sensitive to changes
than traditional physical measures.33 Furthermore, the pain visual analog scale (VAS)
on the MDHAQ is more sensitive than the WOMAC an osteoarthritis specific questionnaire to distinguish diclofenac/misoprotol from acetaminophen (paracetamol)34 or
celecoxib from acetaminophen (paracetamol).35 In fibromyalgia, ratios of pain or
fatigue to physical function scores, as well as the number of symptoms reported on
a review-of-systems symptom checklist, distinguish these patients from those with
RA as effectively as ESR.36,37
The MDHAQ was adapted from the HAQ for feasibility in standard clinical care,
with reduction of the number of activities from 20 to 10, VAS as 21 circles rather
than a 10-cm line, availability of all American College of Rheumatology (ACR)
Core Data Set patient self-report measures and scoring templates on the front
page, with a review of systems symptom checklist and review of recent medical
history on the reverse side of a single page. Scoring templates are also available
for Routine Assessment of Patient Index Data (RAPID) scores, based on a composite
of the three patient-reported outcome (PRO) measures from the Core Data Set included on the HAQ and MDHAQ. RAPID 3 a composite of physical function, pain,
and global status (derived from the Core Data Set) can be calculated without
a ruler, calculator, computer or website in about 10 seconds. RAPID 3 distinguishes
active from control treatment in RA clinical trials involving leflunomide38,39, methotrexate38,39, adalimumab40, and abatacept41 at levels similar to ACR or DAS-28 criteria, and are correlated significantly with DAS-28 in these trials and in standard
clinical care.42 A preliminary proposed classification of RAPID scores includes four
categories: 01 near remission, 1.012 low severity, 2.014 moderate severity,
4.0110 high severity. These categories can be useful to guide tight control43 of
inflammation in RA and other diseases.
Routine completion of an MDHAQ by every patient at every visit in the infrastructure of standard rheumatology care44 might allow effective quantitative monitoring of
clinical status with minimal work on the part of the physician and the staff. The author
have empirically collected MDHAQ scores to monitor clinical status in patients with all
rheumatic diseases for many years. In this report, data are presented concerning the
MDHAQ and RAPID 3 in patients with rheumatic diseases other than RA, including
examples of flow sheets to illustrate the courses of individual patients monitored in
standard clinical care.
MDHAQ SCORES IN 1107 PATIENTS WITH VARIOUS

RHEUMATIC DISEASES
Mean and median scores for physical function, pain, global status, as well as fatigue
and RAPID 3 are illustrated in Table 1 for 1107 patients at their first visit between
September 1996 (when a patient global score and RAPID 3 score became available in
the clinic) and December 2005. Scores for patients with fibromyalgia are higher for
all three components of RAPID 3, as well as for the index. Lowest scores on all
three scales are seen in patients with vasculitis. A high score for pain with lower
scores for physical function are seen in patients with osteoarthritis compared to
RA, inflammatory and psoriatic arthritis. Patients with SLE have higher global scores
and lower pain scores than patients with osteoarthritis, although SLE patients generally are younger.
Mean and median scores were compared in patients who were in their first visit to
this clinical setting versus patients who had been monitored previously over 0.115
years. In patients with RA, scores for pain and global status were approximately
12 units lower in established patients than in new patients, suggesting that effective
therapy had been delivered. By contrast, established patients with fibromyalgia had
mean and median scores that were similar to new patients with fibromyalgia seen at
their first visit, indicating that effective treatment for these patients is generally not
available. Some progression was seen in scores for patients with SLE and osteoarthritis,
suggesting a decline in status over long periods.
FLOW SHEETS TO ILLUSTRATE PATIENT MONITORING
OF MDHAQ AND RAPID SCORES
Figures 111 illustrate courses over periods varying from a few months to 15 years in
patients with different diagnoses other than RA, to illustrate the value of monitoring
scores on the MDHAQ for the three Core Data Set PRO measures and RAPID 3 over
time in all patients seen in standard rheumatology clinical care.
These flow sheets of 11 patients who did not have RA have been selected to
illustrate that use of MDHAQ data from the same patient questionnaire can be
helpful in formulating clinical decisions and documenting results of care in patients
with all rheumatic diseases. Patient questionnaires, as all quantitative measures in
clinical medicine, ranging from vital signs to laboratory tests, generally confirm
the impressions of a clinician and do not provide major surprises. The flow sheets
illustrate that the patient questionnaire scores can be regarded as quantitative data
similar to laboratory tests or vital signs. If the clinician has questionnaire scores
available before seeing the patient, particularly comparative data from previous
visits on a flow sheet, evidence of a RAPID score in a low severity range of
<2, or near remission <1, provides reassurance that the situation is under good
control.
Table 1. Summary of first recorded among all 010, for physical function (function) pain \ global estimate
(global) fatigue, and RAPID 3 comparable of physical functions pain \ patient global estimate composite
RAPID 3 data collected in 1,107 patients seen 19962005 according to diagnosis.
All First
Recorded MDHAQ
1-Rheumatoid
arthritis
2-Inflammatory
arthritis
3-Psoriatic arthritis
4-Systemic lupus
erythematosus
5-Systemic sclerosis
6-Vasculitis
7-Osteoarthritis
8-Fibromyalgia
9-Other
Function
N
Pain
Global
Fatigue
RAPID3
Mean Median Mean Median Mean Median Mean Median Mean Median
280 2.91
2.67
4.70
4.60
4.45
4.80
4.89
5.05
4.02
3.92
175 1.99
1.67
4.71
4.80
4.24
4.20
4.76
4.55
3.65
3.41
30 2.62
36 1.71
2.50
1.33
5.39
3.45
5.55
3.60
4.35
4.19
4.75
4.70
3.74
5.29
3.90
5.75
4.12
3.12
4.56
2.85
2.56
1.42
1.89
2.93
2.00
2.00
1.00
1.67
3.00
1.67
3.79
2.78
4.52
6.44
4.53
3.25
2.30
5.20
6.80
4.60
4.04
3.03
3.99
6.05
4.30
4.15
2.30
4.60
6.30
4.40
4.88
4.87
3.81
7.32
4.52
5.55
4.80
3.20
7.90
4.60
3.46
2.41
3.47
5.14
3.61
3.19
1.81
3.59
5.28
3.47
Total
1107 2.41
2.00
4.92
5.10
4.63
4.80
5.19
5.40
3.99
3.92
867 patients seen at 1st

1-Rheumatoid arthritis
2-Inflammatory
arthritis
4-Systemic lupus
erythematosus
6-Vasculitis
7-Osteoarthritis
8-Fibromyalgia
9-Other
visit
174 3.15
151 2.02
3.00
1.67
5.32
4.88
5.35
4.90
5.25
4.43
5.35
4.30
5.58
5.01
6.20
4.80
4.58
3.78
4.64
3.52
17 2.69
28 1.56
2.67
1.17
5.47
3.15
5.80
2.55
5.03
3.90
4.90
4.70
4.02
5.07
4.80
5.45
4.40
2.87
4.61
2.85
2.82
1.54
1.75
2.94
1.95
2.00
1.34
1.67
3.00
1.33
3.56
3.45
4.30
6.44
4.52
3.60
3.05
5.15
6.70
4.60
4.97
3.85
3.97
6.11
4.35
4.90
4.40
4.45
6.30
4.40
4.76
5.50
3.39
7.29
4.47
6.00
5.55
3.10
7.90
4.50
3.78
2.95
3.34
5.17
3.61
3.50
3.30
3.48
5.32
3.40
867 2.42
2.00
5.10
5.40
4.91
5.00
5.37
5.70
4.14
4.18
2.50
2.00
3.68
3.25
3.12
2.40
3.75
3.40
3.10
2.65
1.81
1.17
3.64
3.35
3.02
2.25
3.18
1.90
2.82
2.48
2.54
2.25
2.33
1.50
5.28
4.50
5.20
3.95
3.47
5.18
4.70
4.95
3.36
6.05
2.80
7.75
3.76
3.98
3.59
3.71
2.00
1.33
2.51
2.87
2.42
1.67
1.00
2.22
2.98
2.33
4.28
2.30
5.50
6.38
4.56
2.90
1.50
6.10
7.15
4.40
2.00
2.43
4.11
5.71
3.88
0.80
2.10
4.70
5.60
4.25
5.12
4.41
5.69
7.49
4.91
3.90
4.80
6.80
7.75
5.70
2.76
2.02
4.04
4.99
3.62
2.58
1.62
4.54
4.90
3.79
240 2.40
2.00
4.28
4.05
3.62
3.05
4.53
4.35
3.43
3.24
Total
16
19
39
217
295
11
8
32
185
261
240 patients with previous care

1-Rheumatoid
106
arthritis
2-Inflammatory
24
arthritis
13
4-Systemic lupus
8
erythematosus
5
6-Vasculitis
11
7-Osteoarthritis
7
8-Fibromyalgia
32
9-Other
34
Total
As noted in Chapter 1, an increase in patient questionnaire scores can be due to

circumstances other than the rheumatic disease for which the patient is being treated,
such as trauma or injury or acute back pain. However, this circumstance is similar to an
increased ESR, which might be due to an infection or development of a lymphoma
rather than a flare of inflammatory rheumatic disease. All quantitative data must be
interpreted by a clinician, along with information from the history, physical examination, and other sources in a clinical decision. Nonetheless, the availability of quantitative data in many situations can add immeasurably to the decision process and help
focus the visit on the concerns of the patient.
Finally, it might appear that one loses considerable data by including only patient
data in a quantitative index without any laboratory or physician-generated data. Inclusion of data from a physical examination, radiograph, and/or laboratory test renders an
index more comprehensive and specific. At the same time, in RA clinical trials, an
index of the three Core Data Set measures distinguishes active from control treatment at levels similar to criteria using the full ACR Core Data Set and DAS criteria.
Furthermore, a patient questionnaire not a joint count, radiograph, or laboratory
test is the most significant clinical prognosis measure of all severe long-term outcomes in patients with RA, including functional status46,47, work disability4850, costs51,
joint replacement surgery52, and premature death.46,5359 Poor functional status also
appears to predict premature mortality in the elderly general population59 in congestive heart failure at levels as significant as ejection fraction60, in AIDS at levels higher
than T4/T8 cell ratios61, and in elderly patients.62 These observations suggest that a patient questionnaire might be useful to assess patients with all rheumatic diseases, as
well as non-rheumatic diseases.
The importance of function, pain, and global status might be less in diseases other
than RA but they remain important considerations in all rheumatic diseases. Although
the data might not be as comprehensive or specific for the MDHAQ compared to disease-specific questionnaires, or for a RAPID index compared to disease-specific indices, nonetheless the information has proven useful in many patients, examples of
which are illustrated in this chapter. One consideration might be to include a simple
questionnaire, such as MDHAQ or other simplified generic self-report instrument,
along with all extensive disease-specific research questionnaires and indices in clinical
trials and other clinical research to give a better estimate of how much data might be
lost if clinicians were to attempt to monitor patients directly using a questionnaire
such as the MDHAQ.
The value of a simple measure that might be useful in all rheumatic diseases can be
illustrated by simple measures of acute-phase reactants, such as ESR or CRP. If these
tests were available only as disease-specific measures of acute-phase reactants, such as
the polymyositis ESR versus the vasculitis ESR, the value of these tests would be
considerably less than the availability of one ESR that serves all diseases. To be sure,
there is a loss of specificity, as an elevated ESR could be the result of development
of an infection or lymphoma rather than a flare of disease activity, as noted above.
Nonetheless, as emphasized in this chapter and previous writing, all measures in clinical
medicine, ranging from laboratory tests to patient questionnaires, require interpretation
by a clinician to guide clinical decisions. This is a concern, as administrative guidelines seek
to suggest that certain levels of certain measures should trigger certain actions. Such
levels might provide a reasonable guideline, but the ultimate decision must include the
judgment of a clinician.
This chapter presents 11 examples of specific patients with psoriatic arthritis, SLE,
AS, gout, systemic sclerosis, vasculitis, fibromyalgia, inflammatory bowel disease
arthritis, Behcets syndrome, and familial mediterranean fever, to illustrate use of the
MDHAQ in many rheumatic diseases.
Psoriatic arthritis in a 24-year-old woman
A 24-year-old female patient was seen in an emergency room for a swollen right elbow
on 24 May 2004. An arthrocentesis revealed milky fluid and the patient was admitted
for presumed septic arthritis. She did not improve with antibiotic therapy on the second day and a rheumatologist was called, who elicited a history of mild psoriasis and
polyarthralgias over the previous 2 years, and made a diagnosis of psoriatic arthritis.
The patients MDHAQ scores were 4 (010) for physical function, pain 7.6 (010),
global status 6.5 (010), and RAPID 3 was 18.1 on a 030 scale or 6.0 on a 010 scale,
indicating high severity (RAPID 3 > 4.0, see Chapter 12). She was treated with 20 mg
prednisone daily and 10 mg methotrexate per week. By 3 June 2004, her functional
status had improved to 2, pain to 2.5, global status to 2.1, and RAPID 3 (010) to
2.2, indicating moderate severity. On 7 September 2004, RAPID 3 (010) was 1.7, indicating mild severity. However, on 14 December 2004, she experienced a flare; her
score for physical function rose to 2.0, pain to 4.1, global status to 6.9, and RAPID
3 (010) to 3.3, indicating moderate severity. After discussion with the patient and
her family, it was elected to begin adalimumab 40 mg every other week. Ten months
later, on 25 October 2005, her functional status score was 0, pain 0 and global status
1.0, and RAPID 3 (010) 0.3, indicating near remission. Her scores remained stable
over the next year.
Multi-Dimensional Health Assessment Questionnaire (MDHAQ) Scores, Laboratory Tests, Medications
DOB: April 1980 1
st
Visit: 27 May 2004 DX ICD9: 696.00 Onset: Oct 2003 Education: 16

27 May 04
3 June 04
7 Sept 04
14 Dec 04
14 Apr 05
25 Oct 05
27 Jun 06
PATIENT SELF-REPORT QUESTIONNAIRE DATA

FN-FUNCTIONAL STATUS [0-10]
4.00
2.00
1.00
2.00
0.67
0.3
PN-PAIN [0-10]
7.6
2.5
2.5
4.1
1.1
0.8
0.8
GL-GLOBAL STATUS [0-10]
6.5
2.1
1.6
6.9
2.8
RAPID 3 (0-30)
18.1
6.6
5.1
13.0
3.9
1.9
RAPID 3 (0-10)
6.0
2.2
1.7
3.3
1.3
0.3
0.6
PHYSICAL MEASURES DATA

Weight (lbs)
136
136
135
136
137
141.8
128/72
117/70
131/78
114/66
113/69
131/85
ESR (mm/hr) [M:0-20/F:0-30]
12
CRP (mg/L) [0.0-10.0]
3.2
1.5
0.9
Blood Pressure (mmHg)
NA
LABORATORY DATA
WBC (thou/uL) [4-11]
10.7
6.7
13.2
12.3
7.5
7.0
HGB (g/dL) [M:14-18]/F:12-16]
12.4
14.5
14.9
15.5
15.4
14.7
HCT (%) [M:42-50/F:37-44]
37
40
45
45
43
42
PLATELETS (thou/uL) [150-400]
436
268
383
401
335
363
ALBUMIN (g/dL) [3.5-5.0]
4.7
4.5
GLUCOSE (mg/dL) [70-110]
75
ALK PHOS (U/L) [40-100]
78
72
64
59
79
SGOT (U/L) [4-40]
18
17
29
24
26
4.5
62
4.9
5.1
86
68
CREATININE (mg/dL) [0.7-1.5]

0.7
1
0.7
0.7
RHEUMATOLOGY MEDICATIONS (C=Change Dose, D=D/C, N=New, O=On at visit, P=Parenteral, R=Resume, S=Short Term, T=Taper)
Prednisone
O-20 QD
Methotrexate
O-10 QOK
T-19 QD
T-9 QD
O-10 QOK
C-10 QOK
Folic Acid
O-1 QD
O-1 QD
O-1 QD
Rofecoxib
O-50 QD
C-25 QD
D-25 QD
Adalimumab
O-6 QD
O-3 QD
D-2 QD
N-3 QD
O-5 QOK
O-5 QOK
O-5 QOK
O-1 QD
O-1 QD
O-1 QD
O-1 QD
N-40 QOO
O-40 QOO
O-40 QOO
O-40 QOO
C-5 QOK
Figure 1. Patient flow sheet: psoriatic arthritis in a 24-year-woman.
Systemic lupus erythematosus in a 39-year-old woman

A 39-year-old woman was seen with pleuritis, pleural effusions, arthralgias and positive
tests for antinuclear antibody (ANA) and DNA-antibodies on 15 February 2005. A
diagnosis of systemic lupus erythematosus (SLE) was made. Her score for physical
function was 4.3, pain 5.6, global status 6.5, and RAPID 3 (010) 5.5, indicating high
severity. She was given a prednisolone acetate injection 80 mg and prednisone 5 mg
per day was begun. At her next visit of 17 May 2005, her score for functional status
was 0, pain 2, global status 6, and RAPID 3 (010) 2.7, indicating moderate severity,
with improvement. She was given a prescription for mycophenolate mofetil, 500 mg
twice a day. On 19 July 2005, her scores were 0 for physical function, 4 for pain, 3
for global status, and 2.3 for RAPID 3 (010). Her mycophenolate mofetil was raised
to 1000 mg BID and her prednisone was reduced to 5 mg QD. On 20 September
2005, hydroxychloroguine 200 bid was prescribed. However, she did not tolerate
it, and discontinued it after 3 weeks. Nonetheless, over the next year, she showed
considerable improvement, with scores on 26 September 2006 of 0 for physical function, 0.5 for pain, 0.5 for global status, and 0.3 for RAPID 3 (010), suggesting near
remission status.

DOB: Aug 1965 1
st
Visit: 15 Feb 2005 DX ICD9: 710.10 Onset: Sept 2004 Education: 12
VISIT DATE
15 Feb 05
FUNCTIONAL STATUS (FN) [0-10]
4.33
PAIN (PN) [0-10]
5.6
GLOBAL STATUS (GL) [0-10]
6.5
RAPID 3 (0-30)
16.4
RAPID 3 (0-10)
5.5
WEIGHT (lbs)
BLOOD PRESSURE (mm/Hg)
LABORATORY DATA
ESR (mm/hr) [M:0-20 / F:0-30]
CRP (mg/L) [0-10]
HGB (g/dL) [M:14-18/F:12-16]
HCT (%) [M:42-50/F:37-44]
ALK PHOS (U/L) [40-100]
SGOT (U/L) [4-40]
17 May 05
19 Jul 05
20 Sep 05
23 May 06
26 Sep 06
0
2
6
8
2.7
0
4
3
7
2.3
0
3.5
2
5.5
1.8
0
0.4
0.1
0.5
0.2
0
0.5
0.5
1
0.3
106
132/74
120
170/94
101
153/75
103
143/84
104
116/60
104
115/70
66
44.7
4.3
10.8
33
390
3.7
108
21
36
8
1.2
5.1
13.8
41
265
4.8
74
17
11
1
5.6
12.9
41
300
4.8
86
15
15
0.9
4.1
13.1
41
315
4.7
91
19
0.6
0.7
0.6
0.7
0.8
8
10.6
31
213
1.9
1.8
6.8
12.6
40
390
0.7
Ibuprofen
Prednisone
Methylprednisolone acetate
Mycophenolate mofetil
Hydroxycholoroquine
O-600 TID
N-5 QD
N-80
600 TID
C-10 QD
T-5QD
5 QD
C 4 QD
4 QD
N-500 BID
1000 BID
1000 BID
N-200 BID
1000 BID
D-200 BID
1000 BID
Figure 2. Patient flow sheet: systemic lupus erythematosus in a 39-year-old woman.
Ankylosing spondylitis in a 35-year-old man

A 35-year-old male was seen on 12 August 2003 for severe back pain, seeking work
disability status. He related a history of back pain since age 24 but a diagnosis of
ankylosing spondylitis had been made only 2 weeks earlier by his family physician. Physical examination revealed a marked kyphosis and flexion contractures of both hips and
both knees, with obvious ankylosing spondylitis. His scores were 5.7 for physical function, 8.8 for pain, 4.9 for global status, and 6.5 for RAPID 3 (010), indicating high
severity. He was treated with prednisone 5 mg per day and phenylbutazone 300 mg
per day. Two weeks later he had some improvement, with scores of 4.7 for physical
function, 5.2 for pain, 3.5 for global status, and 3.5 for RAPID 3 (010), indicating moderate severity. Methotrexate 10 mg per week was added. However, on 23 September
2003, the patient was clinically unchanged from his first visit, with recurrent high
scores for functional status, pain, global status, and RAPID 3 (010) of 6.7. Therefore,
etanercept 25 mg twice a week was initiated. Two months later, on 25 November
2003, his score for physical function had improved from 6.3 to 3.7, pain from 8.8 to
0.6, global status from 5.0 to 2.4, and RAPID 3 (010) from 6.7 to 3.2. Over the
next 3 years, he maintained scores of less than 1 for pain and global status, although
his physical function remained 3.3 and RAPID scores were in the range of 12, suggesting mild severity on the basis of damage occured over more than a decade from
chronic ankylosing spondylitis over the more than a decade before appropriate treatment was given for his condition.

DOB: Jan 19681
st
Visit: 12 Aug 2003 DX ICD9: 720.00 Onset: Jan 1990 Education: 10
VISIT DATE
12 Aug 03
5.7
PAIN (PN) [0-10]
8.8
4.9
RAPID 3 (0-30)
19.4
RAPID 3 (0-10)
6.5
WEIGHT (lbs)
LABORATORY DATA
ESR (mm/hr) [M:0-20 / F:0-30]
CRP (mg/L) [0-10]
HGB (g/dL) [M:14-18/F:12-16]
HCT (%) [M:42-50/F:37-44]
ALK PHOS (U/L) [40-100]
SGOT (U/L) [4-40]
158
122/80
25 Nov 03
16 Mar 04
15 Mar 05
5 Sep 06
4.7
5.2
3.5
13.4
3.5
26 Aug 03
6.33
8.8
5.0
20.1
6.7
3.7
0.6
2.4
6.7
3.2
3.3
0.2
0.3
3.8
1.3
3.7
0.2
0.3
4.2
1.4
3.3
0.5
0.5
4.3
1.4
160
126/76
162.6
129/78
181
133/80
180
130.78
189
139/76
220
130/82
39
67
11.2
14.3
45
338
4.5
93
17
8
2
9.7
14.4
44
213
4
7
9.8
15.6
48
218
4.4
73
29
6
3.4
9.3
16.6
48
235
4.5
69
20
13
20.3
8.6
14.1
44
227
4.3
87
21
0.7
0.7
0.8
0.7
17
36
14.5
15
45
373
4.4
94
17
23 Sep 03
0.7
Prednisone
Phenylbutazone
Methotrexate
Folic Acid
Etanercept
N-5 QD
N-300 QD
5 QD
300 QD
5 QD
300 QD
T-4 QD
300 QD
4 QD
D-300QD
4 QD
10 QWK
N-10 QW
C-20 QW
20 QW
D-20QW
N-1 QD
1 QD
N-25 BIW
1 QD
25 BIW
D-1 QD
25 BIW
1 QD
25 BIW
Figure 3. Patient flow sheet: ankylosing spondylitis in a 35-year-old man.
D-4 QD
D-10
QWK
D-1 QD
25 BIW
Gout in a 68-year-old man

A 68-year-old man was seen because of chronic gout with a recent acute attack on 9
December 2003, referred from the emergency department. His attack had abated,
although he had some residual erythema of his right great toe. His MDHAQ scores
were 0.7 for physical function, 4.3 for pain, 1.2 for global status, and 2.1 for RAPID
3 (010). He was treated with prednisone 5 mg per day, allopurinol 300 mg per day,
and colchicine 0.6 mg per day. Two months later, on 10 February 2004, his scores
were all 0; his prednisone was discontinued and allopurinol and colchicine were continued. On 17 August 2004, his score for physical function was 0, pain 0.5, global status
0.3, and RAPID 3 (010) 0.3, suggesting near remission status. His colchicine was discontinued and he was returned to care of his family physician.

DOB: May 1935 1
st
Visit: 9 Dec 2003 DX ICD9: 274.90 Onset: Jan 1973 Education:16
VISIT DATE
9 Dec 03
0.7
PAIN (PN) [0-10]
4.3
1.2
RAPID 3 (0-30)
6.2
RAPID 3 (0-10)
2.1
WEIGHT (lbs)
198
177/98
LABORATORY DATA
ESR (mm/hr) [M:0-20 / F:0-30]
5
CRP (mg/L) [0-10]
5.3
HGB (g/dL) [M:14-18/F:12-16]
14.4
HCT (%) [M:42-50/F:37-44]
42
178
ALK PHOS (U/L) [40-100]
SGOT (U/L) [4-40]
1.1
10 Feb 04
17 Aug 04
0
0
0
0
0
0
0.5
0.3
0.8
0.3
201
112/78
194
127/64
6.7
15
44
208
4.7
15.8
45
186
4.7
67
25
1.1
1.1
Prednisone
Allopurinol
Colchicine
Propranolol hydrochloride
N-5 QD
N-300 QD
R-0.6 QD
O-10 QD
D-5 QD
300 QD
0.6 QD
10 QD
300 QD
D
10 QD
Figure 4. Patient flow sheet: gout in a 68-year-old man.
Scleroderma in a 45-year-old woman

A 45-year-old woman with long-standing scleroderma since age 33 was seen initially on
8 September 1992. Physical examination revealed classical proximal scleroderma with
contractures of the PIP joints of both hands. Her score for physical function was 2.9,
and pain was 3.2 (patient global scores were not obtained until 1995), indicating
a RAPID score (mean of the two scores) of 3.1. She was treated with penicillamine,
with no improvement and worsening of her pain score to 5.7, on 10 November
1992. Prednisone 3 mg per day was added, resulting in a substantial improvement
by 12 January 1993, with a pain score of 1 and RAPID score of 1.4. She was stable until
1996, but experienced a flare on 29 October 1996, with a score for physical function
of 3.0, pain of 3.0, global status of 0.9 and full RAPID 010 score of 2.3. Methotrexate
10 mg/week was added. She was maintained on low-dose prednisone, low-dose methotrexate, and penicillamine for many years, with maintenance of functional status and
low pain scores. Her most recent scores, on 12 September 2006, were 2.0 for physical
function, 0.5 for pain, 0 for global status, 2.5 (0-30) and 0.8 (010) for RAPID 3,
suggesting near remission status.

st
DOB: Mar 1947 1
Visit: 8 Sep 1992 DX ICD9: 710.10 Onset: July 1980 Education:16
VISIT DATE
8 Sep 92
2.92
PAIN (PN) [0-10]
3.2
RAPID 3 (0-30)
6.1
RAPID 3 (0-10)
3.1
WEIGHT (lbs)
LABORATORY DATA
ESR (mm/hr) [M:0-20 / F:0-30]
CRP (mg/L) [0-10]
HGB (g/dL) [M:14-18/F:12-16]
HCT (%) [M:42-50/F:37-44]
ALK PHOS (U/L) [40-100]
SGOT (U/L) [4-40]
137
102/68
10 Nov 92
12 Jan 93
29 Oct 96
28 Jan 97
11 Jul 00
12 Sep 06
2.67
1.3
1.8
5.8
1.9
3.67
0.6
0.7
5.0
1.7
2.0
0.5
0
2.5
0.8
2.50
5.7
1.67
1
8.2
4.1
2.7
1.4
3.0
3
0.9
6.9
2.3
135
90/52
135
110/68
132
106/70
133
92/60
128
94/55
137
117/72
10
5.2
25
1
6.3
36
3
7.4
22
5
6.1
41
106
4
47
13
40
151
3.5
46
18
42
212
3.6
54
20
39
168
3.3
91
28
14
0.6
6
14
43
145
4.4
77
30
0.8
0.7
0.9
0.9
0.9
14
Penicillamine
Sulindac
Prednisone
Methotrexate
Folic acid
O-250 QD
O-200 QD
250 QD
200 BID
N-3 QD
250 QD
200 BID
3 QD
625 QD
200 BID
3 QD
7.5 QWK
1 QD
C-750 QD
200 BID
3 QD
7.5 QWK
1 QD
750 QD
200 BID
3 QD
C-5 QWK
1 QD
Figure 5. Patient flow sheet: systemic sclerosis in a 45-year-old woman.
750 QD
200 BID
3 QD
15 QWK
1 QD
Vasculitis in a 34-year-old woman

A 34-year-old woman was seen on 16 January 1990 with palpable purpura, right foot
drop, and hematuria. A diagnosis of vasculitis was made. Her score for functional disability was 1.3, pain was 5.3 (global scores were not obtained until 1995), and RAPID
score based only on two scores of 3.3. She was treated with prednisone and
cyclophosphamide for 1 year, then with methotrexate, with substantial clinical
improvement, and she was largely asymptomatic for 12 years, from 1991 to 2003.
She decided on her own to discontinue methotrexate in the summer of 2003. On
12 August 2003, her score for physical function was 1.0, pain 0.8, global status 1.8
and RAPID 3 (010) 1.2. On 21 December 2004, she noted recurrent right foot
drop and a new left foot drop. She had an increase in her score for pain to 5.1, global
status to 4.9, and RAPID 3 (010) to 3.8. She was hospitalized with a recurrent foot
drop, treated with three daily methylprednisolone 1000 mg per day pulses and showed
gradual improvement. However, on 31 May 2005 she had a further exacerbation and
was hospitalized and treated again with cyclophosphamide, which was maintained over
6 months. On 29 November 2005, her scores were 2.3 for physical function, 3 for
pain, 3.5 for global status, and 2.9 for RAPID 3 (010). On 3 July, RAPID 3 (010)
was 2.2 and cyclophosphamide was discontinued; methotrexate 15 mg per week
was reinstated. At her most recent visit of 19 September 2006, her score for physical
function was 1.7, pain 1.5, global status 2.5 and RAPID 3 (010) 1.9, suggesting low
severity. She was much improved, but has not recovered to her 2003 level.

DOB: July 1956 1
st
Visit: 16 Jan 1990 DX ICD9: 447.60 Onset: July 1989 Education: 12
Visit Date
16 Jan 90
20 Mar 90
12 Aug 03
21 Dec 04
31 May 05
29 Nov 05
3 Jul 06
19 Sep 06
1.67
1.67
2.2
1.5
3.5
2.7
2.5

1.25
0.83
1.00
1.33
1.00
PN-PAIN [0-10]
0.9
0.8
5.1
1.8
4.9
5.3
2.33
RAPID 3 (0-30)
6.6
1.7
3.6
11.3
8.8
6.6
5.7
RAPID 3 (0-10)
3.3
0.9
1.2
3.8
3.0
2.9
2.2
1.9
159
156
131/86
120/79

Weight (lbs)
113
117.2
124
131
132
153
110/70
120/90
97/65
127/71
111/77
143/90
LABORATORY DATA
ESR (mm/hr) [M:0-20/F:0-30]
12
17
CRP (mg/L) [0.0-10.0]
9.9
HGB (g/dL) [M:14-18]/F:12-16]
38
16
13
24.3
3.8
4.5
7.9
7.5
4.7
6.3
7.3
7.8
15
13.4
13.9
14.5
14.2
HCT (%) [M:42-50/F:37-44]
34.5
44
38
43
44
44
281
242
190
194
215
237
93
123
3.8
4.2
4.3
4.6
111
206
169
103
ALK PHOS (U/L) [40-100]
70
72
92
SGOT (U/L) [4-40]
15
14
16
23
0.7
0.8
0.6
0.5
0.6
Cyclophosphamide
O-200 QD
R-50 QD
R-50 QD
C-100 QWK D-100 QD
prednisone
methotrexate
Folic Acid
O-30 QD
T-35 QD
2 QD
R-3 QD
3 QD
15 QWK
R-10 QWK
15 QWK
1 QD
1 QD
1 QD
T-5 QD
1 QD
Figure 6. Patient flow sheet: vasculitis in a 34-year-old woman.
5 QD
C-3 QD
R-15 QWK
15 QWK
1 QD
1 QD
Fibromyalgia in a 49-year-old woman

A 49-year-old woman was seen on 28 March 1995 because of widespread musculoskeletal pain. She was a hair dresser who opened her beauty shop at 6 a.m., although by temperament a night person. Her scores were 2.7 for functional disability and 4.9 for pain,
giving a mean of 3.8. She was advised to try to arrange for an employee to open her beauty
shop in the morning, so that she could sleep until she naturally would awake at 8 a.m., and
to exercise by walking an hour per day. No new medications were prescribed. She was
seen again 3 months later on 27 June 1995, with a weight loss of 26 pounds, and an improvement of her physical function score to 0 and pain to 2.1, mean 1.1. She was seen
again 6 months later on 19 December 1995, with a further loss of 32 pounds for a total
of 58 pounds over 8 months. Her score for physical function was 0 and pain 1.9, mean 1.0.
This patient showed a very atypical response for patients with fibromyalgia, most of
whom do not heed advice to exercise regularly (and do not show weight loss). The
flow sheet illustrates documentation of her response.

DOB: Dec 1945 1st Visit: 28 Mar 1995 DX ICD9: 729.10 Onset: July 1992 Education: 12
VISIT DATE
28 Mar 95
2.67
PAIN (PN) [0-10]
4.9
RAPID 3 (0-30)
7.6
RAPID 3 (0-10)
3.8
WEIGHT (lbs)
LABORATORY DATA
ESR (mm/hr) [M:0-20 / F:0-30]
CRP (mg/L) [0-10]
HGB (g/dL) [M:14-18/F:12-16]
HCT (%) [M:42-50/F:37-44]
ALK PHOS (U/L) [40-100]
SGOT (U/L) [4-40]
206
174/100
27 Jun 95
19 Dec 95
0
2.1
0
1.9
2.1
1.1
1.9
1.0
180
146/94
148
170/100
15
7.9
13.4
38.8
285
4.5
65
21
0.8
Nabumetone
O-750 BID
Figure 7. Patient flow sheet: fibromyalgia in a 49-year-old woman.
Fibromyalgia in a 53-year-old woman

A more typical patient with fibromyalgia is a 53-year-old woman, seen initially on 28
May 1996, with a score for functional disability of 0.7, pain of 9.8, mean 5.3. This is
a rather typical pattern of fibromyalgia, reflecting a high ratio of pain to functional status, which is virtually pathognomonic for fibromyalgia.36,45 This patient, as most
patients with chronic widespread pain in this clinic, received an n of 1 trial of lowdose prednisone 35 mg over the years, which she said was helpful and continued.
However, she showed essentially no improvement in scores and, after 7 years of treatment, on 29 July 2003, her physical function score was 5.0, pain score 9.9, global score
9.6, and RAPID 3 (010) 7.9. She went to a detoxification center in September 2003
and was weaned off all pain medications. She returned on 21 October 2003, with
scores of 0 for functional status, 0.3 for pain, 0.1 for global status, RAPID 3 (010)
0.1. She was told she need not return to this clinic. After a typical course for 7 years,
an atypical response of a patient with fibromyalgia is documented.

DOB: July 19421
st
Visit: 28 May 1996 DX ICD9: 729.10 Onset: July 1986 Education: 12
VISIT DATE
28 May 96
0.67
PAIN (PN) [0-10]
9.8
RAPID 3 (0-30)
10.5
RAPID 3 (0-10)
5.3
WEIGHT (lbs)
LABORATORY DATA
ESR (mm/hr) [M:0-20 / F:0-30]
CRP (mg/L) [0-10]
HGB (g/dL) [M:14-18/F:12-16]
HCT (%) [M:42-50/F:37-44]
ALK PHOS (U/L) [40-100]
SGOT (U/L) [4-40]
121
140/90
9 Jun 98
13 Jun 00
10 Dec 02
29 Jul 03
21 Oct 03
2.33
6.9
5.8
15.0
5.0
2.67
9.9
9.5
22.1
7.4
3.00
9.7
8.6
21.3
7.1
5.00
9.9
9.6
23.5
7.9
0
0.3
0.1
0.4
0.1
122
138/70
122
152/76
139
174/84
125
172/89
122
160/80
48
3
67
3.9
85
18
6.6
11.1
35
220
4
106
32
0.8
0.8
Prednisone
Celecoxib
Methotrexate
Depo-Medrol
Valdecoxib
3 QD
D-1 QD
100 BID
5 QD
5 QD
N-10 QWK
40
40
D-5QD
O-20 BID
Figure 8. Patient flow sheet: fibromyalgia in a 53-year-old woman.
Inflammatory bowel disease arthritis in a 29-year-old man

A 29-year-old man was seen on 16 March 2004 with widespread musculoskeletal pain,
most severe in his back. He had a history of ulcerative colitis. On physical examination,
he could not reverse his lumbar lordosis and a radiograph revealed sacroiilitis. He had
a score for physical function of 5.7, pain of 10, global status of 7.0, RAPID 3 of 22.7 (0
30) or 7.6 (010). He had been treated with valdecoxib, which was not helpful, and his
treatment was changed to indomethacin SR 75 mg QD. He returned 1 week later with
minimal improvement, documented by similar scores for physical function, pain and
global status. He was then treated with phenylbutazone 100 mg TID, which proved
only mildly efficacious, as his scores 3 months later on 8 June 2004 were 4.3 for functional status, 7.2 for pain, 7.5 for global status, 19.0 for RAPID 3 (030) or 6.3 (010).
At that time he was treated with adalimumab 40 mg every other week. One month
later, he had a dramatic response with a reduction of his score for physical function
from 4.3 to 0.3, pain from 7.2 to 4, global status from 7.5 to 2, RAPID 3 (010)
from 6.3 to 2.1. He has continued this treatment with fluctuating scores for pain,
but was able to do his work as a store manager effectively.

DOB: Nov 1974 1
st
Visit: 16 Mar 2004 DX ICD9: 713.1 Onset: Jan 2001 Education: 14
VISIT DATE
16 Mar 04
5.67
PAIN (PN) [0-10]
10
7.0
RAPID 3 (0-30)
22.7
RAPID 3 (0-10)
7.6
WEIGHT (lbs)
LABORATORY DATA
ESR (mm/hr) [M:0-20 / F:0-30]
CRP (mg/L) [0-10]
HGB (g/dL) [M:14-18/F:12-16]
HCT (%) [M:42-50/F:37-44]
ALK PHOS (U/L) [40-100]
SGOT (U/L) [4-40]
161
120/66
8 Jun 04
13 Jul 04
16 Aug 05
11 Jul 06
7.00
8.5
8.7
24.2
8.1
23 Mar 04
8.00
10
10
28
9.3
18 May 04
4.33
7.2
7.5
19
6.3
0.33
4.0
2.0
6.3
2.1
0.33
1
0
1.3
0.4
1.00
3.7
3.1
7.8
2.6
156
122/80
161
106/70
161
134/68
160
112/61
179
115/78
182
116/72
76
213
9.1
10.1
34
574
68
65
12.7
9
31
475
3.9
139
15
45
9
9.7
9.4
31
477
4.1
124
51
62.8
11.6
13.3
41
345
4.3
92
17
0.9
0.8
0.7
0.9
Valdecoxib
Indomethacin SR
Infliximab
Phenylbutazone
Adalimumab
Prednisone
Methotrexate
Folic Acid
Ibuprofen
D-20 QD
N-75 QD
O-20 QD
D-75 QD
N Q8W
N-100 TID
20 QD
D-20 QD
C-6 Q8W
100 TID
D/c
100 TID
N-40 QOW
D-5 QD
D-100 TID
40 QOW
O-10 QW
O-1 QD
40 QOW
R-3 QD
15 QWK
1 QD
40 QOW
3 QD
15 QWK
1 QD
400 PRN
Figure 9. Patient flow sheet: inflammatory bowel disease arthritis in a 29-year-old man.
Behcets syndrome in a 39-year-old woman

A 39-year-old woman was seen on 27 May 2003 with a history of genital and oral
ulcers. A diagnosis of Behcets syndrome had been made by another rheumatologist,
who treated her with colchicine 0.6 mg BID, which led to significant improvement
but also to chronic diarrhea. Her score for physical function was 0, but her score
for pain 7, global status 5.2, and RAPID 3 (010) 4.0. Prednisone 3 mg/day, the usual
starting dose in this clinic, was added. She did not improve and her dose was raised by
her local physician to 15 mg per day, which led to substantial improvement. When she
was seen 12 August 2003, her score for physical function remained at 0, pain had
improved from 7 to 0, although global status remained 5.1 and RAPID 3 (010) 1.7.
Methotrexate 10 mg/week was added and prednisone tapered by 1 mg every 2 weeks.
Three months later, on 11 November 2003, her prednisone was 8 mg/day; score for
physical function remained 0, pain was 1, global status 4.6, and RAPID 3 (010)1.9. Her
prednisone-tapering schedule was changed to 1 mg every 3 months. On 15 February
2005, scores for function, pain and global status were all 0, with RAPID 3 of 0, maintained on 4 mg prednisone per day and 10 mg methotrexate per week.

DOB: June 1963 1
st
Visit: 27 May 2003 DX ICD9: 136.10 Onset: Jan 1999 Education: 12
Visit Date
27 May 03
12 Aug 03
11 Nov 03
3 Feb 04
15 Feb 05
9 Aug 05
21 Feb 06

PN-PAIN [0-10]
2.2
5.2
5.1
4.6
RAPID 3 (0-30)
12.2
5.1
5.6
2.2
RAPID 3 (0-10)
4.0
1.7
1.9
0.7
120

Weight (lbs)
97
95
102
111.8
98/58
122/81
146/64
100/70
114/74
120
149/91
128
110/70
LABORATORY DATA
ESR (mm/hr) [M:0-20/F:0-30]
15
CRP (mg/L) [0.0-10.0]
0.4
0.5
0.5
5.5
5.5
8.8
7.4
8.1
6.2
HGB (g/dL) [M:14-18]/F:12-16]
12.3
13.6
13.4
13.7
14.1
HCT (%) [M:42-50/F:37-44]

14
5.4
12.8
35
39
40
41
43
43
40
432
299
320
316
281
305
324
4.6
4.4
4.9
4.8
89
86
96
97
80
ALK PHOS (U/L) [40-100]
64
53
62
74
63
59
SGOT (U/L) [4-40]
24
27
28
33
33
45
0.6
0.7
0.7
0.6
0.7
4.4
82
0.7
RHEUMATOLOGY MEDICATIONS (C=Change Dose, D=D/C, N=New, O=On at visit, P=Parenteral, R=Resume, T=Taper)
Ibuprofen
O-800 Q6H
Colchicine
O-0.6 BID
0.6 BID
0.6 BID
0.6 BID
0.6 BID
prednisone
N-3 QD
C-15 QD
T-8 QD
T-7 QD
C-4 QD
N-10 QOK
O-10 QOK
methotrexate
Folic Acid
800 Q6H
O-10 QOK
O-10 QOK
O-1 QD
O-1 QD
0.6 BID
R-3 QD
0.6 BID
C-4 QD
O-10 QOK
O-20 QOK
O-1 QD
O-1 QD
Figure 10. Patient flow sheet: Behcets syndrome in a 39-year-old woman.
DOB: May 1968 1
st
Visit: 23 Sep 2003 DX ICD9: 579.0 Onset: Jan 1971 Education: 17
VISIT DATE
23 Sep 03
0
PAIN (PN) [0-10]
6.2
4.5
RAPID 3 (0-30)
10.7
RAPID 3 (0-10)
3.9
WEIGHT (lbs)
166
111/84
LABORATORY DATA
ESR (mm/hr) [M:0-20 / F:0-30]
76
CRP (mg/L) [0-10]
184
5
HGB (g/dL) [M:14-18/F:12-16]
15.5
HCT (%) [M:42-50/F:37-44]
46
298
ALK PHOS (U/L) [40-100]
SGOT (U/L) [4-40]
0.8
27 Jan 04
16 Mar 04
0
7
5.5
12.5
4.2
0
0
0
0
0
169
112/82
177
130/68
8
6.5
15.6
47
232
3.5
49
28
1.2
MiraLax
Colchicine
O-17 PRN
17 PRN
N-0.6 QD
17 PRN
0.6 QD
Figure 11. Patient flow sheet: familial Mediterranean fever in a 35-year-old man.
Familial Mediterranean fever in a 35-year-old man

A 35-year-man was seen on 23 September 2003. He reported recurrent abdominal
pain since childhood, for which he was bedridden for a day or two with recovery.
He had received diagnoses of multiple food allergies and gluten enteropathy. He had
experienced an attack 3 days before the visit. His score for physical function was 0,
but pain 6.2, global status 4.5, and RAPID 3 (010) 3.9. Because of his history of possible allergies and gluten enteropathy, it was elected to analyze his medical records
before suggesting any new intervention. His ESR rate was 76 and CRP 184 (upper limit
of normal 10) on that date. He returned on 27 January 2004 with similar scores for
physical function, pain, global status and RAPID 3. A prescription was given for colchicine 0.6 mg twice a day (BID). On 16 March 2004, his scores for physical function, pain,
global status and RAPID 3 had reverted to 0. He was then dismissed to the care of his
local physician to manage his colchicine therapy.
Practice points
Most standard rheumatology care outside of clinical trials and other clinical
research studies is conducted largely according to gestalt impressions without quantitative measures, other than laboratory tests, which often give false
positive and false negative results.
Patient questionnaires designed for research may be long and are not designed
to improve care at the visit; patient questionnaires designed for standard care
are short, completed by patient within 5-10 minutes, eyeballed and scored
within 10 seconds, save time for the physician, and add to clinical care.
A multidimensional health assessment questionnaire (MDHAQ) appears useful

in patients with all rheumatic diseases, and might be completed by each patient
at each rheumatology visit as a component of the infrastructure of standard
clinical care.
Research agenda
Further development of patient questionnaires designed for standard clinical
care to improve assessment, monitoring and documentation of care.
New strategies for clinicians to introduce patient questionnaires in the
infrastructure of standard rheumatology care.
ACKNOWLEDGEMENT
Supported in part by grants from the U.S. Arthritis Foundation and the Jack Massey
Foundation.
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An A Multi-Dimensional Health Assessment Questionnaire (MDHAQ) and Routine Assessment of Patient Index Data (RAPID) Scores Be Informative in Patients With All Rheumatic Diseases

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An A Multi-Dimensional Health Assessment Questionnaire (MDHAQ) and Routine Assessment of Patient Index Data (RAPID) Scores Be Informative in Patients With All Rheumatic Diseases

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Best Practice & Research Clinical Rheumatology

Vol. 21, No. 4, pp. 733753, 2007

Director of Outcomes Research

A multidimensional health assessment questionnaire (MDHAQ) is useful in standard care of

* Tel.: 1 615 936 2152; Fax: 1 615 936 2159.

734 T. Pincus and T. Sokka

In vasculitis: the Birmingham Vasculitis Activity Score (BVAS)22, Vasculitis Activity

736 T. Pincus and T. Sokka

MDHAQ SCORES IN 1107 PATIENTS WITH VARIOUS

867 patients seen at 1st

240 patients with previous care

738 T. Pincus and T. Sokka

As noted in Chapter 1, an increase in patient questionnaire scores can be due to

Visit: 27 May 2004 DX ICD9: 696.00 Onset: Oct 2003 Education: 16

PATIENT SELF-REPORT QUESTIONNAIRE DATA

GL-GLOBAL STATUS [0-10]

PHYSICAL MEASURES DATA

ESR (mm/hr) [M:0-20/F:0-30]

CRP (mg/L) [0.0-10.0]

Blood Pressure (mmHg)

WBC (thou/uL) [4-11]

HGB (g/dL) [M:14-18]/F:12-16]

HCT (%) [M:42-50/F:37-44]

PLATELETS (thou/uL) [150-400]

ALBUMIN (g/dL) [3.5-5.0]

GLUCOSE (mg/dL) [70-110]

ALK PHOS (U/L) [40-100]

SGOT (U/L) [4-40]

CREATININE (mg/dL) [0.7-1.5]

Figure 1. Patient flow sheet: psoriatic arthritis in a 24-year-woman.

740 T. Pincus and T. Sokka

Systemic lupus erythematosus in a 39-year-old woman

Multi-Dimensional Health Assessment Questionnaire (MDHAQ) Scores, Laboratory Tests, Medications

Visit: 15 Feb 2005 DX ICD9: 710.10 Onset: Sept 2004 Education: 12

Figure 2. Patient flow sheet: systemic lupus erythematosus in a 39-year-old woman.

Ankylosing spondylitis in a 35-year-old man

Multi-Dimensional Health Assessment Questionnaire (MDHAQ) Scores, Laboratory Tests, Medications

Visit: 12 Aug 2003 DX ICD9: 720.00 Onset: Jan 1990 Education: 10

Figure 3. Patient flow sheet: ankylosing spondylitis in a 35-year-old man.

742 T. Pincus and T. Sokka

Gout in a 68-year-old man

Multi-Dimensional Health Assessment Questionnaire (MDHAQ) Scores, Laboratory Tests, Medications

Visit: 9 Dec 2003 DX ICD9: 274.90 Onset: Jan 1973 Education:16

Figure 4. Patient flow sheet: gout in a 68-year-old man.

Scleroderma in a 45-year-old woman

Multi-Dimensional Health Assessment Questionnaire (MDHAQ) Scores, Laboratory Tests, Medications

DOB: Mar 1947 1

Visit: 8 Sep 1992 DX ICD9: 710.10 Onset: July 1980 Education:16

Figure 5. Patient flow sheet: systemic sclerosis in a 45-year-old woman.

744 T. Pincus and T. Sokka

Vasculitis in a 34-year-old woman

Multi-Dimensional Health Assessment Questionnaire (MDHAQ) Scores, Laboratory Tests, Medications

Visit: 16 Jan 1990 DX ICD9: 447.60 Onset: July 1989 Education: 12

PATIENT SELF-REPORT QUESTIONNAIRE DATA

GL-GLOBAL STATUS [0-10]

PHYSICAL MEASURES DATA

CRP (mg/L) [0.0-10.0]

Blood Pressure (mmHg)

WBC (thou/uL) [4-11]

HGB (g/dL) [M:14-18]/F:12-16]

HCT (%) [M:42-50/F:37-44]

PLATELETS (thou/uL) [150-400]

ALBUMIN (g/dL) [3.5-5.0]