J Rheum Dis.  2016 Aug;23(4):212-233. 10.4078/jrd.2016.23.4.212.

Evidence from a Multidimensional Health Assessment Questionnaire (MDHAQ) of the Value of a Biopsychosocial Model to Complement a Traditional Biomedical Model in Care of Patients with Rheumatoid Arthritis

• Pincus T
• Chua JR
• Gibson KA

• KMID: 2352465
• DOI: http://doi.org/10.4078/jrd.2016.23.4.212

Abstract

Patient self-report questionnaires such as a multidimensional health assessment questionnaire (MDHAQ) have advanced knowledge concerning prognosis, care, course and outcomes of rheumatoid arthritis (RA). The MDHAQ may overcome some limitations of a "biomedical model," the dominant paradigm of contemporary medical services, including limitations of laboratory tests, radiographs, joint counts, and clinical trials, to predict and depict the long-term course and outcomes of RA. A complementary "biopsychosocial model" captures components of a patient medical history on patient questionnaires as quantitative, standard, "scientific" scores for physical function, pain, fatigue, and other problems, rather than as 'subjective" narrative descriptions. A rationale for a biopsychosocial model in RA includes the importance of a patient history in diagnosis and management compared to biomarkers in many chronic diseases such as hypertension and diabetes. Some important observations which support a biopsychosocial model in RA based on patient questionnaires include that MDHAQ physical function scores are far more significant than radiographs or laboratory tests to predict severe RA outcomes such as work disability and premature death; patient self-report measures are more efficient than tender joint counts and laboratory tests to distinguish active from control treatments in RA clinical trials involving biological agents; and MDHAQ scores are more likely than laboratory tests to be abnormal at presentation and to document incomplete responses to methotrexate at initiation of biological agents. Patient questionnaires can save time for doctors and patients, and improve doctor-patient communication. A standardized database of MDHAQ scores consecutive patients over long periods might be considered by all rheumatologists in routine clinical care.

Keyword

Rheumatoid arthritis (RA); Multidimensional health assessment questionnaire (MDHAQ); Routine assessment of patient index data 3 (RAPID3); Biomedical model; biopsychosocial model

MeSH Terms

Arthritis, Rheumatoid*
Biological Factors
Biomarkers
Chronic Disease
Complement System Proteins*
Diagnosis
Fatigue
Humans
Hypertension
Joints
Methotrexate
Mortality, Premature
Prognosis
Biological Factors
Biomarkers
Complement System Proteins
Methotrexate

Figure

• 

  Figure 1. Standard composite treatment effect (in standard units). Meta-analysis of 66 clinical trials reported in 1990 concerning the efficacy of DMARDs in the treatment of RA [91]. This meta-analysis included 117 treatment groups: 11 for anti-malarial drugs (e.g., hydroxychloroquine), 23 for auranofin, 29 for injectable gold, 7 for methotrexate, 19 for d-penicill-amine, 6 for sulfasalazine, and 22 for placebo. All drugs have greater efficacy than placebo in the management of RA, determined according to a composite of grip strength (a measure of effectiveness of grip), TJC, and ESR, adjusted for disease duration, trial length, initial tender joint count, and blinding. In these analyses, no significant differences were seen between sulfasalazine, d-penicillamine, methotrexate, and injectable gold (From Felson et al. The comparative efficacy and toxicity of second-line drugs in rheumatoid arthritis. Results of two metaanalyses. Arthritis Rheum 1990;33:1449-61; with per-mission) [63]. DMARDs: disease-modifying anti-rheumatic drugs, RA: rheumatoid arthritis, TJC: tender joint count, AUR: auranofin, AntiM: antimalarial drug, AZA: azathioprine, MTX: methotrexate, DPen: d-penicillamine, SSZ: sulfasalazine, ESR: erythrocyte sedimentation rate.

• 

  Figure 2. (A) Estimated continuation of all 1,083 courses of second line therapies in 532 patients with rheumatoid arthritis over 60 months. Differences between methotrexate and all other drugs, as well as between oral gold (auranofin) and all other drugs, are statistically significant (p＜0.001), while differences among other drugs are not significant. (B) Estimated continuation of 477 courses of the initial second line therapy used in the same 532 patients over 12 months. Differences between methotrexate versus oral gold (auranofin) are not statistically significant, and are considerably less apparent than in (A), in which estimated continuation was studied for all courses over 60 months (Pincus et al. Longterm drug therapy for rheumatoid arthritis in seven rheumatology private practices: II. Second line drugs and prednisone. J Rheumatol 1992;19:1885-94) [64].

• 

  Figure 3. The multidimensional health assessment questionnaire (MDHAQ). (From Pincus et al. RAPID3 (Routine Assessment of Patient Index Data 3), a rheumatoid arthritis index without formal joint counts for routine care: proposed severity categories compared to disease activity score and clinical disease activity index categories. J Rheumatol 2008;35:2136-47) [83].

• 

  Figure 4. Time to score various rheumatoid arthritis indices in seconds, including 28 joint count, health assessment questionnaire-disability index (HAQ-DI), disease activity score 28 (DAS28), clinical disease activity index (CDAI), routine assessment of patient index data (RAPID3) scores 0∼10, RAPID3 scored 0∼30 (Pincus et al. RAPID3 (Routine Assessment of Patient Index Data) on an MDHAQ (Multidimensional Health Assessment Questionnaire): agreement with DAS28 (Disease Activity Score) and CDAI (Clinical Disease Activity Index) activity categories, scored in five versus more than ninety seconds. Arthritis Care Res (Hoboken) 2010;62:181-9) [60].

• 

  Figure 5. Nine to ten year survival according to quantitative markers in three chronic diseases, rheumatoid arthritis, Hodgkin's disease, coronary artery disease. Adapted from Figure 1 in the article of Pincus and Callahan (J Rheumatol 1986;13:841-5) [102].

• 

  Figure 6. Significance of 8 variables as predictors of mortality, in a review of 84 reports concerning mortality in rheumatoid arthritis, 53 cohorts presented predictors of mortality. For each variable, n=the number of reports that included the variable, and bars indicate the percentage of those reports in which the variable was a significant predictor of mortality in multivariate analyses (black), in univariate analyses (dotted), or not significant (white). ESR: erythrocyte sedimentation rate. Adapted from Figure 2 in the article of Sokka et al. (Clin Exp Rheumatol 2008;26(5 Suppl 51):S35-61) [100].

• 

  Figure 7. Relative efficiencies of 7 rheumatoid arthritis Core Data Set measures to distinguish active from control treatments in 9 clinical trials, involving methotrexate, leflunomide, placebo, infliximab, adalimumab, and abatacept according to arithmetic and percentage changes. TJC: tender joint count, SJC: swollen joint count, DOCGL: physician global assessment, ESR: erythrocyte sedimentation rate, CRP: C-reactive protein, HAQ-FN: health assessment questionnaire-function, PATGL: patient global estimate of status, MTX: methotrexate, PBO: placebo, LEF: leflunomide, INF: infliximab, ADA: adalimumab, ABA: abatacept. Adapted from Figure 3 in the article of Pincus et al. (Clin Exp Rheumatol 2014;32 Suppl 85(5):S-47-54) [55].

• 

  Figure 8. Spearman correlations of routine assessment of patient index data 3 (RAPID3) scores with (A, C) the disease activity score 28 (DAS28) and (B, D) clinical disease activity index (CDAI) in (A, B) the rheumatoid arthritis prevention of structural damage 1 (RAPID1) clinical trial of certolizumab pegol in 982 patients at 52 weeks and (C, D) in 285 patients with RA seen in usual clinical care. Adapted from (A, B) Figure 1 in the article of Pincus et al. (Arthritis Care Res (Hoboken) 2011;63:1142-9) [107] and (C, D) Figure 3 in the article of Pincus et al. (Bull NYU Hosp Jt Dis 2009;67:211-25) [90].

• 

  Figure 9. Improvement in routine assessment of patient index data 3 (RAPID3) scores over 2 months in patients with 5 rheumatic diseases, rheumatoid arthritis (RA), osteoarthritis (OA), systemic lupus erythematosus (SLE), spondyloarthritis (SpA), gout. CI: confidence interval. Adapted from Figure 1 in the article of Castrejón et al. (J Clin Rheumatol 2013;19:169-74) [116].

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