July 3, 2007 Rheumatologists substantially overestimate the physical disability of patients with rheumatoid arthritis – which may lead to inaccurate evaluations of the patient’s ability to work and need for lifestyle modifications, a new study found.
Researchers at the University of South Florida College of Medicine and James A. Haley Veterans’ Hospital found a clear physician-patient difference in assessment of the patients’ functional disability. The rheumatologists consistently rated their rheumatoid arthritis patients’ degree of difficulty in performing activities of daily living, such as walking, dressing and eating, higher than the patients themselves. This was particularly true for patients in advanced stages of the disease. The findings appear in the May 2007 issue of the Journal of Rheumatology.
“We flunked,” said co-first author John D. Carter, MD, assistant professor of medicine in the USF Division of Rheumatology. “The very physicians deemed to be experts in rheumatoid arthritis failed to make the grade when it came to determining their patients’ functional status.
“This discrepancy is important to correct because patients can rely on these assessments for their livelihood or other necessities to perform activities of daily living.”
Rheumatologists are frequently asked to complete functional disability reports by employers, disability attorneys, insurance companies and government agencies weighing a person’s eligibility for disability payments, employment, or assistive devices such as wheelchairs, walkers, braces and splints.
Using the Stanford Health Assessment Questionnaire-Disability Index (HAQ-DI), rheumatologists evaluated 223 patients during their regularly scheduled visits to the USF Rheumatology Clinics and James A. Haley Veterans’ Hospital. The effectiveness of the HAQ-DI, based on patient self-reporting of their disability status, has been validated in clinical studies. The questionnaire covers eight activities of daily living: dressing, arising, eating, hygiene, walking, reach, grip and outside activity.
Both physician and patient completed the HAQ-DI independently immediately following the visit and their respective scores were not shared.
The rheumatologists overestimated the degree of functional disability in 154, or 69 percent, of the 223 the patients. However, they were significantly more accurate at determining the degree of physical limitations in patients with less severe disease.
The reasons for the overestimation are unclear, but may include empathy and suggest that even patients with advanced rheumatoid arthritis adapt their activities to the progression of the chronic disease, Dr. Carter said. “We tend to associate visible joint deformities with incapacitated function, but patients may actually be more capable than we think.”
Rheumatologists typically determine functional disability based on the patient’s examination and medical history, but these impressions during routine care are inadequate, Dr. Carter said. The study points to the need for a formal, standardized evaluation, such as the HAQ-DI. “It needs to be reimbursable and include input from physical and occupational therapists who could add valuable insight to the process of evaluating disability,” he added.
Rheumatoid arthritis affects about 2.1 million Americans, or 1 percent of the population. Over the last decade new drugs have revolutionized the treatment of this debilitating inflammatory disease, but nearly all patients with rheumatoid arthritis eventually develop some degree of work or daily lifestyle disability, often severe.
Other authors of the study were Abdul B. Lohdi, MD (co-first author); Sonia R. Nagda; Louis Ricca, MD; Colleen Ward, DO; Erica Traina; Zachary J. Thompson; Yangxin Huang, PhD; Joanne Valeriano, MD; and Frank B. Vasey, MD.
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