Importance of patient history and physical examination in rheumatoid arthritis compared to other chronic diseases: Results of a physician survey

Abstract

Objective. To survey physicians' opinions concerning the relative importance of 5 clinical encounter components-vital signs, patient history, physical examination, laboratory tests, and ancillary studies-in the diagnosis and management of 8 chronic diseases. Methods. A SurveyMonkey internet survey was e-mailed to 7,265 US physicians, including 3,542 rheumatologists and 3,723 nonrheumatologists, with the following query: "Please indicate the relative importance of 5 sources of information-vital signs, patient history, physical examination, laboratory tests, and ancillary studies-in diagnosis of congestive heart failure (CHF), diabetes mellitus, hypercholesterolemia, hypertension, lymphoma, pulmonary fibrosis, rheumatoid arthritis (RA), and ulcerative colitis." The response options were 0 -20%, 21-40%, 41-60%, 61-80%, and 81-100%. A second query with an identical structure addressed management of the 8 diseases. The proportions of physicians who estimated each component as most (or tied for most) important in diagnosis or in management were computed. Results. The survey was completed by 313 physicians (154 rheumatologists and 159 nonrheumatologists). More than 90%estimated vital signs as most important for hypertension, and laboratory tests for diabetes mellitus and hypercholesterolemia. More than 70% estimated ancillary studies as most important for lymphoma, pulmonary fibrosis, and ulcerative colitis. Patient history and physical examination were estimated as most important for RA and CHF by >50% of nonrheumatologists. Conclusion. RA and CHF were the only 2 of the 8 diseases studied for which >50% of nonrheumatologists estimated a patient history and physical examination as most important for diagnosis and management. Confirmation and extension of these observations in actual care may have implications for reimbursement and organization of clinical care.

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

“…A 2007 report indicated that ESR and CRP were normal in about 40% of patients from the USA and Finland (Table 2) [30]. The diagnosis of RA, as noted, depends primarily on the history and physical examination, rather than on laboratory tests, imaging, or other high-technology data [26]. If a physician seeks to establish a diagnosis of RA with laboratory tests, a "false negative" result will be seen for rheumatoid factor or ACPA in 3 of 10 patients, and a normal ESR or CRP will be seen in 4 of 10 patients.…”

“…However, about 1 in 6 individuals in the general population sees a doctor because of musculoskeletal problems. Many clinicians order a rheumatoid factor or ACPA test to "screen" for RA, even when there is no clinical evidence of RA, despite evidence that medical history and physical examination data are far more prominent in diagnosis and management decisions in RA than laboratory tests or ancillary studies [26]. Since the prevalence of RA is 0.5%∼1%, even if rheumatoid factor or ACPA is tested in only 15% of the population, at a 5% "false-positive" rate, a positive test for rheumatoid factor or ACPA is seen in as many people who do not have RA as in people who have this disease (70% of 1%=0.70%, 5% of 15%=0.75%).…”

“…Patient medical history data depicted as quantitative scores on standard patient questionnaires as the foundation for a "scientific," evidence-based biopsychosocial model Even in traditional medical care conducted according to a biomedical model, a patient history is recognized as contributing substantially to diagnosis, management, prognosis, and assessment of outcomes [26,[73][74][75][76]. In a biopsychosocial model, the importance of a patient medical history is recognized and regarded as having equal or greater importance compared to laboratory tests and other high technology data.…”

Documenting the Value of Care for Rheumatoid Arthritis, Analogous to Hypertension, Diabetes, and Hyperlipidemia: Is Control of Individual Patient Self-Report Measures of Global Estimate and Physical Function More Valuable Than Laboratory Tests, Radiographs, Indices, or Remission Criteria?

“…Clinical decisions in RA are based more on a patient history and physical examination than on biomarkers; in contrast, biomarkers dominate clinical decisions in many chronic diseases, and may include vital signs (e.g., blood pressure in hypertension); laboratory tests (e.g., hemoglobin A1c in diabetes); imaging (e.g., computed tomographic scan in pulmonary fibrosis), or other ancillary studies (e.g., endoscopy in inflammatory bowel disease) 10 .…”

“…These indices are based on a core data set for RA 14 of 7 measures: 3 from patient self-report, 3 from physical examination, but only 1 laboratory test -ESR or CRP -reflecting limitations of biomarkers and the promin-ence of patient history and physical examination in RA 10 . Remission according to Disease Activity Score with 28 joint count (DAS28) 15 , Simplified Disease Activity Index (SDAI) 16 , Clinical Disease Activity Index (CDAI) 16 , and Routine Assessment of Patient Index Data (RAPID3) 17 has been described.…”