AB0313 Physician global assessment of the status of patients with rheumatoid arthritis (RA) at their first visit to an academic routine care setting are explained as much by damage and distress as by inflammation, according to physician ratings: should the structure of rheumatology care be modified?
Authors: T. Pincus, I. Castrejon, J.A. Block
Journal: Annals of the Rheumatic Diseases (2018)

<h3>Background</h3> A physician global assessment (DOCGL) on a 0–10 visual analogue scale (VAS) reflects inflammatory activity in patients who meet criteria for RA clinical trials, in which DOCGL is more efficient than laboratory tests or joint counts to distinguish active from control treatments.<sup>1</sup> However, in routine clinical care, patients are not selected for inflammatory activity, and may have joint damage and/or distress (fibromyalgia, depression, etc.) as important clinical problems. Some rheumatologists consider damage and distress in assigning a 0–10 DOCGL; others consider only inflammation. One approach to resolve this matter is for physicians to estimate the proportion of DOCGL attributed to inflammation, damage, or distress (total=100%). <h3>Objectives</h3> To analyse a physician 0–10 VAS overall global assessment for estimates of the proportions attributed to inflammation, damage, or distress (total=100%). <h3>Methods</h3> Rheumatologists at one academic setting complete a 0–10 VAS for DOCGL, and estimates of the proportion of DOCGL attributed to inflammation, damage, and/or distress (total=100%). These scales were analysed in 38 new patients with RA seen between April and November 2017, using cross-tabulations to compare patients whose DOCGL was 0–4 vs 4.1–10 vs the proportion of inflammation, damage, or distress (total=100%) as 0%–40% or 41%–100%. <h3>Results</h3> Physician global assessment was 4–10 in 23/38 patients (61%) at first visit, and 0–4 in 15/38 (39%) (table 1). In all 38 patients, inflammation was rated as explaining 41%–100% of DOCGL in 11/38 (29%), compared to damage in 18/38 (47%), and distress in 6/38 patients (16%). Among the 23/38 patients with DOCGL 4–10, inflammation was rated as explaining 41%–10%% of DOCGL in 6/23 (29%), versus 10/23 (43%) for damage, and 5/23 (22%) distress. Therefore, inflammation appear to account for &gt;40% of DOCGL only in a minority of new RA patients, which were explained more by either damage or distress (or both). <h3>Conclusions</h3> At one academic rheumatology site, a physician global assessment VAS at the initial visit of patients with RA was explained as much by damage and/or distress as by inflammatory activity. One important limitation of the study is that some patients had already received treatment at other rheumatology sites. Nonetheless, the data indicate that damage and distress appear as prominent as inflammation in contemporary management of RA, reflecting a well-known delay in diagnosis and patient management. The findings suggest a possible need to restructure rheumatology practice to see patients more urgently, including education of primary care physicians, in order to improve outcomes for patients with RA. The data also support the possible value of physician estimates of the proportion of DOCGL attributed to inflammation, damage, or distress. <h3>Disclosure of Interest</h3> T. Pincus Shareholder of: Dr. Pincus holds a copyright and trademark on MDHAQ and RAPID3 for which he receives royalties and license fees. All revenue is used to support further development of quantitative questionnaire measures for patients and doctors in clinical rheumatology care., I. Castrejon: None declared, J. Block: None declared