How to score MDHAQ

Scoring Instructions for R808 Multi-Dimensional Health Assessment Questionnaire (MDHAQ) and Rheumatology Assessment Patient Index Data (RAPID3) mdhaq.org tedpincus@gmail.com

The August 2009 version of the Multi-Dimensional Health Assessment Questionnaire (MDHAQ), R808, is a 2-page version for new and returning patients. Scoring is facilitated by visual analog scales (VAS) of 21 circles rather than 10 cm lines, and by templates and boxes to enter scores in a “For Office Use Only” section at the right-hand edge of the page. The RAPID3 composite score (on a 0-30 scale) includes 4 categories: High Severity >12, Moderate Severity=6.1-12, Low severity=3.1-6, and Remission <=3. A signature box appears at the end to document review of the questionnare, as described below for Page 2. RAPID3 (routine assessment of patient index data) is an index of the 3 patient-reported outcome measures in the RA Core Data Set: physical function, pain and patient global estimate.

RAPID3 can be calculated from an MDHAQ in fewer than 10 seconds, without a ruler, calculator, computer or website. RAPID3 measures and scores may serve as “vital signs” in patients with chronic rheumatic diseases, and possibly all chronic diseases, analogous to pulse and temperature in acute diseases and blood pressure and cholesterol in long-term health.

The most effective method to collect patient questionnaire data in standard care is to ask each patient (regardless of diagnosis) to complete an MDHAQ as a component of the care infrastructure, when the patient registers for each visit. If there is a need for a visit, there is a need for MDHAQ/RAPID3 “vital signs” on clinical status.

The MDHAQ should be reviewed by the rheumatologist prior to seeing the patient and/or with the patient. It may simply be “eyeballed” and filed, though it is much more effective to score RAPID3, review during the visit, and enter into a flow sheet. A visit without quantitative data is a lost opportunity that can never be replaced.

Scoring of R808 MDHAQ – RAPID3 Page 1:

  1. a-j: FN = FUNCTION. Ten activities of daily living (ADL) are scored 0-3 by the patient: 0="without any difficulty", 1="with some difficulty", 2="with much difficulty", and 3="unable to do." The sum of a-j is totaled mentally by the health professional in about 3 seconds by totaling the number of 3s, 2s, 1s and 0s, for a total of 0-30. This raw score is divided by 3 using the template in the “For Office Use Only” section at the right to give a score of 0-10, and entered in the FN box in the “For Office Use Only” section. k, l, m constitute a psychological status (PS) scale, with each of 3 items scored 0-3.3 for a total of 9.9. A PS score may be calculated as the simple total of the 3 items. It is not entered in the right side box.
  2. PN = PAIN visual analog scale (VAS) is presented as 21 circles, rather than as a traditional 10 cm line, to facilitate scoring without a ruler. An arithmetic scale of 0-10 in 0.5 unit increments is printed below the circles. The raw score is entered in the PN box in the “For Office Use Only” section at the right.
  3. JTCT = RADAI (Rheumatoid Arthritis Disease Activity Index) self-report joint count includes 8 joints or joint groups, scored 0, 1, 2 or 3 by the patient. Neck and back are recorded. The RADAI may be scored formally, but extensive research indicates that it adds little to RAPID3 and consumes more time. Therefore, formal scoring is not needed, although the information can be clinically valuable.
  4. PTGL = PATIENT GLOBAL estimate VAS is also in a 21 circle format, with an arithmetic 0-10 scale in 0.5 unit increments below the circles. The raw score is entered in the PTGL box in the “For Office Use Only” section at the right.

    RAPID3
    (0-30 scale): total score of 3 measures in the ACR Core Data Set. Templates to score RAPID3 on a 0-30 scale are found at the right side of the “For Office Use Only” section. RAPID3 is highly significantly correlated with DAS28 and CDAI [6], as well as with other RAPID versions, including RAPID4 0-40 (4 measures) which adds the RADAI patient self-report joint count (0-10), and RAPID5 (5 measures), which adds RADAI and a physician global estimate (0-10). The added time to score does not appear justified, as RAPID3 gives similar data as DAS28 and CDAI to distinguish active versus placebo treatments in clinical trials (7). RAPID 3 is calculated in 10 seconds or less, compared to 42 for a HAQ, 90 for a 28 joint count, 108 for CDAI and 114 for DAS28 (8).
  5. ROS = Symptom checklist review of systems. Quantitative review is the count of checked boxes, which may be entered as “ROS” in box at right. More than 20 “positive” checks suggests fibromyalgia or somatization, even in patients who meet criteria for SLE or RA; more than 30 check in an outpatient setting is virtually pathognomonic for fibromyalgia or somatization.
  6. AM = Morning stiffness, scored in minutes, maximum 300 minutes – not formally scored.
  7. CHG = Change in status over the last week scored 1 = Much better, 2 = Better, 3 = Same, 4 = Worse, 5 = Much worse (5), not formally scored.
  8. EX = Exercise frequency – increasingly important in patient management, scored 3 = 3 or more times a week, 2 = 1-2 times per week, 1 = 1-2 times per month, 0 = Do not exercise regularly, 9 = Cannot exercise due to disability/ handicap, not formally scored.
  9. FT = FATIGUE VAS, scored 0-10, not formally scored.
  10. Recent medical history developments, including falls – saves time and very helpful in standard care, not scored quantitatively.

At the bottom of page 2: demographic data, today’s date, signature for evidence of documentation.

A health professional should review the patient questionnaire with the patient; it is highly recommended to enter data onto a standard flow sheet, which may include questionnaire scores, laboratory tests and therapies; flow sheets can be very helpful and save further time in clinical care.

Other options for options for management include:

  • “eyeball” data-physical function, pain and global, and self-report joint count on 1-side of 1-page;
  • score questionnaire for FN, PN, PTGL for RAPID 3 may be scored in research studies at a later time;
  • enter into a computer database, which is not necessary, but allows compiling of data for reports.

The MDHAQ is protected by copyright. Rheumatologists may use any version in their patient care without concern for copyright protection, though profit making entities are requested to contact the developer at tedpincus@gmail.com regarding royalty arrangements. Possible users are encouraged to contact this E-mail address, or telephone, 615-479-5303.

References:

  1. Pincus T, Yazici Y, Bergman M. Development of a multi-dimensional health assessment questionnaire (MDHAQ) for the infrastructure of standard clinical care. Clin Exp Rheumatol 2005; 23:S19-S28. website www.clinexprheumatol.org
  2. Pincus T, Wolfe F. Patient questionnaires for clinical research and improved standard patient care: is it better to have 80% of the information in 100% of patients or 100% of the information in 5% of patients? J Rheumatol 2005;32:575-7.
  3. Pincus T, Segurado OG: Most visits of most patients with rheumatoid arthritis to most rheumatologists do not include a formal quantitative joint count. Ann Rheum Dis 65:820-822, 2006.
  4. Pincus T: Advantages and limitations of quantitative measures to assess rheumatoid arthritis: joint counts, radiographs, laboratory tests, and patient questionnaires. Bull Hosp Joint Dis 64:32-39, 2006.
  5. Pincus T, Sokka T: 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? Best Pract Res Clin Rheumatol 21:733-753, 2007.
  6. Pincus T, Swearingen CJ, Bergman M, Yazici Y. RAPID3 (routine assessment of patient index data 3), a rheumatoid arthritis index without formal joint counts for routine care: Proposed severity categories compared to DAS and CDAI categories. J Rheumatol 2008; 35:2136-47.
  7. Pincus T, Bergman MJ, Yazici Y, Hines P, Raghupathi K, Maclean R. An index of only patient-reported outcome measures, routine assessment of patient index data 3 (RAPID3), in two abatacept clinical trials: similar results to disease activity score (DAS28) and other RAPID indices that include physician-reported measures. Rheumatology 2008; 47(3):345-9.
  8. Pincus T, Swearingen CJ, Bergman MJ, Colglazier CL, Kaell A, Kunath A et al. RAPID3 on an MDHAQ is correlated significantly with activity levels of DAS28 and CDAI, but scored in 5 versus more than 90 seconds. Arthritis Care Res 2010; 62:181-9.
  9. Pincus T, Bergman MJ, Yazici Y. RAPID3—An index of physical function, pain, and global status as “vital signs” to improve care for people with chronic rheumatic diseases. Bull NYU Hosp Jt Dis. 2009;67(2):211-25

G808-scoring.pdf