Routine assessment of patient index data (RAPID) scores

No single measure can serve as a “gold standard” for assessment of patient status in rheumatoid arthritis (RA). Therefore, a pooled index (1), such as the American College of Rheumatology (ACR) Core Data Set (2-4) and disease activity score (DAS) (5;6), and more recently, a simplified disease activity index (SDAI) (7) and clinical disease activity index (CDAI) (7) have been developed. All these indices include a formal joint count of tender and swollen joints performed by a physician/assessor.

The joint count is the most specific measure to assess RA (8), and is regarded by rheumatologists as the most important assessment measure (9). However, while most rheumatologists perform careful qualitative joint examinations at most visits, a formal quantitative joint count is not included at most visits of most patients with RA to rheumatologists (10). Therefore, most care of patients with RA is conducted without quantitative data, other than laboratory tests, which often are not informative, or associated with false positive and false negative results (11).

An index of only the 3 ACR Core Data Set patient reported outcome (PRO) measures - physical function, pain, and global estimate, is available on the health assessment questionnaire (HAQ), and distinguishes active from control treatments at levels similar to the ACR Core Data Set and DAS in clinical trials involving leflunomide (12;13), methotrexate (12;13), and adalimumab (14). PRO indices are correlated with the DAS in clinical trials (12-14) and in clinical settings (15). An index which does not require formal joint counts might enhance feasibility to incorporate quantitative data into standard rheumatology care. The additional indices are termed “routine assessment of patient index data” (RAPID), as they have been designed for use in a busy clinical setting; a number is added to indicate the number of individual measures included.

The prototype RAPID 3 includes physical function, pain, and patient global estimate, the 3 patient measures from the Core Data Set (2-4). RAPID 3 is mathematically identical to a patient activity score (PAS), but with a raw score of 0-30 and adjusted score of 0-10 rather than 0-9 (15). The score for physical function is converted from 0-3 to 0-10 by multiplying by 3.33, using a template on the MDHAQ. Pain and global estimate are assessed according to visual analog scales (VAS), both scored 0-10. The three 0-10 scores for physical function, pain VAS, and global VAS, are added together for a raw score of 0-30, and divided by 3 to give an adjusted 0-10 score for comparison with other RAPID indices. The rationale for RAPID 3 is to include the three PRO measures from the ACR Core Data Set, available on a standard patient questionnaire, requiring no activity on the part of a health professional, other than to calculate simple arithmetic totals.

RAPID 4 adds to RAPID 3 a rheumatoid arthritis disease activity index (RADAI) self-report joint count, which includes 8 joints or joint groups, scored 0, 1, 2 or 3, for a 0-48 scale, which is recoded to 0-10, using scoring templates on the MHAQ, The rationale for RAPID 4JC is that rheumatologists indicate that the joint count is the most valuable measure to assess patients with RA (9), and the joint count is the most specific measure of RA (8). A 66 tender joint count is converted to a 0-10 scale using simple division by 6.6. The raw RAPID 4JC score is 0-40, i.e., the sum of four 0-10 scores for physical function, pain VAS, global VAS, and tender joint count. The raw RAPID 4JC score is divided by 4 to give an adjusted 0-10 score.

RAPID5 adds a physician global estimate (0-10) to RAPID4. The rationale for RAPID 5 is to include both the measure that most rheumatologists indicate is most valuable to assess patients with RA, i.e., the joint count (9), and the measure with the highest relative efficiency in clinical trials, i.e., physician/assessor estimate of global status (16). RAPID 5 is therefore the most comprehensive RAPID index. The RAPID 5 raw score is 0-50 and divided by 5 to give an adjusted 0-10 score.

Templates to score RAPID3, RAPID4,and RAPID5 are found at the right side of the “For Office Use Only” section at the right. Templates at the bottom of page 1 of the MDHAQ recode 0-30 scores for RAPID3, 0-40 scores for RAPID4, and 0-50 scores for RAPID5 to 0-10. In general, RAPID3, 4, and 5 yield very similar scores, and it is necessary to score only RAPID3, which can be accomplished in 10 seconds or less. If the rheumatologist is more comfortable to include a joint count in the index, RAPID5 requires about 20 seconds.

Reference List

  1. Goldsmith CH, Smythe HA, Helewa A. Interpretation and power of pooled index. J Rheumatol 1993; 20:575-578.
  2. Felson DT, Anderson JJ, Boers M, Bombardier C, Chernoff M, Fried B et al. The American College of Rheumatology preliminary core set of disease activity measures for rheumatoid arthritis clinical trials. Arthritis Rheum 1993; 36:729-740.
  3. Tugwell P, Boers M. OMERACT Committee. Proceedings of the OMERACT Conferences on outcome measures in rheumatoid arthritis clinical trials, Maastrict, Netherlands. J Rheumatol 1993; 20:527-591.
  4. Boers M, Tugwell P, Felson DT, van Riel PLCM, Kirwan JR, Edmonds JP et al. World Health Organization and International League of Associations for Rheumatology core endpoints for symptom modifying antirheumatic drugs in rheumatoid arthritis clinical trials. J Rheumatol 1994; 21(Suppl 41):86-89.
  5. van der Heijde DMFM, van't Hof MA, van Riel PLCM, Theunisse LM, Lubberts EW, van Leeuwen MA et al. Judging disease activity in clinical practice in rheumatoid arthritis: first step in the development of a disease activity score. Ann Rheum Dis 1990; 49:916-920.
  6. van der Heijde DMFM, van't Hof M, van Riel PLCM, van de Putte LBA. Development of a disease activity score based on judgment in clinical practice by rheumatologists. J Rheumatol 1993; 20:579-581.
  7. Aletaha D, Smolen J. The simplified disease activity index (SDAI) and the clinical disease activity index (CDAI): a review of their usefulness and validity in rheumatoid arthritis. Clin Exp Rheumatol 2005; 23:S100-S108.
  8. Pincus T. The DAS is the most specific measure, but a patient questionnaire is the most informative measure to assess rheumatoid arthritis. J Rheumatol 2006; 33:834-837.
  9. Wolfe F, Pincus T, Thompson AK, Doyle J. The assessment of rheumatoid arthritis and the acceptability of self-report questionnaires in clinical practice. Arthritis Care Res 2003; 49(1):59-63.
  10. 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 2006; 65:820-822.
  11. Wolfe F, Michaud K. The clinical and research significance of the erythrocyte sedimentation rate. J Rheumatol 1994; 21:1227-1237.
  12. Pincus T, Strand V, Koch G, Amara I, Crawford B, Wolfe F et al. An index of the three core data set patient questionnaire measures distinguishes efficacy of active treatment from placebo as effectively as the American College of Rheumatology 20% response criteria (ACR20) or the disease activity score (DAS) in a rheumatoid arthritis clinical trial. Arthritis Rheum 2003; 48(3):625-630.
  13. Pincus T, Amara I, Koch GG. Continuous indices of Core Data Set measures in rheumatoid arthritis clinical trials: lower responses to placebo than seen with categorical responses with the American College of Rheumatology 20% criteria. Arthritis Rheum 2005; 52:1031-1036.
  14. Pincus T, Chung C, Segurado OG, Amara I, Koch GG. An index of patient self-reported outcomes (PRO Index) discriminates effectively between active and control treatment in 4 clinical trials of adalimumab in rheumatoid arthritis. J Rheumatol 2006; 33:2146-2152.
  15. Wolfe F, Michaud K, Pincus T. A composite disease activity scale for clinical practice, observational studies and clinical trials: the patient activity scale (PAS/PAS-II). J Rheumatol 2005; 32:2410-2415.
  16. Tugwell P, Wells G, Strand V, Maetzel A, Bombardier C, Crawford B et al. Clinical improvement as reflected in measures of function and health-related quality of life following treatment with leflunomide compared with methotrexate in patients with rheumatoid arthritis: Sensitivity and relative efficiency to detect a treatment effect in a twelve-month, placebo-controlled trial. Leflunomide rheumatoid arthritis investigators group. Arthritis Rheum 2000; 43:506-514.

Download as PDF