Faculty Bibliography

Objective: To analyze discordance between global estimates by patients (PATGL) and their physicians (DOCGL) according to demographic and self-report variables on a multidimensional health assessment questionnaire (MDHAQ), in patients with many rheumatic diseases seen in usual care. Methods: Each patient completes an MDHAQ at each visit, which includes scores for physical function, pain and PATGL, each found on the HAQ, and scores for sleep quality, anxiety, depression, self-report joint count and fatigue, which are not found on the HAQ. A random visit of 980 patients with any rheumatic diagnosis was analyzed in 3 categories: PATGL=DOCGL (within 2/10 units); PATGL>DOCGL (by >/=2/10 units); DOCGL>PATGL (by >/=2/10 units), using descriptive statistics and multinomial logistic regression models. Results: Patients included 145 with rheumatoid arthritis, 57 systemic lupus erythematosus, 173 osteoarthritis, 348 other inflammatory, and 257 other non-inflammatory diseases. Overall, PATGL=DOCGL in 509 (52%), PATGL>DOCGL in 371 (38%) and DOCGL>PATGL in 100 (10%). PATGL>DOCGL was associated significantly with older age, female gender, low formal education, Hispanic ethnicity, not working, high MDHAQ physical function and pain, and high scores for fatigue, poor sleep, anxiety, depression, and self-report joint count, not available on the HAQ. Pain and fatigue were significant in a final multinomial logistic regression; the other variables may raise awareness of discordance to clinicians. Conclusions: Global estimates of patients indicated significantly poorer status than estimates of their physicians in 38% of 980 patients with rheumatic conditions, and were associated with demographic and MDHAQ scores, 5 of which are not available on the HAQ. (c) 2013 American College of Rheumatology.

With no specific histologic, laboratory or imaging features the diagnosis/classification of Behcet's Disease (BD) remains clinical. As such, disease criteria are needed. The International Study Group Criteria set is the most widely used. It has some limitations, especially in telling BD from Crohn's disease. On the other hand the main issue, as it also applies to many of the other criteria sets in rheumatology, is our lack of appreciation of a list of misconceptions - some examples of which are unluckily also found in the 2010 ACR/EULAR RA Criteria set- about diagnostic/classification criteria making and their implementation. 1. The view that classification and diagnostic criteria should be different is ill advised in that the cerebral/arithmetic basis of both are the same. 2. The default promise of diagnostic criteria to come once we formulate a classification criteria set is an extension of the previous misconception. 3.Taking pains to avoid circularity in criteria making is unwarranted since the essence of criteria making is circular. In addition we fail to exploit the utility of the disease criteria in ruling out, rather than ruling in, the diseases we seek. Finally we also fail to appreciate the paramount importance of the Bayesian prior (the pretest) probability in formulating and implementing these disease criteria. To formulate criteria tailored to subspecialties, as well as giving the often forgotten family history more importance in our criteria sets are some ways to improve the prior probability on which our diagnostic/classification decisions will be based. We first have to reconcile with ourselves that probabilities are very important in our practice and research. Moreover that reconciliation must also be shared with the public, which includes our patients.

BACKGROUND: Observational studies of patients with rheumatoid arthritis have suggested that racial and ethnic disparities exist for minority populations. We compared disease activity and clinical outcomes across racial and ethnic groups using data from a large, contemporary US registry. METHODS: We analyzed data from 2 time periods (2005-2007 and 2010-2012). The Clinical Disease Activity Index was examined as both a continuous measure and a dichotomous measure of disease activity states. Outcomes were compared in a series of cross-sectional and longitudinal multivariable regression models. RESULTS: For 2005-2007, significant differences of mean disease activity level (P < .001) were observed across racial and ethnic groups. Over the 5-year period, modest improvements in disease activity were observed across all groups, including whites (3.7; 95% confidence interval [CI], 3.2-4.1) compared with African Americans (4.3; 95% CI, 2.7-5.8) and Hispanics (2.7; 95% CI, 1.2-4.3). For 2010-2012, significant differences of mean disease activity level persisted (P < .046) across racial and ethnic groups, ranging from 11.6 (95% CI, 10.4-12.8) in Hispanics to 10.7 (95% CI, 9.6-11.7) in whites. Remission rates remained significantly different across racial/ethnic groups across all models for 2010-2012, ranging from 22.7 (95% CI, 19.5-25.8) in African Americans to 27.4 (95% CI, 24.9-29.8) in whites. CONCLUSIONS: Despite improvements in disease activity across racial and ethnic groups over a 5-year period, disparities persist in disease activity and clinical outcomes for minority groups versus white patients.