Should a Swollen Joint Count Be Conducted at Every Office Visit?

BOSTON — Because patient self-reported rheumatoid arthritis outcomes are insufficient on their own for making therapeutic decisions, a swollen joint count should be conducted at every visit, according to Dr. Edward Keystone.

In a small clinical study, Dr. Keystone and his colleagues of the University of Toronto's Mount Sinai Hospital surveyed 66 rheumatoid arthritis patients about their disease status during routine visits.

“Patients were asked to rate how they were feeling—very well, well, fair, poor, or very poor—on the day of their visit with respect to their rheumatoid arthritis,” Dr. Keystone said at a meeting on rheumatology sponsored by Harvard Medical School. The investigators then correlated the self-reported outcomes with a variety of disease measures including pain and fatigue visual analog scales, physician global assessment quality of life and disease activity scales, and formal joint counts.

“By and large, pain and fatigue dictated the self-assessments,” said Dr. Keystone. Patients who had high scores on these measures were most likely to report “poor” or “very poor.” Yet there was only a modest correlation between patient self-assessment and swollen joint count. In fact, he said, some of the patients with the most swollen joints reported “fair,” “well,” or “very well” with respect to their disease.

The fact that swollen joint count does not correlate with patients' perceptions of their conditions is especially troublesome in light of a recent study suggesting that many rheumatologists don't perform a formal quantitative joint count during routine visits with patients under their care, said Dr. Keystone.

For the study, investigators queried approximately 600 rheumatologists attending the annual European League Against Rheumatism (EULAR) meeting regarding their use of formal joint counts in routine care (Ann. Rheum. Dis. 2006;65:820–2). “More than half [of the respondents] reported performing a joint count at fewer than half of the routine visits, and 45% said they performed joint counts at less than 25% of the visits,” said Dr. Keystone. Thirteen percent of the respondents said they never perform a formal joint count, he noted.

As a result, many physicians are missing signs of disease progression as well as important windows of opportunity for effective intervention, said Dr. Keystone. “Patients with mild to moderate disease activity might report that they're doing 'well,' when in fact a joint count might suggest disease progression,” he said. “And we know that tight, early control of moderate disease can substantially improve patient outcomes.”

It's not enough to ask patients how they are doing and leave it at that, Dr. Keystone stressed. “While it's not feasible to get an MRI or radiographic assessment of disease status at every visit, performing a swollen joint count is easy and extremely valuable in clinical practice.”

'Performing a swollen joint count is easy and extremely valuable in clinical practice.' DR. KEYSTONE

BOSTON — Because patient self-reported rheumatoid arthritis outcomes are insufficient on their own for making therapeutic decisions, a swollen joint count should be conducted at every visit, according to Dr. Edward Keystone.

In a small clinical study, Dr. Keystone and his colleagues of the University of Toronto's Mount Sinai Hospital surveyed 66 rheumatoid arthritis patients about their disease status during routine visits.

“Patients were asked to rate how they were feeling—very well, well, fair, poor, or very poor—on the day of their visit with respect to their rheumatoid arthritis,” Dr. Keystone said at a meeting on rheumatology sponsored by Harvard Medical School. The investigators then correlated the self-reported outcomes with a variety of disease measures including pain and fatigue visual analog scales, physician global assessment quality of life and disease activity scales, and formal joint counts.

“By and large, pain and fatigue dictated the self-assessments,” said Dr. Keystone. Patients who had high scores on these measures were most likely to report “poor” or “very poor.” Yet there was only a modest correlation between patient self-assessment and swollen joint count. In fact, he said, some of the patients with the most swollen joints reported “fair,” “well,” or “very well” with respect to their disease.

The fact that swollen joint count does not correlate with patients' perceptions of their conditions is especially troublesome in light of a recent study suggesting that many rheumatologists don't perform a formal quantitative joint count during routine visits with patients under their care, said Dr. Keystone.

For the study, investigators queried approximately 600 rheumatologists attending the annual European League Against Rheumatism (EULAR) meeting regarding their use of formal joint counts in routine care (Ann. Rheum. Dis. 2006;65:820–2). “More than half [of the respondents] reported performing a joint count at fewer than half of the routine visits, and 45% said they performed joint counts at less than 25% of the visits,” said Dr. Keystone. Thirteen percent of the respondents said they never perform a formal joint count, he noted.

As a result, many physicians are missing signs of disease progression as well as important windows of opportunity for effective intervention, said Dr. Keystone. “Patients with mild to moderate disease activity might report that they're doing 'well,' when in fact a joint count might suggest disease progression,” he said. “And we know that tight, early control of moderate disease can substantially improve patient outcomes.”

It's not enough to ask patients how they are doing and leave it at that, Dr. Keystone stressed. “While it's not feasible to get an MRI or radiographic assessment of disease status at every visit, performing a swollen joint count is easy and extremely valuable in clinical practice.”

'Performing a swollen joint count is easy and extremely valuable in clinical practice.' DR. KEYSTONE

BOSTON — Because patient self-reported rheumatoid arthritis outcomes are insufficient on their own for making therapeutic decisions, a swollen joint count should be conducted at every visit, according to Dr. Edward Keystone.

In a small clinical study, Dr. Keystone and his colleagues of the University of Toronto's Mount Sinai Hospital surveyed 66 rheumatoid arthritis patients about their disease status during routine visits.

“Patients were asked to rate how they were feeling—very well, well, fair, poor, or very poor—on the day of their visit with respect to their rheumatoid arthritis,” Dr. Keystone said at a meeting on rheumatology sponsored by Harvard Medical School. The investigators then correlated the self-reported outcomes with a variety of disease measures including pain and fatigue visual analog scales, physician global assessment quality of life and disease activity scales, and formal joint counts.

“By and large, pain and fatigue dictated the self-assessments,” said Dr. Keystone. Patients who had high scores on these measures were most likely to report “poor” or “very poor.” Yet there was only a modest correlation between patient self-assessment and swollen joint count. In fact, he said, some of the patients with the most swollen joints reported “fair,” “well,” or “very well” with respect to their disease.

The fact that swollen joint count does not correlate with patients' perceptions of their conditions is especially troublesome in light of a recent study suggesting that many rheumatologists don't perform a formal quantitative joint count during routine visits with patients under their care, said Dr. Keystone.

For the study, investigators queried approximately 600 rheumatologists attending the annual European League Against Rheumatism (EULAR) meeting regarding their use of formal joint counts in routine care (Ann. Rheum. Dis. 2006;65:820–2). “More than half [of the respondents] reported performing a joint count at fewer than half of the routine visits, and 45% said they performed joint counts at less than 25% of the visits,” said Dr. Keystone. Thirteen percent of the respondents said they never perform a formal joint count, he noted.

As a result, many physicians are missing signs of disease progression as well as important windows of opportunity for effective intervention, said Dr. Keystone. “Patients with mild to moderate disease activity might report that they're doing 'well,' when in fact a joint count might suggest disease progression,” he said. “And we know that tight, early control of moderate disease can substantially improve patient outcomes.”

It's not enough to ask patients how they are doing and leave it at that, Dr. Keystone stressed. “While it's not feasible to get an MRI or radiographic assessment of disease status at every visit, performing a swollen joint count is easy and extremely valuable in clinical practice.”

'Performing a swollen joint count is easy and extremely valuable in clinical practice.' DR. KEYSTONE