Background Physician estimates of prognosis affect management of patients with chronic rheumatic diseases. Different rheumatic diseases may be associated with varying estimates of the value of therapy in affecting prognosis in individual patients. Therefore, two simple quantitative scales for prognosis without and with therapy, may be useful as a form of “triage,” to support and document the basis for clinical decisions in patient care.
Objectives To analyze physician estimates of prognosis without and with treatment in 4 rheumatic diseases: rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), osteoarthritis (OA), and fibromyalgia (FM), seen in routine care at an academic rheumatology center.
Methods All patients complete a multi-dimensional health assessment questionnaire (MDHAQ) at each visit, and doctors complete a RheuMetric, which includes prognosis estimated without and with therapy as excellent=1, very good=2, good=3, fair=4, and poor=5. Patients seen over a six-month period in 2015 were classified according to diagnosis into four categories: RA, SLE, OA, and FM. Mean levels of prognosis without and with therapies, and the differences between estimates with and without therapies, were compared for each diagnosis according to ANOVA.
Results The study included 791 patients, 231 with RA, 146 with SLE, 263 with OA, and 151 with FM. Mean estimate for prognosis without therapy in all patients was 2.67 (between “fair” and “good” - closer to “fair”); estimates were in a relatively narrow range from 2.55 in OA to 2.60 in SLE, 2.75 in RA, and 2.81 in FM (Table). Estimates of prognosis with therapy in all patients was 1.76 (between “good” and “very good” – closer to good), a difference of 0.91 units from the prognosis without therapy (34%, p<0.001). These estimates differed over a wider range, from 1.44 in SLE, to 1.49 in RA, 1.91 in OA, and 2.21 in FM. The rheumatic disease rated most likely to improve with therapy was RA (1.26 units), followed by SLE (1.16 units), OA (0.65 units) and FM (0.60 units) (p<0.001). The proportion of patients rated to have a poor or fair prognosis without therapy ranged from 57% for OA, to 63% for SLE, 64% for RA and 74% for FM, versus very good or excellent in 10% or fewer. The proportions rated as likely to have a good to excellent prognosis with therapy were 12% for FM, 21% for OA, 34% for SLE, and 49% in RA with therapy (p<0.001), with an increase of 43% in RA, 24% in SLE, 18% in OA, and 8% in FM (Table).
Conclusions Rheumatologists estimated improvement with therapy to be greatest for patients with RA, followed by SLE, OA, and FM. While these findings have face validity, they demonstrate the practicality of assigning quantitative estimates of prognosis in routine care. Quantitative estimates of prognosis rather than narrative descriptions may influence clinical decisions and help document a rationale for treatment choices.
Disclosure of Interest I. Castrejon: None declared, J. Chua: None declared, J. Block: None declared, T. Pincus Shareholder of: Health Report Services, Inc