Background/Purpose: Inflammation generally is regarded as the primary concern of rheumatologists, and measures of inflammation, such as laboratory tests and pooled indices, usually are the only quantitative data recorded in routine care. Structural damage to joints and other organs, as well as patient distress seen as fibromyalgia, depression, etc., are recognized, but not quantitated routinely in clinical care. In recent years, advances in control of inflammation, along with increases of degenerative diseases in an aging population, and recognition of a high prevalence of fibromyalgia, may have shifted rheumatology patient mix and decision-making more toward damage and distress vs inflammation. We sought to analyze the importance of inflammation, damage, and distress in care of individual rheumatology patients, by quantifying levels on 0-10 visual analog scales (VAS) and estimating their relative contributions to management decisions.

Methods: As part of routine care, rheumatologists at one academic site complete a 0-10 physician global assessment (DOCGL) VAS, as well as 3 further 0-10 VAS to assess inflammation ­(reversible disease) (DOCINF), joint and other organ damage (irreversible disease) (DOCDAM), and patient distress (fibromyalgia, depression), etc. (DOCSTR). The proportion of clinical management decisions attributed to inflammation, damage, and distress (total=100%) also is estimated. Mean values were analyzed in a cross-sectional study of 570 patients, and compared in subgroups of 98 with rheumatoid arthritis (RA), 131 with osteoarthritis (OA) and 89 with fibromyalgia (FM), using t tests and analysis of variance (ANOVA).

Results: Mean 0-10 DOCGL scores were 4.4 in all patients, 4.4 in OA, 4.6 in RA, and 5.2 in FM (Table) (p=0.04). Highest mean scores were seen for DOCINF in RA, DOCDAM in OA, and DOCSTR in FM, and differing significantly in each diagnosis (Table), confirming face validity. Importantly, damage VAS scores (DOCDAM) were higher than inflammation (DOCINF) scores in all groups, including in RA, and mean estimates of the proportion of clinical management decisions attributed primarily to damage were greater than to inflammation in all conditions (Table). Scores for DOCSTR were higher than for DOCINF in all patients and subgroups, other than in RA.

Mean VAS Scores and % of clinical management decision attributed to inflammation, damage, and distress in patients with rheumatic diseases

*ANOVA – RA vs OA vs FM

† -only comparison in which DOCINF higher than DOCSTR

Conclusion: Physician VAS scores and attributions to clinical decisions in individual patients were higher for damage than for inflammation in all groups seen in a rheumatology setting, even in RA patients as a group. Control of inflammation remains the primary concern for rheumatologists, but has improved considerably in recent years, as damage and distress may have become more prominent in routine patient care, and systematic quantitation appears of value.

ACR Meeting Abstracts - https://acrabstracts.org/abstract/is-the-nature-of-rheumatology-practice-changing-damage-and-distress-contribute-a-greater-proportion-to-decision-making-than-inflammation-in-contemporary-care/