Importance of Patient History and Physical Examination in Rheumatoid Arthritis Compared to Other Chronic Diseases: Results of a Physician Survey

Transcription

1 Arthritis Care & Research Vol. 64, No. 8, August 2012, pp DOI /acr , American College of Rheumatology BRIEF REPORT Importance of Patient History and Physical Examination in Rheumatoid Arthritis Compared to Other Chronic Diseases: Results of a Physician Survey ISABEL CASTREJÓN, 1 LAUREN MCCOLLUM, 1 MINE DURUSU TANRIOVER, 2 AND THEODORE PINCUS 1 Objective. To survey physicians opinions concerning the relative importance of 5 clinical encounter components vital signs, patient history, physical examination, laboratory tests, and ancillary studies in the diagnosis and management of 8 chronic diseases. Methods. A SurveyMonkey internet survey was ed to 7,265 US physicians, including 3,542 rheumatologists and 3,723 nonrheumatologists, with the following query: Please indicate the relative importance of 5 sources of information vital signs, patient history, physical examination, laboratory tests, and ancillary studies in diagnosis of congestive heart failure (CHF), diabetes mellitus, hypercholesterolemia, hypertension, lymphoma, pulmonary fibrosis, rheumatoid arthritis (RA), and ulcerative colitis. The response options were 0 20%, 21 40%, 41 60%, 61 80%, and %. A second query with an identical structure addressed management of the 8 diseases. The proportions of physicians who estimated each component as most (or tied for most) important in diagnosis or in management were computed. Results. The survey was completed by 313 physicians (154 rheumatologists and 159 nonrheumatologists). More than 90% estimated vital signs as most important for hypertension, and laboratory tests for diabetes mellitus and hypercholesterolemia. More than 70% estimated ancillary studies as most important for lymphoma, pulmonary fibrosis, and ulcerative colitis. Patient history and physical examination were estimated as most important for RA and CHF by >50% of nonrheumatologists. Conclusion. RA and CHF were the only 2 of the 8 diseases studied for which >50% of nonrheumatologists estimated a patient history and physical examination as most important for diagnosis and management. Confirmation and extension of these observations in actual care may have implications for reimbursement and organization of clinical care. Introduction A clinical encounter between a patient and physician may include 5 components: vital signs, patient history, physical examination, laboratory tests, and ancillary studies. Several reports have suggested that a patient history may provide most of the information for diagnosis in most patients (1 4); however, relatively little information is available in the medical literature concerning possible differences in the importance of each of the 5 encounter 1 Isabel Castrejón, MD, Lauren McCollum, BA, MA, Theodore Pincus, MD: New York University School of Medicine and New York University Hospital for Joint Diseases, New York; 2 Mine Durusu Tanriover, MD: Hacettepe University, Ankara, Turkey. Address correspondence to Theodore Pincus, MD, Division of Rheumatology, New York University Hospital for Joint Diseases, 301 East 17th Street, Room 1608, New York, NY tedpincus@gmail.com. Submitted for publication November 11, 2011; accepted in revised form February 15, components in the diagnosis and management of specific diseases. A patient history and physical examination may be regarded as clinician-intensive components of the clinical encounter, based on a requirement for the clinician to acquire the information in the examination room. By contrast, laboratory tests and ancillary studies may be regarded as non clinician-intensive components, collected and reimbursed outside of the examination room. Differences in the importance of clinician-intensive versus non clinician-intensive activities in (most) patients with different diagnoses might be considered in rational allocation of time and resources for scheduling, reimbursement, and general planning for optimal care. We surveyed physicians for their estimates of the relative importance of the 5 clinical encounter components in the diagnosis and management of 8 diseases: congestive heart failure (CHF), diabetes mellitus, hypercholesterolemia, hypertension, lymphoma, pulmonary fibrosis, rheumatoid arthritis (RA), and ulcerative colitis. Among these 1250

2 Impact of History and Physical Examination on Care of RA Patients 1251 Significance & Innovations Clinical encounters for the diagnosis and management of rheumatoid arthritis involve greater importance of information from a patient history and physical examination than for many other diseases, in which vital signs, laboratory tests, and ancillary studies are more important for diagnosis and management. A patient history and physical examination may be regarded as clinician-intensive components of a patient encounter, based on a requirement that the clinician acquire the information in the examination room, in contrast to non clinician-intensive laboratory tests and ancillary studies collected outside of the examination room. The findings support evidence that the care of patients with rheumatic diseases involves a higher burden for doctors than the care of patients with many other diseases. These observations appear to support the political positions of the American College of Rheumatology over many years, suggesting that rheumatologists may deserve greater reimbursement. 8 diseases, patient history and physical examination were estimated as most important by 50% of rheumatologists for only RA, and by 50% of nonrheumatologists for only RA and CHF, as presented in this report. Materials and methods Survey. The survey was conducted between January 7, 2010 and March 15, 2010 using the internet program SurveyMonkey. Physicians were queried to estimate the approximate percentage that each of 5 components vital signs, patient history, physical examination, laboratory tests, and ancillary studies contributes to the diagnosis or management of 8 diseases: CHF, diabetes mellitus, hypercholesterolemia, hypertension, lymphoma, pulmonary fibrosis, RA, and ulcerative colitis. The 8 diseases were selected to include the 2 most common diseases seen in internal medicine, hypertension and hypercholesterolemia) (5), and 6 diseases from 6 major disease categories: cardiovascular, neoplastic, musculoskeletal, gastrointestinal, pulmonary, and endocrine. The response options were 0 20%, 21 40%, 41 60%, 61 80%, or %. Two separate, identical drop-down menus were presented, the first for diagnosis and the second for management. This format was reported as the most user friendly by participants among several pilot formats, including 1 that queried an exact percentage for each component for a total of 100%. No honorarium was offered. Survey dissemination and completion. s with a link to the survey were sent to 7,265 US physicians, including 3,542 rheumatologists identified as members of the American College of Rheumatology and 3,723 family practitioners identified on the internet as affiliated with family practice training programs. The source of the survey was not identified as a rheumatologist to minimize possible bias in estimates concerning RA. Overall, 365 health professionals responded ( 5%). Analysis of responses. The 365 responses were downloaded to a Microsoft Excel spreadsheet. Fifty-two responses were excluded according to prespecified criteria: responses by a nonphysician, or not allowing a plausible comparison of the 5 clinical encounter components (after responses were recoded to the midpoint of each range, i.e., 10%, 30%, 50%, 70%, 90%), with sums of 350% in 6 diseases, 450% for 3 diseases, or omission of 3 diseases entirely over the 2 matrices. The 313 remaining responses were analyzed using Stata 12.0 for Windows (StataCorp) with several strategies, all yielding similar results. This study presents the proportions of rheumatologists and nonrheumatologists who estimated each component as the most important (or tied for the most important) in the diagnosis or management of each disease. Chi-square and Fischer s exact tests were performed to compare each of the 5 components for each diagnosis with one another; an adjusted P value of less than or less than , based on a P value less than 0.05 adjusted for 40 or 80 comparisons, respectively (6), was designated as statistically significant. Ethical approval. This survey study was reviewed prior to its performance by the Institutional Review Board (IRB) of New York University School of Medicine, which determined that the survey and study were exempt from a requirement of IRB approval. Results Responses of all physicians. One clinical encounter component was estimated as most important by significantly more physicians for the diagnosis and management of 5 of the 8 diseases (P , adjusted for 40 comparisons) (Table 1). More than 90% of the respondents estimated a single component as the most important in 3 diseases: vital signs for hypertension (97% for diagnosis and 96% for management) and laboratory tests for diabetes mellitus (96% for diagnosis and 95% for management) and hypercholesterolemia (99% for diagnosis and 97% for management) (Table 1 and Figure 1). Ancillary studies were estimated as most important by 90% for the diagnosis of pulmonary fibrosis (93%) and ulcerative colitis (92%), by 70% for the diagnosis and management of lymphoma (72% and 74%, respectively), and by 50% for the diagnosis of CHF (61%), the management of pulmonary fibrosis (69%), and the management of ulcerative colitis (58%) (Table 1). Only 5 comparisons (for the diagnosis and management of CHF and RA and the management of ulcerative colitis) included 2 components that were estimated to differ significantly from the other components (Table 1). Patient history was estimated as most important by 50% for the diagnosis and management of RA (64% and 74%, respectively) and the management of CHF (58%),

3 1252 Castrejón et al Table 1. Proportions of 313 US physicians who estimated each of 5 clinical encounter components as most important in the diagnosis and management of 8 diseases* Vital signs Patient history Physical examination Laboratory tests Ancillary studies P P Congestive heart failure Diagnosis Management Diabetes mellitus Diagnosis Management Hypercholesterolemia Diagnosis Management Hypertension Diagnosis Management Lymphoma Diagnosis Management Pulmonary fibrosis Diagnosis Management Rheumatoid arthritis Diagnosis Management Ulcerative colitis Diagnosis Management * Values are the percentage. Totals may exceed 100% because of ties. Comparisons were by chi-square test; P was significant (P 0.05, adjusted for 40 comparisons). Highest versus others. Highest versus others, except second highest. pulmonary fibrosis (51%), and ulcerative colitis (58%). Physical examination was estimated as most important by 50% for the diagnosis and management of RA (71% and 65%, respectively) and the diagnosis and management of CHF (65% and 62%, respectively) (Table 1). Patient history and physical examination were estimated as most important by 46% of all respondents for only 2 of the 8 diseases, RA and CHF. In general, the same component was estimated as most important for both the diagnosis and management of each disease (Table 1 and Figure 1); 30 of 40 comparisons for diagnosis and management were within a 10% range for each component, and 36 of 40 comparisons were within a 20% range. The only 4 comparisons that differed by 20% were higher estimated importance of ancillary studies in the diagnosis (versus management) of pulmonary fibrosis and ulcerative colitis, and higher estimated importance of patient history in the management (versus diagnosis) of these 2 diseases. Rheumatologists compared to nonrheumatologists. The estimates of rheumatologists and nonrheumatologists concerning the most important clinical encounter component were in the same range; 57 of 80 comparisons differed by 10%, 68 of 80 by 20%, and all 80 by 31% (Table 2). Significant differences (P adjusted for multiple comparisons) were seen for 10 comparisons. Patient history was estimated as most important for the management of CHF by 68% of nonrheumatologists versus 48% of rheumatologists. Physical examination was estimated as most important for the diagnosis and management of RA by 86% and 80% of rheumatologists, respectively, compared to 55% and 50% of nonrheumatologists, respectively. Laboratory tests were estimated as most important for the diagnosis and management of lymphoma by 54% and 56% of nonrheumatologists, respectively, compared to 32% and 37% of rheumatologists, respectively, and for the diagnosis and management of RA by 42% and 26% of nonrheumatologists, respectively, compared to 16% and 10% of rheumatologists, respectively. Ancillary studies were estimated as most important for the management of CHF by 53% of rheumatologists compared to 31% of nonrheumatologists, and were estimated as most important for the diagnosis and management of lymphoma by 84% and 79% of rheumatologists, respectively, compared to 60% and 68% of nonrheumatologists, respectively. Other differences were not statistically significant in adjusted analyses, although some differences likely would be significant with a larger sample. Nonetheless, most estimates were in a similar range. Discussion Substantial differences were seen in the physicians estimates of the most important components of the clinical encounter for the diagnosis and management of 8 diseases.

4 Impact of History and Physical Examination on Care of RA Patients 1253 Figure 1. The most important sources of information for diagnosis (A) and management (B) of 8 chronic diseases. VS vital signs; HX patient history; PE physical examination; LAB laboratory tests; ANC ancillary studies. These differences appear to have face validity, despite a response rate of only 5%, although few formal studies that sought to estimate the importance of different components of the clinical encounter in different diseases have been previously reported. Previous reports, published between 1975 and 1993, have suggested that a patient history provides most of the information for the diagnosis in most patients (1 4). Patient history certainly contributes to the choices of laboratory tests and ancillary studies in most diagnostic evaluations, and would likely be estimated as more important in the diagnosis of many common diseases not included in this study, such as angina, asthma, and others. Nonetheless, contemporary medical activities include the care of many asymptomatic individuals with chronic conditions such as hypertension and hyperlipidemia, in whom a patient history is required primarily to recognize the possible complications of these conditions and adverse effects of medications, but usually not to treat the primary disease. The growing prominence of laboratory tests and ancillary studies in many diseases at this time may render the traditional medical history and physical examination less important in the diagnosis and management of diseases than in years past. The patient history and physical examination were estimated as having high importance for RA by 50% of both rheumatologists and nonrheumatologists, and for CHF by 50% of nonrheumatologists. The patient history was estimated as most important in the management of ulcerative colitis by 50% of both groups, and the management of pulmonary fibrosis by 50% of nonrheumatologists. Otherwise, the patient history and physical examination were estimated as most important by fewer than 50% of the respondents for the 6 diseases other than RA and CHF, generally far fewer than 50%. Laboratory tests and ancillary studies dominate the clinical information sought by most physicians and patients from a medical encounter at this time. This perspective appears appropriate for certain diseases such as diabetes mellitus and hypercholesterolemia, but may be poorly informative for clinical decisions in many other diseases. For example, many physicians order extensive laboratory tests for patients with suspected RA, which often may not be helpful. Only 55 65% of RA patients have abnormal values for erythrocyte sedimentation rate and C-reactive protein (7), and only 70 75% have positive tests for rheumatoid factor and anti citrullinated peptide antibodies (8). Furthermore, false-positive tests are seen in 5% of normal individuals, 10 times more common than the prevalence of RA of 0.5% (8). Perhaps greater awareness of the data presented here may reduce laboratory testing in certain diseases to improve cost-effectiveness without compromising quality of care. Patient history and physical examination may be regarded as clinician-intensive activities within a clinical encounter, since the clinician collects this information in

5 1254 Castrejón et al Table 2. Proportions of 154 rheumatologists and 159 nonrheumatologists who estimated each of 5 clinical encounter components as most important in the diagnosis and management of 8 diseases* Vital signs Patient history Physical examination Laboratory tests Ancillary studies Rh Non-Rh Rh Non-Rh Rh Non-Rh Rh Non-Rh Rh Non-Rh Congestive heart failure Diagnosis Management Diabetes mellitus Diagnosis Management Hypercholesterolemia Diagnosis Management Hypertension Diagnosis Management Lymphoma Diagnosis Management Pulmonary fibrosis Diagnosis Management Rheumatoid arthritis Diagnosis Management Ulcerative colitis Diagnosis Management * Values are the percentage. Totals may exceed 100% due to ties. P for 70 of 80 comparisons (P 0.05, adjusted for 80 comparisons). Rh rheumatologist. P for nonrheumatologists versus rheumatologists, adjusted for 80 comparisons. the examination room. By contrast, laboratory tests and ancillary studies are non clinician intensive, generally collected outside of the examination room and reimbursed independently. Patients whose diseases require greater clinician-intensive information might require longer and more complex visits than patients with diseases in which decisions are based largely on non clinician-intensive information. Rheumatologists estimated physical examination as more important in RA than nonrheumatologists, who estimated patient history and laboratory tests as more important (Table 2). This pattern may apply to other specialists in the care of patients with diseases within their specialties (e.g., CHF and pulmonary fibrosis). Further research concerning this matter would appear of interest, but it is beyond the scope of this study. Nonetheless, 50% of both rheumatologists and nonrheumatologists estimated patient history and physical examination as having high importance for RA. Many limitations are seen to this study. First, only 365 physicians responded to the survey ( 5%); however, this response rate may be seen in survey research. Furthermore, the face validity and consistency of responses suggest that the data likely reflected clinical practice accurately. Second, the queries were overly simplified, without attention to possible differences in individual patients and practices that may affect the estimated importance of assessment components in clinical decisions. For example, increased use of ultrasound and nonphysician rheumatology health professionals in the diagnosis and management of RA might have altered the estimates of some clinicians. Third, no attempt was made to validate the physicians opinions through observations in actual care (1 4,9); however, information concerning the importance to physicians of components of a clinical encounter must necessarily be based on their estimates (10). Fourth, many small differences between subgroups were not addressed, as the focus of this report was large differences that have not been reported previously. Fifth, all physicians were regarded as identical, ignoring possible differences according to age, sex, experience levels, and geographic areas, among others, although no significant trends were seen according to respondent characteristics in this relatively small sample (data not shown). Sixth, all patients were regarded as identical, although certain patients, particularly disadvantaged individuals (11), may require considerable clinicianintensive counseling, which may render an encounter of a patient with hypertension or diabetes mellitus as complex as a visit of a patient with other diseases. The magnitude of estimated differences of the most important encounter components in the diagnosis and management of most patients with different diseases suggests possible new approaches to address some limitations of current evaluation and management guidelines for medi-

6 Impact of History and Physical Examination on Care of RA Patients 1255 cal visits (12). Further surveys of additional diseases, and studies to record the actual time spent by clinicians in reviewing a patient history and performing a physical examination in patients with different diseases, could further validate the physicians estimates in this study; however, such investigations are beyond the scope of the present study. Further research concerning how different assessment components are used in the diseases studied here, additional diseases, by different types of physicians, and in different types of patients might lead to better strategies for cost containment and reimbursement, more rational allocation of time and resources in the care of patients with chronic diseases, and improved patient outcomes. AUTHOR CONTRIBUTIONS All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be published. Dr. Pincus had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study conception and design. Castrejón, McCollum, Pincus. Acquisition of data. McCollum, Durusu Tanriover. Analysis and interpretation of data. Castrejón, McCollum, Pincus. REFERENCES 1. Hampton JR, Harrison MJ, Mitchell JR, Prichard JS, Seymour C. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. Br Med J 1975;2: Sandler G. The importance of the history in the medical clinic and the cost of unnecessary tests. Am Heart J 1980;100: Peterson MC, Holbrook JH, Hales DV, Smith NL, Staker LV. Contributions of the history, physical examination, and laboratory investigation in marking medical diagnoses. West J Med 1992;56: Pryor DB, Shaw L, McCants CB, Lee KL, Mark DB, Harrell FE Jr, et al. Value of the history and physical in identifying patients at increased risk for coronary artery disease. Ann Intern Med 1993;118: Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH, Himmelstein DU. A national study of chronic disease prevalence and access to care in uninsured U.S. adults. Ann Intern Med 2008;149: Cupples LA, Heeren T, Schatzkin A, Colton T. Multiple testing of hypotheses in comparing two groups. Ann Intern Med 1984;100: Sokka T, Pincus T. Erythrocyte sedimentation rate, C-reactive protein, or rheumatoid factor are normal at presentation in 35%-45% of patients with rheumatoid arthritis seen between 1980 and 2004: analyses from Finland and the United States. J Rheumatol 2009;36: Nishimura K, Sugiyama D, Kogata Y, Tsuji G, Nakazawa T, Kawano S, et al. Meta-analysis: diagnostic accuracy of anticyclic citrullinated peptide antibody and rheumatoid factor for rheumatoid arthritis. Ann Intern Med 2007;146: Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet 2003;362: Laine C, Davidoff F, Lewis CE, Nelson EC, Nelson E, Kessler RC, et al. Important elements of outpatient care: a comparison of patients and physicians opinions. Ann Intern Med 1996; 125: Pincus T, Esther R, De Walt DA, Callahan LF. Social conditions and self-management are more powerful determinants of health than access to care. Ann Intern Med 1998;129: Kassirer JP, Angell M. Evaluation and management guidelines: fatally flawed [editorial]. N Engl J Med 1998;339: