RHEUMATOID ARTHRITIS: THE IMPORTANCE OF EVIDENCE BASED DIAGNOSTIC REASONING IN PREVENTING DEBILITATING CONSEQUENCES
AbstractBackground: The early diagnosis of Rheumatoid arthritis can improve clinical outcomes, in terms of morbidity and mortality. This study evaluates the role of evidence informed diagnostic reasoning in the early diagnosis of Rheumatoid arthritis. Methods: A cross-sectional survey was conducted on 200 respondents inclusive of doctors and medical students, at Shifa college of Medicine, Islamabad from April to December 2010. A questionnaire with three common clinical scenarios of low, intermediate and high pre-test probability for rheumatoid arthritis (RA) was provided to the respondents. The differences between the reference and respondents’ estimates of pre and post-test probability were used to assess the respondents’ clinical diagnostic reasoning process, as a tool to diagnose RA early. Respondents were also enquired about the cost effectiveness or potential harms of Rheumatoid factor (RF). Consecutive sampling technique was used and the data was analysed using SPSS-15. Results: In all scenarios, the pre-test probability was estimated close to the reference estimates suggesting respondents’ ability to rule in or rule out the disease. However, some over-estimation of the pre-test probability was noticed in low and intermediate pre-test probability settings. Post-test probabilities were significantly underestimated reflecting their inability to calculate post-test probabilities in all scenarios. More tests were ordered as the disease probability increased. Most respondents were of the opinion that RF is cost effective and safe. Conclusions: The significant underestimation of the post-test probability necessitates more emphasis on Bayesian probabilistic thinking in clinical practice to facilitate early diagnosis of rheumatoid arthritis.Keywords: Rheumatoid arthritis. Rheumatoid factor, Probability, Early diagnosis
Alamanos Y, Voulgari PV, Drosos AA. Incidence and prevalence of rheumatoid arthritis based on the 1987 American College of Rheumatology criteria: a systematic review. Semin Arthritis Rheum 2006;36(3):182–8.
Farooqi A, Gibson T. Prevalence of the major rheumatic disorders in the adult population of north Pakistan. Br J Rheumatol 1998;37:491–5.
Sokolove J, Strand V. Rheumatoid Arthritis classification Criteria- Its time to finally move on. Bull NYU Hosp Jt Dis 2010;68:232–8.
Darmawan J. Recommendations from the Community Oriented Program for Control of Rheumatic Disease for data collection for the measurement and monitoring of health in developing countries. Clin Rheumatol 2007;26:853–7.
Banal F, Dougados M, Combescure C, Gossec L. Sensitivity and Specificity of the American College of Rheumatology 1987 criteria for the diagnosis of rheumatoid arthritis according to the disease duration: a systematic literature review and meta-analysis. Ann Rheum Dis 2009;68:1184–91.
Richardson WS, Wilson MC, McGinn TG. Differential diagnosis. In: Guyatt G, Rennie D, Meade M, Cook D, editors. Users Guide to the Medical Literature: A manual of Evidence-based Clinical Practice. 2nd ed. USA: McGraw-hill Professional; 2008. p. 407–18.
Straus SE, Richardson WS, Glasziou P, Haynes RB. Diagnosis and screening. In: Evidence Based Medicine: How to practice and teach EBM. 3rd ed. Edinburgh: ELSEVIER Churchill Living Stone; 2005. p. 67–100.
Richardson WS, Wilson MC. The process of diagnosis. In: Guyatt G, Rennie D, Meade M, Cook D, editors. Users Guide to the Medical Literature: A manual of Evidence-based Clinical Practice. 2nd ed. USA: McGraw-hill Professional; 2008. p. 399–406.
Jansen AL, van der Horst-Bruinsma I, van Schaardenburg D, van de Stadt RJ, de Koning MH, Dijkmans BA. Rheumatoid factor and antibodies to cyclic citrullinated Peptide differentiate rheumatoid arthritis from undifferentiated polyarthritis in patients with early arthritis. J Rheumatol 2002;29:2074–6.
Hodkinson B, Meyer PW, Musenge E, Ally MM, Wadee AA, Anderson R, et al. The diagnostic utility of the anti-CCP antibody test is no better than rheumatoid factor in South Africans with early rheumatoid arthritis. Clin Rheumatol 2010;29:615–8.
Nell VP, Machold KP, Eberl G, Stamm TA, Uffmann M, Smolen JS. Benefit of very early referral and very early therapy with disease-modifying anti-rheumatic drugs in patients with early rheumatoid arthritis. Rheumatology (Oxford) 2004;43:906–14.
Michou L, Rat AC, Lasbleiz S, Bardin T, Cornelis F. Prevalence and distribution of autoimmue diseases in 368 rheumatoid arthritis families. J Rheumatol 2008;35:790–6.
Fagan TJ. Letter: Nomogram for Bayes theorem. N Engl J Med 1975;293(5): 257.
Nishimura k, Sugiyama D, Kogata Y, Tsuji G, Nakazawa T, Kawano S, et al. Meta-analysis: diagnostic accuracy of anti-cyclic citrullinated peptide antibody and rheumatoid factor for rheumatoid arthritis. Ann Intern Med 2007;146:797–808.
Huntington MK, Thanel FH. Rational screening strategies. S D Med 2010;63:379–81.
Lyman GH, Balducci L. Overestimation of test effects in clinical judgment. J Cancer Educ1993;8:297–307.
Noguchi Y, Matsui K, Imura H, Kiyota M, Fukui T. Quantitative evaluation of the diagnostic thinking process in medical students. J Gen Intern Med 2002;17:839–44.
Vanichapuntu M, Phuekfon P, Suwannalai P, Verasertniyom O, Nantiruj K, Janwityanujit S. Are anti-citrulline autoantibodies better serum markers for rheumatoid arthritis than rheumatoid factor in Thai population? Rheumatol Int. 2010;30:755–9.
McGinn T, Jervis R, Wisnivesky J, Keitz S, Wyer PC. Tips for teachers of evidence based medicine: clinical prediction rules and estimating pretest probability. J Gen Intern Med 2008;23:1261–8.