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Kasturi S, Wong JB, Mandl LA, McAlindon TE, LeClair A. "Unspoken Questions": A Qualitative Study of Rheumatologists' Perspectives on the Clinical Implementation of Patient-reported Outcome Measures. J Rheumatol 2020; 47:1822-1830. [PMID: 32611667 DOI: 10.3899/jrheum.200232] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To identify rheumatologists' views on perceived barriers and facilitators to the clinical implementation of patient-reported outcome measures (PROM). METHODS Semistructured interviews were conducted with academically affiliated clinical rheumatologists. Interviews were audio-recorded and transcribed. Deidentified transcripts were independently coded and analyzed for themes. RESULTS Fifteen attending rheumatologists, 8 women (53%) and 7 men (47%) with a mean of 17.3 years in practice (range 5-43) at 2 urban academic medical centers, participated in interviews. Rheumatologists identified several barriers to integrating PROM in clinical care, highlighting physician buy-in and culture change as significant challenges beyond logistical considerations. They further underscored the lack of effective interventions and resources for addressing the domains of most interest to patients. Physicians also recognized significant benefits of PROM in clinical care, including contributing to the clinical impression by providing the patient perspective, and promoting agenda setting by uncovering "unspoken questions." They additionally noted that PROM could support treatment planning, build patient-physician relationships, and facilitate patient engagement. Participants suggested that technology, physician education, and team-based care could facilitate the effective implementation of PROM. CONCLUSION Rheumatologists identified multiple mechanisms through which PROM could augment clinical care, but also noted several obstacles to implementation, questioning the added value of PROM and the limited availability of interventions to improve patient-centered outcomes. Programs seeking to successfully integrate PROM to enhance patient-centered care and meet quality benchmarks should prioritize physician buy-in and training, and provide resources to address the outcomes that are measured.
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Affiliation(s)
- Shanthini Kasturi
- S. Kasturi, MD, MS, T.E. McAlindon, MD, MPH, Division of Rheumatology, Allergy & Immunology/Department of Medicine, Tufts Medical Center, Boston, Massachusetts;
| | - John B Wong
- J.B. Wong, MD, Division of Clinical Decision Making, Tufts Medical Center, Boston, Massachusetts
| | - Lisa A Mandl
- L.A. Mandl, MD, MPH, Division of Rheumatology/Department of Medicine, Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Timothy E McAlindon
- S. Kasturi, MD, MS, T.E. McAlindon, MD, MPH, Division of Rheumatology, Allergy & Immunology/Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Amy LeClair
- A.LeClair, PhD, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
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Abstract
The rheumatology community began incorporating patient-reported outcomes in the early 1980s, helping shift the care of chronic diseases from a narrower biomedical model to a broader biopsychosocial model of health. Early efforts were focused primarily in clinical trials and clinical research, but over the last decade there has been increasing use in routine rheumatology clinical care. More than 250 valid and reliable scales to assess domains of importance to patients with rheumatic conditions have been developed. The approach to measurement continues to be refined. Rheumatology has much to be proud of in contributions to the important field of patient-reported outcomes.
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Affiliation(s)
- Leigh F Callahan
- Department of Medicine, Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, 3330 Thurston Building, CB 7280, Chapel Hill, NC 27599, USA.
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Choi HJ, Seo MR, Ryu HJ, Baek HJ. Behçet's Disease Current Activity Form as a Patient's Derived Measure. JOURNAL OF RHEUMATIC DISEASES 2016. [DOI: 10.4078/jrd.2016.23.1.19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Hyo Jin Choi
- Division of Rheumatology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Mi Ryoung Seo
- Division of Rheumatology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hee Jung Ryu
- Division of Rheumatology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Han Joo Baek
- Division of Rheumatology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
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Pincus T, Gibson KA, Block JA. Premature Mortality: A Neglected Outcome in Rheumatic Diseases? Arthritis Care Res (Hoboken) 2015; 67:1043-6. [DOI: 10.1002/acr.22554] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 01/14/2015] [Accepted: 01/20/2015] [Indexed: 11/05/2022]
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Kojima M, Kojima T, Ishiguro N, Oguchi T, Oba M, Tsuchiya H, Sugiura F, Furukawa TA, Suzuki S, Tokudome S. Psychosocial factors, disease status, and quality of life in patients with rheumatoid arthritis. J Psychosom Res 2009; 67:425-31. [PMID: 19837205 DOI: 10.1016/j.jpsychores.2009.01.001] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Revised: 11/04/2008] [Accepted: 01/08/2009] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To explore the interrelationships between the psychosocial and illness factors that determine the disease status of patients with rheumatoid arthritis (RA) and to identify how each factor is associated with quality of life (QOL). METHODS The study group comprised 120 RA outpatients who completed a series of health examinations and questionnaires. Disease severity, functional disability, counts of swollen and/or tender joints, duration of RA, frequency of arthritis surgery, and C-reactive protein level were assessed by rheumatologists. Self-report inventories completed by the patients were used to assess perceived degree of pain, fatigue (visual analogue scales), depression (Beck Depression Inventory-II), anxiety (Hospital Anxiety and Depression Scale), and social support (Social Support Questionnaire). Mental and physical components of health-related QOL were evaluated using the Short-Form 36 Health Survey. RESULTS After z-transformation of the data, a principal axis factor analysis was conducted. A four-factor structure was identified in which the components reflected psychosocial factors, disease activity, current symptoms, and physical functional status, respectively. There was no significant association between psychosocial factors and disease activity, while the other components were moderately correlated with each other. Multiple regression analysis revealed that physical QOL was determined by current symptoms and physical functions. Mental QOL was determined by psychosocial factors, current symptoms, and physical functions. CONCLUSION Disease activity was independent from psychosocial factors and failed to reflect the perceived physical and mental QOL of RA patients. Clinicians should therefore evaluate psychosocial factors, as well as subjective disease status, to improve the QOL of patients with RA.
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Affiliation(s)
- Masayo Kojima
- Department of Public Health, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Japan.
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Rupp I, Boshuizen HC, Dinant HJ, Jacobi CE, van den Bos GAM. Disability and health‐related quality of life among patients with rheumatoid arthritis: association with radiographic joint damage, disease activity, pain, and depressive symptoms. Scand J Rheumatol 2009; 35:175-81. [PMID: 16766363 DOI: 10.1080/03009740500343260] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To study the associations between disability and health-related quality of life (HRQoL), respectively, and radiographic joint damage, disease activity, pain, and depressive symptoms among patients with rheumatoid arthritis (RA). METHODS Data were collected through questionnaires and clinical examinations at baseline (1997) and at 2 years' follow-up among patients with RA (n = 307). Disability was measured with a validated Dutch questionnaire, derived from the Health Assessment Questionnaire (HAQ), and HRQoL with a validated Dutch version of the RAND-36, using physical (PCS) and mental (MCS) component summary scales. Multivariate linear regression analyses were performed to assess the relationship between disability or HRQoL and radiographic damage, disease activity, pain, and depressive symptoms. RESULTS Pain, with respect to disability and PCS, and depressive symptoms, with respect to MCS, were more important predictors than radiographic damage and disease activity. CONCLUSIONS Daily RA practice needs to be broadened by regular assessment of disease burden from the patients' perspectives. Patient-reported measures, such as disability or HRQoL, should be incorporated for monitoring health outcomes of individual patients and for initiating and evaluating therapy.
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Affiliation(s)
- I Rupp
- Department of Social Medicine, Academic Medical Centre, University of Amsterdam, the Netherlands.
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Abstract
PURPOSE OF REVIEW This review highlights the present state of efforts at registry implementation which exist internationally. These efforts are contrasted with those in the USA. RECENT FINDINGS The implications of the different data which are derived from diverse registry sources are discussed. The need for long-term data from large and varied sources is fulfilled by registries that collect data from different populations. The potential differences in the nature of the data derived from these registries is dependent upon the national healthcare system from which they are derived, as there are significant differences in access to newer biologic agents which are inconsistent across countries. SUMMARY Registry data are critical in order to develop an understanding of the performance and safety of new agents in the real world. The challenges for implementing a registry are manifold in the USA because of the somewhat chaotic nature of the healthcare delivery system. In order to overcome these unique challenges, registries in the USA need to be exceptionally well organized and funded, while maintaining independence from the pharmaceutical industry funding sources in the reporting and interpretation of data in peer-reviewed publications. Examples of these registries are provided and discussed.
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Bennett RM, Jones J, Turk DC, Russell IJ, Matallana L. An internet survey of 2,596 people with fibromyalgia. BMC Musculoskelet Disord 2007; 8:27. [PMID: 17349056 PMCID: PMC1829161 DOI: 10.1186/1471-2474-8-27] [Citation(s) in RCA: 552] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2006] [Accepted: 03/09/2007] [Indexed: 12/02/2022] Open
Abstract
Background This study explored the feasibility of using an Internet survey of people with fibromyalgia (FM), with a view to providing information on demographics, sources of information, symptoms, functionality, perceived aggravating factors, perceived triggering events, health care utilization, management strategies, and medication use. Methods A survey questionnaire was developed by the National Fibromyalgia Association (NFA) in conjunction with a task force of "experts in the field". The questionnaire underwent several rounds of testing to improve its face validity, content validity, clarity and readability before it was mounted on the internet. The questionnaire consisted of 121 items and is available online at the website of the National Fibromyalgia Association. Results The questionnaire was completed by 2,569 people. Most were from the United States, with at least one respondent from each of the 50 states. Respondents were predominantly middle-aged Caucasian females, most of whom had FM symptoms for ≥ 4 years. The most common problems were morning stiffness, fatigue, nonrestorative sleep, pain, concentration, and memory. Aggravating factors included: emotional distress, weather changes, insomnia, and strenuous activity. Respondents rated the most effective management modalities as rest, heat, pain medications, antidepressants, and hypnotics. The most commonly used medications were: acetaminophen, ibuprofen, naproxen, cyclobenzaprine, amitriptyline, and aspirin. The medications perceived to be the most effective were: hydrocodone preparations, aprazolam, oxycodone preparations, zolpidem, cyclobenzaprine, and clonazepam. Conclusion This survey provides a snap-shot of FM at the end of 2005, as reported by a self-selected population of people. This descriptive data has a heuristic function, in that it identifies several issues for further research, such as the prescribing habits of FM health care providers, the role of emotional precipitants, the impact of obesity, the significance of low back pain and the nature of FM related stiffness.
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Affiliation(s)
| | | | | | - I Jon Russell
- The University of Texas Health Science Center at San Antonio, TX, USA
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Wong AL, Harker JO, Mittman BS, Levy GD, Bulpitt KJ, Colburn KK, Liu H, Kahn KL, Hahn BH, Paulus HE, Rubenstein LZ. Development and evaluation of a patient self-report case-finding method for rheumatoid arthritis. Semin Arthritis Rheum 2004; 34:484-99. [PMID: 15305246 DOI: 10.1016/j.semarthrit.2003.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To describe the development and evaluation of a patient self-report case-finding method for rheumatoid arthritis (RA) not dependent on direct contact with the treating physicians. METHODS The American College of Rheumatology criteria for RA diagnosis were adapted for patient self-report using a questionnaire, and alternative scoring algorithms were evaluated to balance case-finding sensitivity and specificity. Positive rheumatoid factor tests were used to identify 1053 individuals in 2 large healthcare organizations; 440 agreed to receive study materials. Case-finding results were validated by medical record review (MRR) for a random sample of 90 patients. Three scoring algorithms were compared with MRR for likelihood of RA diagnosis. Cases not classifiable by algorithm were flagged and reviewed by 2 expert physicians for likelihood of RA diagnosis. RESULTS Pilot testing demonstrated that patients comprehended the questionnaire and were willing to answer the questions. Completed questionnaires were returned by 265 (60%) of the 440 patients contacted. Following expert physician review of 16 flagged cases in the 90-patient MRR subsample, the most accurate scoring algorithm demonstrated 80% sensitivity, 67% specificity, 74% accuracy, and 77% positive predictive value for detecting early RA. CONCLUSION The case-finding method represents a promising tool for identifying RA patients, with potential application in research and quality-assurance activities. RELEVANCE This case-finding method should be useful in research and quality-assurance efforts requiring identification of RA patients treated by all types of providers in healthcare organizations in which centralized laboratory data are available.
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Affiliation(s)
- Andrew L Wong
- Olive View-UCLA Medical Center, Sylmar, CA 91342, USA.
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Wolfe F, Albert DA, Pincus T. A survey of United States rheumatologists concerning effectiveness of disease-modifying antirheumatic drugs and prednisone in the treatment of rheumatoid arthritis. ARTHRITIS CARE AND RESEARCH : THE OFFICIAL JOURNAL OF THE ARTHRITIS HEALTH PROFESSIONS ASSOCIATION 1998; 11:375-81. [PMID: 9830881 DOI: 10.1002/art.1790110508] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To collect the ratings of American rheumatologists regarding relative short-term and long-term effectiveness of disease-modifying antirheumatic drug (DMARD) therapy in the treatment of rheumatoid arthritis and to compare these data with results of a meta-analysis of randomized, controlled clinical trials (RCTs) of these drugs. METHODS A survey was mailed to 3,200 United States rheumatologists who were members of the American College of Rheumatology during the summer of 1996. The survey was completed by 645 rheumatologists. RESULTS Methotrexate (MTX) was rated as substantially more effective than any other DMARD after both 1 year and 4 years of therapy. At 1 year, more than 90% of rheumatologists rated MTX as "good or excellent," compared with 35% giving a similar rating to intramuscular (IM) gold, the second-ranked DMARD. At 4 years, MTX was rated as "good or excellent" by 65%, compared with 53% for combinations, 30% for prednisone, and 11% for hydroxychloroquine, the second-ranked single DMARD. These ratings reflect results of long-term observational studies, but differ considerably from a meta-analysis of results of short-term RCTs, in which the efficacy of MTX, sulfasalazine, penicillamine, and IM gold were indistinguishable. CONCLUSION The ratings of US rheumatologists regarding effectiveness of DMARD therapies are in agreement with observational data, but differ substantially from results of RCTs. These findings suggest that observational studies may yield useful and important information about treatment results, which are complementary to, but not available from, the RCT model. Regulatory agencies should consider long-term observational studies as a part of the evaluation of drugs.
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Affiliation(s)
- F Wolfe
- Arthritis Research Center, Wichita, KS 67214, USA
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Callahan LF, Pincus T, Huston JW, Brooks RH, Nance EP, Kaye JJ. Measures of activity and damage in rheumatoid arthritis: depiction of changes and prediction of mortality over five years. ARTHRITIS CARE AND RESEARCH : THE OFFICIAL JOURNAL OF THE ARTHRITIS HEALTH PROFESSIONS ASSOCIATION 1997; 10:381-94. [PMID: 9481230 DOI: 10.1002/art.1790100606] [Citation(s) in RCA: 96] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To analyze various quantitative measures of inflammatory activity and joint damage, including articular, radiographic, laboratory, questionnaire, and physical function measures, in regard to changes in status in surviving patients and prediction of mortality in non-survivors over 5 years in a cohort of patients with rheumatoid arthritis (RA) monitored in the mid-1980s and early 1990s. METHODS A comprehensive evaluation, which included a complete joint count, radiograph, laboratory tests, physical measures of function, and self-report questionnaire scales, was performed at baseline and 5 years later in 210 consecutive patients with RA. RESULTS Five years after baseline, 206 of the 210 patients were accounted for: 37 had died, 130 had a comprehensive repeat assessment, and 39 had a more limited repeat assessment. In surviving patients, most measures of activity were generally unchanged or somewhat better, including joint tenderness, pain on motion, and swelling; erythrocyte sedimentation rate and rheumatoid factor; as well as questionnaire scores for pain, global status, helplessness, and difficulty in performing 8 activities of daily living (ADL) according to a modified Health Assessment Questionnaire (MHAQ). By contrast, measures of damage, including joint deformity, grip strength, walk time, and radiographic scores, indicated worse status. Mortality over 5 years was predicted significantly in univariable analyses by American College of Rheumatology (formerly the American Rheumatism Association) Functional Class, limited joint motion, scores for MHAQ, global status, helplessness, grip strength, walk time, button time, and number of comorbidities and duration of diseases, as well as the sociodemographic measures of age and formal education. In multivariable Cox regressions, age, comorbidities, MHAQ, and other measures of functional status were the most effective predictors of 5-year mortality. CONCLUSION In patients with RA, most measures of inflammatory activity were unchanged and sometimes better, while measures of damage indicated worse status in the same patients over 5 years. Measures indicating functional disability, as well as age and comorbidities, predict 5-year mortality more effectively than radiographic and laboratory data. Measures of inflammatory activity may underestimate long-term outcomes in RA, and long-term studies should include measures of damage.
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Affiliation(s)
- L F Callahan
- Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, USA
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Callahan LF, Pincus T. Education, self-care, and outcomes of rheumatic diseases: further challenges to the "biomedical model" paradigm. ARTHRITIS CARE AND RESEARCH : THE OFFICIAL JOURNAL OF THE ARTHRITIS HEALTH PROFESSIONS ASSOCIATION 1997; 10:283-8. [PMID: 9362594 DOI: 10.1002/art.1790100502] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Callahan LF, Cordray DS, Wells G, Pincus T. Formal education and five-year mortality in rheumatoid arthritis: mediation by helplessness scale score. ARTHRITIS CARE AND RESEARCH : THE OFFICIAL JOURNAL OF THE ARTHRITIS HEALTH PROFESSIONS ASSOCIATION 1996; 9:463-72. [PMID: 9136290 DOI: 10.1002/art.1790090608] [Citation(s) in RCA: 81] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To analyze scores on a scale designed to measure helplessness, a cognitive variable, as a possible mediator of the association between formal education level and mortality over 5 years in patients with rheumatoid arthritis (RA). METHODS A cohort of 1,416 patients with RA from 15 private practices in 6 states and Washington, DC was monitored for over 5 years. Demographic, socioeconomic, therapy, functional status, and psychological variables were analyzed as possible predictors of mortality in invariable and multivariable Cox Proportional Hazards models. RESULTS In a 5-year followup, 1,384 patients were accounted for (97.3%), including 174 who died versus 111 expected (standardized mortality ratio = 1.54). Higher mortality was associated significantly with low formal education, high age, poor scores for activities of daily living (ADL) on a modified health assessment questionnaire (MHAQ), and poor scores on a helplessness scale (all P < 0.01) in univariable analyses. High age, few years of formal education, and poor MHAQ ADL scores were all significant independent predictors of mortality when analyzed simultaneously in a Cox Proportional Hazards model. When helplessness scale scores were included in a model, scores greater than 2.4 (on a scale of 1 to 4), higher age, male gender, and increased MHAQ ADL difficulty scores were all independently significantly predictive of 5-year mortality (P < 0.05), while years of education was no longer a significant predictor. CONCLUSION Scores on a helplessness scale appear to mediate a component of the association between formal education level and 5-year mortality in these patients with RA. Health professionals and policy makers might consider interventions directed at modification of helplessness as adjunctive to standard interventions to improve outcomes in RA.
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Affiliation(s)
- L F Callahan
- Thurston Arthritis Research Center, University of North Carolina, Chapel Hill 27599, USA
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Pincus T. Documenting quality management in rheumatic disease: are patient questionnaires the best (and only) method? ARTHRITIS CARE AND RESEARCH : THE OFFICIAL JOURNAL OF THE ARTHRITIS HEALTH PROFESSIONS ASSOCIATION 1996; 9:339-48. [PMID: 8997923 DOI: 10.1002/1529-0131(199610)9:5<339::aid-anr1790090502>3.0.co;2-m] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- T Pincus
- Vanderbilt University School of Medicine, Department of Medicine, Nashville, TN 37232-4500, USA
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