Friday, 17 Aug 2018

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The Brooklyn HAQ

The Health Assessment Questionnaire is a utilitarian outcome measure, often used in clinical trials and daily practice.  It was originally invented by Dr. James Fries at Stanford University in 1979, morphing over the years from the original 2-page, 20-question survey (HAQ-DI) to the modified 8-question mHAQ or the updated, 10-question MD-HAQ.

This premier, patient-reported outcome (PRO) and functional measure has been popularized by the iconic mentors of rheumatology, Drs. Fred Wolfe and Ted Pincus, through years of research and teaching. Their efforts have guided legions of rheumatologists to use the easily administered survey such that it has become either a highly objective serial measure of disease or, in the least, a quick look gestalt-o-meter of patient status. The HAQ and its many forms have been superior to all other measures in predicting future disability, radiographic damage, future surgery and survival.

The HAQ has become an important element in many commonly used multidimensional assessments of disease activity, including the ACR 20/50/70 response, RAPID3, and Global Arthritis Score (GAS). A recent survey by Cush and Curtis showed the use of the HAQ has grown from 17% in 2005 to 39% in 2014, making it one of the most common measures employed by US rheumatologists.

So, unless you’re still prescribing penacillamine, never attended an ACR meeting, and never read an RA clinical trial, you’re quite familiar with the HAQ and its use in practice.

Surely you’ve heard of the “Brooklyn HAQ”. 

What’s the Brooklyn HAQ you say?  It refers to the common question/declaration, “How you doin’?” It is most certainly and unofficial bastardization of the original. Born of a suspect small group of rogue rheumatologists, the Brooklyn HAQ is a snarky, simplified version of the HAQ that is clearly spreading throughout the country.

The History
Many believe the “Brooklyn HAQ” should be attributed to razor-witted Dr. Allan Gibofsky from the Hospital for Special Surgery in NYC.  The popular teacher and well-traveled academic, Dr. Gibofsky refers to the Brooklyn HAQ, but has officially declared that “Danny Ricciardi is originator of the Brooklyn HAQ, which I’ve popularized (always giving him credit)." An adept instructor and advisor, he often uses the term when characterizing the “gestalt assessments” done by many.  But Gibo has gone one step further by adding "…if she answers, that gives you the Patient Global. But if the patient replies "I'm doin’ fine, how YOU doin' Doc?"  then you can get the Physician Global as well."

Not surprisingly, the Brooklyn HAQ begins in Brooklyn, NY, circa 2011.

At a dinner meeting, within view of the Brooklyn Bridge, a gathering of New York rheumatologists were discussing the merits of treat-to-target and clinical measurements. The number of NY opinions on T2T and metrics exceeded the number of NY rheumatologists in attendance. Yet it was the seasoned opinion of a Brooklyn rheumatologist, Dr. Dan Ricciardi, who pronounced, "We don’t need no numbers, scores or HAQs, we just ask “How You Doin’?” and boom – you got your “Brooklyn HAQ”!  (for full effect this has to be delivered with an inquisitive raise of the chin, a bit of NY interjection and a Brooklyn accent. Think Travolta in Saturday Night Fever or as Vinnie Barbarino.)

Simplistic, direct and exacting, this mirthful question is more than a greeting. It is a direct, non-Likert, patient global assessment that will ultimately be weighed against other clinical findings, the exam, labs and a physician global assessment. It reminds me of a lesson learned during fellowship. While I was evaluating numerous ways to assess inflammatory myositis, a senior faculty member set me straight by pointing out that just asking the patient “How are you doing” would likely yield an accurate and predictive assessment equal to any chemical tests of muscle health. Over the years, this has held up well in many rheumatic disorders.  “How you doin” is the wise person's invitation for PRO, information that is approximated by the HAQ. If you object that such global assessments are invalidated by intercurrent illness and fibromyalgia, I won’t object. Instead Ill remind you the same applies to all metrics (e.g., DAS, CDAI, etc.) in such patients.

The master of metrics, Dr. Ted Pincus, of Rush University, has taught billions of rheumatologists on the merits of practice measures.  I reached out to Ted for his comments about the Brooklyn HAQ and its growth. 

He responded by offering up the quote, "'Science in medicine involves standardization, quantitation, and documentation to recognize change and prognostic value.' Patient questionnaires (the HAQ) meet these criteria far more effectively than lab tests for rheumatic diseases. And the patient does all the work. The "How ya' doing" approach has been documented to be for less accurate, as patients try to please doctors, derive secondary gains, etc.  Which is not seen with a neutral piece of paper or the computer screen? It remains to be seen if the Brooklyn HAQ would produce results similar to those I published in treatment of RA. Until then, the MDHAQ would appear a much better approach." Ted was happy to point out that he was born in the Brooklyn Jewish hospital and did his schooling in NY – hence the unique NY accent and style of an influential teacher.

Benefits of the Brooklyn HAQ

  • Everyone does it. Now you know what to call it.
  • Global assessments of any kind are valuable, including the physician global assessment or patient global assessment. However, a “scored” HAQ is known to yield useful, accurate information. Will Dr. Ricciardi’s Brooklyn HAQ perform as well?  Time and research may tell. 

Sufferings of the Brooklyn HAQ

  • Patient responses may be unpredictable and recordable. A patient retort of “How YOU Doin’?”; “Who wants to know?” or “Fuggedaboutit” are probably not going to correlate well with the ESR or CRP.
  • A dearth of research has shown the formal HAQ is superior to the patient global assessment and that PRO “subjective” measures are superior to “objective” measures like the CRP, ESR or swollen joint count in predicting outcomes. The Brooklyn HAQ has no rigor or research to stand up to these claims.

So now when you query your patients, with or without the Brooklyn accent, you know the origins, utility and limitation of the Brooklyn HAQ.

Ricciardi coined it; Gibofsky popularized it; but Cush has the patent and future royalties.

 

 

 

 

 

The 3FB's - Cush, Gibofsky and Ricciardi

Disclosures: 
The author has no conflicts of interest to disclose related to this subject
Dr. Cush is the Director of Clinical Rheumatology at the Baylor Research Institute and a Professor of Medicine and Rheumatology at Baylor University Medical Center in Dallas, TX. He is the Executive Editor of RheumNow.com and Co-Editor of the online textbook RheumaKnowledgy.com. Dr. Cush's research and interests include novel drug development, rheumatoid arthritis, spondyloarthritis, drug safety, pregnancy and Still's disease/autoinflammatory syndromes. He has published over 140 articles and 2 books in rheumatology.
He can be followed on twitter: @RheumNow.

Rheumatologists' Comments

Dear Danny, Gibo and Jack This sounds like the functional equivalent of selling us the Brooklyn Bridge. Caveat Emptor. Be well Art
Great article. I'm still laughing. Sterling
"Physician Gestalt" lives on - nothing is better no matter what you call it.