On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.98 n.9 Cape Town Sep. 2008
Margaret S WestawayI; Paul RheederII; Geoffrey GulobaIII
IPhD, Cert Ed; Environment and Health Research Unit, Medical Research Council, Pretoria, and School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria
IIPhD, MB BCh; Clinical Epidemiology Unit, Faculty of Health Sciences, University of Pretoria
IIIBSc Hons; School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria
To the Editor: The Health Assessment Questionnaire Disability Index (HAQ-DI) is widely used for measuring functioning in patients with rheumatoid arthritis (RA), since it is a better predictor of future morbidity, mortality and work disability than other disease outcome variables.1-2 Median scores for public and private health care patients with RA in the USA range between 1 and 1.253 compared with 1.6 for South African public health care patients,4 indicating more severe disability in our public health care sector.
Although the goal of health care for patients with RA is to maximise functioning in everyday life, functional disability is rarely assessed in South African public health care facilities. Owing to staff shortages and resources, patient overload and poor staff morale in South African public health facilities, routine administration of the HAQ-DI by existing staff is extremely difficult to implement. We administered the HAQ-DI to a consecutive sample of 108 outpatients with RA at Pretoria Academic Hospital.
The subjects' ages ranged between 21 and 72 years. The female/male ratio was 5.3:1, lower than the 6.5:1 reported at Johannesburg Hospital.4 Most patients (78%) were unemployed; of these 37% received a pension and 17% a disability grant, and 46% were financially supported by their partner/relatives. The latter figure indicates the burden RA places on patients and their families. Only 17% of the patients were completely self-sufficient (HAQ-DI 0.00 - 0.50), 22% were reasonably self-sufficient (HAQ-DI >0.50<1.25), 26% had many major problems with activities of daily living (HAQ-DI >1.25<2.00), and 35% could be regarded as severely handicapped (HAQ-DI >2.00 - 3.00).5 The median HAQ-DI score of 1.6 was identical to that at Johannesburg Hospital.4 Female and unemployed patients had more difficulties in performing daily living activities than male and employed patients (p<0.05). HAQ-DI scores/categories were related to pain intensity (r=0.62) and the American College of Rheumatology (ACR) classification (p<0.001).
We found that RA patients experienced considerable discomfort and disability from their disease. The positive correlation between HAQ-DI and pain intensity mirrored the reality of disease experience, and the relationship between HAQ-DI and ACR classification demonstrated similar patient/ physician perceptions on functioning.
1. Ramsey D, Fries J, Singh G. The Health Assessment Questionnaire 1995 - status and review. In: Spilker B, ed. Quality of Life and Pharmacoeconomics in Clinical Trials. 2nd ed. Philadelphia: Lippincott-Raven, 1996: 227-237. [ Links ]
2. Bruce B, Fries JF. The Stanford Health Assessment Questionnaire: a review of its history, issues, progress, and documentation. J Rheumatol 2003; 30: 167-178. [ Links ]
3. Krishnan E, Tugwell P, Fries JF. Percentile benchmarks in patients with rheumatoid arthritis: Health Assessment Questionnaire as a quality indicator (QI). Arthritis Res Ther 2004; 6: R505-513. [ Links ]
4. Solomon A, Christian BF, Dessein PH, Stanwix AE. The need for tighter rheumatoid arthritis control in a South African public health care center. Semin Arthritis Rheum 2005; 35: 122-131. [ Links ]
5. Siegert CEH, Vleming L-J, Van-Denbroucke JP, Cats A. Measurement of disability in Dutch rheumatoid arthritis patients. Clin Rheumatol 1984; 3: 305-309. [ Links ]