Christopher T. Ritchlin, MD, MPH: Dr. [Elaine] Husni from the Cleveland Clinic and I had a long discussion about this, as well as Linda Grinnell-Merrick from the NP perspective. What we've learned is that there's a lot of efforts around the world actually to develop outcome measures, to help us understand how patients are doing. And we have many of them. We have MDA, VLDA, as well as DAPSA and others. What we've learned is that those are very valuable in helping the doctor understand whether a patient is reaching a certain bar. What we do know, though, is that patients view their illness and how they're doing completely differently. And there have been a number of studies not only in psoriatic arthritis, but an axial spondylitis and rheumatoid arthritis where you see a physician's understanding of where the patient is. And it's really very different than what the patient is thinking. We don't understand all this right now, but probably a lot of it has to do with how a patient is doing in their life—how are they managing their activities? How are they able to enjoy their families and be able to perform well at work? We need better ways of capturing that.
And one of the instruments that's now being used in many centers is called PROMIS. This is a questionnaire that is given to the patient before they see their doctor. It's electronic. It's really guided toward how the patient answers a question, as to what next question comes up. And it provides a doctor a snapshot, before they even see the patient, of how the patient is doing in terms of fatigue, pain, wellness, and their activities. I think incorporating that into our evaluations, which we've worked very hard to complete, will provide a more comprehensive picture of how patients are doing.