A physician checklist to record patient levels of inflammation, damage and distress as quantitative data rather than as narrative impressions.
DOCGL is described most often in RA but has been applied to many rheumatic diseases. Some physicians restrict DOCGL estimates to the level of inflammation, ignoring possible organ (joint) damage and patient distress, which are unexplained by symptoms and signs of inflammation or damage, e.g., fibromyalgia. However, other physicians may incorporate damage and distress into their DOCGL estimate, in addition to inflammation. (6,7)
One approach to clarify DOCGL is to estimate three additional 0 to 10 VAS for inflammation, or reversible symptoms and signs; damage, or irreversible symptoms and signs; and distress, or symptoms and signs explained by neither inflammation nor damage. A RheuMetric physician checklist (Fig. 1) includes a 0 to 10 VAS for overall DOCGL, and three 0 to 10 subscales VAS for inflammation (DOCINF), damage (DOCDAM), and distress (DOCSTR). (7) This report presents analyses of RheuMetric estimates in 205 patients with 4 primary rheumatic diagnoses, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), osteoarthritis (OA), and fibromyalgia (FM).
Materials and Methods
Since 2007, all patients (with all diagnoses) seen by rheumatologists at Rush University Medical Center have completed a two-page MDHAQ (Fig. 2) in 5 to 10 minutes in the waiting area at all visits, prior to seeing the rheumatologist. The MDHAQ8 is a two-page, single-sheet questionnaire, adapted from the Stanford health assessment questionnaire (HAQ) (9) to improve the quality of care in busy clinical settings while saving time for patients and doctors. (10) The MDHAQ includes queries concerning 10 activities, in the format of the original HAQ, (9) scored 0 to 3: 0 = "without any difficulty," 1 = "with some difficulty," 2 = "with much difficulty," and 3 = "unable to do." A total physical function score of 0 to 30 is converted to 0 to 10, using a template on the MDHAQ. Three 0 to 10 VAS scores for pain, patient global assessment (PATGL), and fatigue (8) are included.
RAPID3 (routine assessment of patient index data 3) is a composite of the three patient-reported RA Core Data Set measures for RA (1): physical function, pain, and PATGL from the MDHAQ, (11) each scored 0 to 10, for a total of 0 to 30. (11) MDHAQ also includes a RA disease activity index (RADAI) self-report joint count (12) to score pain in 16 specific joint groups, reported to be useful in patients with different rheumatic diseases. (13)
Physician RheuMetric Checklist
Since 2014, eight Rush University Medical Center rheumatologists have completed a RheuMetric checklist, a onepage physician checklist with four 0 to 10 VAS for overall global patient status (DOCGL), and levels of inflammation or reversible symptoms and signs) (DOCINF), damage or irreversible symptoms and signs (DOCDAM), and distress (DOCSTR) (Fig. 2).
Mean MDHAQ scores and RheuMetric estimates were compared in patients in the four diagnosis groups: RA, SLE, OA, and FM. Correlations of DOCGL with the three sub-scale scores were computed. MANOVA (multivariate analysis of variance) was performed to compare estimates in the four groups, adjusted for age, disease duration, and education with RA as the reference group.
Overall, 205 patients were studied, 50 with RA, 66 with SLE, 57 with OA, and 32 with FM (Table 1). Mean scores on each of five MDHAQ scales, including physical function, PATGL, RAPID3, fatigue, and number of symptoms, were all highest in FM (p < 0.001) followed by OA, RA, and SLE. Although MDHAQ scores were higher in OA than in RA, and higher in RA than in SLE, scores for physical function, patient global estimate, and fatigue were within 1 unit for patients with OA, RA, or SLE. Only scores for FM differed significantly from the other diseases (p < 0.001).
The RheuMetric checklist was completed in 10 to 15 seconds by the treating rheumatologists. DOCGL RheuMetric estimates were highest for FM, followed by OA, RA, and SLE, a pattern similar to patient MDHAQ scores, including PATGL (Table 2). However, mean PATGL (Table 1) was 1.0 to 2.6 units higher than DOCGL (Table 2), reflecting discordance of DOCGL and PATGL in many rheumatic diseases. (14-20)
DOCINF estimates were 2.4 in patients with RA followed by 1.4 in SLE, 1.0 in OA, and 0.8 in FM (p < 0.001) (Table 2). DOCDAM estimates were 4.4 in OA compared to 2.6 in RA, 1.8 in SLE, and 1.9 in fibromyalgia (p < 0.001). DOCSTR estimates were 5.4 in FM versus 2.1 in OA, 1.1 in SLE, and 0.6 in RA (p < 0.001) (Table 2).
Differences between DOCDAM in OA and other diseases were at least 1.8, and differences between DOCDAM in OA and other RheuMetric estimates were at least 2.2. Differences between DOCSTR in FM and other diseases were at least 3.2, and differences between DOCSTR in FM and other RheuMetric estimates were at least 3.5. By contrast, estimates for the three scales ranged over 2 units in RA and 0.7 units in SLE. DOCDAM estimates were somewhat higher than DOCINF estimates in RA (2.6 versus 2.4) and SLE (1.8 versus 1.4) (Table 2). These data suggest that damage may be as important a clinical problem as inflammation in contemporary management of RA and SLE; furthermore, all three constructs, inflammation, damage, and distress are clinically important in SLE.
DOCGL was correlated significantly with PATGL in RA, OA, and SLE, but not in FM (Table 3). Correlations of overall DOCGL with RheuMetric subscales indicated significant correlations greater than 0.5 for DOCINF with RA and SLE, DOCDAM with OA and SLE, and DOCSTR only with FM (all p < 0.001) (Table 3).
These data extend previous reports that physician estimates of inflammation, damage, and distress can be assessed quantitatively in routine care using a physician RheuMetric checklist. (6-7) The scale was previously termed "RHEUMDOC" (7); however, an electronic medical record termed RHEUMDOC is currently being marketed, and it seemed most pragmatic to change the name of the scale. Furthermore, in previous versions, the final subscale for distress "DOCSTR" was termed "DOCNON" to indicate symptoms and signs explained by neither inflammation nor damage. (6,7)
As in previous reports of databases from Tennessee (6) and Pennsylvania, (7) data reported here from Rush University Medical Center in Illinois indicate that most patient MDHAQ scores for all variables were higher in FM than in other diagnoses, and physician RheuMetric estimates were highest for DOCINF in RA and SLE, for DOCDAM in OA, and for DOCSTR in FM (Table 2). Differences between DOCDAM in OA and DOCSTR in fibromyalgia were more pronounced than differences between DOCINF, DOCDAM and DOCSTR in RA and SLE. The data suggest that damage and distress may complicate management of RA and SLE.
Physician global estimates were about 1 unit lower than patient global estimates in RA, SLE, and OA, but differed by 2.2 units in FM (Tables 2 and 3), findings that reflect discordance of physician and patient global estimates in many rheumatic diseases. (14-20) The greater discordance seen in FM is consistent with the absence of significant correlations between patient and physician global estimates in FM, in contrast to significant correlations in RA, SLE, and OA (Table 3). Although a diagnosis of FM generally is easily made on the basis of a patient history and physical examination in most patients. Simple patient and physician questionnaires may provide useful clues to recognize FM, (21,22) particularly secondary FM, which may be difficult in some patients. Fibromyalgia is seen in 20% to 40% of patients with RA (23-25) and SLE (23,26) and may complicate management of all rheumatic diseases.
It may appear ironic that a physician checklist helps to clarify a patient self-report questionnaire. Checklists have long been used by pilots and more recently by surgeons to improve quality and safety. (27) The possible value in rheumatic diseases of quantitative patient MDHAQ scores and physician RheuMetric checklists with estimates of inflammation, damage, and distress is consistent with data that the patient history and physical examination are far more important to guide clinical decisions in treatment of RA than in seven other chronic diseases. (28) A self-report questionnaire may be regarded as providing quantitative data from a patient history, and a RheuMetric checklist as providing quantitative data from a physical examination and overall impressions of a physician, to supplement narrative descriptions.
Quantitative physical examination data have traditionally been collected in RA as a formal tender and swollen joint count. However, while formal joint counts are performed in all clinical trials, they are not performed at most rheumatology encounters. (29,30) Furthermore, a formal joint count for tender and swollen joints does not recognize damage or distress, which may be important considerations in patient management. For example, joint damage and fibromyalgia appear to explain in part some limitations to "treat-to-target" in RA, (31) as intensification of therapy in some patients with high to moderate RA index scores may not be appropriate on the basis of damage or distress. (32,33) In addition, estimation of inflammation (or damage and distress) in other rheumatic diseases cannot be accomplished according to a formal joint count.
Several limitations are seen in this report. First, the data were collected from only one setting; however, results indicating highest scores for DOCINF in RA, DOCDAM in OA, and DOCSTR in fibromyalgia are similar to those from two previous settings. (6,7) Second, data concerning test-retest reliability of RheuMetric are not yet available but under study. Third, face validity is not yet documented, e.g., comparisons of DOCINF with swollen joint counts in RA, DOCDAM with radiographic damage in OA, and DOCSTR with fibromyalgia tender points. At the same time, the recorded estimates form the basis of clinical decisions by physicians in busy clinical care. Some quantitative documentation of these constructs might be preferable to only narrative descriptions without any quantitative data, as is the case in most settings at this time. (34)
The expertise of a rheumatologist is not only to recognize the severity of symptoms and signs but also to interpret whether symptoms and signs are explained by inflammation, damage, or distress, or two or three of these components. Recording this information quantitatively may help clarify clinical decisions to doctors, patients, and payers. Our findings suggest that many patients have clinically important levels of both inflammation and damage or distress, and some patients may have inflammation, damage, and distress, indicating the complexity of management of many patients seen in rheumatology care.
Documentation of physician estimates of inflammation, damage, and distress on a RheuMetric checklist may be useful to recognize some of the challenges presented by many patients with rheumatic diseases and to help clarify and support clinical decisions to meet these challenges.
Isabel Castrejon, M.D., Ph.D., Joel A. Block, M.D., Sarah L. Everakes, M.D., Ruchi Jain, M.D., and Theodore Pincus, M.D., Division of Rheumatology, Rush University Medical Center, Chicago, Illinois. Kathryn A. Gibson, M.D., Ph.D., Department of Rheumatology, Liverpool Hospital, Liverpool, Australia.
Correspondence: Theodore Pincus, M.D., Division of Rheumatology, Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL 60612; firstname.lastname@example.org.
Theodore Pincus, M.D., is president of Health Report Services, Inc. which owns a copyright and trademark for MDHAQ/RAPID3. No license is needed for clinicians and non-profit researchers, who may freely use paper copies of MDHAQ/RAPID3 to monitor patient status in usual clinical care and academic research. Royalties and license fees are received from for-profit organizations, including pharmaceutical companies and electronic medical record companies, for use of MDHAQ/RAPID3; all license fees are used to support further development of quantitative measurement in clinical rheumatology care.
(1.) Felson DT, Anderson JJ, Boers M, et al. The American College of Rheumatology preliminary core set of disease activity measures for rheumatoid arthritis clinical trials. The Committee on Outcome Measures in Rheumatoid Arthritis Clinical Trials. Arthritis Rheum. 1993 Jun; 36(6):729-40.
(2.) Pincus T, Chung C, Segurado OG, et al. An index of patient reported outcomes (PRO-Index) discriminates effectively between active and control treatment in 4 clinical trials of adalimumab in rheumatoid arthritis. J Rheumatol. 2006 Nov; 33(11):2146-52.
(3.) Pincus T, Bergman MJ, Yazici Y, et al. An index of only patient-reported outcome measures, routine assessment of patient index data 3 (RAPID3), in two abatacept clinical trials: similar results to disease activity score (DAS28) and other RAPID indices that include physician-reported measures. Rheumatology (Oxford). 2008 Mar; 47(3):345-9.
(4.) Pincus T, Furer V, Keystone E, et al. RAPID3 (Routine Assessment of Patient Index Data 3) severity categories and response criteria: Similar results to DAS28 (Disease Activity Score) and CDAI (Clinical Disease Activity Index) in the RAPID 1 (Rheumatoid Arthritis Prevention of Structural Damage) clinical trial of certolizumab pegol. Arthritis Care Res (Hoboken). 2011 Aug; 63(8):1142-9.
(5.) Pincus T, Richardson B, Strand V, Bergman MJ. Relative efficiencies of the 7 rheumatoid arthritis Core Data Set measures to distinguish active from control treatments in 9 comparisons from clinical trials of 5 agents. Clin Exp Rheumatol. 2014 Sep-Oct; 32 (5 Suppl 85):S47-54.
(6.) Pincus T, Bergman MJ. Quantitative recording of physician clinical estimates, beyond a global estimate and formal joint count, in usual care: applying the scientific method, using a simple one-page worksheet. Rheum Dis Clin North Am. 2009 Nov; 35(4):813-7, x.
(7.) Bergman MJ, Castrejon I, Pincus T. RHEUMDOC: a one-page RHEUMatology DOCtor form with four physician global estimates for overall status, inflammation, damage, and symptoms based on neither inflammation nor damage. Bull Hosp Jt Dis (2013). 2014; 72(2):142-7.
(8.) Pincus T, Sokka T, Kautiainen H. Further development of a physical function scale on a MDHAQ [corrected] for standard care of patients with rheumatic diseases. J Rheumatol. 2005 Aug; 32(8):1432-9.
(9.) Fries JF, Spitz P, Kraines RG, et al. Measurement of patient outcome in arthritis. Arthritis Rheum. 1980 Feb; 23(2):137-45.
(10.) Pincus T, Yazici Y, Bergman M, et al. A proposed continuous quality improvement approach to assessment and management of patients with rheumatoid arthritis without formal joint counts, based on quantitative routine assessment of patient index data (RAPID) scores on a multidimensional health assessment questionnaire (MDHAQ). Best Pract Res Clin Rheumatol. 2007 Aug; 21(4):789-804.
(11.) Pincus T, Yazici Y, Bergman MJ. RAPID3, an index to assess and monitor patients with rheumatoid arthritis, without formal joint counts: similar results to DAS28 and CDAI in clinical trials and clinical care. Rheum Dis Clin North Am. 2009 Nov; 35(4):773-8, viii.
(12.) Stucki G, Liang MH, Stucki S, et al. A self-administered rheumatoid arthritis disease activity index (RADAI) for epidemiologic research. Psychometric properties and correlation with parameters of disease activity. Arthritis Rheum. 1995 Jun; 38(6):795-8.
(13.) Castrejon I, Yazici Y, Pincus T. Patient self-report RADAI (Rheumatoid Arthritis Disease Activity Index) joint counts on an MDHAQ (Multidimensional Health Assessment Questionnaire) in usual care of consecutive patients with rheumatic diseases other than rheumatoid arthritis. Arthritis Care Res (Hoboken). 2013 Feb; 65(2):288-93.
(14.) Neville C, Clarke AE, Joseph L, et al. Learning from discordance in patient and physician global assessments of systemic lupus erythematosus disease activity. J Rheumatol. 2000 Mar; 27(3):675-9.
(15.) Yen JC, Abrahamowicz M, Dobkin PL, et al. Determinants of discordance between patients and physicians in their assessment of lupus disease activity. J Rheumatol. 2003 Sep; 30(9):1967-76.
(16.) Sztajnbok F, Coronel-Martinez DL, Diaz-Maldonado A, et al. Discordance between physician's and parent's global assessments in juvenile idiopathic arthritis. Rheumatology (Oxford). 2007 Jan; 46(1):141-5.
(17.) Barton JL, Imboden J, Graf J, et al. Patient-physician discordance in assessments of global disease severity in rheumatoid arthritis. Arthritis Care Res (Hoboken). 2010 Jun; 62(6):857-64.
(18.) Hudson M, Impens A, Baron M, et al. Discordance between patient and physician assessments of disease severity in systemic sclerosis. J Rheumatol. 2010 Nov; 37(11):2307-12.
(19.) Khan NA, Spencer HJ, Abda E, et al. Determinants of discordance in patients' and physicians' rating of rheumatoid arthritis disease activity. Arthritis Care Res (Hoboken). 2012 Feb; 64(2):206-14.
(20.) Castrejon I, Yazici Y, Samuels J, et al. Discordance of global estimates by patients and their physicians in usual care of many rheumatic diseases: association with 5 scores on a multidimensional health assessment questionnaire (MDHAQ) that are not found on the health assessment questionnaire (HAQ). Arthritis Care Res (Hoboken). 2014 Jun; 66(6):934-42.
(21.) Callahan LF, Pincus T. A clue from a self-report questionnaire to distinguish rheumatoid arthritis from noninflammatory diffuse musculoskeletal pain. The P-VAS:D-ADL ratio. Arthritis Rheum. 1990 Sep; 33(9):1317-22.
(22.) DeWalt DA, Reed GW, Pincus T. Further clues to recognition of patients with fibromyalgia from a simple 2-page patient multidimensional health assessment questionnaire (MDHAQ). Clin Exp Rheumatol. 2004 Jul-Aug; 22(4):453-61.
(23.) Clauw DJ, Katz P. The overlap between fibromyalgia and inflammatory rheumatic disease: when and why does it occur? J Clin Rheumatol. 1995 Dec; 1(6):335-42.
(24.) Pincus T. Management of associated rheumatoid arthritis and fibromyalgia. J Rheumatol. 2009 Sep; 36(9):2123-4; discussion 2124-5.
(25.) Wolfe F, Hauser W, Hassett AL, et al. The development of fibromyalgia - I: examination of rates and predictors in patients with rheumatoid arthritis (RA). Pain. 2011 Feb; 152(2):291-9.
(26.) Wolfe F, Petri M, Alarcon GS, et al. Fibromyalgia, systemic lupus erythematosus (SLE), and evaluation of SLE activity. J Rheumatol. 2009 Jan; 36(1):82-8.
(27.) Haynes AB, Berry WR, Gawande AA. What do we know about the safe surgery checklist now? Ann Surg. 2015 May; 261(5):829-30.
(28.) Castrejon I, McCollum L, Tanriover MD, Pincus T. Importance of patient history and physical examination in rheumatoid arthritis compared to other chronic diseases: Results of a physician survey. Arthritis Care Res (Hoboken). 2012 Aug; 64(8):1250-5.
(29.) Pincus T, Segurado OG. Most visits of most patients with rheumatoid arthritis to most rheumatologists do not include a formal quantitative joint count. Ann Rheum Dis. 2006 Jun; 65(6):820-2.
(30.) Anderson J, Caplan L, Yazdany J, et al. Rheumatoid arthritis disease activity measures: American College of Rheumatology recommendations for use in clinical practice. Arthritis Care Res (Hoboken). 2012 May; 64(5):640-7.
(31.) Smolen JS, Aletaha D, Bijlsma JW, et al. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis. 2010 Apr; 69(4):631-7.
(32.) Pincus T, Castrejon I, Bergman M, et al. Treat-to-target: not as simple as it appears. Clin Exp Rheumatol. 2012 Jul-Aug; 30(4 Suppl 73):S10-S20.
(33.) Tymms K, Zochling J, Scott J, et al. Barriers to optimal disease control for rheumatoid arthritis patients with moderate and high disease activity. Arthritis Care Res (Hoboken). 2014 Feb; 66(2):190-6.
(34.) Pincus T, Wolfe F. Patient questionnaires for clinical research and improved standard patient care: is it better to have 80% of the information in 100% of patients or 100% of the information in 5% of patients? J Rheumatol. 2005 Apr; 32(4):575-7.
Caption: Figure 1 RheuMetric checklist for four physician estimates of overall global status (DOCGL), inflammation (DOCINF), damage (DOCDAM), and Distress (DOCSTR).
Caption: Figure 2 Page 1 of multi-dimensional health assessment questionnaire (MDHAQ), a two-page patient self-report questionnaire.
Figure 2 Page 2 of multi-dimensional health assessment questionnaire (MDHAQ), a two-page patient self-report questionnaire.
Table 1 Mean MDHAQ Patient Scores in Patients with Four Rheumatic Diseases Variable (range) All (205) RA (50) SLE (66) Physical Function 2.5 (1.9) 2.4 (2.0) 1.8 (1.7) (0 to 10) Pain (0 to 10) 5.7 (3.0) 5.1 (3.1) 4.3 (3.2) Patient Global 5.0 (3.0) 4.5 (3.2) 4.0 (3.0) Estimate (0 to 10) RAPID3 (0 to 30) 13.0 (7.2) 11.4 (7.4) 9.9 (7.3) Fatigue (0 to 10) 5.0 (3.0) 4.6 (3.2) 4.4 (3.1) Number of 11.1 (8.5) 8.1 (8.5) 10.4 (8.2) Symptoms (0 to 60) Variable (range) OA (67) FM (32) P-value Physical Function 2.9 (1.9) 3.6 (1.9) * p = 0.001 (0 to 10) Pain (0 to 10) 6.8 (2.2) * 7.6 (1.7)t p < 0.001 Patient Global 5.4 (2.8) 7.1 p < 0.001 Estimate (1.9) ([dagger]) (0 to 10) RAPID3 (0 to 30) 15.1 (5.8) 18.2 p < 0.001 (4.4) ([dagger]) Fatigue (0 to 10) 5.2 (3.0) 6.7 (1.8) * p = 0.007 Number of 11.1 (7.1) 17.9 p < 0.001 Symptoms (8.2) ([double dagger]) (0 to 60) Numbers are mean (standard deviation); * p < 0.05 ([dagger]) p < 0.01 ([double dagger]) p < 0.001 (p-values using RA as reference group). Table 2 Mean RheuMetric Physician Estimates in Four Rheumatic Diseases Variable (range) All (205) RA (50) SLE (66) Patient Global 3.9 (2.1) 3.9 (2.2) 2.9 (2.1) Estimate (PATGL) (0 to 10) Inflammation 1.5 (1.8) 2.4 (2.4) 1.4 (1.6) * (DOCINF) (0 to 10) Damage (DOCDAM) 2.8 (2.1) 2.6 (2.2) 1.8 (1.8) (0 to 10) Distress (DOCSTR) 2.1 (3.0) 0.6 (1.9) 1.1 (2.3) (0 to 10) Variable (range) OA (67) FM (32) P-value Patient Global 4.5 (1.6) 4.9 (1.8) p < 0.001 Estimate (PATGL) (0 to 10) Inflammation 1.0 (1.5) 0.8 (1.2) p = 0.001 (DOCINF) ([dagger]) ([dagger]) (0 to 10) Damage (DOCDAM) 4.4 (1.6) 1.9 (1.8) p < 0.001 (0 to 10) ([double dagger]) Distress (DOCSTR) 2.1 (3.1) * 5.4 (2.2) p < 0.001 (0 to 10) ([double dagger]) Numbers are mean (standard deviation); * p < 0.05 ([dagger]) p < 0.01 ([double dagger]) p < 0.001 (p-values using RA as reference group). Table 3 Correlations of Physician Global Estimates (DOCGL) with Subscales and Patient Global Estimates (PATGL) Variable (range) All (205) RA (50) Inflammation (DOCINF) 0.42 ([double 0.73 ([double dagger]) dagger]) Damage (DOCDAM) 0.57 ([double 0.38 * dagger]) Distress (DOCSTR) 0.43 ([double 0.27 dagger]) Patient Global 0.64 ([double 0.67 ([double Estimate (PATGL) dagger]) dagger]) Variable (range) SLE (66) OA (67) Inflammation (DOCINF) 0.69 ([double -0.02 dagger]) Damage (DOCDAM) 0.70 ([double 0.71 ([double dagger]) dagger]) Distress (DOCSTR) 0.40 * 0.43 * Patient Global 0.41 ([dagger]) 0.57 ([double Estimate (PATGL) dagger]) Variable (range) FM (32) P-value Inflammation (DOCINF) -0.05 p = 0.42 ([double dagger]) Damage (DOCDAM) 0.09 p = 0.57 ([double dagger]) Distress (DOCSTR) 0.65 * p = 0.43 ([double dagger]) Patient Global 0.19 p = 0.64 ([double Estimate (PATGL) dagger]) * p < 0.05 ([dagger]) p < 0.01 ([double dagger]) p < 0.001.
Please note: Illustration(s) are not available due to copyright restrictions.
|Printer friendly Cite/link Email Feedback|
|Author:||Castrejon, Isabel; Gibson, Kathryn A.; Block, Joel A.; Everakes, Sarah L.; Jain, Ruchi; Pincus, Theo|
|Publication:||Bulletin of the NYU Hospital for Joint Diseases|
|Date:||Jul 1, 2015|
|Previous Article:||Improvement thresholds for morning stiffness duration in patients receiving delayed-versus immediate-release prednisone for rheumatoid arthritis.|
|Next Article:||Analysis of failure with the use of locked plates for stabilization of proximal humerus fractures.|