Modelling the effect of function and disease activity on costs and quality of life in rheumatoid arthritis

OBJECTIVE: When treatments with the potential to change the natural history of a disease are introduced, their longer-term effect on costs and quality of life (utility) has to be estimated using economic models. However, to remain useful tools, models must be updated when new information becomes available. Our earlier models in rheumatoid arthritis (RA) have been based on functional status, but it has recently been shown that disease activity might have an independent effect on utility. The objective of this study was to improve the model by incorporating the effect of a subjective measure of disease severity and activity (global VAS). METHODS: A Markov model was constructed with five states according to functional status (HAQ), and each state was subdivided according to the VAS (<40 and >40). Disease development (transition probabilities between the states) was taken from a longitudinal cohort study of patients with early RA in Sweden. A recent population-based survey of 616 patients with RA provided data on costs and utilities. The model incorporates the full distribution of costs and utilities from the survey, and long-term projections are made using Monte Carlo simulation. RESULTS: The global VAS had a highly significant effect on utilities independently of HAQ. For resource consumption, only HAQ was a significant predictor, with the exception of sick leave, which was correlated with the VAS but not with HAQ. Using the cohort distribution from the longitudinal study, expected mean costs per patient over 10 yr were 106 034 euros (s.d. 5091 euros) (1 euro = SEK 9.20) and the expected number of quality-adjusted life years (QALYs) was 5.08 (s.d. 0.09). Patients starting at HAQ <0.6 but with consistently high VAS scores would have expected costs of 102 830 euros and 4.96 QALYs, while patients with low VAS scores would have costs of 81 603 euros and 6.01 QALYs. CONCLUSION: Our new model incorporates for the first time the effect of a subjective measure of disease severity and activity on both costs and utility, making it a sensitive tool to estimate the cost-effectiveness of disease-modifying treatments. New data on resource consumption indicate a shift to higher direct costs, particularly in early disease, and lower indirect costs in more advanced disease. The large size of the data sets used in this model reduces the uncertainty and makes estimates very stable.     

Assessment of cervical pain and function in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is characterized by inflammation of the synovial membrane, which can lead to deformities and functional disability. Unlike the dorsal and lumbar spine, the cervical spine is often affected by RA. The objective of this paper is to assess cervical pain and function in patients with RA and correlate these variables with overall function, quality of life, and radiographic findings on the cervical spine. One hundred individuals aged 18 to 65 years were divided into study group (50 patients with rheumatoid arthritis) and control group (50 healthy individuals, paired for gender and age). Patients with prior surgery, prior trauma or other symptomatic cervical spine condition were excluded. The visual analogue pain scale (VAS), Neck Pain and Disability Scale (NPDS), SF-36, HAQ and X-rays were used for evaluation purposes. Mean disease duration was 11.1 years. The cervical VAS was 2.4 cm and 1.3 cm for the study and control groups, respectively (p = 0.074). Statistical differences were found in NPDS scores, mean = 26.7 and 6.9, and HAQ scores, mean = 1.1 and 0.1, for the study and control groups, respectively (p < 0.001). SF-36 scores were statistically worse in the study group, except for the vitality, social aspects and mental health subscales. There was a positive correlation between the NPDS and VAS (r = 0.54) and between the NPDS and HAQ (r = 0.67). There was a negative correlation between the NPDS and SF-36 functional capacity domain (r = −0.53) and physical limitation domain (r = −0.58). The radiographic findings revealed more prevalent anterior atlanto-axial subluxation (p = 0.030), listhesis in neutral posture (p = 0.037), listhesis in extension (p = 0.007), degenerative alteration of C4–C5 segment (p = 0.023), size of C2 spinal canal (p = 0.002) and C3 spinal canal (p = 0.029) in the study group. Patients with RA have poorer cervical function than healthy individuals, although there is no difference in cervical pain.     

Scores for functional disability in patients with rheumatoid arthritis are correlated at higher levels with pain scores than with radiographic scores

OBJECTIVE: To analyze correlations of functional disability scores with other measures of clinical status, in particular, Larsen radiographic scores and pain scores, in patients with rheumatoid arthritis (RA). METHODS: The functional capacity of 141 patients with RA (102 women, 39 men; median age 57 years; median disease duration 11.8 years; 83% rheumatoid factor positive) was assessed according to the Stanford Health Assessment Questionnaire (HAQ). Other variables studied included Larsen scores for radiographic damage of the small joints of the hands, wrists, and feet, pain scores by visual analog scale (VAS), Disease Activity Scores, general health scores by VAS, and Beck Depression Inventory (BDI) scores. RESULTS: The Spearman correlation coefficient comparing HAQ and Larsen scores was 0.277 (P = 0.001) and between HAQ and pain scores 0.652 (P < 0.001). In regression analysis, pain scores explained 41.4% of the variation in HAQ scores, normalized Larsen scores explained 7.3%, and BDI scores explained 5.5%; other variables were not significant in the model. CONCLUSION: Functional capacity scores of patients with RA are correlated at higher levels with pain scores than with radiographic scores of small joints.     

Assessing joint involvement in haemophilia by clinical rheumatologic scores. A pilot study on similarities with subjects with psoriatic arthritis

Because of joint haemorrhages, severe haemophilia subjects often have limitations in their daily activities. Current orthopaedic scores (OJS) in haemophilia miss mild joint impairments and only pick up severe alterations. Twelve young severe haemophiliacs (20.25 ± 1.9 years of age), were evaluated for OJS as well as for indices employed in rheumatoid arthritis [28-joint Disease Activity Score (DAS-28), Ritchie index, Health Assessment Questionnaire (HAQ), visual analogue scale (VAS)], spondyloarthritis [Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), HAQ, VAS] and osteoarthritis [Knee injury and Osteoarthritis Outcome Score (KOOS), VAS]. Twenty-four matched apparently healthy subjects and 29 subjects with psoriatic arthritis (PsA) with oligoarticular involvement (one to three swollen joints) served as controls. In addition to the impairment of target joints (elbow, in five of five in those on-demand treatment; three, elbows; four, knee in those on secondary prophylaxis), HAQ (mean 0.71 ± 0.95) and VAS (3.12 ± 2.36) documented a quality of life and a perception of pain in haemophiliacs similar to that of PsA subjects (p = 0.061 and p = 0.063, respectively). Their Ritchie index did not differ from that of subjects with psoriatic arthritis (5.75 ± 8.1 vs 7.73 ± 9.22; p = 0.408), nor did the BASDAI score with respect to psoriatic arthritis patients (p = 0.105). Six of 12 haemophiliacs (50%) had KOOS values from 70 to 50 (significant function joint impairment); 3 of 12 (25%) showed DAS-28 values >3.2 (moderate disease activity), 2 of 12 (16.6%) severe disease activity (>5.1). All these indices significantly correlated with VAS and HAQ in haemophilia subjects. A rheumatologic assessment may help identify early polyarticular disease and subclinical abnormalities involving joints not usually studied (not target joint) in haemophiliacs. These pilot data provide the rationale for testing a systemic involvement in haemophiliacs by means of high-tech imaging and to start early-onset prophylaxis/treatment in this setting.     

Functional capacity in rheumatoid arthritis patients: comparison between Spanish and Brazilian sample

The main objective of this study is to compare Spanish and Brazilian self-reported health-related functional capacity in patients with rheumatoid arthritis (RA). 197 patients diagnosed with RA were studied in Spain (n = 127) and Brazil (n = 70). Pain (Visual analog scale) and functional capacity (Health Assessment Questionnaire/HAQ) were assessed. Patients were questioned about regular exercise practice. Comparisons between groups were performed with Chi-square tests and Student t test. Pearson’s correlation coefficient and linear regression models were used to analyze the associations. Brazilian patients were younger (p = 0.013), had worse levels of pain (p = 0.001) and a trend to experience worse functional capacity (p = 0.057) than Spanish ones. Spanish RA patients had higher body mass index (BMI) (p = 0.019) and longer disease duration (p = 0.001). Also, a higher percentage of subjects with RA from the Spanish cohort had been elected to take early retirement when compared with Brazilian patients (p = 0.010). Spanish RA patients had received more drugs than Brazilians (oral corticosteroids p = 0.010, Leflunomide p = 0.023, Methotrexate p = 0.072, non-steroidal anti-inflammatory drugs p = 0.064, biologic therapies p = 0.001). The functional capacity (HAQ) was correlated with age (p = 0.001), disease duration (p = 0.001), age at diagnosis (p = 0.001), pain (p = 0.001) and BMI (p = 0.001) in Spanish patients. In Brazilian, these correlations were only found with disease duration (p = 0.004) and pain (p = 0.001). In conclusion, our data suggest a better management of RA in Spanish when compared with Brazilians. Even with less pain and functional capacity, they receive more drug treatment and a higher percentage of them are retired early.     

Functional and work outcomes improve in patients with rheumatoid arthritis who receive targeted,comprehensive occupational therapy

Objective

Work disability is a serious consequence of rheumatoid arthritis (RA). We conducted a 6‐month, prospective randomized controlled trial comparing assessments of function, work, coping, and disease activity in employed patients with RA receiving occupational therapy intervention versus usual care.

Methods

Employed patients with RA with increased perceived work disability risk were identified by the RA Work Instability Scale (WIS; score ≥10). Patients were stratified into medium‐ (score ≥10 and <17) and high‐risk (≥17) groups, then randomized into occupational therapy or usual care groups. Assessments were conducted at baseline and 6 months. The primary outcome was the Canadian Occupational Performance Measure (COPM), a standardized patient self‐report of function. Other outcomes included the disability index (DI) of the Health Assessment Questionnaire (HAQ); Disease Activity Score in 28 joints (DAS28); RA WIS; EuroQol Index; visual analog scales (VAS) for pain, work satisfaction, and work performance; and days missed/month. Independent sample t‐tests and Mann‐Whitney U tests were used.

Results

We recruited 32 employed patients with RA. At baseline the groups were well matched. At 6 months the improvement in the occupational therapy group was significantly greater than that in the usual care group for all functional outcomes (COPM performance P < 0.001, COPM satisfaction P < 0.001, HAQ DI P = 0.02) and most work outcomes (RA WIS [P = 0.04], VAS work satisfaction [P < 0.001], VAS work performance [P = 0.01]). Additionally, Arthritis Helplessness Index (P = 0.02), Arthritis Impact Measurement Scales II pain subscale (P = 0.03), VAS pain (P = 0.007), EuroQol Index (P = 0.02), EuroQol global (P = 0.02), and DAS28 (P = 0.03) scores significantly improved.

Conclusion

Targeted, comprehensive occupational therapy intervention improves functional and work‐related outcomes in employed RA patients at risk of work disability.     

Improved functional outcome in patients with early rheumatoid arthritis treated with intramuscular gold: results of a five year prospective study

OBJECTIVE—To determine whether there is a relation between disease duration and functional outcome in patients with rheumatoid arthritis (RA) treated with intramuscular sodium aurothiomolate (gold) for five years.
METHODS—440 patients with RA were enrolled in a prospective trial of gold treatment. Initial demographic details were recorded. Disease activity was assessed at yearly intervals using a combination of clinical (pain score, Ritchie articular index, duration of morning stiffness) and laboratory (erythrocyte sedimentation rate, C reactive protein) parameters. Change in functional status was assessed using the health status questionnaire (HAQ). Patients were stratified according to disease duration at outset (group 1= 0-2 years n=106, group 2 = >2-5 years n=93, and group 3= >5 years n=235).
RESULTS—There were no significant differences between the groups at outset. A total of 160 patients completed five years of treatment (group 1 n=44 (42%), group 2 n=37 (40%), and group 3 n=79 (34%)). Patients in group 1 had a significantly lower HAQ from year 1 to year 5 with a mean improvement of 30% at the end of the study (p<0.001). Neither group 2 nor group 3 had a significant change in their HAQ at study end. There were significant improvements in all other variables (p<0.05) in each group apart from pain in group 2.
CONCLUSION—Patients with early RA have a larger reversible component to their HAQ. Only patients with disease duration of up to two years have a longlasting improvement in their functional ability after starting intramuscular gold treatment.

Keywords: gold; rheumatoid arthritis; function; HAQ     

Adrenocorticotropic hormone response to hypoglycemic stress was preserved by a single bedtime 3-mg dose of prednisolone in patients with rheumatoid arthritis

We have studied the effect of low-dose prednisolone administered before sleep on the hypothalamic–pituitary–adrenal axis and the symptoms of patients with rheumatoid arthritis (RA). Plasma adrenocorticotropic hormone (ACTH) and serum cortisol levels were measured in the basal state and after hypoglycemic stress induced by the insulin tolerance test in 21 patients receiving prednisolone at 3–5 mg daily. The patient's global assessment of their disease activity scores on a 100-mm visual analogue scale (VAS) and self-reporting of their functional status using the health assessment questionnaire (HAQ) were evaluated. While both the cortisol and the ACTH responses were impaired dose-dependently in patients treated with prednisolone, the ACTH response was maintained in patients treated with a single daily 3-mg dose of prednisolone before sleep. There was an inverse correlation between the extent of the ACTH response and disease activity as revealed by the VAS (r = 0.521, P < 0.05). There was also a weak correlation between VAS and the self-rating depression scale (SDS) (r = 0.443), especially when only patients with an HAQ score > 10 were included in order to exclude any possible contribution of the limitations in the activities of daily living to the SDS score (r = 0.859, P < 0.05). These results suggest that a single daily low dose (3 mg) of prednisolone administered before sleep maintains the ACTH response in RA patients, and patients with a good ACTH response appear to be less depressed and have milder symptoms.     

Adrenocorticotropic hormone response to hypoglycemic stress was preserved by a single bedtime 3-mg dose of prednisolone in patients with rheumatoid arthritis

Abstract

We have studied the effect of low-dose prednisolone administered before sleep on the hypothalamic–pituitary–adrenal axis and the symptoms of patients with rheumatoid arthritis (RA). Plasma adrenocorticotropic hormone (ACTH) and serum cortisol levels were measured in the basal state and after hypoglycemic stress induced by the insulin tolerance test in 21 patients receiving prednisolone at 3–5?mg daily. The patient's global assessment of their disease activity scores on a 100-mm visual analogue scale (VAS) and self-reporting of their functional status using the health assessment questionnaire (HAQ) were evaluated. While both the cortisol and the ACTH responses were impaired dose-dependently in patients treated with prednisolone, the ACTH response was maintained in patients treated with a single daily 3-mg dose of prednisolone before sleep. There was an inverse correlation between the extent of the ACTH response and disease activity as revealed by the VAS (r = 0.521, P < 0.05). There was also a weak correlation between VAS and the self-rating depression scale (SDS) (r = 0.443), especially when only patients with an HAQ score > 10 were included in order to exclude any possible contribution of the limitations in the activities of daily living to the SDS score (r = 0.859, P < 0.05). These results suggest that a single daily low dose (3?mg) of prednisolone administered before sleep maintains the ACTH response in RA patients, and patients with a good ACTH response appear to be less depressed and have milder symptoms.     

Clinical assessment and health status in standard care in Indian and Iranian patients suffering from rheumatoid arthritis (RA)

Disease activity and quality of life (QOL) including functional status in rheumatoid arthritis (RA) is influenced by several ethnic, cultural and other factors. Standard of care management should cater for country specific needs.ObjectivesTo assess and compare clinical disease characteristics and health status in patients with RA from two countries, India and Iran.Material and methodsA cross-sectional survey of 140 RA patients (Indian70 and Iranian70) was chosen from rheumatology outpatients (Bandar Abbas, Iran and Pune, India) in random manner. One of the authors evaluated all patients under Rheumatologist supervision. Standard evaluation was as per current American College of Rheumatology guidelines and included a 68/66 joint count and laboratory tests. Health assessment questionnaire (CRD Pune version HAQ) and SF36v2 was utilized to assess functional and health status. While Iranian patients were all Muslims, the Indian patients were predominantly Hindu.ResultsThe groups matched well for age, gender, duration of disease and rheumatoid factor. Patients in Iran had less years of education as compared to patients from India (p < 0.001), Pains and SF 36 domains (barring vitality, social function and mental health) and sedimentation rate (ESR) scored significantly higher in the Iranian group. Swollen joint counts, global disease assessment and blood hemoglobin were higher in the Indian group. The overall DAS 28 (disease activity score) index, general health (VAS), HAQ and SF 36 Mental health domain scores did not differ significantly in two groups.ConclusionsThough there were some important differences in pain perception, joint counts and QOL, the study cohorts of RA belonging to the Iranian and Indian ethnicity were similar for disease activity (DAS) and functional status (HAQ).     

Quality of sleep in rheumatoid arthritis patients: Relationship with disease activity,depression and functional status

Aim of the workTo assess sleep quality in Egyptian patients with rheumatoid arthritis (RA) and its relationship with disease activity, depression and functional status.Patients and methodsThis cross-sectional study included 133 RA patients and 76 age and sex matched controls. Sleep using the Pittsburg Sleep Quality Index (PSQI), Beck depression inventory (BDI), functional status using health assessment questionnaire (HAQ), visual analogue scale-pain (VAS), and disease activity score (DAS28) were assessed.ResultsPatients were 125 females and 8 males with a mean age of 42.5 ± 9.5 years and disease duration of 3.9 ± 1.3 years. 76 age and sex matched control were also included. Poor sleep quality was detected in 54.1% of patients. Patients had significantly higher scores in the subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, day-time dysfunction domains and in terms of the total PSQI score compared to the control (p < 0.05). A significant difference was found between RA patients with poor sleep quality and those with good sleep quality as regards marital status, HAQ, erythrocyte sedimentation rate (ESR), VAS, DAS28, morning stiffness duration, anti-cyclic citrullinated peptide (anti-CCP) (p < 0.05), and the BDI (p < 0.001). The multivariate regression analysis found that disease activity, functional disability and depression were predictors for poor sleep quality (p = 0.04, p = 0.01 and p < 0.001; respectively).ConclusionThe sleep quality is impaired in RA patients. The poor sleep quality is associated with disease activity, depression and functional disability. Systemic psychiatric screening, holistic assessment and targeted interventions are required to improve sleep quality and quality of life.     

Which outcome measures should be used in rheumatoid arthritis clinical trials?.

Objective. To determine the discriminant validity of the core set of outcome measures proposed by the American College of Rheumatology (ACR) and the Outcome Measures in Clinical Trials (OMERACT) conference committee to be used in clinical trials of rheumatoid arthritis (RA). Methods. Utilizing data from a multicenter randomized double-blind clinical trial of low-dose cyclosporine and placebo in RA, we estimated the relative efficiency (RE) of measures to detect a treatment effect (relative to tender joint count, which was assigned a value of 1). Four pain measures (10-cm visual analog scale [VAS], 5-point categorical scale, Health Assessment Questionnaire [HAQ] pain index, Arthritis Impact Measurement Scales [AIMS] pain score) and 3 quality-of-life measures (Problem Elicitation Technique [PET], HAQ, AIMS) were compared. Results. Physician and patient global measures were the most responsive instruments, although neither was statistically superior to tender joint count. Swollen joint count, grip strength, pain measured on a 10-cm VAS, and functional status as measured by the PET and HAQ were all of intermediate responsiveness. Morning stiffness, 5-point pain scale, and erythrocyte sedimentation rate were the least responsive instruments. Conclusion. This study provides further evidence to support the core set of outce measures proposed by the ACR and OMERACT.     

The Nottingham health profile in rheumatoid arthritis: correlation with other health status measurements and clinical variables

Objective The overall effect of rheumatoid arthritis (RA) on general health status has drawn attention in recent years. The aim of this study was to determine the clinical relevance of the Nottingham Health Profile (NHP) in RA patients and the relationship between conventional clinical measures, the Health Assessment Questionnaire (HAQ), and the Beck Depression Inventory (BDI)Method One hundred RA patients (mean age 48.9±12.1 years, mean disease duration 101.3±85.5 months) were included in the study. Quality of life, health status, and psychological mood of the patients were assessed using NHP, HAQ, and BDI. The Ritchie Articular Index (RAI), visual analog scale, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor, and modified Larsen Scale were used to assess clinical, laboratory, and radiological changes.Results All subgroups of the NHP significantly correlated to VAS, RAI, BDI, and HAQ scores (P<0.001). Except in the social isolation subgroup, there were significant correlations with ESR (P<0.05, P<0.001, and P<0.0001, respectively). There were no correlations between CRP levels and health status measures (P>0.05).Conclusion The NHP reflects the clinical and psychological status of RA patients and can be used as a sensitive health status measure for clinical evaluation.     

Effects of home-based exercise program on the functional status and the quality of life in patients with rheumatoid arthritis: 1-year follow-up study

We previously reported the efficacy of a 4-week home-based exercise therapy for patients with rheumatoid arthritis (RA). In this study, we aimed to investigate whether short-term improvements in the functional status and quality of life were maintained at 1 year. Patients who completed 4-week home-based exercise program were advised to maintain the same exercises for 1 year duration. Changes of functional status and quality of life in patients with RA were evaluated by the Health Assessment Questionnaire (HAQ) and the Rheumatoid Arthritis Quality of Life Scale (RAQoL). The change of the variables at the different time points (baseline, 4 weeks, and 1 year) was assessed by the repeated measure of ANOVA test with Geisser-Greenhouse correction. Pairwise ANOVA comparisons adjusted using the Bonferroni correction were conducted. Twenty-eight (63.6%) of 44 patients were available for follow-up at 1 year. The results of repeated measure ANOVA showed that there was a statistically significant difference between three assessments in the HAQ (P = 0.015) and RAQoL (P = 0.037) scores at the end of the follow-up. Improvements in the functional status and health-related quality of life at 4 weeks were maintained at 1-year follow-up. In conclusion, we observed significant improvements in the functional status and health-related quality of life by 4-week home-based exercise program. Furthermore, these improvements were maintained at 1-year follow-up. Further studies are needed to confirm the usefulness of the home-based exercise therapy.     

Body image in patients with rheumatoid arthritis

We investigated body image in patients with rheumatoid arthritis (RA), correlating it with self-esteem, function, and quality of life. Forty-three RA patients and 39 control individuals from the community between 18 and 70 years of age and paired for gender, age, and body mass index (BMI) were evaluated. Patients were assessed for body image [Body Dysmorphic Disorder Examination (BDDE)], self-esteem (Rosenberg Self-Esteem Scale), function [Health Assessment Questionnaire (HAQ)] and quality of life [Short Form-36 (SF-36)]. The RA group had a mean age of 51.6 years, BMI 26.01, and disease duration 12.2 years. Most participants were categorized in functional class I. The BDDE score of the RA group (51.8) was significantly higher than in the control group (22.6) (p < 0.001). Rosenberg Self-Esteem Scale, HAQ and some SF-36 subscales were worse in the RA group than in the control group. These scores had a direct correlation with body image scores (p < 0.001). Individuals with RA had a worse body image than individuals without this condition. Body image was directly correlated with self-esteem, function, and quality of life.     

Healthcare consumption and direct costs of rheumatoid arthritis in Belgium

The aim of this study was to compare the socioeconomic consequences of early and late rheumatoid arthritis in Belgium and to assess the patient out-of-pocket contributions. This multicentre longitudinal study in Belgium evaluated patients with rheumatoid arthritis. Early disease was defined as diagnosis since less than 1 year. At baseline sociodemographic and disease characteristics were assessed and during the following year patients recorded all healthcare- and non-healthcare-related direct costs and out-of-pocket contributions. The study included 48 patients with early and 85 patients with late rheumatoid arthritis. Mean disease duration was 0.5 vs 12.5 years in patients with early and late rheumatoid arthritis, respectively. The disease activity score (DAS28) was comparable between both groups (4.1 vs 4.5, p=0.14), but physical function (Health Assessment Questionnaire, HAQ) was more impaired in patients with long-standing disease (1.0 vs 1.7, p<0.001). Work disability had increased from 2% in patients with early to 18% in patients with late disease. The annual societal direct costs per patient were € 3055 (median: € 1518) opposed to € 9946 (median: € 4017) for early and late rheumatoid arthritis, respectively. The higher direct cost for patients with long-standing disease was seen for all categories, but especially for physiotherapy and need for devices and adaptations. Patients with early as well as late disease contribute out of pocket about one-third to the direct healthcare costs. Within each group, HAQ was a strong determinant of costs. In Belgium, patients with long-standing rheumatoid arthritis are nine times more likely to be work disabled than patients with less than 1 year disease duration and have a threefold increase in costs. Differences in healthcare consumption between patients could be mainly explained by differences in physical function (HAQ).     

Socioeconomic deprivation and rheumatoid disease: what lessons for the health service? ERAS Study Group. Early Rheumatoid Arthritis Study

OBJECTIVE—To assess how socioeconomic deprivation influences the presentation, treatment, and outcome of patients with rheumatoid arthritis (RA).
METHODS—Three year follow up of 869 consecutive patients with RA from nine hospital rheumatology clinics, with patients categorised by the Carstairs deprivation score of their enumeration district of residence. Outcomes included Health Assessment Questionnaire (HAQ), joint and pain scores, grip strength, functional grade, radiological evidence of bony erosions, and medical/surgical interventions.
RESULTS—Patients from more deprived enumeration districts presented with more severe disease as judged by the HAQ score and joint scores. An increase from the 5th to the 95th centile of the Carstairs distribution was associated with an odds ratio of 1.87 (95% confidence interval (95% CI) 1.31 to 2.66) for an above-median HAQ score and 1.77 (95% CI 1.23 to 2.54) for an above-median joint score. Statistically non-significant deprivation trends were seen with erythrocyte sedimentation rate, pain score, and grip strength. By three years, despite no important differences in clinical management, socioeconomic differentials had worsened or remained unchanged such that clear deprivation trends were then seen in HAQ (p=0.002) and joint scores (p=0.001), in grip strength (p=0.008), and in functional grade (p=0.003). The association between deprivation and HAQ at three years was present after adjustment for age, sex, treatment centre, and HAQ at presentation (adjusted odds ratio 1.74, 95% CI 1.1 to 2.74).
CONCLUSIONS—Socioeconomic deprivation was associated with a worse clinical course of rheumatoid disease, and this effect was already apparent at presentation, but not with systematic differentials in its treatment. This suggests that individual susceptibility and lifestyle factors contribute to socioeconomic differentials in outcome, an observation that has implications for clinical management.

     

Factors associated with functional disability in patients with rheumatoid arthritis

To determine factors associated with functional disability in patients with rheumatoid arthritis (RA). A total of 100 RA patients were reviewed retrospectively. Multiple regression analysis was used to investigate associations between the dependent variable (health assessment questionnaire) and independent variables (age, disease duration, hand grip strength values, VAS and DAS-28 scores). Main factors associated with functional disability were disease activity score as reflected in a high score on the DAS-28 (r = 0.68, p < 0.001) and disease duration (r = 0.23, p < 0.05). Increased age, decreased grip strength and high pain level were associated with lower functional ability, but none of these was a predictor of disability in the regression model. The results indicate that age, disease duration, disease activity, pain intensity and hand grip strength are related to physical disability in patients with RA. However, only disease activity has an impact on physical function. Thus, treatment of RA patients should focus on early inhibition of disease activity in order to achieve a good functional outcome.     

Clinical significance of serum survivin in rheumatoid arthritis patients: Relation to disease activity,functional status and radiological damage

Aim of the workTo measure the levels of serum survivin in rheumatoid arthritis (RA) patients and to assess its relation to disease activity, functional impairment, and radiological damage.Patients and methodsThis study included 58 RA patients and 34 controls. The erythrocyte sedimentation rate (ESR), anti-cyclic citrullinated peptide (anti-CCP), rheumatoid factor (RF), C-reactive protein (CRP), disease activity score 28 (DAS28), health assessment questionnaire score (HAQ), modified Larsen radiological score and serum survivin level were assessed.ResultsThe mean age of the patients was 43.5 ± 11.5 years; 43 females and 15 males (F:M 2.9:1) with a mean disease duration of 2.6 ± 1.13 years. RF was positive in 79% Survivin level was significantly increased in patients compared to the controls (171.8 ± 74.4 pg/ml vs. 98.7 ± 16 pg/ml, p < 0.001) and in those with activity (203.1 ± 69.1 pg/ml) compared to those in remission (102.1 ± 12.1 pg/ml). Survivin level tended to be higher in females (177.1 ± 79.5 pg/ml) compared to males (156.4 ± 57 pg/ml) (p = 0.36) and was significantly higher in those with positive RF (183 ± 75.9 pg/ml) compared to those with a negative test (128.6 ± 50.5 pg/ml) (p = 0.02). A significant correlation was detected between survivin and disease duration, DAS28, ESR, CRP, VAS, HAQ, RF, and modified Larsen scores (p < 0.001). On univariate logistic regression the RF, HAQ, modified Larsen and survivin level were significant predictors but were insignificant on multivariate analysis.ConclusionIn RA patients the serum survivin is significantly increased compared to the controls. The disease activity, functional impairment, and radiological joint damage were associated with these high concentrations.     

The relationship between vitamin D and disease activity and functional health status in rheumatoid arthritis

We aimed to establish the relationship between serum vitamin D levels and disease activity and health status in rheumatoid arthritis. Sixty-five patients with RA fulfilling ACR criteria for the classification of rheumatoid arthritis and forty healthy controls were included in this study. Disease activity was assessed according to the Disease Activity Score including 28 joint counts. C-reactive protein (CRP, mg/dl) was determined by the nephelometric method. Erythrocyte sedimentation rate (ESR, mm/h) was determined by the Westergren method. Rheumatoid factor (RF, IU/ml) was also determined by the nephelometric method, and RF > 20 IU/ml was defined as positive. 25-OH Vitamin D EIA Kit was used to measure serum 25-OH Vitamin D levels. We found that the mean of the 25-OH D vitamin levels of the patients with RA was not different than that of controls (P = 0.936). We divided patients with RA into three groups according to DAS28 as low activity group (group 1, n = 25), moderate activity group (group 2, n = 25), and high activity group (group 3, n = 15). 25-OH vitamin D levels of the patients in the high activity group (group 3) were found to be the lowest (P < 0.001), and the patients with moderate disease activity had lower levels than those in the mild group (P = 0.033). Serum 25-OH vitamin D levels were significantly negatively correlated with DAS28, CRP, and HAQ (respectively, r = −0.431, P = 0.000, r = −0.276, P = 0.026, and r = −0.267, P = 0.031). Serum vitamin D levels in patients with RA were similar those in the healthy controls, while it significantly decreases in accordance with the disease activity and decreasing functional capacity.