Quantifying the burden of emotional ill-health amongst patients referred to a specialist rheumatology service.

OBJECTIVES: (1) To determine the prevalence of emotional disorders (DSM IV depression, anxiety and panic disorders) amongst patients referred to a rheumatology out-patient service and the proportion of these detected by the rheumatologist. (2) To test the hypotheses that emotional disorders are associated with (i) broad categories of rheumatological diagnosis (systemic, inflammatory vs non-systemic, non-inflammatory), (ii) female gender, (iii) greater symptom burden and disability and (iv) markers of socio-economic deprivation. METHODS: A cross-sectional study was made of consecutive newly referred attenders at a hospital-based, regional rheumatology service. Emotional disorders, pain, health status and socio-economic factors were assessed by questionnaire. The letter to the referrer was scrutinized for the rheumatological diagnosis and mention of emotional disorder. RESULTS: A total of 256 patients were eligible and 203 (79%) participated. The sample was 69% female, had a mean age of 50 yr and 68 patients (33.5%) had one or more emotional disorders. Only a minority were detected. There was no association with type of rheumatological diagnosis. Patients with an emotional disorder were more likely to be female (81 vs 62%; P<0.007), to report more pain (mean Visual Analogue Score 70 vs 50 mm, P<0.001), a greater number of somatic symptoms (median 3 vs 1, P<0.001) and greater disability (median Health Assessment Questionnaire 1.1 vs 0.5, P<0.001). Emotional disorders were also associated with some, but not all, measures of lower social and economic status and life dissatisfaction. CONCLUSIONS: Emotional disorder is present in one-third of new rheumatology referrals. The course, causation and management of this important component of rheumatological illness merit further attention.

Medically unexplained symptoms in patients referred to a specialist rheumatology service: prevalence and associations.

OBJECTIVES: To determine the prevalence of medically unexplained rheumatic symptoms amongst patients newly referred to a rheumatology out-patient service and to examine their relationship with pain, disability, socioeconomic factors and the presence of emotional disorders (anxiety, depression and panic). METHODS: A sample of newly referred consecutive patients to a hospital-based, regional rheumatology service was administered a questionnaire for assessment of emotional disorders, pain, health status and socioeconomic factors. Rheumatologists rated the degree to which patients' symptoms were explained by organic disease (organicity rating). RESULTS: Two hundred and fifty-six patients were eligible and 203 (79%) participated. The sample included 69% females and mean age was 50 yr. Ninety-three (46%) had symptoms that were completely explained, 52 (26%) largely explained, 41 (20%) somewhat explained and 17 (8%) not at all explained by organic disease. Patients whose symptoms were of "low organicity" (somewhat or not at all explained) were more likely to be female [relative risk (RR) 1.8, 95% confidence interval (CI) 1.0-3.1], younger (mean age 44 vs 52 yr, P<0.001) and to report more somatic symptoms (median 2 vs 1, P=0.021). On univariate analysis they were more likely to be experiencing financial hardship (RR 1.7, 95% CI 1.1-2.6) and work dissatisfaction (RR 1.6, 95% CI 1.0-2.4) and to live in rented housing (RR 1.8, 95% CI 1.2-2.8) or with dependent relatives (RR 1.6, 95% CI 1.0-2.5). Logistic regression showed that female gender and living in rented housing were the significant independent predictors of low organicity. Organicity ratings were not associated with pain severity, disability, physical and mental health status or the presence of emotional disorders. CONCLUSIONS: Twenty-nine per cent of patients newly referred to rheumatology clinics had symptoms that were poorly explained by identifiable rheumatic disease. Having unexplained symptoms was associated with socioeconomic factors but not levels of pain, disability or emotional disorders.

Does waiting matter? A randomized controlled trial of new non-urgent rheumatology out-patient referrals.

OBJECTIVE: To examine the effect of waiting times on the health status of patients referred for a non-urgent rheumatology opinion. METHODS: The study was a randomized controlled clinical study evaluating a 'fast track' appointment with a 6-week target waiting time against an 'ordinary' appointment in the main city out-patient clinic of the rheumatology service for the Lothian and Borders region (population approximately 1 million). Health status was measured using the SF12 physical and mental summary component T-scores and pain was measured with a 100 mm visual analogue pain scale. Secondary outcomes were health utility and perceived health both measured with the EuroQol instrument, mental health measured with the Hospital Anxiety and Depression scale, disability with the modified Health Assessment Questionnaire and economic costs measured from a societal perspective. RESULTS: Mean waiting times were 43 days (sigma = +/-16) and 105 days (sigma = +/-51) for 'fast track' and 'ordinary' appointments, respectively. Both groups showed significant improvements in mean [95% confidence interval (CI)] scores for pain: 11 (7, 16)(P < 0.001); physical health status: 4 (2, 5) (P < 0.001); mental health status: 2 (0.1, 4) (P < 0.02); and health utility: 0.11 (0.07, 0.16) (P < 0.001) by the end of the 15-month period of the study, but there was no significant difference between either arm of the study. CONCLUSIONS: Rationing by delay was not detrimental to either mental or physical health and patients in both arms of the study showed significant and similar improvement in health by 15 months. Expenditure of resources on waiting times without regard to clinical outcomes is likely to be wasteful and additional resources should be directed at achieving the greatest clinical benefit. More research into effective methods of controlling demand and better identification of those who would benefit from access to specialist care is needed.

Comparison of the MOS short form-12 (SF12) health status questionnaire with the SF36 in patients with rheumatoid arthritis.

OBJECTIVE: To compare the performance of the MOS SF12 health survey (SF12) with the SF36 in a sample of 233 patients with rheumatoid arthritis (RA) stratified by functional class. METHODS: The SF12 and SF36 physical and mental component summary scales (PCS and MCS) were compared for test retest reliability [intra-class correlation coefficient (RC) and repeatability], construct validity and responsiveness [standardized response mean (SRM)] to self-reported change in health. RESULTS: Overall, despite its brevity, the SF12 is comparable to the SF36 with only some loss of performance. The SF12-PCS is slightly less reliable (RC = 0.75) and responsive to improvements in health (SRM = 0.52) than the SF36-PCS (RC = 0.81; SRM = 0.61). The SF12-PCS correlates strongly with the SF36-PCS (R = 0.94), SF36 physical function subscale (R = 0.77) and modified Stanford Health Assessment Questionnaire (MHAQ) (R = 0.71), but only weakly with the SF36 mental health subscale (R = 0.22). SF12-PCS discriminated well between Steinbrocker functional classes; patients in functional classes 1-4, respectively, have SF12-PCS scores 1sigma, 2sigma, 2.4sigma and 2.7sigma below the population norm (ANOVA, F = 35.8, P < 0.000). The SF12-MCS is relatively unresponsive to reported improvement in RA (SRM = 0.31), but is reliable (RC = 0.71) and correlates well with the SF36-MCS (R = 0.71). SF12-MCS correlates more closely than the SF36-MCS with the SF36 mental health subscale (R = 0.86) and Hospital Anxiety and Depression (HAD) scale (R = 0.76). In ANOVA models, only the HAD (R2 = 57%) score contributes significantly to variance in SF12-MCS (F = 254.8; P < 0.000), but both the HAD (R2 = 24%) and MHAQ (R2 = 10%) scores contribute to variance in the SF36-MCS (F = 50.9; P < 0.000). Thus, the SF12-MCS has better construct validity for mental health than SF36-MCS in RA subjects. Missing responses to items were high amongst patients in functional class 4 (34%). CONCLUSION: The SF12 is a reliable, valid and responsive measure of health status in the majority of RA patients, and meets standards required for comparing groups of patients. Its application in the most severely disabled subjects is uncertain.

The short-term health outcome of out-patient rheumatology consultations in relation to rationing: a pilot study.

The objectives were to test whether the short-term health outcome of rheumatology out-patients differs according to clinical priority. The setting was an NHS regional rheumatology out-patient department serving a catchment population of over 1 million. The subjects were 249 consecutive rheumatology out-patients categorized on the basis of the referral letter as 'urgent' (n = 50), 'soon' (n = 100) or 'routine' (n = 99). Primary outcome measures were the proportion of patients reporting improvement in health categorized by clinical priority (urgent, soon or routine) or main diagnostic group (inflammatory or non-inflammatory disease). Secondary outcome was change in health status measured using the EuroQol generic health instrument (EQ-5D). Small but insignificant differences in the proportion of patients reporting health improvement were found between the urgent (28%), soon (23%) and routine (17%) categories (Kruskal-Wallis, P = 0.186). Thirty per cent of patients with inflammatory joint disease reported improvement compared with 17% of those with non-inflammatory conditions (Mann-Whitney U, P = 0.019). In patients reporting improvement, the median (interquartile range) improvement in EQ-5D health utility score was +0.2 (0.58) (P = 0.0001) and that of visual analogue health score was +5 (16) (P = 0.001). Clinical priority setting, by giving priority to some patients over others, results in rationing by delay. These data do not support the hypothesis that fewer patients given a low clinical priority gain health benefit compared with those given a high priority. However, those with inflammatory joint disease do appear to have better short-term health outcomes.

Measuring health status in British patients with rheumatoid arthritis: reliability, validity and responsiveness of the short form 36-item health survey (SF-36).

The objective was to assess the performance of the SF-36 health survey (SF-36) in a sample of patients with rheumatoid arthritis (RA) stratified by functional class. The eight SF-36 subscales and the two summary scales (the physical and mental component scales) were assessed for test retest reliability, construct validity and responsiveness to self-reported change in health. In 233 patients with RA, the SF-36 scales were: reliable (intra-class correlation coefficients 0.76-0.93); correlated with American College of Rheumatology (ACR) core disease activity measures [Spearman r = -0.12 (erythrocyte sedimentation rate) to -0.89 (Modified Health Assessment Questionnaire)]; and responsive to improvements in health (standardized response means 0.27-0.9). The distribution of scores on four of the eight subscales (physical function, role limitations physical, role limitations emotional and social function) was clearly non-Gaussian. Very marked floor effects were noted with the physical function scale, and both ceiling and floor effects with the other three subscales. The two SF-36 physical and mental component summary scales are reliable, valid and responsive measures of health status in patients with RA. Six of the eight subscales meet standards required for comparing groups of patients, and the physical function and general health scales may be suitable for monitoring individuals. The two scales measuring role limitations have poor measurement characteristics. The SF-36 pain and physical function scales may be suitable for use as patient self-assessed measures of pain and physical function within the ACR core disease activity set.

Is day care equivalent to inpatient care for active rheumatoid arthritis? Randomised controlled clinical and economic evaluation.

OBJECTIVE: To test the clinical equivalence and resource consequences of day care with inpatient care for active rheumatoid arthritis. DESIGN: Randomised controlled clinical trial with integrated cost minimisation economic evaluation. SETTING: Rheumatic diseases unit at a teaching hospital between 1994 and 1996. SUBJECTS: 118 consecutive patients with active rheumatoid arthritis randomised to receive either day care or inpatient care. MAIN OUTCOME MEASURES: Clinical assessments recorded on admission, discharge, and follow up at 12 months comprised: the health assessment questionnaire, Ritchie articular index, erythrocyte sedimentation rate, hospital anxiety and depression scale, and Steinbrocker functional class. Resource estimates were of the direct and indirect costs relating to treatment for rheumatoid arthritis. Secondary outcome measures (health utility) were ascertained by time trade off and with the quality of well being scale. RESULTS: Both groups had improvement in scores on the health assessment questionnaire and Ritchie index and erythrocyte sedimentation rate after hospital treatment (P < 0.0001) but clinical outcome did not differ significantly between the groups either at discharge or follow up. The mean hospital cost per patient for day care, 798 Pounds (95% confidence interval 705 Pounds to 888 Pounds), was lower than for inpatient care, 1253 Pounds (1155 Pounds to 1370 Pounds), but this difference was offset by higher community, travel, and readmission costs. The difference in total cost per patient between day care and inpatient care was small (1789 Pounds (1539 Pounds to 2027 Pounds) v 2021 Pounds (1834 Pounds to 2230 Pounds)). Quantile regression analysis showed a cost difference in favour of day care up to the 50th centile (374 Pounds; 639 Pounds to 109 Pounds). CONCLUSIONS: Day care and inpatient care for patients with uncomplicated active rheumatoid arthritis have equivalent clinical outcome with a small difference in overall resource cost in favour of day care. The choice of management strategy may depend increasingly on convenience, satisfaction, or more comprehensive health measures reflecting the preferences of patients, providers, and service commissioners.

Measuring health-related quality of life in rheumatoid arthritis: validity, responsiveness and reliability of EuroQol (EQ-5D).

The EuroQol (EQ-5D) generic health index comprises a five-part questionnaire and a visual analogue self-rating scale. The questionnaire may be used as a health index to calculate a 'utility' value or as a health profile. The validity, reliability and responsiveness of EQ-5D were tested in 233 patients with rheumatoid arthritis stratified by functional class. EQ-5D demonstrated moderate to high correlations with measures of impairment and high correlations with disability measures. Stepwise regression models showed that EQ-5D utility values and visual analogue scores were explained best as a function of pain, disability, disease activity and mood (R2 approximately 70%), although other variables (side-effects, years of education) were required to explain the visual analogue scores. The EQ-5D health index and visual analogue scale are more responsive than any of the other measures, except pain and doctor-assessed disease activity. The reliability of the EQ-5D index and EQ-5D visual analogue scale is as good or better than that of all other instruments except the Health Assessment Questionnaire. Some patients with severe long-standing disease had health states which attracted utility values below zero, i.e. from a societal perspective they were regarded as being in states 'worse than death'. The practical and ethical implications of these utility valuations are discussed, and at present the utility values should be used and interpreted with caution. With this caveat, EQ-5D is simple to use, valid, responsive to change and sufficiently reliable for group comparisons. It is of potential use as an outcome measure in clinical trials, audit and health economic studies, but further work is required on its performance in other clinical contexts and on the interpretation of the utility values.

Cervical spine surgery in patients with rheumatoid arthritis: an appraisal.

OBJECTIVES: To review the outcome of surgery undertaken to stabilise the neck in patients with rheumatoid arthritis performed over a five year period, to compare the results with those of previous reports, and to identify factors that may predict surgical outcome. METHODS: Outcome was assessed at time of discharge from hospital after surgery by review of patients' notes, and at follow up by patient interview, clinical examination, anonymous questionnaire, and cervical spine radiograph. The Ranawat classification of neurological impairment and Steinbrocker functional classification were used. RESULTS: Thirty nine patients underwent 44 procedures; 28 patients were available for review after a mean period of 29.8 months (range 12-65 months). Fourteen patients had preoperative neurological impairment and were available for follow up; 13 returned the questionnaire. Four (29%) had improved Ranawat class, nine were unchanged, and one had deteriorated. Nine (69%) reported a subjective improvement in neurological symptoms by questionnaire, even though the Ranawat class was unchanged in five. Twenty five of the patients reviewed had pain before operation; 21 returned the questionnaire. Pain relief was reported by direct questioning and questionnaire in 76% and 67% of patients, respectively. Overall, 67% felt that surgery had been successful. Surgery was more successful in producing symptomatic relief in patients with neck or radicular pain than in those with neurological deficit, but did prevent progression of neurological symptoms. CONCLUSIONS: Our results are similar to those from other centres. Overall patient satisfaction with surgery was good. Surgery was more likely to produce symptomatic relief in patients with neck or radicular pain before operation than in those with neurological deficit. The greater subjective improvement in neurological symptoms as judged by questionnaire probably reflects the relative insensitivity of the Ranawat classification in detecting change in neurological status; previous reports of poor outcome for patients with neurological symptoms who undergo surgery may in part be a reflection of the insensitivity of this method of assessment. No clear factors emerged which allowed prediction of those patients at greatest risk of operative mortality. In particular, an increased risk of neurological compromise appeared to confer no additional risk of immediate perioperative death. Our data support the suggestion that early surgery to correct symptomatic atlantoaxial subluxation may prevent progression of instability.

An audit of methotrexate and folic acid for rheumatoid arthritis. Experience from a teaching centre.

We describe an audit of 158 patients with RA treated with weekly methotrexate and 5 mg of folic acid 24 h later. Our aim was to assess the safety and efficacy of this regime in our hands compared with published clinical trials of methotrexate in RA, and to examine patient outcomes. Treatment improved ESR, but only 69% of patients continuing therapy for prolonged periods believed their arthritis to be better on treatment. Health Assessment Questionnaire and Hospital Anxiety and Depression questionnaire scores in prospectively studied patients were not significantly altered by treatment. Toxicity occurred frequently (59% in those continuing and 89% in those ceasing therapy) and cessation of therapy solely due to lack of efficacy was rare. The probability of patients continuing with methotrexate and folic acid after 1, 2, 3 and 4 yr was 87, 76, 74 and 74%, respectively, figures that are at the upper end of the reported range for methotrexate alone.

Health economics as an aspect of health outcome: basic principles and application in rheumatoid arthritis.

Health economic evaluation comprises the systematic appraisal of the costs, the benefits and the relative economic efficiency of different medical interventions. The first section of this paper outlines the techniques of economic analysis and how they relate to the efficient use of health resources. This is followed by a review of the health economics of rheumatoid arthritis as a model for the wider application of health economics in the field of rheumatology.

Validity of Euroqol--a generic health status instrument--in patients with rheumatoid arthritis. Economic and Health Outcomes Research Group.

The main aim of this pilot study was to test the 'construct' validity of Euroqol, a new generic health status instrument which consists of a questionnaire and visual analogue scale. Its ability to measure both current health status and change in health status was assessed in 55 patients with RA. The Euroqol questionnaire and visual analogue scales showed significant and clinically relevant correlations with other condition-specific instruments measuring loss of function, joint pain, joint tenderness and mood; change in these symptoms as measured by the condition-specific instruments was also predictive of change in Euroqol scores. Either component of the Euroqol instrument provide an index of current clinical status and these data provide preliminary evidence for the 'construct' validity of Euroqol in RA. Further work is needed to evaluate more fully the sensitivity of Euroqol to change over time.

A pilot study of the economic cost and clinical outcome of day patient vs inpatient management of active rheumatoid arthritis.

The aims of this pilot study, which compares day patient with inpatient care for management of active RA were (i) to test the feasibility of a trial protocol design including the method of randomization and the practicality of data collection, and (ii) to obtain preliminary information on economic cost and clinical outcome of these two methods of management. Twenty consecutive patients requiring admission for management of active RA were randomized to receive either day patient or inpatient care. All hospital, transport, community and indirect costs incurred over a 6-month period from recruitment were collected for each patient. Disease activity and clinical outcome were assessed using the Ritchie articular index, ESR, Health Assessment Questionnaire, Functional Independence Measure and Hospital Anxiety and Depression Scale. The trial protocol was found to be feasible and no patient allocated to the day patient group requested or required to be transferred to inpatient care. Day care was significantly cheaper than inpatient care despite higher transport costs; the total cost of treating 10 day patients was UK 10,272 pounds compared with 14,528 pounds for 10 inpatients. Clinical outcome was comparable in both groups for all parameters studied and there was no obvious detrimental effect on patients receiving day care. This pilot study demonstrates that day care is feasible and acceptable to patients with active RA. The preliminary data suggest that day care is substantially cheaper than inpatient care and does not apparently compromise clinical outcome.