The mortality of rheumatoid arthritis.

OBJECTIVE: To determine the risk and causes of death and to quantify mortality predictors in patients with rheumatoid arthritis (RA). METHODS: RA patients (n = 3,501) from 4 centers (Saskatoon n = 905, Wichita n = 1,405, Stanford n = 886, and Santa Clara n = 305) were followed for up to 35 years; 922 patients died. RESULTS: The overall standardized mortality ratio (SMR) was 2.26 (Saskatoon 2.24, Wichita 1.98, Stanford 3.08, Santa Clara 2.18) and increased with time. Mortality was strikingly increased for specific causes: infection, lymphoproliferative malignancy, gastroenterologic, and RA. In addition, as an effect of the SMR of 2.26, the expected number of deaths was increased nonspecifically across all causes (except cancer), with a large excess of deaths attributable to cardiovascular and cerebrovascular diseases. Independent predictors of mortality included age, education, male sex, function, rheumatoid factor, nodules, erythrocyte sedimentation rate, joint count, and prednisone use. CONCLUSION: Mortality rates are increased at least 2-fold in RA, and are linked to clinical severity.

The clinical value of the Stanford Health Assessment Questionnaire Functional Disability Index in patients with rheumatoid arthritis.

We administered the Stanford Health Assessment Questionnaire functional disability questionnaire to a cohort of 400 patients with rheumatoid arthritis (RA) every 6 months during a mean followup of 3.1 years. Simple classification into 3 groups based on Functional Disability Index (FDI) scores (0-1, 1.1-2, 2.1-3) identified patients with increasingly more severe scores for clinical, psychological, and demographic variables; and FDI scores at entry predicted increased inpatient and outpatient utilization of services, and mortality. The FDI provided important and clinically useful current and predictive information regarding RA status, utilization of services, and mortality that was not available through conventional testing. Our data suggest that such information can be easily and inexpensively obtained.

Familial vs sporadic rheumatoid arthritis: a comparison of the demographic and clinical characteristics of 956 patients.

We studied the demographic, clinical, and disease severity characteristics of 96 patients with rheumatoid arthritis (RA) from multicase families (familial RA+) and 860 nonfamilial RA cases (familial RA-) seen consecutively in an outpatient rheumatic disease clinic between April, 1976 and August, 1986. Familial RA (+) and (-) cases were similar in essentially all demographic, clinical, and disease severity characteristics. Subgroups of 2nd generation patients with familial RA and sib-sib patients were similar, and neither group differed from the set of familial RA (-) individuals. The failure to find differential severity in these groups indicates that inferences from studies of families with RA may be extrapolated safely to patients with RA at large, but differences between rheumatoid factor positive (RF+) and RF (-) patients suggest that RA (+) and RF (-) patients should be analyzed separately.

Prevalence of familial occurrence in patients with rheumatoid arthritis.

We studied 985 consecutive patients with definite or classical rheumatoid arthritis (RA) at an arthritis clinic, between April 1976 and August 1986, to investigate the prevalence of familial disease. We have demonstrated that at least 10.9% of unrelated patients with definite or classical RA have one or more first-degree relative(s) affected with definite or classical RA. Moreover, familial RA is not more severe than the more prevalent non-familial, i.e. sporadic, form of the disease.

HLA DR4 and B27 antigens in familial and sporadic rheumatoid arthritis.

We studied HLA antigens in 105 unrelated American Caucasian patients with rheumatoid arthritis (RA), 70 of them with familial disease. HLA-DR4 was observed in 71% of familial RA, 63% of non-familial RA, and 27% of normal controls, confirming the already well-established association between HLA-DR4 and both familial and non-familial RA. HLA-B27 was present in 14.3% of patients, versus 8% of normal controls (p = 0.04), and was not more common in familial (10 of 70, or 14.3%) versus non-familial (5 of 35, or 14.3%) disease. These results are compared with those observed in Scandinavian patients.

Socioeconomic impact of fibrositis. A study of 81 patients with primary fibrositis.

Demographics and health service utilization were studied for 81 patients with fibrositis during 1985. Patients reported high levels of pain, mild disability, and moderate impairment of global health. Work disability was limited and only 6.3 percent described themselves as disabled. Employed patients were able to work full work weeks. Utilization of outpatient medical services was increased compared with that of control subjects and national averages during the study year, but was consistent with other rheumatic disorders such as osteoarthritis and low back pain. Medication usage was limited and seemed appropriate. Very high hospitalization rates were noted prior to diagnosis of fibrositis, both for musculoskeletal and non-musculoskeletal hospitalizations, but these rates dropped during the post-diagnosis study year.

A multicenter study of hospitalization in rheumatoid arthritis. Frequency, medical-surgical admissions, and charges.

During 1981, 123 of 816 patients (15.1%) with rheumatoid arthritis were hospitalized 160 times because of the disease. The mean length of hospitalization was 13.1 days, and the cost $7,845. Surgery accounted for 54.4% of admissions, but 69.2% of costs. The average cost for total joint surgery was $12,287. Most medical admissions (46.6%) were for the diagnosis or treatment of articular disease, but 42.5% were for treatment of side effects of therapy, and 11.0% for complications of RA. The most commonly performed surgical procedures included reconstructive surgery of the hand/wrist (n = 35) and foot (n = 22), followed by total knee replacement (n = 18).

A multicenter study of hospitalization in rheumatoid arthritis: effect of health care system, severity, and regional difference.

During 1981, centers in Phoenix, Saskatoon, Stanford and Wichita monitored hospitalizations for 816 patients with rheumatoid arthritis. Admission rates varied 2-fold, and admissions for evaluation and treatment 10-fold across centers. Admissions were related primarily to disease severity, but in US centers, were reduced by a factor of 3 by prepaid health care. Length of stay was shortest in California (7.3 days), and longest in Saskatoon (16.3) where designated arthritis beds and government prepaid health care existed. Average charges for surgery were as high as $10,000 in Phoenix and as low as $4550 in Wichita. Charges and length of stay were unrelated to disease severity, but were responsive to health care delivery system, availability of facilities, and geographic and center variation.

Fibrositis (Fibromyalgia) in rheumatoid arthritis.

We studied demographic socioeconomic and clinical characteristics of 38 patients with fibrositis (fibromyalgia) that occurred in association with rheumatoid arthritis (RAFIB) and 242 patients with rheumatoid arthritis (RA) alone. Fewer RAFIB patients were married (57.1%), and most (97.4%) were women. No statistically significant differences in income, medical expenditures or other demographic variables were identified. All measures of function, pain, disease activity and psychological status were more abnormal in RAFIB patients. The clinical characteristics that best differentiated RAFIB and RA patients were pain, depression, anxiety and erythrocyte sedimentation rate, in logistic and stepwise regression models. Evaluation of disease severity markers, including radiographic erosions and frequency of total joint replacement, suggested that disease severity in RAFIB and RA is similar.

Psychological status in primary fibrositis and fibrositis associated with rheumatoid arthritis.

Psychological status was investigated in 46 primary fibrositis (PF) patients, 32 with fibrositis occurring in association with rheumatoid arthritis (RAFIB) and in 76 control patients with rheumatoid arthritis. Groups were similar in tests of life stresses: Family Inventory of Life Events, Multidimensional Health Locus of Control, and self-motivation. Only 28% of PF and 25% of RAFIB had Minnesota Multiphasic Personality Inventory profiles classified as "normal" compared with 51-60% of controls. Both PF and RAFIB had elevated "neurotic" scales (hypochondriasis, depression, hysteria), but only PF patients had statistically significant elevations in the pychopathic deviancy, psychasthenia and paranoia scales. When the Arthritis Impact Measurement Scales were used, PF but not RAFIB patients demonstrated statistically significant elevations on the anxiety and depression scales.