The association of fatigue, comorbidity burden, disease activity, disability and gross domestic product in patients with rheumatoid arthritis. Results from 34 countries participating in the Quest-RA program.

OBJECTIVES: The aim is to assess the prevalence of comorbidities and to further analyse to which degree fatigue can be explained by comorbidity burden, disease activity, disability and gross domestic product (GDP) in patients with rheumatoid arthritis (RA). METHODS: Nine thousands eight hundred seventy-four patients from 34 countries, 16 with high GDP (>24.000 US dollars [USD] per capita) and 18 low-GDP countries (<24.000 USD) participated in the Quantitative Standard monitoring of Patients with RA (QUEST-RA) study. The prevalence of 31 comorbid conditions, fatigue (0-10 cm visual analogue scale [VAS] [10=worst]), disease activity in 28 joints (DAS28), and physical disability (Health Assessment Questionnaire score [HAQ]) were assessed. Univariate and multivariate linear regression analyses were performed to assess the association between fatigue and comorbidities, disease activity, disability and GDP. RESULTS: Overall, patients reported a median of 2 comorbid conditions of which hypertension (31.5%), osteoporosis (17.6%), osteoarthritis (15.5%) and hyperlipidaemia (14.2%) were the most prevalent. The majority of comorbidities were more common in high-GDP countries. The median fatigue score was 4.4 (4.8 in low-GDP countries and 3.8 in high-GDP countries, p<0.001). In low-GDP countries 25.4% of the patients had a high level of fatigue (>6.6) compared with 23.0% in high-GDP countries (p<0.001). In univariate analysis, fatigue increased with increasing number of comorbidities, disease activity and disability in both high- and low-GDP countries. In multivariate analysis of all countries, these 3 variables explained 29.4% of the variability, whereas GDP was not significant. CONCLUSIONS: Fatigue is a widespread problem associated with high comorbidity burden, disease activity and disability regardless of GDP.

Cost-effectiveness of Spa treatment for fibromyalgia: general health improvement is not for free.

OBJECTIVES: To estimate the cost-effectiveness of an adjuvant treatment course of spa treatment compared with usual care only in patients with fibromyalgia syndrome (FM). METHODS: 134 patients with FM, selected from a rheumatology outpatient department and from members of the Dutch FM patient association were randomly assigned to a 2(1/2) week spa treatment course in Tunisia or to usual care only. Results are expressed as quality-adjusted life years (QALYs) for a 6-month as well as a 12-month time horizon. Utilities were derived form the Short Form 6D (SF-6D) scores and the visual analogue scale (VAS) rating general health. Costs were reported from societal perspective. Mean incremental cost per patient and the incremental cost utility ratio (ICER) were calculated; 95% confidence intervals (CIs) were estimated using double-sided bootstrapping. RESULTS: The data of 128 (55 spa and 73 controls) of the 134 patients (96%) could be used for analysis. Improvement in general health was found in the spa group until 6 months of follow-up by both the SF-6D (AUC 0.32 vs 0.30, P < 0.05) and the VAS (AUC 0.23 vs 0.19, P < 0.01). After 1yr no significant between-group differences were found. Mean incremental cost of spa treatment was 1311 Euro per patient (95% CI 369-2439), equalling the cost of the intervention (thalassotherapy including airfare and lodging), or 885 Euro per patient based on a more realistic cost estimate. CONCLUSIONS: The temporary improvement in quality of life due to an adjuvant treatment course of spa therapy for patients with FM is associated with limited incremental costs per patient.

Validation of a Dutch translation of the fibromyalgia impact questionnaire.

OBJECTIVES: To validate a Dutch translation of the fibromyalgia impact questionnaire (FIQ). MATERIALS AND METHODS: Data were taken from two randomized clinical trials on Spa treatment and venlafaxine in fibromyalgia (FM). Participants completed the Dutch FIQ and a set of validated questionnaires for general health (RAND-36), depression (Beck depression inventory, BDI), pain (McGill pain questionnaire, MPQ) and fatigue (checklist individual strength, CIS). Internal consistency within the FIQ item 'physical functioning' was studied using Cronbach's alpha. Test-retest reliability was studied with intra-class-correlation (ICC) in a subsample of 76 control subjects over a 3 month period without specific intervention. Construct validity was evaluated by correlating the FIQ to other questionnaires. Sensitivity to change was studied using standardized response means (SRM). RESULTS: The study sample consisted of 213 women and 11 men (mean age 47 yrs, mean disease duration 11 yrs). Cronbach's alpha for the item 'physical functioning' was 0.91, indicating high internal consistency. Test-retest reliability was acceptable, with ICC ranging from 0.45 for 'morning tiredness' to 0.71 for 'physical function'. FIQ correlated significantly with the RAND-36, with Spearman's rho ranging from -0.60 to -0.70 for items measuring the same concept. Similar patterns of correlation were seen with MPQ, BDI and CIS. Sensitivity to change was sufficient, with SRM after Spa treatment ranging from 0.3 for 'work days missed' to 0.9 for 'days felt good'. Similar SRM were found in the venlafaxine trial for patients reporting general improvement. CONCLUSION: The Dutch FIQ is a valid instrument for measuring health status in FM, showing sufficient reliability, construct validity and responsiveness.

Sensitivity to change of AIMS2 and AIMS2-SF components in comparison to M-HAQ and VAS-pain.

OBJECTIVE: To examine sensitivity to change of Dutch versions of AIMS2 (arthritis impact measurement scales-2) and AIMS2-SF (short form) components, in comparison with M-HAQ (modified health assessment questionnaire) and the 100 mm visual analogue scale for pain (VAS-pain) in patients with rheumatoid arthritis. METHODS: 218 patients participated in a study on patient education. Participants completed the Dutch AIMS2, M-HAQ, and VAS-pain at baseline and after one year; 165 completed both assessments. The education programme did not have any effect on health status. Patients were classified according to change over one year in their responses to the AIMS2 question about general health perception: improved health (n = 32), no change (n = 101), and poorer health (n = 32). Changes in scores over one year were tested with paired t tests, and standardised response means were calculated for AIMS2 and AIMS2-SF components, M-HAQ total score, and VAS-pain in the three classifications of change in health perception. RESULTS: AIMS2 and AIMS2-SF physical, symptom, and affect components showed similar sensitivity to change. The physical and symptom components performed better than M-HAQ and VAS-pain. AIMS2 and AIMS2-SF social interaction and role components were not sensitive to changes in general health perception. The role component was only applicable in 63 patients, because the others were unemployed, disabled, or retired. CONCLUSIONS: AIMS2-SF is a good alternative to the AIMS2 long form for the assessment of health status in rheumatoid arthritis, and is preferable to M-HAQ and VAS-pain. Use of the AIMS2-SF makes it easier and less costly to collect data and reduces the burden on patients.

A comparison of two recently developed health status instruments for patients with arthritis: Dutch-AIMS2 and IRGL. Arthritis Impact Measurement Scales. Impact of Rheumatic diseases on General health and Lifestyle.

Two multidimensional health status instruments of rheumatic diseases, the Dutch-AIMS2 and the IRGL (Impact of Rheumatic diseases on General health and Lifestyle), were compared in a sample of 284 rheumatoid arthritis patients with regard to their measurement properties and usefulness for research purposes. Both questionnaires showed an excellent reliability (Cronbach's alpha), and were highly comparable with regard to their construct and convergent validity. Second-order factor analysis confirmed the physical, psychological and social health dimensions for both questionnaires. The comparability between the instruments was established by high intercorrelations between the physical and psychological health dimensions. Sufficient convergent validity was indicated by the strong correlations between the physical functioning scales and clinical and laboratory measures. The main differences between both questionnaires relate to their length and emphasis on health aspects. The Dutch-AIMS2 is characterized by a more extensive assessment of the physical dimension and the additional measurement of general health aspects. The shorter IRGL exclusively assesses the main health dimensions with a more comprehensive measurement of the psychological and social dimensions. The instrument that reflects the subject in question most adequately should be chosen.

The supply of and demand for informal and professional care for patients with rheumatoid arthritis.

The objective of this study is to determine supply of, and demand for, informal care for rheumatoid arthritis (RA) patients and to evaluate the factors that contribute to the amounts of help needed and received from professional and informal care providers at home. Data were collected by questionnaire from 229 RA patients and 174 informal caregivers. Most of the help required is also received, though 24% of the patients did not receive help for one or more tasks. Most help given at home is by informal caregivers. The amount of help needed is related primarily to the patient's physical condition, sex, and self-efficacy expectations towards coping with RA. The amount of help received from informal caregivers is largely explained by the physical condition and the marital status of the patient, the sex of the caregiver, the patient's self-efficacy expectations towards coping with RA, and the age of the patient. The amount of help received from health professionals is related primarily to the marital status and the physical condition of the patient.

Measures of physical function and emotional well being for young adults with arthritis.

We investigated whether it is necessary to adapt measures of functional status as used with adults with rheumatoid arthritis when measuring physical function in young adults between 16 and 30 years of age with arthritis, and which aspects of emotional well being are important outcomes in young adults with arthritis. A questionnaire as filled in by 196 young adults with arthritis and 117 healthy peers of same age and sex. Functional status was measured with the 17 item Young Adults Disability Inventory (YADI), which includes the 8 item Modified Health Assessment Questionnaire (M-HAQ). Four aspects of emotional well being were assessed: depression, anxiety, loneliness, and self-esteem. The mean score of the patients on the YADI was significantly higher than that on the M-HAQ. YADI scores correlated significantly higher with a measure of disease symptoms than the scores on the M-HAQ with disease symptoms. Anxiety was not strongly correlated with functional status, disease symptoms, or self-reported Thompson joint score. Depression, loneliness, and self-esteem were moderately correlated with functional status and disease symptoms and weakly correlated with the Thompson score. There were no significant difference in emotional well being between patients and their healthy peers. Patients with severe symptoms were significantly more depressed than their healthy peers. It seems that the YADI is more appropriate measure of functional status in young adults with arthritis than the M-HAQ. Depression seems to be an important emotional outcome for young adults with arthritis. Anxiety does not seem to be a severely affected area of emotional well being.

Opinions of patients with rheumatoid arthritis about their own functional capacity: how valid is it?

Self assessment health status questionnaires are increasingly used to measure health status or the effect of treatment in patients with rheumatoid arthritis (RA). Most of these questionnaires measure functional (physical) disabilities. The question arises, however, as to how well self assessment questionnaires reflect the true functional status of patients or whether they only reflect their imaginary functional capacities. How valid is the opinion of patients with RA about their own functional capacity? To answer this question an investigation was performed in 80 patients with RA. Forty Dutch and 40 Belgian patients with RA completed the functional items of the DUTCH-AIMS, the Dutch version of the Arthritis Impact Measurement Scales (AIMS), a self assessment questionnaire specific to arthritis. Their scores on the functional scales were compared with the scores on the same scales completed by two experienced physiotherapists after evaluation of the functional ability of these patients. This was achieved by observing the patients perform the tasks given in the questionnaire. Correlation coefficients between the scores of the patients and the physiotherapists were highly significant for all the scales. No significant differences were found between the patients' and physiotherapists' mean scale scores except for the mobility scale in the Dutch patients. The strength of agreement (Cohen's kappa) of most scale scores of the patients and physiotherapists was substantial. The estimates of the overall functional capacity (the mean of the five scale scores) of the Belgian and Dutch patients show high correlations between the patients and the physiotherapists. It is concluded that patients' opinion about their functional ability is valid in that it is in agreement with their real functional abilities. This study provides further evidence for the validity of the DUTCH-AIMS as a measure of functional disability and health status in Dutch and Belgian patients with RA.

Radiological study of cervical spine and hand in patients with rheumatoid arthritis of 15 years' duration: an assessment of the effects of corticosteroid treatment.

Radiological abnormalities in the cervical spine were assessed in detail in a group of 62 patients with rheumatoid arthritis of approximately 15 years' duration, of whom 33 had been treated with corticosteroids and 29 had not. The 10 criteria of damage described by Bland (1974), which include subluxation, correlated as a whole with the severity of the disease in general but not with the duration of corticosteroid treatment. Subluxation alone, whether assessed in the cervical spine as a whole or in the atlanto-axial joint alone, was less closely related to disease activity, was on average greater in patients treated with corticosteroids, and tended to increase in relation to the duration of treatment. Corticosteroid treatment thus tends to produce, over the course of years, a degree of subluxation in addition to that caused by the disease itself. Radiological signs of damage to the metacarpophalangeal (MCP) joints and carpal bones correlated with both the degree of damage and the degree of subluxation in the cervical spine as well as with corticosteroid treatment. Mutilans deformity at the MCP joints was associated with subluxation in the neck and with corticosteroid treatment.