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A prospective descriptive study was done on the direct and indirect costs to ambulatory patients with rheumatoid arthritis and osteoarthritis, stratified at study entry by level of function. Measures of health status over a 1-year period were taken. On a yearly basis, in 1979 dollars, patients spent an average of $147 for arthritis medications, aids, and devices, and $207 for outpatient visits. A small number were hospitalized and incurred an average charge of $245, and an additional $84 for physician fees. In addition to direct monetary costs, patients averaged 6.8 days of restricted activity costs, patients averaged 6.8 days of restricted activity per month, in some cases so severe as to confine patients to bed for an average of 1.3 days per month. Among students and working patients, 2.5 work-days per month were lost due to arthritis, and 30% reported that they were unemployed or retired because of impaired health. Functional capacity and specific diagnosis on entry to the study were the most important determinants of arthritis-related expenditures. Both direct and indirect costs varied considerably from the observed average. Twenty percent of patients incurred no costs for arthritis-related purchases, 42+ had no costs for outpatient visits, and 93% had no inpatient costs. Yet for some patients, the financial burden was very high.

Six systems for defining and evaluating disease activity in patients with systemic lupus erythematosus (SLE) (the Ropes system, the National Institutes of Health [NIH] system, the New York Hospital for Special Surgery system, the British Isles Lupus Assessment Group [BILAG] scale, the University of Toronto SLE Disease Activity Index [SLE-DAI], and the Systemic Lupus Activity Measure [SLAM]) were tested on 25 SLE patients who were selected to represent a range of disease activity. The patients were evaluated independently by 2 physicians on 2 occasions approximately 1 month apart. Differences between patients demonstrated the largest source of variation in scores, accounting for 56-84% of the total variance, depending on the instrument. Differences between physicians (i.e., error) showed the next largest variation, 11-28% of the total variance, and differences between visits made up 5-16% of the total. The BILAG, SLE-DAI, and SLAM had the best inter-visit and inter-rater reliability. Convergent validity was shown by the strong correlations of scores among the different instruments (r = 0.81-0.97). All instruments correlated highly with the physicians' clinical impression of disease but less well with their evaluation of disease severity. The number of American Rheumatism Association criteria for SLE that were met by the patients correlated poorly with the physicians' global evaluation and with the scores of the instruments. The patients' self-reported disease activity scores correlated highly with the physicians' assessments of disease activity (r = 0.85-0.91), and the mean values from self-reports and from physicians' assessments were nearly equal. In contrast, severity scores correlated less well between self-reports and physician assessments (r = 0.49-0.69), and mean self-reported severity values were lower than the means from physicians. The BILAG, SLE-DAI, and SLAM systems appear to have better psychometric properties than the others for clinical research.

A high rate of turnover of professional personnel in a clinic is disruptive to patient care and organizational stability as well as to the individual clinician. The turnover rate for clinicians (physicians, nurse practitioners, and physician assistants) working in neighborhood health centers (NHCs) is considerably higher than that for clinicians in other forms of practices. All 10 of the neighborhood health centers in HEW (Department of Health, Education, and Welfare--now the Department of Health and Human Services) Region X (Alaska, Idaho, Washington, and Oregon) that offered a full range of medical services provided information about the clinicians that they had employed since their inception. One hundred and one clinicians were surveyed about their work experience. The vast majority of those clinicians who had left a neighborhood health center remained in the community; they cited organizational issues as being at the heart of their dissatisfaction with the centers. Clinicians who began work during the initiation of a clinic remained significantly longer. The results suggest the immediate need for a strategy directed at the smooth organizational evolution of each NHC right from its inception.

The revised criteria for the classification of rheumatoid arthritis (RA) were formulated from a computerized analysis of 262 contemporary, consecutively studied patients with RA and 262 control subjects with rheumatic diseases other than RA (non-RA). The new criteria are as follows: 1) morning stiffness in and around joints lasting at least 1 hour before maximal improvement; 2) soft tissue swelling (arthritis) of 3 or more joint areas observed by a physician; 3) swelling (arthritis) of the proximal interphalangeal, metacarpophalangeal, or wrist joints; 4) symmetric swelling (arthritis); 5) rheumatoid nodules; 6) the presence of rheumatoid factor; and 7) radiographic erosions and/or periarticular osteopenia in hand and/or wrist joints. Criteria 1 through 4 must have been present for at least 6 weeks. Rheumatoid arthritis is defined by the presence of 4 or more criteria, and no further qualifications (classic, definite, or probable) or list of exclusions are required. In addition, a "classification tree" schema is presented which performs equally as well as the traditional (4 of 7) format. The new criteria demonstrated 91-94% sensitivity and 89% specificity for RA when compared with non-RA rheumatic disease control subjects.

Fifty-seven elderly homebound patients with musculoskeletal disability were randomized to a stepped-up outreach rehabilitation program or to usual treatment. Sixty-four percent of patient goals were met, but overall there were no significant differences in functional scores, institutionalization, or quality of life. Twenty-three patients had maintained clinical improvement at the end of the study. The services were achieved at a modest marginal cost.

A 16-hour introductory course in prescription drugs for community health workers was developed by a systems approach. It featured an emphasis on: (1) learning the broad indications, side effects, and adverse reactions of the 30 most commonly prescribed drugs in the outpatient clinic, and (2) aiding the workers in patient education. Teaching materials were simple and inexpensive. An evaluation based on a pretest of the course's objectives compared to a final test documented the success of the instruction.

Fifty consecutive psychiatric consultations on 48 patients over an 18-month period in an arthritis hospital are analyzed. The range of psychiatric disorders and their relationship to characteristics of the patient population, such as age, sex, and medical diagnosis, are described. Approximately 2% of patients admitted to the hospital during this period elicited psychiatric consultation. This rate is one-third of the consultation rate of an acute medical and surgical hospital serviced by the same consultants. The relative distribution of psychiatric diagnoses--depression 59%, personality disorders and drug abuse 15%, psychosis 10%, conversion reaction 10%, and "other" 6%--was similar to that encountered in an acute general hospital setting. Although depression was the most prevalent psychiatric problem, it was severe enough to elicit consultation only in 1% of the total hospitalized population; its severity did not correlate directly with the severity of rheumatoid arthritis, the most common medical diagnosis encountered. Neither a particular medical illness nor sex accounted for a disproportionate share of the psychiatric consultations.

Colchicine is an effective and relatively specific treatment for acute gout and has a long, venerable history. Serious toxic reactions to colchicine could be prevented if guidelines for its use were followed strictly, but because of its relatively infrequent use and conflicting recommendations, considerable toxic effects might occur and still be undetected by passive surveillance. A review of a teaching hospital's four years' experience showed two deaths (2% incidence) due to inappropriate use. Colchicine has the smallest benefit-to-toxicity ratio of drugs that are effective for acute gout. This article gives specific recommendations for the use of colchicine in different clinical settings.

A variety of mechanisms have been demonstrated or suggested to explain the neutropenia that accompanies Felty's syndrome. This case report presents with Felty's syndrome with recurrent infections with initially had a clinical response to splenectomy. Eleven years later profound neutropenia recurred. In-vitro evidence for cell mediated autosensitisation of peripheral blood lymphocytes to autologous bone marrow cells was found. The cellular abnormalities improved after high-dose corticosteroids but not lithium. However, there did not appear to be a reduction in the incidence of clinical infections. The finding suggests that granulocytopenia in some patients with Felty's syndrome may be an autoimmune phenomenon.

Since an original report suggesting a protective effect of oral contraceptives on rheumatoid arthritis incidence, 12 studies from four countries have shown conflicting results. Using the method of DerSimonian and Laird all available studies (including two completed but not as yet published) were evaluated. Overall, the relative risk of oral contraceptive use on the development of RA were less than unity. When summary statistics for case-control studies were examined, a small protective effect was noted, but was not statistically significant.

We have summarized the limitations of traditional outcome measures in rheumatology, reviewed the growing field of measures emphasizing the patient's perception of improvement, and provided guidelines for choosing a specific instrument for a clinical trial. Newer measures have measurement properties equal to or surpassing traditional measures, but no one ADL or quality-of-life instrument can be used to assess outcome in every situation as no one test can indicate success of a treatment in a chronic disease. An instrument needs to be judged by the following criteria: Is it metrically sound? Does it fit the socio-demographic characteristics of the target population? Does it measure the specific changes which are likely to be affected by the treatment? Will it capture or measure the expected changes?

Total joint replacement surgery has revolutionized the management of chronic arthritis. Careful patient selection, medical follow-up, patient education, and rehabilitation management produce the best results. The indications, contraindications, and results of total knee and hip replacement are reviewed.

A survey design which uses two tests in series greatly increases the efficiency of screening. We conducted a study to ascertain the sensitivity, specificity, and predictive value of a screening questionnaire for systemic lupus erythematosus (SLE) patients. A series design in which this questionnaire is used, followed by an antinuclear antibody test, increased the predictive value of a positive screening result by 5 to 10-fold, depending on estimates of disease prevalence. An empirical study of the series design identified two new cases of SLE and indicated that the use of a questionnaire based on accepted criteria is theoretically sound and practical. This approach should prove useful for population surveys of SLE to avoid the sampling and detection biases of previous epidemiologic studies.

A teaching module in ambulatory internal medicine has been added to a residency program in a large referral hospital. The effort was directed to structure a program of instruction reflecting common problems seen by primary care internists. Patients were screened by supervising staff to make the rotation an efficient learning experience. Experienced nurse clinicians were used to monitor patients with stabilized medical problems, thus freeing the housestaff for problems more suited to their level of training. The nurses also served as role models with which the housestaff could interact and provide continuity and accessibility of care to patients being followed up by transient physicians-in-training. Various teaching conferences based on traditional inpatient models were conducted. Self-assessment and peer review techniques were structured around monthly conferences in which medical records were assessed by each participant.

Over the past 300 years the classification of disease has changed in accordance with the dominant concept of its nature. Disease is now viewed as both a biological and social phenomenon and assessment of function is becoming increasingly important. Instruments have been developed to measure function and health status. Although they all have limitations, they provide valuable tools for the clinician to evaluate treatment effects on the quality of life of his patient.

A program for the systematic detection and management of arthritis disability was developed for an urban population. A survey identified 601 persons with rheumatic disability in a population of 9,500-10,550. Seventy-eight persons were evaluated and given recommendations. An ombudsman assisted the clients in obtaining health services and coordinated care. An evaluation 6-8 months later showed increased utilization of and referrals to relevant services but, on the whole, little improvement in functional capacity was noted. However, the small numbers do not definite conclusions.

Five percent of the population aged over 65 years, or more than 1 million people, are homebound. Musculoskeletal dysfunction is the final common pathway of all forms of arthritis and many neuromuscular disorders and is the prime cause for being homebound. The US health care system, with its emphasis on acute illness, does not address adequately the functional problems of homebound patients. Many can be helped by modification of the home environment or physical and occupational therapy. This paper outlines the diagnosis and management of common functional disabilities found in homebound patients.

These case histories illustrate how medical, psychosocial, cultural and economic factors affect the elderly with chronic arthritis. Physicians need to be aware of their patient's attitudes, concerns, support systems and goals resulting from a lifetime of experience, to provide the most appropriate and effective care. 'Images of future are usually only caricatures of the present' (Starr, 1982), but based on current demography, one can predict trends for the future. It is likely that the elderly of the future will be better off financially, better educated, healthier, more politically connected and strident, but their social support systems will be less effective. The last stems from trends such as declining birth rate, an increasingly mobile society, diminished importance of the nuclear family, and the diminishing attractiveness of professions involved with providing maintenance care. This suggests that the physician and nurse, being the primary gatekeepers for the care of and services for the elderly, must be even more attentive to the non-biological determinants of arthritis disability.

Seventy-six ambulatory patients with systemic lupus erythematosus and a comparison group of 23 ambulatory patients with rheumatoid arthritis were given a structured interview and standard psychological tests, including the Minnesota Multiphasic Personality Inventory, to determine the psychosocial impact of the illness. Both groups had significantly elevated scores on 3 Minnesota Multiphasic Personality Inventory scales: Hypochondriasis, Depression, and Hysteria. Psychological difficulties are an integral part of systemic lupus erythematosus and are as common as most other manifestations. The implications for clinical practice are discussed.

To determine the effect of warm-up on anthropometric measures, 10 patients with ankylosing spondylitis and 10 normal control subjects were measured over a 1-hour period by one therapist. A series of 4 measures--a modified Schober's test, finger-to-floor with the subject standing on a 23-cm stool, chest expansion, and cervical rotation using an arthrodial protractor--were repeated completely 4 times. Subjects exercised between each series (except between the third and fourth series). Intra-rater reliability was determined by comparing measurement 3 with measurement 4, and the warm-up effect was determined by comparing measurement 1 with measurement 3. The Schober's test and chest expansion are stable measures and are not affected by warm-up. However, the finger-to-floor and cervical rotation exercises require warm-up to ensure stable values for clinical or research followup of spondylitis.

Fatigue, a complex symptom, significantly affects the quality of life in many patients with systemic lupus erythematosus (SLE). To understand this phenomenon, 23 patients with SLE and fatigue were studied. Standardized tests of depression (NIMH), fatigue, exercise tolerance (ETT) on a bicycle ergometer, and SLE activity were obtained. At baseline, SLE patients had significantly lower maximum oxygen consumption (VO2 max) than normals (p less than 0.005). Adjusted for age and sex, SLE patients perform at 54% of their expected maximum VO2, which is similar to published data from patients with rheumatoid arthritis. Depression by NIMH was not correlated with VO2 max or length of time on ETT. Fatigue measured by Profile of Mood States (POMS) was correlated with ETT time (r = 0.476, p less than 0.025) and with VO2 max (r = -0.402, p less than 0.07). After an 8-week aerobic conditioning programme the experimental group increased their aerobic capacity by 19% in contrast to 8% in controls. This change correlated with decreased fatigue as measured by visual analogue scales. Exercise did not exacerbate disease, and only two of 16 experimental subjects experienced transient joint symptoms during exercise.

Industrialized countries face the challenge of increasing home care services to the growing number of functionally dependent elderly. The disability model suggests that social and health policy should be directed at supporting the caretakers and providing the social and physical environment to allow elderly maximum opportunities to be physically and socially active. The natural trajectory of ageing is punctuated by critical events which can place the patient on a steeper, lower trajectory of decline. Efforts could be made to identify these at the earliest point and to educate the patient, the caretakers, and the primary care physician. Functional disability is multideterminant and once established cannot be easily sorted out or treated. Sensitive techniques for detecting the earliest problem might allow more effective intervention. Research areas and goals for improved medical education are suggested.

The management of asymptomatic hyperuricemia is controversial. Reported benefits from treatment prevention of acute gouty arthritis, chronic tophaceous gout, urolithiasis, or gouty nephropathy. A review of experimental and clinical data suggests that the risks of asymptomatic hyperuricemia are small or unknown and the efficacy of long-term treatment in preventing gout or renal disease is unproved. The costs and risks of prolonged drug administration and practical considerations such as patient compliance mitigate against long-term therapy in asymptomatic persons. We offer some recommendations for an expectant approach to the management of asymptomatic hyperuricemia.

Functional disabilities, the final common pathway of all medical and surgical conditions, are frequently preventable and treatable. Etiologic diagnosis of functional problems is important so that one does not miss the opportunity to improve and increase independence. Rehabilitation of the elderly can be a special problem. Their habits are longstanding and difficult to change. It is important to establish realistic and attainable goals with the patient. Not every habit needs to be altered. What is more important is that the patient safely achieve maximum independence. An environmental assessment is "key" to a full understanding the limitations of function, and how well management strategies can be integrated.

Noncompliance has been treated as a deviant behavior. This paper argues that nonadherence is more complex and is the expression of independence and a judgment about the utility of any medical, surgical, or rehabilitation intervention. The quality of one's life is a personally defined concept and so too are the reasons why a patient refuses to do what is recommended. Appropriate health behavior should be thought of as a behavior that meets the person's goals and achieves some mutually definable outcome.

Forty-six orthopedic patients were studied to determine the incidence, natural history, and risk factors associated with post-operative delirium. Pre-operatively, patients were given a neuropsychological screening evaluation, the Mood Adjective Checklist (MACL), the Zung Depression Scale, the Anxiety Inventory Scale, and the Health Assessment Questionnaire (HAQ). A psychiatrist interviewed each patient on post-op day four for evidence of delirium as defined by DSM III criteria. Of the patients studied, thirteen (26%) were possibly or definitely delirious following surgery. Treatment with propranolol, scopolamine, or flurazepam (Dalmane) conferred a relative risk for delirium of 11.7 (p = 0.0028). Delirium was associated with increased post-operative complications (p = 0.01), poorer post-operative mood (p = 0.06), and an increase of about 1.5 days in length of stay (not significant). Delirious patients were significantly less likely than matched controls to improve in function at six months compared with a pre-operative baseline HAQ (t = 6.43, p less than 0.001).

The predictive information provided by renal biopsy was assessed for four systemic lupus erythematosus (SLE) patient populations and compared with the predictive information from clinical data without benefit of biopsy, both measured against actual outcome. Renal biopsy results, whether studied by light or electron microscopy, contain important prognostic information. However, the prognostic information from renal biopsies in these patient groups is generally less than that of even the simplest clinical classifications; and when combined with clinical information, the total prognostic content is essentially that of the clinical information alone. Thus, judged by presently available data, the renal biopsy in SLE provides mainly redundant prognostic information. The marginal benefit is the difference between what is known before and after a test. Quantitation of predictive accuracy allows assessment of marginal benefit, that is, the increment in accuracy afforded by an additional test. Costly and potentially hazardous procedures, such as renal biopsy, require reassessment in terms of marginal rather than absolute predictive ability.