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Hospitalization and death were markedly more common among rheumatoid arthritis (RA) patients experiencing more pain and worse self-assessed health, analysis of a prospective Australian registry showed.

With 806 RA patients stratified into four groups by pain and health status, 29 of the 176 (16%) classified into the "poorest" category had died after 18 years of follow-up, compared with 45 of 630 (7%) with less pain and better health (HR 2.4, 95% CI 1.5-3.8), according to Huai Leng Pisaniello, MBBS, of the University of Adelaide in Australia, and colleagues.

Cardio- and cerebrovascular events were the most common causes of death in the "poorest" condition group, the researchers reported in an .

Patients who rated their condition the poorest were also three times more likely to be hospitalized at some point than those in the "best" category (OR 3.1, 95% CI 2.3-4.2), Pisaniello and colleagues found.

"This is the first study to demonstrate the associations between poorer pain-related health status in RA and higher risk of hospitalisations and mortality," the group wrote. "Overall, the burden of increased mortality risk in RA may be largely borne by this identifiable subset of patients."

It wasn't obvious that those who felt the worst also had more active RA. Pisaniello and colleagues didn't have direct measures of disease activity on scales such as the , as the registry providing data for the study doesn't collect these data, but patient-reported arthritis scores and anti-rheumatic drug use was generally similar between groups. (In light of their greater pain, however, those in the "poorest" category used opioids at much higher rates than others, at 58% versus 17% in the "best" category and 28%-41% in the two middle strata.)

But worse pain/health status was significantly associated with other factors, including obesity, low educational level and socioeconomic status, and comorbidity index values. Also, some 43% of the "best" group were men, a much higher proportion than in the other groups (21%-31%).

Patients in the study were enrolled in the Australian Rheumatology Association Database (ARAD), which the researchers described as "a large voluntary national registry with longitudinal self-reported data on treatment and health outcomes in inflammatory arthritis." Pisaniello's group focused on those ages 25-75 entering ARAD within 5 years of diagnosis (mean disease duration was about 2.3 years) and followed for at least 3 years.

Hospitalizations were self-reported; deaths were identified through national records.

Stratification for pain and health status were based on five self-reported measures:

• Overall pain
• Arthritis
• Global health
• (HAQ-DI)

These five elements were combined to calculate overall status, with group 1 having the best and group 4 the worst. (These were not quartiles, but were rather defined by a model such that group sizes ranged. Group 1 had 143 patients [18%], while group 4 had 176 [22%].)

Pain scores in group 4 averaged 63 on a 100-point scale, versus 51, 40, and 25, respectively, in groups 3, 2, and 1. Similarly, mean HAQ-DI scores were 1.7, 1.2, 0.7, and 0.3 in the four groups on the 3-point scale. When evaluated over time, most patients remained within the same category, Pisaniello and colleagues indicated.

The researchers stopped short of calling for extra monitoring or management in patients who fall into the "poorest" status category. It's already the case that published guidelines recommend that RA patients' cardiovascular health be tracked closely.

"More work is required to establish whether implementing timely and strategic pain management improves morbidity and mortality in these patients," Pisaniello's group cautioned.

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